Belvoir Woods Health Care Center At The Fairfax
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Belvoir, Virginia.
- Location
- 9160 Belvoir Woods Pkwy, Fort Belvoir, Virginia 22060
- CMS Provider Number
- 495197
- Inspections on file
- 11
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Belvoir Woods Health Care Center At The Fairfax during CMS and state inspections, most recent first.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
Staff failed to ensure that required contact information for the State Survey Agency, State licensure office, and the State LTC Ombudsman was posted in an accessible location. The information was placed behind a concierge desk in an area where residents are not allowed, and no other signage was posted on the affected floor. During a Resident Council meeting, all residents present were unable to identify where this information was located and were unaware of their right to file complaints with these agencies. When two residents in wheelchairs were later shown the sign, they could not see it from their position in front of the desk while staff pointed to the posting behind the desk.
Staff failed to update person-centered care plans for several residents after significant changes in condition and services. One resident with severe cognitive impairment and multiple chronic conditions was admitted to hospice, but this was not added to the care plan. Another resident with severe cognitive impairment, diabetes, hypertension with orthostatic hypotension, and impaired mobility had an unwitnessed fall from bed to a fall mat and recurrent low BP episodes, yet the fall and orthostatic hypotension were not incorporated into the care plan. A third resident with vascular dementia, malnutrition, and hearing loss did not tolerate dentures or a hearing aid and was repeatedly observed without them, struggling to chew and communicate, but this intolerance was not reflected in the care plan. In addition, a cognitively intact resident with atrial fibrillation, CKD stage 4, and heart failure had a care plan that continued to list hospice services even though hospice had been discontinued, and this change was not updated in the care plan.
Staff failed to provide and coordinate required bathing and hygiene assistance for four dependent residents. One cognitively intact resident with a history of falls reported only receiving basin baths and having to request showers, despite a care plan and ADL schedule for twice-weekly showers, and the ADON acknowledged showers were not documented. Another resident with a femur fracture stated he received his first thorough shower only on the survey day, although he was scheduled for twice-weekly showers and his room board lacked shower-day postings. A cognitively impaired resident dependent for self-care was repeatedly observed with oily hair, dry rough skin, and later an offensive odor, while records only showed two refusals of showers/tub baths and no alternative bathing. A fourth cognitively intact resident requiring substantial assistance for bathing reported she had not taken showers or tub baths because she believed hospital instructions about dressings prohibited immersion, and she stated no one at the facility had educated her that bandages could be removed and reapplied for bathing, despite documentation indicating she was receiving scheduled showers or tub baths.
The facility’s QAPI/QAA program failed to identify multiple systemic problems, focusing only on falls, pressure ulcers, and transcription errors while missing significant issues in ADLs, care planning, and the environment. Surveyors found that several dependent residents were not receiving regular full-body baths, with observations of oily hair, scaly skin, body odor, and complaints about not getting showers or hair washed, corroborated by shower/tub documentation. Review of person-centered care plans for sampled residents showed they were not being routinely reviewed and revised as residents’ conditions changed. Environmental observations revealed resident rooms that were not safe, clean, comfortable, or homelike, including a room with ongoing heating problems where a resident reported being cold at night, and more than 15 rooms with damaged or deteriorated wall surfaces. These system failures had not been identified or brought to the QAPI team by facility staff.
Staff failed to maintain a comfortable and homelike environment for two residents when one cognitively intact resident repeatedly reported her room was cold despite prior complaints to maintenance and ongoing issues with the PTAC heat setting, and another resident with severe cognitive impairment was found in a room with scattered personal belongings and torn wallpaper behind the bed, despite her stated preference for stored belongings and wall repair. Staff interviews revealed that a CNA responded to cold complaints only by providing extra blankets, the maintenance engineer acknowledged incorrectly switching the PTAC from cold to heat, and the assistant engineer reported multiple rooms with unrepaired accent walls damaged during bed moves, while the DON stated nursing was responsible for proper storage of residents’ belongings.
A resident with osteomyelitis, CHF, and atrial fibrillation was admitted on apixaban 2.5 mg PO BID. A subsequent physician order for apixaban 2.5 mg was incorrectly transcribed as 12.5 mg PO BID, and a nurse later signed off administration of the erroneous 12.5 mg dose. The resident had recently reported new left leg swelling and redness and had a negative ultrasound for DVT, but there was no documented physician order to increase apixaban. The ADON reported that the nurse who transcribed the order mistakenly changed the dose and that the nurse administering the medication did not recognize that the new dose would require five tablets instead of one, resulting in a documented medication order and MAR entry that did not meet professional standards of quality.
