Berea Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fredericksburg, Virginia.
- Location
- 55 Brimley Drive, Fredericksburg, Virginia 22406
- CMS Provider Number
- 495431
- Inspections on file
- 11
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Berea Health & Rehab Center during CMS and state inspections, most recent first.
Improper Storage of Refrigerated Food: During a kitchen observation, a two-gallon zip lock bag of fish in the walk-in refrigerator was found unsealed. The cook sealed the bag during the observation and stated that refrigerated food should be kept in sealed containers. The facility policy requires all food and leftovers to be stored in covered, approved, food grade containers.
A RN used the same BP cuff and monitor on two residents without disinfecting the equipment between uses, and later used it again on another resident without cleaning it before or after use. In a separate observation, a housekeeper/laundry aide moved a bin of soiled laundry through the clean side of the laundry room instead of using the soiled-laundry entrance, contrary to the facility's linen handling process.
A resident with severe cognitive impairment was observed having BP taken at a dining room table while seated with two other residents during breakfast. The RN rolled a vital sign monitor to the table and checked the BP in the open dining area. Staff interviews stated vital signs were normally taken in residents’ rooms for privacy and resident rights, and the facility policy stated it complies with resident rights.
A resident with CHF had an ordered fluid restriction that was provided in the MARs and observed in practice, but the care plan did not include the restriction even though staff said it should be there for CNA access. Another resident’s care plan called for bilateral floor mats, but only one mat was in place while the other was rolled up in the room. A third resident with an indwelling catheter had a care plan directing that no part of the drainage system touch the floor, yet the catheter bag was observed on or touching the floor during multiple observations.
An RN crushed and administered a delayed-release pantoprazole tablet to a resident even though the order did not include crushing instructions. An LPN said crushed meds are checked on the eMAR, and the pharmacist stated pantoprazole should not be crushed because it can change the medication; the pharmacy reference also listed it as a medication that should not be crushed.
A resident with a history of falls and multiple fall risk factors had a care plan calling for bilateral floor mats, but staff observed only one mat in place while the resident was in bed and the other mat rolled up against the wall. An LPN stated that bilateral mats should be on the floor on each side of the bed when the resident is in bed.
A resident with an indwelling urinary catheter for urinary retention, neurogenic bladder, and obstructive/reflux uropathy was observed with the drainage bag touching the floor while in bed. The bag was seen on the floor more than once, and the resident said it was leaking and staff had been told earlier. The care plan and facility policy both stated the drainage system should not touch the floor.
Failure to Honor Documented Food Allergy: A resident with a documented pineapple allergy was served ham that had been cooked with pineapple and then had the pineapple removed before serving. The resident was cognitively intact, the meal ticket identified the allergy, and the DM confirmed the ham should have been cooked separately but was not.
Failure to administer/document a pneumococcal vaccine was identified for a resident with short- and long-term memory deficits and severe cognitive impairment. The EHR showed VIS education and consent from the resident and RP, but staff could not locate documentation showing the vaccine was actually administered. The ADON stated the date and lot number should be documented in the EHR, but no administration record was found.
Failure to document COVID-19 vaccine administration for a resident with severe cognitive impairment. The EHR showed vaccine education was provided and consent was obtained from the resident and RP, but staff could not locate documentation that the vaccine was actually administered, including the date and lot number. The ADON stated the resident’s spouse recalled the resident had received the vaccine, but the record did not evidence when it was given.
Facility staff did not notify the provider or resident representative when two residents experienced multiple episodes of blood glucose readings above 400 mg/dL, despite physician orders and facility policy requiring such notifications. Nursing staff confirmed awareness of the requirement, but clinical records lacked evidence of any notifications following these critical events.
Facility staff did not follow provider orders to notify the provider when two residents' blood sugar levels exceeded 400, as required by sliding scale insulin protocols. Despite multiple documented instances of elevated blood sugar, there was no evidence in the clinical records that the provider was contacted, and staff interviews confirmed the expectation to notify providers in such cases.
