Highland Ridge Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dublin, Virginia.
- Location
- 5872 Hanks Street, Dublin, Virginia 24084
- CMS Provider Number
- 495333
- Inspections on file
- 20
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Highland Ridge Rehab Center during CMS and state inspections, most recent first.
Dietary services failed to consistently match resident diet orders and maintain food service operations during a staffing lapse. During tray line observation, only regular, ground, and puree diets were announced, while staff said a resident on a CCD relied on a spouse to call the kitchen for meal choices. The RD later found a tray ticket listed CCD even though the provider order was for a regular diet, and a diet audit identified 34 residents with CCD orders and one resident with a renal diet. Staff also reported the dietary manager and other dietary staff had quit, leaving the administrator and HR director to cook meals, with a fill-in cook brought in for dinner.
Food storage, labeling, and hand hygiene failures were observed in the kitchen and all 4 unit nutrition rooms. Surveyors found expired and improperly stored food, unlabeled and undated prepared items, dirty refrigeration equipment, and food kept under unsanitary conditions. Dietary staff were also observed entering the kitchen without hair restraints or beard nets, and a cook changed gloves and handled food without performing hand hygiene.
Baseline care plans were not provided, reviewed, or completed for several newly admitted residents. Records showed blank or missing BCP documentation for residents with significant medical needs, including respiratory failure, CHF, CKD, sepsis, fractures, and cognitive impairment, and interviews with residents, family, and an LPN confirmed that copies were not received or reviewed. One resident had no evidence of any admission Nursing Collection Tool or BCP in the chart.
Incomplete Comprehensive Care Planning and Resident Participation: The facility failed to include a cognitively intact resident and/or representative in care plan reviews, and failed to develop comprehensive care plan focus areas for PTSD and self-administration of medications for multiple residents. Records showed bedside medications were ordered for two residents, but there was no documented self-administration assessment or corresponding CCP focus, and one resident’s CCP did not include PTSD despite documented diagnoses.
Failure to Provide Nail Care and Bathing Assistance: Multiple residents were found without needed ADL support, including long, jagged, or painful nails and missed showers. Residents with cognitive impairment and significant medical conditions reported delayed or absent nail care, and one resident stated showers were missed after a room change. Records and staff interviews showed inconsistent bathing documentation and no timely nail care despite facility policy requiring regular nail cleaning, trimming, and at least two baths or showers per week.
Failure to Assess Residents for Self-Administration of Medications: The facility did not complete required self-administration assessments for two residents who kept medications at bedside. One resident had moderate cognitive impairment and had Systane eye drops, Voltaren cream, and Neosporin ointment on the over-bed table, while the record only showed an order for Systane and no assessment. Another resident was cognitively intact and had orders to keep Flonase and Chloraseptic at bedside, but no assessment was in the chart when reviewed.
Failure to provide required Medicare beneficiary notices. Two cognitively intact residents did not receive the proper notices related to Medicare coverage and non-coverage: one resident should have received an ABN and another should have received a NOMNC. The SW confirmed the notices had not been given when the surveyor requested them, and one ABN was provided later that day.
Facility staff failed to notify the state LTC ombudsman of a resident transfer/discharge to a higher level of care. The resident had multiple serious diagnoses, including sepsis, CKD stage 3, AFib, malnutrition, and moderate cognitive impairment (BIMS 8/15), and was sent to the ER for Hgb 7 and severe abdominal pain. SW stated the transfer/discharge list was printed, but there was no evidence it was sent to the ombudsman.
Failure to Follow Up on Pharmacy Recommendations: The facility did not follow up on pharmacist recommendations for two residents. One resident had a history of TBI, MDD, and metabolic encephalopathy with severe cognitive impairment and was receiving an antipsychotic, antidepressant, and antibiotic. Another resident had dementia, delusional disorder, psychotic disorder, and MDD with severe cognitive impairment and was receiving antipsychotics, antianxiety meds, antidepressants, opioids, and anticonvulsants. In both cases, the chart noted that an MRR was completed and recommendations were written to the provider, but the pharmacy reports could not be located.