Staff failed to prevent the development of a sacral stage 3 pressure ulcer in a cognitively impaired, highly dependent resident with multiple comorbidities and documented risk for impaired skin integrity. The care plan called for monitoring pressure areas, turning and positioning, and assisting the resident to bed during the day for pressure relief, but observations showed the resident remaining in a wheelchair for many hours on multiple days, largely to accommodate a spouse’s preference for dining room meals. Skin assessments progressed from no issues to MASD on the sacrum and then to an open sacral wound, which was later staged by a wound care physician as a stage 3 pressure ulcer of pressure etiology. The DON reported relying on staff assurances that weight shifting occurred in the wheelchair, and there was no indication that the responsible party was educated about the need for pressure offloading, while the resident was also observed receiving no encouragement or assistance with meals.
A resident with diabetes, orthostatic hypotension, impaired mobility, and severely impaired cognition (BIMS 5/15) fell from bed to floor while a CNA was providing incontinence care. The resident had a history of intolerance to sitting up, low BP episodes, and resistance to sitting at the edge of the bed, but resistance to care was not included in the care plan. During the incident, the resident resisted care, tried to get out of bed, and slid to the floor, requiring two staff to return her to bed. The DON later stated the CNA should have stopped care when resistance occurred, reminded the resident she needed assistance to get out of bed, ensured safety, and then reapproached, indicating that adequate supervision and assistance were not provided to prevent the fall.
A resident with a femur fracture, history of falls, unsteadiness, and occasional incontinence, who was cognitively intact and required assistance with transfers and toileting, repeatedly requested a bedside urinal but was not provided one. Over several observations, surveyors found the urinal stored in a bag in the bathroom rather than at the bedside, while the resident stated he had not received the requested urinal. CNAs reported that they typically did not allow bedside urinals, citing infection control and a practice of keeping urinals in the bathroom and instructing residents to use the call light for assistance, whereas an LPN stated that residents who cannot transfer independently are allowed bedside urinals to help prevent falls. Leadership later acknowledged there was no policy on bedside urinals and that the resident could have one if able to use it.
An LPN was observed administering Benzonatate 100 mg from a medication card whose pharmacy-printed label had been altered by handwriting a new dosing interval over the original directions. Physician orders for this medication had changed multiple times from PRN dosing to scheduled dosing, and pharmacy instructions directed staff to use the on-hand PRN supply until a new card arrived. Facility policy required nurses to apply a separate "direction change" or similar label when prescriber directions changed, rather than altering the original pharmacy label, but this procedure was not followed. The DON later stated that nurses are expected to follow the medication labeling policy, and the findings were presented to the administrative team.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice for end-of-life care related to senile degeneration of the brain, with a care plan calling for coordinated hospice services and communication. However, staff reported not seeing hospice aides provide services and only occasional visits by a nurse, and a review of the paper chart found no hospice admission paperwork, care plan, or visit notes. As a result, details about hospice services, scheduling, communication processes, and triggers for contacting hospice were not available in the facility’s records, and leadership later acknowledged this non-compliance.
Facility staff did not maintain complete documentation of staff COVID-19 education and vaccination status. The HR manager reported that there was no documentation for long-term employees and that only new hires initialed an orientation form indicating they received COVID-19 education, but could not produce the actual education materials for two selected new hires. The HR manager later provided the facility’s COVID-19 preparedness and response plan as the education but was unable to show records that all staff had been offered the COVID-19 vaccine or that their vaccination status was documented.