Improper Storage of Refrigerated Food
Penalty
Summary
Food was not stored in a sanitary manner in one of one kitchens. During an observation in the walk-in refrigerator, a two-gallon zip lock bag containing fish dated 3/2/26 was found unsealed. The cook sealed the bag during the observation and stated that the bag should have been completely sealed and that the facility standard is to keep refrigerated food in sealed containers. The facility’s policy for storage of refrigerated foods states that all food and leftovers are to be stored in covered, approved, food grade containers.
Failure to Disinfect Shared Equipment and Separate Soiled Laundry Flow
Penalty
Summary
Facility staff failed to follow infection control practices when a registered nurse used the same blood pressure cuff and vital sign monitor on two residents without disinfecting the equipment between uses. On 3/4/2026 at 8:15 AM, the RN was observed checking the blood pressure of Resident #75 in the dining area and did not disinfect the cuff afterward. At 8:23 AM, the same RN used the same blood pressure cuff and monitor to check the blood pressure of Resident #26 in the resident's room without disinfecting it before or after use. The RN later stated that blood pressure cuffs should be cleaned with disinfectant wipes after each use and said she had forgotten to do so during the observation. The same equipment was then used on Resident #17 without disinfection. At 8:23 AM, the RN was observed using the blood pressure monitor and cuff in Resident #26's room without disinfecting it after that use, and at 8:37 AM the RN used the same monitor and cuff to check Resident #17's blood pressure in the resident's room without disinfecting it prior to or after use. In a separate finding, the facility did not use a separate entrance for soiled laundry into the laundry room. On 03/05/2026 at approximately 10:00 AM, observation showed a housekeeper/laundry aide pushing a bin of soiled laundry through the entrance into the clean side of the laundry room and down the hallway to the washers instead of entering through the soiled laundry door. The Director of Housekeeping and Laundry stated that clean and soiled laundry should not be taken in and out through the same door to prevent cross contamination.
Dignity Not Maintained During Blood Pressure Check in Dining Room
Penalty
Summary
The facility staff failed to promote dignity for one resident when a registered nurse checked the resident’s blood pressure at a dining room table during breakfast on 3/4/2026. The resident’s most recent MDS quarterly assessment, with an ARD of 11/25/2025, showed a BIMS score of 4 out of 15, indicating severe impairment in making daily decisions. At the time of the observation, the resident was seated in the dining area with two other residents, had finished breakfast, and was still at the table while the nurse rolled a vital sign monitor to the table and took the blood pressure there. During interviews on 3/5/2026, an LPN stated that vital signs were normally taken in residents’ rooms and that staff usually waited if a resident was in the dining room, explaining this was done for privacy and resident rights because care in open areas lacked privacy. A CNA stated that if she were taking vital signs, they would be done in the resident’s room and not in public areas. The facility’s Resident Rights and Facility Responsibility policy, revised 10/7/25, stated that it is the facility’s policy to comply with all resident rights.
Care plans were incomplete or not followed for fluid restriction, fall protection, and catheter care
Penalty
Summary
The facility failed to develop a comprehensive care plan for fluid restriction for a resident with diagnoses including CVA, CHF, pneumonitis, and chronic respiratory failure. The resident’s quarterly MDS coded a BIMS score of 15 out of 15, indicating no cognitive impairment. The existing care plan addressed impaired cardiovascular status related to CHF and included monitoring and documenting signs and symptoms of CHF, but it did not include the ordered 1500 mL/24 hour fluid restriction. Physician orders dated 1/13/26 specified the fluid restriction, with dietary and nursing assigned portions of the daily allowance, and the January through March 2026 MARs showed the restriction was provided as ordered. Observations on 3/4/26 and 3/5/26 showed the resident on fluid restriction as ordered, and an LPN stated fluid restriction should be on the care plan because CNAs do not have access to the MAR. The facility also failed to implement care plans for two other residents. One resident’s care plan identified bilateral floor mats due to fall risk related to muscle weakness, reduced mobility, osteoarthritis, psychotropic medication use, incontinence, and impaired safety awareness/dementia, but observations showed only one floor mat on the left side of the bed while the other mat was rolled up against the wall in the room corner. Another resident had an indwelling urinary catheter for urinary retention after a failed voiding trial, and the care plan directed staff not to allow tubing or any part of the drainage system to touch the floor. However, observations showed the catheter bag on the floor, touching the floor surface while the resident was in bed, and again hanging beside the bed with the bed in the lowest position and the bag touching the floor.
