Ghent Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Norfolk, Virginia.
- Location
- 3900 Llewellyn Ave, Norfolk, Virginia 23504
- CMS Provider Number
- 495273
- Inspections on file
- 19
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Ghent Health And Rehabilitation during CMS and state inspections, most recent first.
Unsafe and Unsanitary Resident Environment: Surveyors found multiple resident rooms and bathrooms with no hot water, toilets that would not flush, foul odors, and heating problems. Several cognitively intact residents reported these issues, and staff confirmed the conditions during interviews. Surveyors also observed roaches and mice in resident areas, and residents described ongoing pest activity in their rooms.
Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff, and maintain vaccination documentation. Surveyors found no evidence of resident COVID-19 vaccination for the year reviewed and no staff vaccination status logs. An LPN serving as the IP stated the role was new, the pharmacy initially said it did not have the vaccine, and the staff vaccination logs could not be located. The facility policy required education, offering the vaccine, and maintaining staff vaccination records, including NHSN data.
Staff failed to safeguard and return personal clothing after laundering for three residents, including individuals with stroke, diabetes, seizure disorder, hemiparesis, aphasia, atrial fibrillation, and dementia. One resident with moderately impaired cognition reported that clothing sent to the laundry had not been returned and was repeatedly observed asking staff for help retrieving it. Another cognitively intact resident stated that all of his clothing was missing after laundering, that staff brought him other residents’ clothing in his size, and that he had to accept donated items while watching others to see who might be wearing his clothes. A third cognitively intact resident reported that all his coats were missing, expressed fear of removing the coat he was wearing so it would not be lost, and continued to report missing items during interviews with the ADON.
Staff failed to consistently provide and document ADL and incontinence care for multiple dependent residents. One resident with an indwelling catheter was given a bed bath without any covering, with soap left unrinsed and the same washcloth used for both body washing and post-bowel incontinence care. A cognitively intact resident who required assistance with personal hygiene had visible chin hair despite expressing a desire for facial hair removal, which staff acknowledged should be part of routine ADL care. Another dependent resident with severe cognitive impairment and urinary incontinence received fewer showers than scheduled, and her family reported having to wash her hair at bedside due to lack of staff hair washing. Additional residents with significant ADL deficits and severe cognitive or physical impairments had multiple days and shifts with blank ADL documentation for hygiene and bowel/bladder continence, and staff interviews confirmed that care is evidenced by documentation in the electronic ADL system.
Facility staff failed to maintain an effective pest control program, as evidenced by surveyor observations of roaches on a nightstand, in a corridor, and on a toilet seat, and a mouse running across a hallway, along with pest control logs documenting ongoing mice and roach activity over many months. Multiple cognitively intact residents reported mice entering their rooms under doors or through ventilation, roaches present in rooms for an extended period, and one resident described a roach falling out of a food dome when opening a meal and a dead mouse later found in a heater motor. A moderately impaired resident reported baby mice running around his room, and another resident reported a mouse on a glue pad. Staff, including a CNA and the maintenance director, acknowledged the presence of pests and rodents and described hearing rodents in the ceiling, while the pest control contractor confirmed regular visits and use of traps, glue boards, and baiting, despite a facility policy stating it would maintain an effective pest control program to eradicate and contain pests and rodents.
Failure to monitor an ordered fluid restriction was identified for a resident with ICH, DM, and TIA. Although a physician ordered 1420 cc/day, there was no evidence on the MAR-TAR or meal slips of fluid restriction monitoring, and the resident had no knowledge of the restriction. An LPN stated fluid intake is monitored, while the DON said fluid restrictions are not tracked that way, despite the facility policy requiring the order to be verified and recorded.
Failure to monitor a resident’s dialysis access and document communication with the ESRD facility. A resident with CKD, DM, and a left arm AV fistula received HD M/W/F, but staff did not provide evidence of routine fistula checks for bleeding, bruit, or thrill, and the resident reported these checks were not done at the facility. The dialysis communication book also had multiple missing entries, while an LPN said access checks were documented on the MAR/TAR and the book was used for vital signs, weight, and other pertinent information.
Failure to Maintain Safe, Clean, and Functional Resident Environment: Surveyors found that two resident rooms lacked hot water and heat, pests were observed on all units, toilets on two units would not flush, and shower rooms on two units were not safe, sanitary, or comfortable for resident use. The Administrator stated the QAPI committee did not discuss the pest control, heat, hot water, toilet, or shower room issues and said there was no time to develop and implement data collection, monitoring, analysis, and action plans in these areas.
Governing Body failed to ensure policies were implemented to maintain a safe, clean, comfortable, and homelike environment. Surveyors found no hot water in two resident rooms on Unit 2A, no heat in two resident rooms on Unit 2A, inoperable toilets on Units 2A and 1B, unsanitary shower rooms on Units 1A and 1B, and evidence of mice and roaches on all units. The Administrator stated the QAPI committee did not discuss the pest control, heat, hot water, toilet, or shower room issues and said there was no time to develop and implement data collection, monitoring, analysis, and action plans.
QAPI committee failed to address multiple environmental deficiencies identified by surveyors, including no hot water and no heat in two resident rooms on Unit 2A, inoperable toilets on Units 2A and 1B, mice and roaches on all units, and unsanitary shower rooms on Units 1A and 1B. During interview, the Administrator stated the QAPI committee did not discuss these issues and said there was no time to develop and implement data collection, monitoring, analysis, and action plans in the identified areas.
Infection control practices were not followed in a shared shower room when a commode seat had visible brown substance on it, and staff described a process where nursing cleaned the seat before housekeeping sanitized the commode. Staff also failed to follow EBP during wound care for a resident with a right hip wound who was under hospice care and moderately impaired for daily decisions; although a room sign indicated gloves and gowns were required for wound care, an LPN and RN provided the treatment without gowns.
Unsafe and Unsanitary Shower Room Conditions: Staff failed to maintain clean, functional, and comfortable shower rooms. In one shower room, a brown substance was observed on the commode seat, and nursing staff said they would clean the toilet seat before contacting housekeeping to sanitize the commode. In another shower room, the area smelled of stale water, had shower gel and a disposable razor on the shower chair, showed worn and soiled surfaces where a resident's foot would touch, had about 21 shower chairs cluttered in the room, lacked privacy because the door was left unlocked, and had brown dirt, debris, and dingy floor stains around the toilet.