A resident with an L4 wedge compression fracture and intact cognition was observed in bed with the call bell on the floor and not within reach while needing assistance to clean spilled water from his shirt. The resident reported having fallen the previous night after pressing the call bell without receiving a response and then attempting to pull the curtain, resulting in a fall onto his left side. Observations showed the call bell remained on the floor for an extended period until a CNA entered the room and placed it at the bedside, despite stating that resident rounds were done every 15 minutes. The Administrator later stated she had not been informed of this issue.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
Required Ombudsman and State Agency Contact Information Not Accessible to Residents
Penalty
Summary
Facility staff failed to post the required list of names, mailing and email addresses, and telephone numbers for the State Survey Agency, State licensure office, and the Office of the State Long-Term Care Ombudsman in a location accessible to all residents. During an observation of the third floor, this information was found posted behind the concierge’s desk on the wall, an area where residents are not allowed. No other signage with the required information was posted on the third floor. Concierge #2 stated that residents are not permitted behind the desk, that the door to the dining room behind the desk is kept locked so residents cannot go behind the desk, and that residents must ask for the information and phone numbers if they need them. Concierge #2 also reported that in five years of employment, no resident had requested this information. During a Resident Council meeting, all 10 residents present were unable to identify where the required information was located and were unaware that they had the right to file a complaint with the State licensure office or the State Long-Term Care Ombudsman. After the meeting, the Activities Director took two residents in wheelchairs to view the Ombudsman information; they were positioned in front of the concierge’s desk while the Activities Director pointed to the sign behind the desk and explained its contents. From their position, the two residents were unable to see the information on the signage. The Activities Director stated there was another copy of the information outside her office on the second floor for assisted living residents. The Administrator later stated that the Activities Director hands out cards with Ombudsman information from time to time and that the Ombudsman conducts rounds in the facility.
Failure to Review and Revise Person-Centered Care Plans After Changes in Condition and Services
Penalty
Summary
Facility staff failed to review and revise person-centered care plans for multiple residents following significant changes in condition or services. One resident with Alzheimer's disease, heart failure, and diabetes, who had severely impaired cognition per a BIMS score of 3/15, was admitted to hospice services on 3/8/26 after a documented decline including decreased oral intake and episodes of MASD. Despite this, the active care plan with a target date of 3/26/26 did not include the resident's election and admission to hospice services. Another resident with diabetes, hypertension with episodes of orthostatic hypotension, and impaired mobility and self-care after lumbar spine fusion had a BIMS score of 5/15, indicating severely impaired decision-making. This resident experienced an unwitnessed fall from the bed to the fall mat on 3/13/26, and nursing notes documented the fall and stated that no changes to the care plan were needed. The active care plan with a target date of 6/17/26 did not address the fall or the resident's episodes of orthostatic hypotension, despite the Rehab Director reporting that the resident was unable to tolerate therapy, resisted sitting up, had low blood pressure episodes, felt ill when upright, and vomited. A third resident with vascular dementia, mild protein-calorie malnutrition, hearing loss, and severely impaired cognition (BIMS 0/15) had an MDS indicating minimal hearing difficulty, and the care plan stated the resident required assistance with dentures. However, the active care plan with a target date of 5/2/26 did not document that the resident did not tolerate dentures and a hearing aid. During multiple survey visits, the resident was consistently observed without dentures, placing unchewed food into napkins, and having extreme difficulty communicating due to inability to hear. A private duty sitter reported that the resident's son had said it was acceptable for the resident not to wear dentures and the hearing aid because the resident repeatedly removed and discarded them. Additionally, another resident with intact cognition (BIMS 15/15) and diagnoses including atrial fibrillation, stage 4 chronic kidney disease, and heart failure had an active care plan with a target date of 6/5/26 that incorrectly stated the resident was receiving hospice services, even though a nutrition note documented discharge from hospice on 3/4/25 and the DON confirmed the resident was no longer on hospice.
