Fairmont Crossing Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Amherst, Virginia.
- Location
- 173 Brockman Park Drive, Amherst, Virginia 24521
- CMS Provider Number
- 495363
- Inspections on file
- 14
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Fairmont Crossing Health And Rehab Center during CMS and state inspections, most recent first.
Staff failed to maintain a clean and sanitary environment in a first-floor dining room, where a light fixture and bug light above a dining table used by a resident were observed to be covered with cobwebs and dead insects. A CNA acknowledged the buildup had likely been present for some time. Interviews with housekeeping and dietary staff showed conflicting understandings of who was responsible for deep cleaning the dining room, and the housekeeping supervisor could not produce records or a schedule showing when deep cleaning was last performed. Facility policy required regular cleaning and disinfection of environmental and housekeeping surfaces when visibly soiled.
Surveyors found that staff did not consistently review and revise comprehensive care plans after changes in residents’ conditions or interventions. For several residents, care plans continued to list Covid-19 droplet or contact isolation precautions after those precautions were discontinued, and one cognitively intact resident’s plan did not include new interventions to validate outside appointments and restrict transport arrangements after an incident of leaving for an unverified appointment. For residents with pressure ulcers and impaired skin integrity, care plans still called for heel protectors and heels-up devices that were no longer in use or were being refused, and one resident with documented overall decline and initiation of comfort-focused medications did not have these changes reflected in the care plan. These failures occurred despite a facility policy requiring the interdisciplinary team to update care plans with significant changes in condition, goals, needs, or interventions.
Staff failed to ensure hot lunch foods were served at safe, palatable temperatures for residents on two first-floor nursing units. A dietary aide measured multiple hot items on the steam table, including meats, vegetables, and purees, with temperatures ranging from 90°F to 110°F, below the facility policy requirement of >135°F. Although the aide acknowledged the food was not at the correct temperature, she continued plating and serving the meals. The dietary manager later stated she knew the food should have been brought down to reach proper temperature and had previously instructed the aide, while facility policies required monitoring and immediate corrective action when unsafe temperatures were found.
Dietary staff failed to remove expired food from the main kitchen walk‑in freezer, where surveyors observed a case of Dannon yogurt stored past its labeled expiration date. During the observation, the dietary manager acknowledged the yogurt was expired and could not explain how it had been missed. Facility policy required all food to be stored, labeled, and dated to ensure freshness and mandated weekly storage inspections by the dietary manager, but the expired yogurt remained in the freezer despite these requirements.
Staff failed to ensure ordered heel off-loading devices and protectors were available and in use for a resident with a documented stage 4 heel pressure ulcer and multiple areas of impaired skin integrity. During observation, no heel devices were present in the room or on the bed. A CNA reported that none were on the resident’s heels at the start of her shift, and an LPN could not locate the devices despite stating the resident had heels up and booties. The LPN also stated the resident refused the devices and that providers should be notified of refusals, while the resident reported that staff had removed the devices previously to give to someone else. Clinical records, including the MDS and weekly wound evaluation, documented the need for off-loading the heels and use of specialty devices, which were not in place.
A resident’s nasal cannula tubing and CPAP mask were observed on the floor on two occasions, rather than stored in a clean, covered manner as required by facility policy. A CNA reported finding the equipment on the floor at the start of her shift and stated she had informed the charge nurse and requested appropriate storage supplies. An RN and an LPN both acknowledged the equipment should not be on the floor and should be kept in labeled bags, while the DON stated the resident was known to remove his oxygen and was unaware that the tubing on the floor was attached to an oxygen concentrator used at bedtime. The facility’s respiratory care policy requires safe storage, covering of oxygen cannulas and masks when not in use, and clean, labeled storage for CPAP equipment, which was not followed in this case.