A resident with dementia, psychotic and anxiety disorders, but intact daily decision-making abilities, required extensive assistance with self-care, including bathing. During shower care, a CNA repeatedly called the resident a “witch” and then rolled the resident in front of a fan while transporting her in the corridor, causing the resident to yell from discomfort due to the cold air. Other staff later described the resident as sometimes stating she was cold and being impatient but not aggressive, and an LPN reported that staff are instructed to step away and report behaviors when they occur. Despite prior abuse education for staff, this incident showed that the resident was not protected from verbal and physical abuse.
Facility staff failed to investigate an allegation of abuse after a resident with paraplegia and depression, who was cognitively independent, was reported by another resident to have pulled a knife and made him fear for his life. Nursing staff notified the DON, contacted 911, and attempted to search the resident’s belongings, but the resident refused a full search and left the unit. Despite the Administrator’s stated procedure and facility policy requiring prompt initiation of an investigation and reporting of all abuse allegations, no incident report or investigation was completed or documented for this event.
Staff failed to implement a care-planned pain management regimen for a post-surgical resident and did not develop a care plan for a fluid restriction for another resident. One resident with a laminectomy and a surgical wound had physician orders and a care plan for Hydrocodone-Acetaminophen every 4 hours, yet multiple scheduled doses were not administered while staff documented pharmacy communication issues, despite an available in-house stock system for narcotics. Another resident with ICH, DM, and TIA, cognitively intact and requiring maximal assist for ADLs, had a physician order for a 1420 cc/day fluid restriction, but the care plan, MAR/TAR, and meal slips contained no fluid restriction monitoring, and the resident was unaware of any restriction, even though an LPN stated such an order should be on the care plan.
A resident admitted after a lumbar laminectomy arrived with a surgical dressing in place and emergency room documentation noting the recent back surgery, but the admission nursing assessment recorded no skin impairment. A later skin assessment described a lower back surgical incision with granulation tissue, scab, and moderate serous drainage, confirming the wound was present on admission. No wound treatment orders or instructions to leave the dressing intact were in place until days after admission, and the eTAR showed no wound treatments documented for that period. In interviews, nursing staff and the DON reported that their usual process is to perform a head-to-toe skin assessment on admission, identify wounds, and obtain treatment orders or orders not to remove dressings, as required by the facility’s skin assessment policy.
Staff failed to administer ordered Hydrocodone-Acetaminophen for a newly admitted resident with a post-surgical wound and documented pain. Although the ER discharge summary and physician orders specified Hydrocodone-Acetaminophen 5-325 mg every four hours, the eMAR showed multiple missed doses shortly after admission. Progress notes described repeated reports from the pharmacy that no prescription had been received and instructions from an on-call provider to hold the medication until access to e-prescribing was available. Interviews with an LPN, a unit manager, and the DON confirmed that an in-house stock of Hydrocodone-Acetaminophen and a pharmacy code system for accessing it were in place, but these resources were not used, resulting in the resident not receiving the scheduled pain medication as ordered.
Bathroom Call Bell Not Accessible From Floor: A resident with a BIMS score of 14, wheelchair use, and assistance needs for toileting had a bathroom call bell that was not reachable from the floor on one side of the toilet. Observation showed the cord hanging just below seat level on the right side, while the left side had open space with no access if the resident fell there. Staff interviews confirmed the resident could not reach the cord from that floor position, and the resident had a high fall risk with prior falls in the room.
A cognitively intact resident reported not having private access to a phone and having to ask to use the nurses station phone. Observation showed the resident using the phone outside the nurses station with staff nearby, while the phone was placed on the counter ledge above the resident’s reach. Staff confirmed residents without cell phones used the nurses station phone, sat outside the station, and were not provided a private place for calls; the DON stated there was no designated private area for resident phone use.
A resident with aphasia and moderately impaired cognition was overheard using the phone at the nurses' station to call his mother, and an LPN spoke to him during the call. The resident had previously used his own cell phone, and the LPN said a cordless phone had once been available at the nurses' station for privacy but was no longer there.
Failure to document and issue grievance resolutions for a cognitively intact resident who filed multiple grievances. The resident stated no follow-up was ever provided, and review of the grievance forms showed no documented resolutions. The SW confirmed the forms were incomplete and that the facility policy required a written decision at the conclusion of the grievance process.
Unanchored Foley Catheter Observed: A resident with a Foley catheter for urinary retention and a diagnosis of UTI was observed with the catheter unanchored during a bed bath. A CNA was unsure whether the catheter was normally secured, and an RN stated that anchoring helps prevent pulling and pressure on the bladder. The resident’s care plan included catheter care interventions, but the catheter was found unsecured during observation.
A resident with a urostomy and bladder CA had a urinary collection bag hanging from the call bell cord and touching the floor. The resident said the facility had recently changed the bags and the new clips would not attach to the bed frame, so the bag had to be hung that way. An LPN stated the bag should be below the bladder, hung on the bed rail, and kept off the floor for infection control.
A resident with muscle weakness and intact cognition was observed in bed with bilateral upper rails raised on multiple occasions. The clinical record did not show an assessment or informed consent for bed rail use, and the DON confirmed that neither was documented. Facility policy required assessment of alternatives, risks, entrapment risk, and informed consent before bed rails are used.
Menu Items Not Served as Planned: A resident with severe cognitive impairment and dependence for eating received meal trays that did not match the menu. During observed meals, the resident was served items such as mashed potatoes and whole-kernel corn instead of the ordered menu items, and she repeatedly stated she did not receive the taco toppings listed on the meal ticket and did not like the mashed potatoes.
Failure to provide snacks at resident-requested times. A dietary manager said snacks were delivered only at set times, and the available items were limited mainly to crackers, cookies, peanut butter, pudding, and juice. Three residents with nutrition-related care plans and diagnoses including DM, CVA, HIV, COPD, ICH, and TIA reported that snacks were not offered unless they asked for them, and ADL records showed hs snacks were missed on multiple shifts. One resident with intact cognition, one resident with moderate cognitive impairment, and one resident with intact cognition all had documentation showing repeated missed snack offerings.
A resident with dementia and severe cognitive impairment was admitted to hospice, but the facility did not have a hospice-coordinated plan of care in place. Staff interviews showed the hospice service details, schedule, and communication process were not available in the hospice binder until forms were later faxed to the facility, despite the resident’s hospice admission and extensive care needs.
Failure to inspect bed rails and bed frame components was identified for a resident with muscle weakness who was cognitively intact and observed multiple times in bed with bilateral upper rails raised. The clinical record lacked documentation of an assessment and consent for bed rail use, and the DON confirmed there were no bed or bed rail inspections for the resident. The Maintenance Director stated inspections had not been started, despite the facility policy assigning routine inspection responsibility for all bed frames, mattresses, and bed rails.