Failure to Provide and Coordinate Scheduled Bathing and Hygiene Assistance
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically bathing and hair washing, to multiple dependent residents. One resident with a history of repeated falls and unsteadiness on feet was cognitively intact and had a care plan emphasizing her preference and goal to increase functional ability with bathing, including choosing between a tub bath, shower, bed bath, or sponge bath. She reported that staff were relying on her to ask for showers, that she believed she had designated shower days, and that she had instead been taking basin baths and using washcloths to run through her hair. ADL records showed scheduled showers twice weekly, but documentation reflected self-bathing on one date and "NA" on another, and the ADON later acknowledged that showers were not documented for this resident and that her preference for daytime showers had not been aligned with the existing schedule. Another resident admitted with a right intertrochanteric femur fracture, and diagnoses including repeated falls and unsteadiness on feet, reported that he received his first shower on the morning of the survey interview, stating that it was the first thorough washing since admission. He stated that staff had not bathed him in the shower room or in bed prior to that day, although he had been able to perform limited self-care such as shaving, wiping himself with a washcloth, and brushing his teeth. Staff interviews indicated that showers or refusals were to be documented in the electronic record, that there was a set shower schedule, and that shower days should be posted on room boards and in CNA computers. The resident’s room board did not list shower days, although an LPN confirmed that the resident was scheduled for showers twice weekly on the day shift. ADL documentation showed the first recorded shower on a date consistent with the resident’s report and an earlier scheduled date marked as "NA." A third resident with Alzheimer’s dementia and paroxysmal atrial fibrillation, who was severely cognitively impaired and dependent or requiring substantial assistance for most self-care tasks including showering/bathing, was observed on two separate days with oily, flat hair, dry rough skin on the face, and later with an offensive odor. Her care plan included a goal to increase functional ability with bathing and interventions allowing her to choose the type of bath while requiring substantial/maximal assistance. A family member reported that her hair had not been washed for weeks and that he planned to ensure her hair was washed before transfer to another facility. Bathing records showed refusals of showers/tub baths on two dates, with no documentation of alternative bathing or hair washing. A fourth resident, cognitively intact but requiring substantial/maximal assistance with showering/bathing and several other ADLs, had a care plan goal to increase functional ability with bathing and interventions emphasizing her choice of bathing method. She was observed with multiple scabs on her arms and legs, dry and scaly skin on her arms, legs, and face, and hair that had been washed and set at the beauty shop that day. She stated she was not taking showers or tub baths because hospital staff had told her she could not immerse in water due to dressings, and she reported that no one at the facility had informed her that bandages could be removed and reapplied to allow bathing. CNA interview indicated that every resident received showers or tub baths as scheduled, and documentation stated that this resident was receiving showers or tub baths according to her schedule, but the resident’s own account and the DON’s subsequent interview confirmed that she had not been receiving showers or tub baths at the facility due to her understanding of the hospital’s instructions and lack of education from facility staff.
Failure of QAPI Program to Identify Systemic Issues in ADLs, Care Planning, and Environment
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI/QAA program that identifies and addresses failed systems. During an interview, the Administrator stated that the QAPI committee relied on data from the 5-star report, Resident Council meetings, grievances, families, residents, and the IDT, and that current focus areas included falls, pressure ulcers, and transcription errors. However, during the survey, three additional system failures were identified by surveyors—Activities of Daily Living (ADLs) related to showers/tub baths, ongoing review and revision of person-centered care plans, and maintaining a safe, clean, comfortable, and homelike environment—that had not been recognized or presented to the QAPI team by facility staff. Surveyors found that several dependent residents were not receiving regular full-body baths, specifically showers or tub baths, and observations revealed residents with oily hair, scaly skin, and body odor, with some residents reporting not receiving showers or hair washing. Review of shower/tub bath documentation confirmed that residents were not receiving regular full-body bathing. Review of person-centered care plans for all sampled residents showed a pattern of plans not being reviewed and revised on an ongoing basis as residents’ conditions improved or deteriorated. Environmental observations identified resident rooms that were not safe, clean, comfortable, or homelike, including one room with ongoing heating issues where a resident reported being cold on several nights, and more than 15 rooms with walls needing painting or with torn wallpaper and exposed wallboards. These issues were not identified by the facility’s QAPI process, and when given an opportunity, the leadership team did not provide additional information to demonstrate that these system failures had been recognized or addressed through QAPI/QAA activities.