Failure to Maintain Clean and Sanitary Dining Room Environment
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment in one of two dining rooms, specifically the first-floor dining room. During a midday observation, surveyors noted a light fixture with a bug light underneath that had cobwebs covering the bottom of the light fixture and the top of the bug light, as well as dead bugs on the top and sides of the bug light. A resident was seated at a table directly under this fixture at the time of the observation. A CNA, when shown the fixture, acknowledged that the buildup appeared to have been present for some time and confirmed that the bug light was full of bugs. Interviews with staff revealed confusion and inconsistency regarding responsibility for deep cleaning the dining room area. A housekeeping staff member stated that dietary staff were responsible for deep cleaning the dining room, while a dietary aide stated that dietary only deep cleaned the kitchenette area and that housekeeping was responsible for the actual dining area. The housekeeping supervisor reported that housekeeping deep cleaned the dining room twice a month but could not provide any documentation or schedule showing when the deep cleaning was last completed or by whom. Review of the facility’s “Cleaning and Disinfecting Environmental Surfaces” policy indicated that environmental and housekeeping surfaces were to be cleaned and disinfected regularly and when visibly soiled. At the end-of-day meeting, the administrator acknowledged awareness of the condition of the light fixture and bug light.
Failure to Review and Revise Resident Care Plans After Changes in Condition and Interventions
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive, person-centered care plans when residents’ conditions or interventions changed. For one resident with multiple sclerosis and other comorbidities who tested positive for Covid-19, the physician ordered enhanced droplet precautions for seven days, which were later discontinued. However, the resident’s care plan, revised during the period of precautions, continued to document that the resident required droplet precautions and related Covid-19 interventions even after the precautions were stopped. Nursing staff, including the unit manager and the MDS nurse, acknowledged that the Covid-19 precautions should have been removed from the care plan when they were discontinued. Another resident with a history of head lice was placed on contact precautions per physician order and received treatment, after which the contact precautions were discontinued. Despite this, the resident’s care plan, revised after the discontinuation, still documented that the resident was on contact isolation due to head lice and included interventions such as PPE use and isolation precautions. The unit manager and the MDS nurse both stated that the contact precautions should have been removed from the care plan once they were no longer in effect. A third resident, cognitively intact with multiple medical diagnoses, left the facility for an audiology appointment but instead went to other destinations, including a lawyer’s office and a social services office, before returning. Following this event, staff began validating all appointments and modified the resident’s Medicaid transport account to require verification with facility staff before confirming transport and destination, but the resident’s care plan was only revised to add the problem of reporting an appointment that did not exist and did not include the new interventions of appointment validation and transport account restrictions. For a resident with impaired skin integrity and a stage 4 pressure ulcer on the right heel, the care plan, revised in late March, included interventions to apply heel protectors and float heels as tolerated. During observation, no heel protectors or heels-up devices were present in the room or on the resident’s bed, and staff reported that the resident refused these devices and that the provider should be notified when refusals occurred. The care plan was not revised to reflect the resident’s refusals or any alternative interventions. Another resident with a documented decline in overall health—manifested by increased abdominal pain, decreased food and fluid intake, altered level of consciousness, decreased mobility, increased need for assistance with ADLs, and decreased socialization—had comfort-focused interventions initiated, including low-dose morphine and lorazepam for symptom management, as documented by the PA and physician. Despite these documented changes and initiation of comfort-focused measures, the resident’s care plan was not updated to reflect the decline in condition or the comfort-focused interventions. A further resident with metabolic encephalopathy, dementia, diabetes with a left heel ulcer, and severe cognitive impairment had a care plan listing multiple pressure ulcer prevention and treatment interventions, including heel protectors, a heels-up cushion, an alternating air mattress, and a pressure-reducing mattress. Observation showed the resident in bed with a heels-up cushion and a pressure-reducing mattress in use, but no heel protectors were on the resident or visible in the room. The unit manager and DON stated that heel protectors and the alternating air mattress were no longer in use and that only the heels-up cushion and pressure-reducing mattress were being used. The MDS nurse confirmed that the care plan had not been updated to remove the discontinued interventions. Across these residents, the facility’s own care planning policy stated that the interdisciplinary team is responsible for reviewing and updating care plans when there is a significant change in condition, when goals, needs, and preferences change, and at least quarterly and after each OBRA MDS assessment, but these updates were not completed as required.