Unsecured medications were found in two residents' rooms. An LPN left hydrocortisone in one resident's room unattended, and survey staff observed Voltaren cream and Neosporin ointment on another resident's over-the-bed table without orders in the chart at the time. Both residents had moderate cognitive impairment based on BIMS scores, and one resident's record only authorized bedside storage for Systane eye drops.
Food service concerns were not adequately addressed after multiple residents reported cold meals, watery eggs and vegetables, missing condiments, and no snacks at night. Resident council minutes showed repeated complaints that dietary concerns were not being resolved, and an LPN stated snack carts were not stocked consistently, leaving staff to obtain snacks from the kitchen or use items kept in the nursing office. Surveyors also found unit pantries with out-of-date items and limited safe snacks available, while the ADM said prior complaint follow-up documentation was unavailable.
Infection control practices were not followed during medication administration and resident care. An RN handled medications with bare hands during a med pass, including opening a capsule and pouring the contents into pudding. Linens and a wet washcloth were observed on the floor in resident rooms, an incentive spirometer was found under a resident's bed, and a CPAP mask was left uncovered on a nightstand. The ADON stated that linens should not be left on the floor and respiratory equipment should be bagged when not in use.
Dietary staff were observed working in the kitchen without required hair restraints or beard nets, and one staff member stated he had never been educated on hair nets or beard restraints. The cook was also observed handling food with gloves and oven mitts, then changing gloves without hand hygiene. The ADM stated the dietary manager had quit, several dietary staff left soon after, and the RDDS was in the process of establishing training for new dietary employees.
Facility staff did not employ a qualified infection preventionist with the required training, resulting in residents needing EBP or TBP not having proper notification, signage, or PPE available. Interim leadership confirmed they were acting as IPs without certification, and although an LPN had IP certification, she was not performing the IP role. Documentation showed staff education and a job description requiring only the ability to obtain certification, but no further details were provided.
A resident with multiple medical conditions and intact cognition experienced significant delays in call bell response, with the call light remaining unanswered for at least 20 minutes despite staff presence nearby. The facility's policy allowed any staff to respond, but several staff members walked by without addressing the call, and expectations for response times varied among leadership.
Facility staff did not administer a prescribed dose of Cyclobenzaprine, a muscle relaxant, to a resident with multiple medical conditions, despite a clear provider order and the resident being cognitively intact. The omission was confirmed through MAR review and staff interview, with no further explanation provided.
Staff did not follow established infection control protocols for three residents requiring Enhanced Barrier Precautions or Transmission-Based Precautions. In multiple cases, required PPE such as gowns was not worn during care, signage and visual indicators were missing, and PPE supplies were not available as per facility policy. Staff interviews revealed a lack of awareness about precaution requirements, and observations confirmed that infection control measures were not consistently implemented.
Dietary Services Failed to Match Ordered Diets and Maintain Food Service Coverage
Penalty
Summary
The facility staff failed to meet the daily nutritional and dietary needs of residents receiving nutrition by mouth and failed to maintain an overall system to manage and execute food and nutritional services during a lapse in food service management. During tray line observation, the menu included Swedish meatballs, egg noodles, and pacific blend vegetables, but no special diets were called out other than regular, ground, and puree consistencies. When asked why no carbohydrate-controlled diets were announced, staff stated there was only one resident on a carb-controlled diet and that the resident’s spouse called the kitchen to determine the meal choice for that service. Staff also reported that the evening meal was being prepared by the administrator or the human resource director because the dietary manager and other dietary staff had quit. The registered dietician stated that a resident’s tray ticket showed a carbohydrate-controlled diet even though the medical provider order was for a regular diet, and the dietician said they would audit and provide corrections. The administrator later stated that the human resource director had ServSafe certification and that a fill-in cook from within the company would prepare dinner; the certification for that cook was provided later that day. The diet audit identified 34 residents with medical provider orders for consistent carbohydrate diets and one resident with a renal diet, and the tray ticket system had 2 errors.