Failure to Maintain Comfortable Room Temperatures and Homelike Room Conditions
Penalty
Summary
Facility staff failed to ensure a safe, comfortable, and homelike environment for two residents by not adequately addressing room temperature concerns and room condition issues. One cognitively intact resident with chronic kidney disease and neuralgia reported ongoing problems with her room being cold, stating during a resident meeting that maintenance had been informed but the issue was not fixed. Resident council notes documented a prior grievance from this resident about temperature, but it referenced common areas rather than her specific room. On multiple occasions, the resident reported her room felt cold, including one instance where she stated she thought she was going to freeze because she had not had heat in her room since the previous day, despite the maintenance engineer later measuring the room temperature in the low 70s Fahrenheit and acknowledging that the PTAC unit had been incorrectly switched from cold to heat. Another resident with atrial fibrillation and chronic venous insufficiency, who had severely impaired cognitive abilities per a recent MDS assessment, was observed in bed stating she did not feel well, though she could not specify what was wrong. Her room was observed to be cluttered, with personal belongings scattered on the bedside table, chair, and overbed table, and the wall behind her bed had torn wallpaper. When asked, the resident expressed a preference for having her belongings stored and for the wall beside her bed to be repaired. The DON later stated that nursing was responsible for ensuring residents' personal belongings were stored appropriately. Interviews with staff further described the circumstances contributing to these deficiencies. A CNA reported that the resident with temperature concerns had complained of being cold at night and was given two blankets. The maintenance engineer explained that the PTAC unit required switching between heat and cold modes and admitted he had switched it incorrectly, contributing to the resident’s perception of inadequate heat. The assistant engineer reported that many rooms had accent walls needing repair and attributed wall damage to direct care staff tearing walls when moving beds, noting that repairs had not been completed because residents would need to be moved out of rooms for the work. These actions and inactions resulted in residents not consistently experiencing a comfortable temperature or a homelike, well-maintained room environment.
Medication Transcription Error for Anticoagulant Order
Penalty
Summary
Facility staff failed to ensure that a medication order for an anticoagulant met professional standards of quality when a nurse inaccurately transcribed a physician’s order for apixaban. The resident involved had been admitted after an acute care hospital stay with diagnoses including right 5th finger osteomyelitis/septic arthritis requiring IV therapy, congestive heart failure, and atrial fibrillation, and had a BIMS score of 11/15 indicating moderately impaired cognitive abilities for daily decision-making. The resident was admitted with an order for apixaban 2.5 mg by mouth twice daily. A new order was written on 3/13/26 for apixaban 2.5 mg, but it was transcribed in the record as “Give 12.5 mg by mouth twice daily,” changing the dose from 2.5 mg to 12.5 mg. On 3/14/26, a nurse signed off that 12.5 mg of apixaban had been administered, reflecting the incorrect transcribed dose. The physician’s progress note from 3/13/26 documented that the resident had presented with new left leg swelling and redness and had undergone an ultrasound to rule out a blood clot, which was negative, but there was no order from the physician to increase apixaban to 12.5 mg. During an interview, the ADON stated that the nurse who transcribed the order mistakenly changed the apixaban dose and that the nurse who administered the medication did not notice that the new ordered dose would have equaled five tablets instead of one. The ADON further stated that an audit later showed that the 12.5 mg strength was associated with a new order for Aldactone, not apixaban, confirming that the transcription error had occurred in the medication orders for this resident.
Failure to Prevent and Adequately Offload Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to provide necessary care to prevent the development of a sacral stage 3 pressure ulcer in one cognitively impaired, highly dependent resident. The resident had Alzheimer's disease, heart failure, diabetes, severe impairment in daily decision-making (BIMS score 3/15), and required substantial to maximal assistance for most self-care and mobility tasks. The care plan identified a potential for impaired/compromised skin integrity related to bilateral lower extremity edema and incontinence, with interventions including observing pressure areas for redness, notifying the nurse of any redness, encouraging and assisting with turning and positioning, assisting the resident to bed during the day for pressure relief, and assisting with repositioning as needed. A low-air-loss mattress was not added until late February. Weekly skin assessments initially documented no skin issues on 2/4/26, with barrier cream used on both buttocks as a preventative measure due to incontinence. By 2/11/26, nursing documentation identified moisture-associated skin damage (MASD) on the sacrum, which continued to be documented on 2/18/26. On 2/22/26, nursing documentation described an open wound to the sacrum measuring 2 cm x 2 cm, which was not staged at that time but was cleaned with normal saline and covered. When the wound care physician first evaluated the resident on 2/24/26, the sacral wound was identified as a stage 3 pressure ulcer of pressure etiology, measuring 2.0 cm x 1.5 cm x 0.2 cm, with 100% granulation tissue and moderate serous drainage, and treatment with calcium alginate with honey was ordered. Despite the resident’s high risk for pressure injury and the presence of a sacral pressure ulcer, observations on multiple days showed the resident remaining in a wheelchair for extended periods. On 3/11/26, the resident was observed in a wheelchair in her room at approximately 11:00 AM and again at 3:50 PM. On 3/12/26, the resident was observed in bed at about 9:15 AM with breakfast, then out of bed in a wheelchair at 11:07 AM being taken to the dining room, and again in the wheelchair in her room at approximately 4:30 PM. On 3/18/26 at about 11:00 AM, the resident was again observed sitting in a wheelchair in her room. A CNA reported that the resident was out of bed daily before 11:00 AM because the spouse wanted the resident to have lunch in the dining room. The DON stated that direct care staff had assured her they shifted the resident’s weight when seated in the wheelchair, but there was no indication that the nursing team had educated the responsible party or power of attorney about the need to offload pressure to promote healing and prevent additional pressure ulcers, while the resident was also observed receiving no encouragement or assistance from staff with meals.