Two residents experienced discomfort due to non-functioning air conditioning units in their rooms, with temperatures recorded at over 83°F. One resident, with intact cognitive abilities, reported the issue, while the other, with moderate cognitive impairment, was unable to communicate effectively. The facility's maintenance staff acknowledged the problem, but repairs were delayed due to a lack of parts.
The facility's air conditioning system malfunctioned, resulting in high temperatures of 84.6°F and 85.2°F in units 1A and 1B. The Administrator confirmed the use of portable air conditioning units due to the main system's failure and was awaiting repair parts. The facility was collaborating with OSHA to address the issue.
A resident with a documented DNR order experienced a failure in the facility's communication and documentation processes, leading to CPR being performed against their wishes. The DNR document was not uploaded into the medical record, resulting in staff and EMTs being unaware of the resident's code status during an emergency. The DON acknowledged the oversight.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for multiple residents across all four units. Survey observations and resident interviews identified repeated environmental problems, including bathrooms without hot water, toilets that would not flush, foul odors, and heating issues. Several residents who were cognitively intact reported these conditions directly to surveyors, and staff interviews confirmed that the problems were present when observed. For one resident with diagnoses including traumatic subdural hemorrhage, syncope, falls, and COPD, the bathroom sink had no hot water after water was left running for several minutes. The resident and the resident’s daughter both stated that hot water could not be obtained, and a CNA confirmed the water was not getting warm. Another resident with diagnoses including OSA, acute cystitis, and prostate cancer had a bathroom toilet that was half to three-fourths full of urine and would not flush, and the resident stated the heat had gone off the prior night. A third resident with diagnoses including intracranial hemorrhage, DM, and TIA had the same bathroom conditions, and later stated the heat went off again overnight and had to be reset. Staff interviews confirmed the lack of hot water and the nonfunctioning toilet. Additional observations showed a pattern of unsanitary and inoperable bathroom conditions for other residents. One resident’s commode contained dark brown, odorous liquid with feces and toilet paper, and the resident stated the toilet had not flushed for over 30 days. Another resident’s toilet was half-filled with dark brown liquid and wads of toilet paper and would not flush, while a different resident’s toilet had been removed from the floor because of a clogged pipe. Surveyors also observed a strong urine odor in a room occupied by a resident with an indwelling catheter, and staff acknowledged the odor had been present for a while. The report also documented pest activity, including a large roach observed in one resident’s room and a mouse running across a hallway into a locked room, with residents reporting mice and roaches in their rooms and pest control logs showing repeated sightings and treatments.
Failure to Maintain COVID-19 Vaccination Education, Offering, and Documentation
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status. During review of Infection Prevention records on 2/10/26 and 2/11/26, surveyors found no evidence of resident COVID-19 vaccination for 2025 and no evidence that staff COVID-19 vaccination status was being maintained. In interview on 2/11/26, the Infection Preventionist stated the role was new as of June 2025 and reported that the facility’s pharmacy initially said it did not have the vaccine, and she was unsure who had contacted the pharmacy or another pharmacy to obtain it. She also stated the staff COVID-19 vaccination status logs were not available and could not be found in her file cabinets or other file cabinets. The facility’s policy stated that it would educate and offer the COVID-19 vaccine to residents and staff and maintain documentation of staff COVID-19 vaccination status, including the information required by NHSN.
Failure to Safeguard and Return Residents’ Personal Clothing After Laundering
Penalty
Summary
Facility staff failed to protect and maintain residents' personal clothing and ensure items were returned after laundering for three residents. One resident with a history of stroke, hemiparesis, and aphasia, and a BIMS score indicating moderately impaired decision-making, reported that clothing sent to the laundry over a week earlier had not been returned. He repeatedly expressed distress about having to wear the same clothing because his laundered items were missing and was observed on multiple occasions asking staff for assistance in retrieving his clothing from the laundry. During an interview in his room, he again raised the issue of his missing clothing in the presence of the ADON. Another resident with stroke, diabetes, and seizure disorder, and a BIMS score indicating intact cognition, stated that all of his clothing was missing after being sent out for cleaning and that staff continued to bring other residents' clothing in his size instead of returning his own items. He pointed out donated clothing on his bed and reported watching other residents to see who might be wearing his clothing. A third resident with stroke, atrial fibrillation, and dementia, but intact decision-making per BIMS, stated that all his coats were missing and that he was afraid to remove the coat he was wearing for fear it would be lost. He was observed wearing the same coat and later returning from a shower, and during an interview with the ADON he again reported his missing clothing. These incidents demonstrate that staff did not adequately safeguard or track these residents' personal clothing during and after laundering.
Failure to Provide and Document Adequate ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide appropriate activities of daily living (ADL) and incontinence care for multiple dependent residents, as evidenced by observations, interviews, and record reviews. One cognitively intact resident with an indwelling Foley catheter and dependence for toileting hygiene, bathing, and footwear was observed receiving a bed bath and incontinence care that did not follow basic hygiene practices. The CNA removed dirty linens without using a bed/bath blanket or towel, leaving the resident exposed throughout the bath, used only one basin of water, washed the resident’s upper body and lower extremities, and then dried the resident without rinsing off soap. The CNA then removed the resident’s brief and used the same soapy washcloth that had been used for the body bath to clean the perineal area after a bowel movement before discarding it, and later stated she had been taught to provide bed baths in this manner. Another cognitively intact resident with a need for assistance with personal care and an overactive bladder, who required setup or cleanup assistance for bathing, oral hygiene, and personal hygiene, was observed with medium-length chin hair. During interview, this resident stated she wanted both her hair and chin/facial hair trimmed. Staff interviews confirmed that removal of facial or chin hair is considered part of ADL care and should be provided during scheduled showers twice weekly, but the resident’s facial hair had not been addressed. A different dependent resident with severe cognitive impairment and urinary incontinence, who was coded as dependent for eating, oral hygiene, toileting, bathing, and personal hygiene, reported through her daughter that she wanted more showers and hair washing. The daughter produced a modified bath basin she used at bedside to wash her mother’s hair because, according to her, staff would not wash it. Review of ADL documentation showed the resident was scheduled for baths/showers twice weekly, but records for December and January reflected missed or reduced bathing, including days with no documented baths/showers and a pattern of only one shower per week over a two‑month period. Additional dependent residents with significant ADL self-care deficits had missing documentation for hygiene and incontinence care on multiple dates and shifts. One resident with CVA, diabetes, epilepsy, hemiplegia, impaired balance, and limited mobility, who was dependent for mobility, transfers, bathing, dressing, and toileting, had gaps in ADL records for hygiene and bowel/bladder continence across several days and shifts in December and January. Another resident with impaired mobility, maximal assist needs for bed mobility, transfers, and hygiene, and intact cognition had missing documentation for hygiene and bowel/bladder continence on multiple January shifts. A further resident with schizoaffective disorder, depression, severe cognitive impairment, and a need for one-person assistance with personal hygiene had extensive blanks on ADL tracking sheets for personal hygiene over numerous consecutive days in November and December, covering all shifts. CNAs and an RN stated that hygiene and incontinence care are documented in the electronic ADL system and that missing documentation means care was not done, but one CNA also stated she did not know what the blanks indicated, and no additional information was provided before survey exit to clarify or reconcile these omissions.