Failure to Serve Hot Foods at Safe and Palatable Temperatures
Penalty
Summary
Facility staff failed to ensure that lunch meals were served at palatable and safe temperatures for residents on two first-floor nursing units. During an observation of the first-floor kitchenette at 11:45 a.m., a dietary aide (OS7) was seen taking temperatures of multiple hot food items on the steam table, including ham, puree ham, sweet potatoes, grilled chicken, noodles, chopped ham, puree broccoli, pork chops, broccoli, and puree bread. The recorded temperatures ranged from 90°F to 110°F, all below the facility’s policy requirement that hot foods be held and served at temperatures greater than 135°F. While taking these temperatures, OS7 shook her head and verbally acknowledged that the food was not reaching the correct temperature. Despite recognizing that the food was not at the required temperature, OS7 continued plating the food and it was served to residents on the first-floor units. In a subsequent interview, the dietary manager stated that she knew she should have brought the food down to get it to temperature and that she had told OS7 that earlier. Review of facility policies and documentation confirmed that all foods were required to be cooked, held, and served at safe temperatures, that hot foods must be maintained above 135°F, and that corrective action such as reheating, cooling, or discarding was required when unsafe temperatures were identified. The administrator later stated that dietary staff knew what to do when unsafe food temperatures were identified during monitoring.
Expired Yogurt Stored in Walk-In Freezer Beyond Labeled Date
Penalty
Summary
Facility dietary staff failed to ensure that food items stored in the main kitchen walk‑in freezer were within expiration dates, resulting in expired yogurt being available for use. During a kitchen observation with the dietary manager present, surveyors observed a case of Dannon yogurt in the walk‑in freezer labeled with an expiration date of 4/17/26, which remained stored for use after that date. When interviewed, the dietary manager reviewed the date on the case, acknowledged that the yogurt was expired, and stated he did not know how the case had been missed. Review of the facility’s “Food storage and labeling” policy showed it required all food to be stored, labeled, and dated to ensure freshness and specified that the dietary manager would ensure weekly storage inspections, indicating that the expired yogurt remained in storage despite these policy requirements. No residents or specific patient conditions were mentioned in the report, and no additional information was provided by the facility prior to the exit conference.
Failure to Provide Ordered Heel Off-Loading Devices for Resident With Stage 4 Pressure Ulcer
Penalty
Summary
Facility staff failed to implement ordered pressure-relieving measures to promote healing of a stage 4 pressure ulcer for Resident #111. During an observation of the resident’s room, no heel off-loading devices or heel protectors were visible on the bed or in the room, despite the resident having documented impaired skin integrity to the left heel, right heel, sacrum, and left calf, and a stage 4 pressure ulcer per the most recent MDS. A weekly wound evaluation documented a right heel stage 4 pressure ulcer that was unchanged and specified that the resident’s heels were to be off-loaded and that specialty devices were to be used. A CNA interviewed on the same day stated it was her first time caring for the resident and confirmed there were no heel off-loading devices or heel protectors on the bed or on the resident’s heels when she began care that morning. An LPN stated the resident had heels up and booties but was unable to locate any such devices in the room and did not know what had happened to them, further stating that the resident refused the devices and that providers should be notified when refusals occur so alternatives could be initiated. When the nurse asked the resident about the devices, the resident reported that staff had removed them a long time ago to give to someone else. These observations and interviews showed that the ordered pressure-relieving devices were not present or in use for this resident with a documented stage 4 heel pressure ulcer.
Improper Storage of Nasal Cannula Tubing and CPAP Mask
Penalty
Summary
Facility staff failed to maintain appropriate infection prevention and control practices for one resident using oxygen via nasal cannula and a CPAP device. On two separate observations in the resident’s room, surveyors found the nasal cannula tubing and CPAP mask lying on the floor instead of being stored in a clean, protected manner when not in use. The unit manager (RN) acknowledged that the nasal cannula tubing should be replaced and stored in a bag when not in use. A CNA later reported that when she began her shift, the nasal cannula tubing and CPAP mask were already on the floor, and she had notified the charge nurse and requested a table and a bag to store the equipment to keep it clean. The charge nurse (LPN) confirmed that the nasal cannula tubing and CPAP mask should not be on the floor and should be placed in properly labeled bags to keep them clean. During a discussion about the repeated observations of the tubing on the floor, the DON stated that the resident was known to remove his oxygen and could have thrown the tubing on the floor, and was not aware that the resident was wearing oxygen via an E-tank while the tubing on the floor was attached to an oxygen concentrator used at bedtime. Review of the facility’s policy on prevention of infection while providing respiratory care showed that respiratory equipment is to be stored safely when not in use, oxygen cannulas and masks are to be kept covered when not in use, and CPAP equipment is to be cleaned, disinfected, and stored in a clean environment with labeling to indicate cleaning and supply change dates. These policy requirements were not followed for this resident’s nasal cannula tubing and CPAP mask.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