Failure to Provide Adequate Supervision During Incontinence Care Resulting in Fall
Penalty
Summary
Facility staff failed to provide adequate assistance and supervision during incontinence care to prevent a fall for one resident. The resident had diagnoses including diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care related to lumbar spine fusion. An admission MDS with an ARD of 1/6/26 documented a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision-making. According to the Rehab Director, the resident was unable to tolerate therapy, was resistant to sitting up on the side of the bed or in a wheelchair, had episodes of low blood pressure, reported feeling ill while sitting up, and would vomit. Prior to the fall on 3/6/26, the resident’s care plan did not include a problem related to resistance to care. On 3/6/26 at 4:30 AM, while a CNA was providing incontinence care, the resident experienced a witnessed fall from the bed to the floor. Nurse’s notes documented that the resident was resisting care, attempted to get out of bed, and slid off the bed to the floor, requiring two staff members to assist her back into bed. The DON later stated that, in this situation, the CNA should have stopped care when the resident became resistant, reminded the resident that she required assistance to get out of bed, ensured the resident was safe, and then reapproached the resident. Family Member #1 reported observing staff working to transfer the resident back to bed after the fall. These findings show that staff did not provide adequate supervision and assistance during incontinence care to prevent the fall.
Failure to Provide Requested Bedside Urinal to Continent Resident
Penalty
Summary
Facility staff failed to provide a requested bedside urinal to a continent/occasionally incontinent resident who had a right intertrochanteric femur fracture, repeated falls, and unsteadiness on their feet. The resident’s admission MDS showed intact cognition (BIMS 15/15), partial/moderate assistance needs for toileting hygiene, and substantial/maximal assistance for bed-to-chair and toilet transfers, with occasional bladder incontinence. The resident’s care plan indicated partial/moderate assistance with toilet use and use of incontinent briefs, and that the resident was able to make self-care decisions daily. On multiple observations over several days, surveyors noted that the resident’s urinal was stored in a bag in the bathroom and not at the bedside, despite the resident’s repeated statements that he had requested, but not received, a bedside urinal. On one observation, when the resident directly asked a CNA for a bedside urinal, the CNA responded that he could not have one at the bedside and must use the call bell to request assistance with using the urinal in the bathroom. In interviews, one CNA stated that bedside urinals were not usually provided due to infection control and that residents were educated to use the call light for assistance, while another CNA stated that if a resident could walk, the urinal would be left in a bag in the bathroom. In contrast, an LPN reported that residents who cannot transfer independently are allowed to have bedside urinals and that staff use them to prevent falls and keep them close so residents do not get up impulsively. The ADON later stated there was no policy regarding bedside urinals and that the resident could have a bedside urinal if able to use it. Throughout the observation period, the resident consistently reported not being provided with the requested bedside urinal.
Altered Pharmacy Label on Benzonatate Medication Card
Penalty
Summary
Facility staff failed to ensure that a medication label remained unaltered from the pharmacy-printed label for a Benzonatate 100 mg capsule card. During a medication administration observation with an LPN, the Benzonatate medication card was noted to have a handwritten "8" written over the previous hourly instructions for administration, which had indicated intervals such as every 4 hours and every 12 hours. Review of the physician’s order summary showed that the original order for Benzonatate 100 mg was 1 capsule by mouth every three hours PRN for cough, which was then changed to every eight hours PRN for cough, and later changed again to 1 capsule by mouth three times a day for cough for 5 days. Pharmacy instructions indicated that the PRN medication on hand should be used. In an interview, the LPN stated that the order had been changed from PRN to scheduled doses and that the pharmacy had instructed staff to use the on-hand medication until a new medication card was received. The facility’s policy titled “Medication and Medication Labels 3.7” stated that if the prescriber’s directions for use change or the label is inaccurate, the nurse may place a “direction change. Change of order-check chart” or similar label on the container, taking care not to cover important label information. Instead of following this policy, the existing pharmacy label on the Benzonatate card was directly altered by handwriting over the original directions. During a subsequent interview, the DON stated that staff nurses are expected to follow the policy. The survey findings regarding the altered medication label were later presented to the facility’s administrative team, who did not offer comments or concerns.