Failure to Maintain Effective Pest Control Program for Roaches and Mice
Penalty
Summary
Facility staff failed to maintain an effective pest control program to keep the environment free of pests and rodents, as evidenced by multiple observations of roaches and mice over an extended survey period. During observations from 2/3/26–2/6/26 and 2/9/26–2/11/26, surveyors saw a large brown roach climbing on a resident’s nightstand and a mouse running across a first-floor hallway from a biohazard room into a locked room. Additional observations on Unit 1B included a large brown roach lying on its back in the corridor and a small dark roach crawling on a toilet seat in a resident bathroom, which was witnessed by the ADON. Pest control logs and invoices showed ongoing pest activity throughout 2025 and into early 2026, with repeated entries for mice and roaches/ants across multiple months. Resident interviews further demonstrated persistent pest issues in resident rooms. One cognitively intact resident reported that a mouse “lived” in his room and entered through the ventilation system, which he had discussed with the assistant administrator. Another cognitively intact resident stated that a mouse ran from under the door and hid behind a loose baseboard. A third cognitively intact resident reported that roaches had been present in the facility for quite a while, including an incident in December when a roach fell out of a food dome when he opened his meal, and also described a mouse entering his room under the door and a dead mouse later found in his heater motor by maintenance. This same resident reported seeing a roach crawling up his wall the previous day. A moderately impaired resident stated he had seen baby mice running around his room, and another cognitively intact resident reported a mouse on a glue pad in his room during resident council. Staff and contractor interviews corroborated that pests and rodents were an ongoing problem. A night CNA acknowledged the presence of pests and rodents, stating that pest control came three times a week and that something could be heard running in the ceiling at night. The maintenance director confirmed hearing about rodents in the ceiling, placing traps there, and relying on pest control to review pest logs and treat problem areas; he also stated that residents were told not to keep food out and not to leave clothes on the floor. The pest control representative reported that the facility was on a three-times-per-week schedule, using traps, glue boards, and baiting in resident areas, and that pest sighting logs were used to identify treatment locations. Despite the facility’s written policy stating it would maintain an effective pest control program to eradicate and contain common household pests and rodents, the documented observations, resident reports, and pest control logs showed continued presence of roaches and mice in resident rooms and common areas during the survey period.
Failure to Monitor Ordered Fluid Restriction
Penalty
Summary
Failure to monitor fluid intake for Resident #137 was identified. The resident was admitted with diagnoses including ICH, DM, and TIA. The most recent MDS coded the resident as having a BIMS score of 13 out of 15, indicating the resident was not cognitively impaired, and Section GG coded the resident as requiring maximal assistance for bed mobility, transfers, and hygiene. The comprehensive care plan addressed an ADL self-care performance deficit related to impaired mobility and included an intervention to praise all efforts at self-care. A physician order dated 1/26/26 specified a fluid restriction of 1420 cc/day, but review of the January and February 2026 MAR-TAR did not evidence any fluid restriction monitoring, and the resident's meal slips also did not reveal any evidence of fluid restriction monitoring. During interview, the resident had no knowledge of fluid restrictions. An LPN described that fluid intake is monitored, but the DON later stated that fluid restrictions are not tracked that way. The facility's fluid restriction policy stated that fluid restrictions would be followed in accordance with physician orders and that the nurse would obtain and verify the order and record the amount on the medication record or other format per facility protocol.
Failure to Monitor Dialysis Access and Document Communication
Penalty
Summary
The facility failed to provide evidence of dialysis-related monitoring and communication for a resident with chronic kidney disease, diabetes mellitus, and neuromuscular dysfunction of the bladder who had a left arm AV shunt/fistula and received hemodialysis Monday, Wednesday, and Friday. The resident’s care plan directed staff to check and change the dressing daily at the access site and document as indicated, and a physician order required assessment of the left forearm fistula for bleeding and symptoms of infection every shift for dialysis. The resident stated that facility staff did not check the fistula for bleeding, bruit, or thrill, and that these checks were done at the dialysis center instead. A review of the dialysis communication book showed missing communication sheets on multiple dates between December 2025 and February 2026. The December 2025 TAR documented assessments of the left forearm fistula for bleeding and symptoms of infection every shift from 12/1/25 through 12/9/25, then the task was discontinued on 12/9/25. An LPN stated that the communication book was used to provide vital signs, weight, and other pertinent information, and that fistula checks for bruit/thrill and bleeding were documented on the MAR/TAR. The facility did not provide a dialysis care policy, and the dialysis contract stated that the nursing facility must ensure documented collaboration and communication between the nursing facility and the ESRD facility.
Failure to Maintain Safe, Clean, and Functional Resident Environment
Penalty
Summary
The facility failed to provide leadership and oversight to ensure effective systems were in place to support residents’ quality of life in the area of a safe, clean, comfortable, and homelike environment. During the recertification survey, surveyors found that two resident rooms on Unit 2A did not have hot water, two resident rooms on Unit 2A did not have heat, and current observations of mice and roaches were present on all units: 1A, 1B, 2A, and 2B. Surveyors also identified that toilets on Unit 2A and Unit 1B were not operable and could not flush, and that the shower rooms on Units 1A and 1B were not safe, functional, sanitary, or comfortable for residents to use. During an interview, the Administrator stated that the QAPI committee did not discuss the pest control issues, heat issues, hot water issues, inoperable toilets, or the unsanitary shower rooms. The Administrator also stated, "I don't have the time" regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the identified areas. The Administrator further stated that the Administrator is responsible and accountable for the QAPI program. The facility policy on Administration of Facility stated that the facility will provide policies and systems to ensure it is administered in a manner focused on attaining and maintaining the highest practicable physical, mental, and psychosocial well-being of each resident, and that the governing body is responsible for establishing and implementing policies regarding management, operation, and QAPI.