Crushed delayed-release pantoprazole was administered without an order
Penalty
Summary
Facility staff failed to follow professional standards of practice during medication administration for Resident #34. On 3/4/2026 at 8:29 AM, an RN was observed preparing medication for the resident and crushed one 40 mg pantoprazole delayed-release tablet before administering it. The physician order for the resident listed pantoprazole delayed-release 40 mg, one tablet by mouth once daily, with no order documented to crush the medication. During interviews, an LPN stated that crushed medications are reviewed on the eMAR and checked for orders to crush, and that medications are verified before crushing. The pharmacist stated that delayed-release pantoprazole should not be crushed because it can change the medication, and the pharmacy reference Common Oral Dosage Forms That Should Not be Crushed listed pantoprazole as a medication that should not be crushed. The DON, IP/ADON, administrator, and regional director of operations were notified of the finding.
Failure to Maintain Bilateral Floor Mats for a Resident at Risk for Falls
Penalty
Summary
The facility failed to implement fall precautions for one resident who had a history of an actual fall and was identified in the comprehensive care plan as being at risk for falls related to muscle weakness, reduced mobility, osteoarthritis, psychotropic medication use, incontinence, and impaired safety awareness/dementia. The care plan dated 11/19/25 documented bilateral floor mats, but on 3/3/26 at 2:02 p.m. and again on 3/4/26 at 8:38 a.m., the resident was observed lying in bed with a floor mat on the left side only; no mat was present on the right side, and the missing mat was observed rolled up against the wall in the corner of the room. During interview on 3/5/26 at 12:30 p.m., an LPN stated that when a care plan documents bilateral floor mats, a mat should be on the floor on each side of the bed while the resident is in bed.
Catheter drainage bag left touching the floor
Penalty
Summary
The facility failed to maintain an indwelling urinary catheter drainage bag in a sanitary manner for one resident. The resident had diagnoses including urinary retention, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy. The most recent MDS showed the resident had an indwelling catheter for urinary retention and related bladder conditions, and the care plan directed staff not to allow tubing or any part of the drainage system to touch the floor. On 3/4/26, the resident was observed with the catheter bag touching the floor while lying in bed in the lowest position. The resident stated the bag was leaking and that staff had been informed about 15 minutes earlier. Later that morning, the catheter bag was again observed touching the floor surface on the left side of the bed, and another observation showed the bag hanging on the left side of the bed with the bed still in the lowest position and the bag touching the floor. An RN stated catheter bags should be below bladder level and not on the floor for infection control, and the facility policy also stated the urinary drainage bag must be placed below bladder level but not on the floor.
Failure to Honor Documented Food Allergy
Penalty
Summary
The facility failed to honor a documented pineapple allergy for Resident #15 when the resident was served ham that had been cooked with pineapple on Thanksgiving. The resident’s clinical record showed a pineapple allergy, and the admission MDS with an ARD of 9/10/25 indicated the resident was cognitively intact with a BIMS score of 15 out of 15. During interview, the resident stated the meal ticket documented the pineapple allergy and reported that the facility cooked ham with pineapple, removed the pineapple, and served the ham to the resident. The Dietary Manager confirmed that the ham was cooked with pineapple rings and that the pineapple rings were discarded before the resident was served, stating the ham should have been cooked separately but the cook did not think about it. The facility’s food allergies policy stated that individuals with food allergies will be provided with safe foods and fluids and appropriate substitutions to maintain health.