Failure to Maintain Accessible Hospice-Coordinated Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to have a hospice-coordinated plan of care readily available and integrated into the resident’s record for a hospice-enrolled resident. The resident, admitted after an acute hospital stay, had diagnoses including atrial fibrillation and chronic venous insufficiency, and a significant change MDS showed a BIMS score of 3/15, indicating severely impaired cognitive abilities for daily decision-making. The resident’s care plan, dated 2/4/26, documented admission to hospice services for end-of-life care related to senile degeneration of the brain, with a goal to receive uninterrupted supportive services. Interventions listed included coordinating all of the resident’s needs, communicating changes to hospice, and educating the resident, family, responsible party, and caregivers about changing needs and additional hospice services. Despite this, staff interviews and record review showed that hospice services and coordination were not clearly documented or accessible in the facility. A CNA reported never seeing a hospice aide provide services to the resident and only observing a male nurse visiting approximately twice per week. When interviewed, the DON stated that hospice admission paperwork, the care plan, and visit notes were likely in the resident’s paper chart, but a review of the paper charts revealed no hospice documents. As a result, information about what hospice services would be provided, when and how they would be provided, the communication process, and when or why facility staff should contact hospice was not available in the facility at the time of review. Hospice documents confirming the resident’s hospice admission for senile degeneration of the brain were only produced later, after being faxed to the facility, and the facility leadership acknowledged the non-compliance during the surveyor’s discussion.
Failure to Document Staff COVID-19 Education and Vaccination Status
Penalty
Summary
Facility staff failed to document each staff member’s COVID-19 vaccination and education status as required. During the infection control task, the Human Resource Manager (HRM) reported that there was no documentation for employees with longevity and that only new hires initialed an Orientation Acknowledgement form indicating they were given COVID-19 education. However, the HRM could not produce the actual education materials that were purportedly acknowledged by initials for two of two selected new hires. The HRM later provided the facility’s Infectious Disease COVID-19 Preparedness and Response Plan as the education but was unable to provide documentation that all staff had been offered the COVID-19 vaccine or that their vaccination status had been recorded. These findings were confirmed through staff interviews and review of the available records and policies. No specific residents or their medical histories were mentioned in the report, and the deficiency centered on the facility’s failure to maintain complete and verifiable documentation of staff COVID-19 education and vaccination offerings.
Call Bell Inaccessibility in Resident Room
Penalty
Summary
Surveyors identified a deficiency in ensuring that a working call system was accessible in resident care areas when one resident’s call bell was not within reach while he was in bed. The resident, who had a wedge compression fracture of the fourth lumbar vertebra and was on a subsequent encounter for fracture with routine healing, had been assessed on the 5-day MDS with a BIMS score of 15/15, indicating intact cognitive abilities for daily decision making. On 03/12/26 at approximately 10:45 a.m., the resident was observed lying in bed with the head of the bed elevated to about 45 degrees, while his call bell was on the floor beside the bed and not accessible. During an interview at that time, the resident attempted to drink water and spilled a small to moderate amount on his shirt, then requested something to wipe off the water. When asked to use his call bell for assistance, he stated he could not find it. The resident also reported that he had fallen the previous night, stating that he had pressed the call bell but no one came, and that he had been trying to pull the curtain when he fell onto his left side. Follow-up observations on 03/12/26 showed that at 10:55 a.m. the call bell remained in the same location on the floor, still not accessible to the resident. At 11:14 a.m., CNA #2 entered the room, picked up the call bell from the floor, and placed it at the bedside, stating that she performs resident rounds every 15 minutes. In a final interview on 03/18/26 with the Administrator, DON, ADON, and two corporate consultants, the findings were discussed, and the Administrator stated she had not been made aware of the issue.
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Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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