Governing Body Failed to Ensure Safe, Clean, and Functional Environment
Penalty
Summary
The facility's Governing Body failed to ensure that policies were implemented for the management and operation of the facility to support an effective system for resident quality of life in the area of a safe, clean, comfortable, and homelike environment. During the recertification survey, surveyors found that two resident rooms on Unit 2A did not have hot water, two resident rooms on Unit 2A did not have heat, and toilets on Unit 2A and Unit 1B were not operable and could not flush. Surveyors also observed current evidence of mice and roaches on all units: 1A, 1B, 2A, and 2B. Surveyors further found that the shower rooms on Units 1A and 1B were not safe, functional, sanitary, or comfortable for residents to use. During an interview, the Administrator stated that the QAPI committee did not discuss the pest control, heat, hot water, inoperable toilet, or unsanitary shower room issues. The Administrator also stated, "I don't have the time" regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the identified areas, and stated that the Administrator is responsible and accountable for the QAPI program. The facility's Governing Body policy stated that the governing body is legally responsible for establishing and implementing policies regarding management and operation of the facility and is responsible and accountable for the QAPI program.
QAPI Committee Failed to Address Environmental Deficiencies
Penalty
Summary
The facility failed to adequately identify, keep systems functioning properly, and implement necessary action plans through its QAPI committee to address deficiencies in the area of Safe/Clean/Comfortable/Homelike Environment. During the recertification survey completed on 2/11/26, surveyors found that two resident rooms on Unit 2A did not have hot water, two resident rooms on Unit 2A did not have heat, and toilets on Unit 2A and Unit 1B were not operable and could not flush. Surveyors also observed mice and roaches on all units, including 1A, 1B, 2A, and 2B, and found the shower rooms on Units 1A and 1B were not safe, functional, sanitary, or comfortable for residents to use. On 2/26/26, the Administrator stated during interview that the QAPI committee did not discuss the pest control issues, heat issues, hot water issues, inoperable toilets, or the unsanitary shower rooms. The Administrator also stated, "I don't have the time" regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the identified areas. The facility’s QAPI policy, reviewed/revised 10/22/2025, states that the facility will maintain an effective, comprehensive, data-driven QAPI program and that documentation may include systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events.
Infection Control and EBP Failures During Shared Area Cleaning and Wound Care
Penalty
Summary
The facility failed to follow infection control practices during care and in a shared shower area. On 2/5/26 at 3:26 PM, a small to moderate amount of brown substance was observed on the commode seat in the community shower room on unit 1A. During the observation, the unit manager and LPN #6 were present, and LPN #6 stated she would make sure the area was cleaned. When asked who was responsible for cleaning the commode, LPN #6 said nursing staff should clean off the toilet seat and then contact housekeeping to have the commode sanitized. The facility also failed to follow enhanced barrier precautions during wound care for Resident #129, who had a wound to the right trochanter, was moderately impaired for daily decision-making, and was under hospice care. The physician ordered daily wound treatment to the right hip using Dakin's wound cleanser, calcium alginate, and a dry dressing. Although a sign outside the resident's room indicated that staff must wear gloves and gowns for high-contact activities including wound care, LPN #1 and RN #1 were observed providing wound care without gowns while RN #1 assisted with positioning and holding the resident. LPN #1 stated that gowns and gloves should be worn during wound care and that the gown had been overlooked.
Unsafe and Unsanitary Shower Room Conditions
Penalty
Summary
The facility staff failed to maintain a safe, functional, sanitary, and comfortable environment in the shower rooms. During an observation of the shower room on unit 1A with the unit manager/LPN, a small to moderate brown substance was seen on the commode seat. When asked who was responsible for cleaning the commode, the LPN stated that nursing staff would clean off the toilet seat and then contact housekeeping to have the commode sanitized. In a separate inspection of the Unit 1B shower room with the ADON, the room smelled of stale water and had a green bottle of shower gel and a disposable razor on the shower chair seat. Beneath the chair was a worn and soiled area where the resident's naked foot would touch. Approximately 21 shower chairs were cluttered throughout the room, and the resident had to face them while showering. The door was left unlocked because the room was frequently used by others whose in-room toilets were out of order. Around the base of the toilet there was brown dirt and debris, along with dingy floor stains. The ADON stated she was unaware of the clutter and appearance of the shower room.
Failure to Protect Resident From Verbal and Physical Abuse During Shower Care
Penalty
Summary
Facility staff failed to protect a resident’s right to be free from verbal and physical abuse when a certified nursing assistant (CNA) was verbally and physically abusive during and after a shower. The resident involved had dementia, a psychotic disorder, and an anxiety disorder, but was assessed with a BIMS score of 12/15, indicating intact cognitive abilities for daily decision making. The resident required assistance with most self-care activities, including dependence for toileting, oral hygiene, and bathing. Facility documents showed that on the date of the incident, the CNA repeatedly called the resident a “witch” and, while transporting the resident in the corridor after a shower, rolled the resident in front of a fan, causing the resident to yell due to discomfort from the cold air. Interviews conducted during the survey provided additional context. The resident later stated that no staff member had mistreated her and described herself as having a bad temper and being very vocal, which she felt irritated people. Another CNA reported that the resident typically took showers without conflict, sometimes stating she was cold during care, and described the resident as not aggressive but impatient during care. An LPN explained that when residents exhibit behaviors, CNAs are instructed to ensure safety, step away, report behaviors to the nurse, and return later. Despite these expectations and prior abuse in-services completed by the CNA involved, the documented incident of name-calling and exposure to cold air during transport constituted a failure by staff to protect the resident from verbal and physical abuse.
Failure to Investigate Allegation of Resident-to-Resident Threat with Weapon
Penalty
Summary
Facility staff failed to investigate an allegation of abuse involving one resident who had paraplegia and depression and was assessed as cognitively independent for daily decision-making. According to a nursing progress note, another resident reported that this resident had pulled a knife on him and that he feared for his life. The nurse notified the DON, who directed that the resident be placed on 1:1 supervision and remain in his room, and 911 was called. Police arrived and spoke with both residents but stated they did not have protocol to search the resident’s belongings. The nurse and a CNA attempted to search the resident’s belongings; the resident refused to allow a search of his bags but permitted a search of everything else and refused to stay in his room, leaving the unit. Despite this allegation of a resident threatening another resident with a knife and the actions taken at the time, review of facility documents showed no evidence that an incident report or facility investigation was initiated or completed. During interview, the Administrator described the facility’s process for facility-related incidents, including that allegations of abuse, neglect, or mistreatment require initiation of an investigation within two hours, notification of external agencies, and completion of findings within five days. The Administrator acknowledged that no investigation could be located for this incident and that one should have been initiated. The facility’s written policy requires all allegations of abuse, neglect, exploitation, injuries of unknown source, and misappropriation of resident property to be reported immediately to the Administrator and appropriate agencies within prescribed timeframes, but this process was not followed for this event.