Failure to Document Pneumococcal Vaccine Administration
Penalty
Summary
Failure to administer the pneumococcal vaccine was identified for one resident during review of the immunization record. The resident’s MDS admission assessment documented short- and long-term memory difficulties and severe cognitive impairment for making daily decisions. The EHR showed that pneumococcal vaccine education was provided, the risks, benefits, and alternatives were reviewed using the VIS, and consent was obtained from both the resident and the responsible party. Despite this documentation, further record review did not evidence that the pneumococcal vaccine was actually administered. During interview, the ADON stated that when the vaccine is given, the date and lot number are documented in the EHR under preventative health, but no documentation could be located showing when the resident received the vaccine. The ADON also stated that the resident’s spouse recalled the vaccinations being given at the facility, and that there had been a batch of expired vaccines at the time the resident was scheduled to receive the pneumococcal vaccine, but the date of administration was not documented.
Failure to Document Administration of COVID-19 Vaccine
Penalty
Summary
The facility failed to administer the COVID-19 vaccine for one of five residents reviewed in the immunization record review, Resident #27. The resident’s most recent MDS assessment documented short- and long-term memory difficulties and severe cognitive impairment for daily decision-making. The EHR showed that COVID-19 vaccine education was provided, the risks, benefits, and alternatives were reviewed using the vaccine information sheet, the resident verbalized understanding, and the responsible party was contacted by phone and gave consent. Despite documentation that education and consent were obtained, further review did not evidence that the COVID-19 vaccine was actually administered to Resident #27. The ADON stated that when the vaccine was administered, the date and lot number should be documented in the EHR under preventative health, but staff were unable to locate documentation showing when the resident received the vaccine. The ADON also stated that the resident’s spouse recalled the resident had received the vaccination at the facility, and that there had been a batch of expired vaccines at the time the resident was scheduled to receive the COVID-19 vaccine, but the date the vaccine was given was not documented.
Failure to Notify Provider and Representative of Critical Blood Sugar Levels
Penalty
Summary
Facility staff failed to notify the provider and resident representative (RR) of significant changes in condition for two residents with diabetes, as required by physician orders and facility policy. For one resident, multiple blood glucose readings exceeding 400 mg/dL were documented in the medication administration records (MARs) over several dates, but there was no evidence in the clinical record that either the provider or RR was notified of these critical results. The provider's order specifically instructed staff to call the medical doctor if blood sugar exceeded 400, yet this was not done. Interviews with nursing staff confirmed that it is standard practice and expectation to notify the provider and RR when blood sugar readings surpass dangerous thresholds, as indicated in the orders. Staff acknowledged that such instructions are routine and must be followed, emphasizing that 'an order is an order.' Despite this, review of the clinical records for both residents showed no documentation of required notifications following high blood sugar readings. The facility's policy on resident change in condition states that the licensed nurse must recognize and intervene in the event of a change, and notify the physician/provider and family/responsible party as soon as the change is identified and the resident is stable. However, in both cases, there was a lack of evidence that these notifications occurred, despite repeated instances of blood sugar levels exceeding the specified threshold.
Failure to Notify Provider of Critically High Blood Sugar Levels per Insulin Orders
Penalty
Summary
Facility staff failed to follow provider orders for the administration of insulin for two residents. For one resident, provider orders specified that if blood sugar exceeded 400, the provider should be notified. Clinical record review showed multiple instances where the resident's blood sugar was above 400, but there was no evidence that the provider was notified as required. Medication administration records documented blood sugar readings above the threshold on several dates, yet the clinical record lacked documentation of provider notification. Interviews with nursing staff confirmed that the standard practice is to notify the provider when blood sugar readings exceed specified parameters in sliding scale insulin orders. Staff acknowledged that an order is to be followed as written, and that both the provider and resident representative should be notified when such parameters are exceeded. However, review of the records indicated that this protocol was not followed for the residents in question. Administrative and nursing leadership were made aware of these concerns during the survey. The facility's policy on provider orders did not include information regarding the nursing staff's responsibility to follow such orders. No additional information or documentation was provided to demonstrate that the provider was notified in the identified cases.
Latest citations in Virginia
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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