Failure to Implement Pain Management Orders and Omit Fluid Restriction from Care Plan
Penalty
Summary
Facility staff failed to implement a comprehensive care plan for pain management for one resident following admission from the emergency room. The resident had a surgical wound related to a laminectomy and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The care plan identified actual impaired skin to the lower back related to laminectomy and pain related to the surgical wound, with an intervention to treat pain per orders prior to treatment or turning. The ER discharge summary and physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every 4 hours for 5 days, with the facility order entered on 3/29/2024. However, the eMAR showed that multiple scheduled doses from the evening of 3/29/2024 through the afternoon of 3/30/2024 were not administered. Progress notes documented that pharmacy reported not receiving the faxed or e-scribed prescription, and nursing staff made repeated calls to the pharmacy and on-call provider, with instructions at one point to hold the medication until the provider could send a prescription. Later documentation indicated the facility was still waiting for pharmacy delivery while the physician was aware. Despite this, the DON confirmed that the facility maintained an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and that all nurses had access to this stock via a code from the pharmacy, with a witness required for narcotics. Multiple nurses, including an RN, a unit manager LPN, and another LPN, stated that urgent medications could be pulled from in-house stock or obtained stat from the pharmacy, and that this in-house system had been in place for several years. The facility’s own comprehensive care plan policy required implementation of all services identified in the assessment to meet residents’ needs and professional standards of quality. Facility staff also failed to develop a comprehensive care plan addressing fluid restriction monitoring for another resident. This resident was admitted with diagnoses including intracranial hemorrhage, diabetes mellitus, and transient ischemic attack, and was cognitively intact per a BIMS score of 13. The resident required maximal assistance for bed mobility, transfers, and hygiene, and had a physician’s order for a fluid restriction of 1420 cc per day. The comprehensive care plan in place focused on ADL self-care performance deficits related to impaired mobility and included an intervention to praise all efforts at self-care, but did not address the ordered fluid restriction. Review of the MAR/TAR for January and February and the resident’s meal slips showed no evidence of fluid restriction monitoring, and the resident reported not being aware of being on a fluid restriction. An LPN stated that fluid restriction monitoring would involve watching intake and acknowledged that such a restriction should be included on the care plan.
Failure to Timely Assess and Treat Surgical Wound on Admission
Penalty
Summary
Facility staff failed to provide timely assessment and treatment of a surgical wound for one resident following admission. The resident had recently undergone a lumbar laminectomy and was admitted to the facility from the emergency room with a dressing over the laminectomy site that appeared normal and had been placed several days earlier. Emergency room discharge notes documented the recent surgery and the presence of the dressing, and the resident’s admission MDS later identified a surgical wound and surgical wound care. However, the nursing admission assessment dated 3/29/2024 documented no skin impairment, despite a subsequent skin assessment describing a surgical incision to the lower back with specific measurements, granulation tissue, scab, and moderate serous drainage, indicating the wound was present on admission. Physician orders dated 4/1/2024 directed staff to cleanse the lower back surgical wound with wound cleanser, pat dry, and apply calcium alginate and silicone foam dressing daily and as needed until healed, and the comprehensive care plan for impaired skin related to the laminectomy was also initiated on that date. There was no evidence of any wound treatment orders prior to 4/1/2024 or any order to leave the dressing intact and not remove it. Review of the eTAR for March showed no treatments completed for the surgical wound. In interviews, nursing staff and the DON stated that standard practice was to complete a full head-to-toe skin assessment on admission, identify any wounds, and obtain or confirm treatment orders from hospital discharge information or the physician, including orders to leave dressings in place if applicable. The facility’s skin assessment policy required a full body skin assessment by a licensed or registered nurse upon admission, but the resident’s surgical wound was not assessed and treated until several days after admission.
Failure to Administer Ordered Hydrocodone-Acetaminophen for Post-Surgical Pain
Penalty
Summary
Facility staff failed to implement a complete pain management program for Resident #173 by not administering Hydrocodone-Acetaminophen as ordered following admission. The resident had a recent laminectomy with a surgical wound and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The emergency room discharge summary and subsequent physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every four hours for pain for a defined period. The eMAR showed the medication was scheduled to begin on 3/29/2024 at 4:00 PM but documented multiple missed doses from the evening of 3/29/2024 through the afternoon of 3/30/2024. Progress notes indicated that on the evening of admission the pharmacy reported not receiving the faxed or e-scribed prescription, and repeated follow-up calls to the pharmacy revealed that no prescription had been received. The on-call provider reported not having access to send the prescription until the following morning and instructed staff to hold the medication until then. Despite the facility having an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and a system allowing nurses to obtain a code from the pharmacy to access these medications, including narcotics, the resident did not receive the ordered pain medication during this period. The resident’s care plan identified actual impaired skin related to laminectomy and pain related to a surgical wound, with an intervention to treat pain per orders prior to treatment or turning, but the ordered pain medication was not provided as scheduled.
Bathroom Call Bell Not Accessible From Floor
Penalty
Summary
The facility failed to provide a bathroom call bell that was accessible from the floor for Resident #6. The resident’s most recent MDS documented a BIMS score of 14 out of 15, indicating cognitive intactness for daily decisions, and noted no upper or lower extremity range-of-motion limitations. The assessment also documented that the resident used a wheelchair, required setup or clean-up assistance for toilet transfers and toileting hygiene, and was occasionally incontinent of urine and frequently incontinent of bowel. Observation of the shared bathroom showed the toilet on the right wall with a call bell cord hanging approximately 12 inches toward the floor just below seat level, while the left side of the toilet had about six feet of open space with no call bell access if the resident were on the floor there. The resident stated they ambulated around the room and bathroom independently and were unsure whether they could reach the bathroom call bell because they had never needed to use it. The resident had a high fall risk, with documented falls without injury in the room on 11/14/2025 and 12/6/2025. Staff interviews confirmed the bathroom call bell was intended to alert staff, but an LPN stated the resident would not be able to reach the cord if on the floor to the left of the toilet.
Lack of Private Telephone Access
Penalty
Summary
The facility failed to provide one cognitively intact resident with reasonable access to private telephone use. The resident’s most recent MDS quarterly assessment dated 1/15/2026 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact for making daily decisions. During an interview on 2/3/2026, the resident stated they did not have access to a telephone to speak to anyone privately and had to go to the nurses station and beg to use the phone. An observation on 2/5/2026 showed the resident using the telephone at the nurses station while two staff members were seated behind the station and another staff member was at the medication cart beside it. The resident was in a wheelchair outside the nurses station with the phone placed on the ledge approximately two feet above their head, and the resident was observed trying to hang up the receiver from the wheelchair and dropping it onto the nurses station because of the height. Staff interviews confirmed that residents without cell phones used the nurses station phone, sat outside the station, and were not allowed inside; staff also stated the phone could not reach far enough for privacy. The DON stated there were telephone lines throughout the building, but she did not think there was a designated spot for residents to have a private phone call, though staff could allow residents into offices to use a telephone.
Lack of Privacy During Resident Phone Call
Penalty
Summary
The facility failed to ensure a resident was allowed privacy while talking on the facility telephone located at the nurses' station. Resident #82, who was originally admitted and later readmitted after an acute care hospital stay, had diagnoses including aphasia following cerebral infarction and contracture of the muscles of the right hand. The quarterly MDS assessment coded the resident as having completed the BIMS with a score of 8 out of 15, indicating moderately impaired cognitive abilities for daily decision making. The care plan stated the resident was independent in meeting emotional, intellectual, physical, and social needs related to ambulation, with interventions to encourage ongoing family involvement and invite family to special events, activities, meals, and preferred activities. On 02/09/2026, the resident was overheard talking to his mother on the phone at the nurses' station, and an LPN was heard speaking to him during the call, asking, "You're not falling asleep, are you?" The resident shook his head and continued talking. The LPN stated the resident used to have his own cell phone but now used the phone at the nurses' station to call his mother, and said there had previously been a cordless phone at the nurses' station for privacy but did not know what happened to it.
Failure to Document and Issue Grievance Resolutions
Penalty
Summary
The facility failed to resolve grievances for Resident #125, who had filed grievances on 06/09/2025, 07/17/2025, 07/30/2025, and 07/31/2025. During an interview on 2/5/2026, the resident stated that multiple grievances had been filed and that no follow-up had been received regarding the outcomes. The most recent MDS, a significant change assessment with an ARD of 1/29/2026, showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for making daily decisions. Review of the grievance forms showed that the grievances filed by Resident #125 did not document resolutions. During an interview on 02/10/2026, the Social Worker stated that grievance forms should be completed with all portions filled out and that the resolution should be documented on the form. After reviewing the resident’s grievance forms, the Social Worker stated that no resolutions had been completed. The facility policy required the Grievance Official to oversee grievances through conclusion and issue a written decision to the resident or representative at the end of the investigation.
Unanchored Foley Catheter Observed
Penalty
Summary
Appropriate care was not provided for a resident with an indwelling Foley catheter. Resident #106 was admitted after an acute care hospital stay and later re-admitted with a current diagnosis of urinary tract infection. The resident’s care plan identified an indwelling catheter for urinary retention and included an intervention to check tubing for kinks each shift and to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. The resident’s MDS indicated intact cognitive abilities, and the resident was coded as dependent for toileting hygiene and having an indwelling catheter. During a bed bath observation, the resident’s Foley catheter was observed unanchored. In a follow-up interview, the CNA stated she normally worked upstairs and was unsure whether the resident usually had something to keep the Foley catheter anchored. Later, an RN stated that anchoring a Foley catheter keeps it from pulling or causing pressure on the bladder so it does not cause injury to the bladder, and said she was going to place a Stat Lock on the resident’s leg. The concern was discussed with the DON, Administrator, and Regional Director during the end-of-day meeting, and no comments were made.
Urostomy Collection Bag Left Hanging on Call Bell Cord and Touching Floor
Penalty
Summary
Facility staff failed to provide sanitary urostomy care for Resident #125, who was admitted with diagnoses including urostomy and malignant neoplasm of the bladder. The resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness for daily decisions. The physician order directed staff to assess the skin around the urostomy site during care, and the care plan identified that the resident required extensive assistance with urostomy management due to generalized weakness and related conditions. During observation, the resident stated that the urostomy drained into a collection bag and pointed to the bag hanging from the call bell cord. The bag was observed touching the floor surface, and this was seen again later the same day. The resident stated the facility had recently changed the bags and the new bags did not have a clip large enough to attach to the bed frame, so the bag had to be hung on the call bell cord. An LPN stated that urinary collection bags should be positioned below the bladder, hung on the bed rail using the hooks on the bag, and should not touch the floor; she also stated the bag should not be hanging on the call bell cord. The facility policy reviewed did not include guidance for keeping the collection bag off the floor.
Failure to Obtain Assessment and Consent for Bed Rail Use
Penalty
Summary
Facility staff failed to obtain an assessment and consent for the use of bed rails for Resident #125. The resident was admitted with a diagnosis that included muscle weakness, and the most recent comprehensive MDS with an ARD of 01/29/2026 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for making daily decisions. During observations on 02/03/2026 and 02/05/2026, the resident was found in bed with bilateral upper rails raised, and the resident stated he uses them to move in bed. Review of the clinical record did not evidence documentation of an assessment or consent for the bed rails. On 02/09/2026, the DON stated there was no consent and assessment for the resident's use of bed rails. On 02/11/2026, an LPN stated that the provider obtains consent and nursing assesses the resident to determine if bed rails are needed, and the DON stated that consent by the resident or responsible party and a bed rail assessment need to be obtained for a resident using bed rails. The facility policy also stated that the resident assessment must include evaluation of alternatives attempted prior to bed rail use, assessment of risks, assessment of entrapment risk, and informed consent.
Menu Items Not Served as Planned
Penalty
Summary
The facility failed to serve portions of food planned on the menu for 1 of 80 residents, Resident #109. Resident #109 was admitted on 05/23/25 after an acute care hospital stay and had diagnoses including need for assistance with personal care and unspecified urinary incontinence. The resident’s BIMS score was 4 out of 15, indicating severe impairment in daily decision-making, and the resident was dependent for eating, oral hygiene, toileting, showering/bathing, and personal hygiene. The care plan identified a nutritional problem related to cardiovascular disease, hypertension, hypothyroidism, advanced age, underweight BMI, and mechanically altered diet texture, with a goal for adequate nutritional status and interventions to provide and serve the ordered diet and monitor intake. During a meal observation, Resident #109 was being fed by CNA/Restorative Aide #14 when the tray did not match the meal ticket. The lunch ticket listed beef taco filling for flour tortilla, shredded lettuce topping, pinto beans, cream style corn, and ground pineapple tidbits, but the resident received those items plus mashed potatoes, whole kernel corn instead of cream corn, and no lettuce. The resident repeatedly asked where the taco sauce, tomatoes, and lettuce were and stated she did not want more mashed potatoes. In a later meal observation, CNA #9 was heard speaking with the resident, who again said she did not like the mashed potatoes. The meal ticket for that meal listed ground smothered chicken, creamed corn, sliced peaches, cornbread, and tea, but the tray contained ground-smothered chicken, mashed potatoes, whole-kernel corn, sliced peaches, and tea.
Failure to Provide Snacks at Resident-Requested Times
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests, and suitable alternative snacks were not provided for residents who wanted to eat outside of scheduled times. During the survey period, snacks were observed being delivered only at about 10:00 AM, 2:00 PM, and 6:00 PM, with the available items on the units limited mainly to saltine crackers, graham crackers, and on some units captain’s crackers with peanut butter. Pitchers of juice were not observed in the refrigerator on unit 2B until 2/5/26, and a cart later brought oatmeal cookies, crackers, and juice to that unit. Resident #12 had diagnoses including epilepsy, DM, and CVA, and his MDS coded him as not cognitively impaired. His care plan identified a risk for nutrition/hydration imbalance and directed staff to provide diet as ordered and per resident preference. However, the ADL record showed hs snacks were not offered on multiple dates and shifts, and during interview he stated snacks were not offered unless he asked for them and that he usually received only saltine or graham crackers. The dietary manager stated that 6:00 PM was when bedtime snacks were delivered. Resident #14 had diagnoses including polyneuropathy, HIV, and COPD, and his MDS coded him as moderately cognitively impaired. His care plan directed staff to redirect and provide more food if he was asking for food. The ADL record showed hs snacks were not offered on multiple dates and shifts, and he stated snacks were not offered unless he asked for them. Resident #137 had diagnoses including ICH, DM, and TIA, and his MDS coded him as not cognitively impaired. His care plan identified a nutritional problem related to CVA, diabetes, and anemia, but the ADL record showed hs snacks were not offered on multiple dates and shifts, and he stated snacks were not provided. The administrator and DON were made aware of the findings, and no policy was provided by the facility.
Hospice Coordination Plan Missing for Resident
Penalty
Summary
The facility failed to have a hospice-coordinated plan of care for one resident who had been admitted after an acute care hospital stay and whose diagnoses included dementia. The resident’s admission MDS coded a BIMS score of 2 out of 15, indicating severely impaired cognitive abilities for daily decision-making, and section GG showed extensive dependence for toileting, bathing, dressing, footwear, and personal hygiene, with only limited assistance needed for eating and oral care. A physician order dated 1/20/26 called for hospice evaluation and treatment, and a nurse’s note dated 1/29/26 stated the resident had been admitted to hospice with a primary diagnosis of Senile Degeneration of the brain. During observation on 2/4/26, the resident was in bed handling the tip of an indwelling catheter, and a woman was heard stating the catheter was out. Interviews with the ADON and LPN #7 showed the facility did not have information available regarding what hospice services would be provided, when they would be provided, or the communication process for notifying hospice. The RVP stated the facility uses a hospice binder for each resident receiving hospice services, but on 2/11/26 the ADON only presented a binder after hospice forms had been faxed to the facility the day before.
Failure to Inspect Bed Rails and Bed Frame Components
Penalty
Summary
The facility failed to conduct bed and bed rail safety inspections for one resident, who had diagnoses including muscle weakness and was cognitively intact on the most recent comprehensive MDS with a BIMS score of 15 out of 15. During multiple observations, the resident was found in bed with bilateral upper rails raised, and the resident stated he uses them to move in bed. Review of the clinical record did not show documentation of an assessment or consent for the use of bed rails. On interview, the DON stated there were no bed rail or bed inspections for the resident. The Maintenance Director stated that beds are inspected to ensure proper operation and to make sure mattresses fit the bed frame to prevent entrapment, and that bed rails are inspected for proper operation and to prevent entrapment; however, he also stated he had not started the bed and bed rail inspection process and that the facility had recently hired an assistant for maintenance. The facility policy stated the Maintenance Director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.
Failure to Maintain Comfortable Environment Due to Air Conditioning Issues
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for two residents, as observed during a survey. Resident #1, who has cerebral palsy, major depressive disorder, anxiety disorder, and schizoaffective disorder, was found in a room with a non-functioning air conditioning unit. Despite having intact cognitive abilities, as indicated by a BIMS score of 15, Resident #1 reported discomfort due to the high temperature, which was recorded at 83.8°F. The Maintenance Director acknowledged that several rooms, including Resident #1's, were experiencing air conditioning issues, but repairs were pending due to a lack of parts. Resident #2, with diagnoses including hemiplegia, hemiparesis, vascular dementia, and early-onset Alzheimer's disease, was also found in a room with a non-functioning air conditioning unit. The resident's cognitive abilities were moderately impaired, with a BIMS score of 12, and a substantial interview was not conducted. The Maintenance Assistant noted the high temperature in the room, recorded at 84.4°F, and admitted that the facility staff was unaware of the malfunction. During a final interview, the facility's administration did not provide additional information or express concerns about the findings.
Air Conditioning Malfunction Leads to Uncomfortable Environment
Penalty
Summary
The facility staff failed to maintain a comfortable environment for residents, staff, and the public due to a malfunctioning air conditioning system. On a tour of units 1A and 1B, it was observed that the air conditioning was not functioning properly, with recorded ambient temperatures of 84.6°F in unit 1A and 85.2°F in unit 1B. The Maintenance Assistant attributed the high temperatures to the outside weather. The Administrator confirmed that the facility had four portable air conditioning units in use because the main system was not working properly and was awaiting repair parts. The facility was working with the Occupational Safety and Health Administration to resolve the issue with the air conditioning system and the hot temperatures in sections of the building.
Failure to Honor Resident's DNR Wishes
Penalty
Summary
The facility's staff failed to adhere to a resident's Do Not Resuscitate (DNR) wishes, resulting in a deficiency. Resident #6, who was cognitively intact and had a documented DNR order, was admitted to the facility after a hospital stay. The resident's care plan and medical records clearly indicated a DNR status, supported by a Durable Do Not Resuscitate Order signed by both the resident and a physician. Despite this, during an incident where the resident experienced shortness of breath and subsequently became unresponsive, emergency medical personnel performed CPR, contrary to the resident's advance directives. The deficiency occurred because the DNR document was not uploaded into the medical record, leading to a misunderstanding of the resident's code status. Interviews with staff revealed that the resident had been in the facility for five months with an incorrect full code status. During the emergency, staff and emergency medical technicians were not informed of the resident's DNR status, resulting in the initiation of life-saving measures that were against the resident's documented wishes. The Director of Nursing acknowledged that the resident's DNR status should have been followed.
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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