Food Storage, Labeling, and Hand Hygiene Failures
Penalty
Summary
The facility failed to prepare, store, distribute, and serve food in accordance with professional standards in the kitchen and in all 4 unit nutrition rooms. During an initial tour of the kitchen, surveyors observed multiple out-of-date and improperly stored food items in the dry storage area, including expired boxes and bags of food, open containers and bags that were not sealed, and an open container of coffee without an open date. The registered dietician was made aware of these items and removed them. In the walk-in refrigerator, surveyors observed prepared foods stored on the floor, food items without labels or dates, uncovered trays, and multiple containers of food with visible contamination or dried residue. Items included ham, chef salads, coleslaw, shredded cheese, sandwiches, Jell-O cups, pudding cups, ground beef with use or freeze-by dates past due, and turkey meat stored on top of fresh apples. The registered dietician was made aware of these items and removed them. A staff member reported that cooks were trained on first in-first out stock rotation, but that items had been getting missed for about 2 weeks since most of the staff were lost. Surveyors also observed dietary staff entering the kitchen without hair restraints, and one staff member with visible facial hair did not have a beard net visible. Staff stated there were no hair restraints outside the kitchen door and that they had been entering the kitchen this way; another staff member stated he had not been educated on hair nets or beard restraints. During meal preparation, a cook was observed using oven mitts over gloves, changing gloves without hand hygiene, and then continuing food service activities until reminded by the RDDS or asked to wash hands. In the D-, B-, C-, and A-wing nutrition rooms, surveyors found numerous unlabeled or undated food items, expired food products, dirty storage containers, and refrigerators with dried spills and improper storage conditions, including food items in styrofoam bowls, sandwiches in baggies, puddings, peanut butter, juice, mustard, coffee, and a freezer item with a resident's name and an expired date.
Baseline care plans not provided, reviewed, or completed for newly admitted residents
Penalty
Summary
The facility failed to provide, review, or complete baseline care plans for multiple newly admitted residents, and failed to ensure that the resident and/or resident representative received a summary or copy of the baseline care plan when required. The report identified deficiencies involving Residents #6, #2, #13, #126, #134, and #84. Facility policy stated that the resident and their representative would be provided with a summary of the baseline care plan, and for one resident the policy also stated that a baseline care plan would be developed within 48 hours of admission to meet immediate care needs. For Resident #6, who was listed as their own responsible party and had diagnoses including sepsis and chronic pulmonary edema, the clinical record did not show that a copy of the baseline care plan was provided. The resident’s BIMS score was 8, indicating moderate cognitive impairment. An LPN stated the baseline care plan had been initiated but there was no proof anyone received a copy, and the resident stated they were not aware of receiving one. For Resident #2, who had diagnoses including acute on chronic respiratory failure with hypoxia, atrial fibrillation, CHF, anxiety disorder, depression, and COPD, the admission Nursing Collection Tool showed the section indicating that a copy of the baseline care plan and medications had been given was left blank. The resident, who had a BIMS score of 15, did not recall receiving a copy. For Residents #13, #126, and #134, the admission records also showed the baseline care plan review and copy sections were blank, and interviews with the residents and/or family members indicated they had not received or reviewed a copy. Resident #13 had diagnoses including psoas muscle abscess, sepsis due to streptococcus, CKD stage 3, and malnutrition, with a BIMS score of 8. Resident #126 had diagnoses including surgical aftercare following circulatory system surgery, infection and inflammatory reaction due to a cardiac valve prosthesis, diabetes with hyperglycemia, CKD, gastroparesis, and pleural effusion, with a BIMS score of 12. Resident #134 had diagnoses including lumbar compression fracture, displaced intertrochanteric fracture of the right femur, CHF, CKD stage 3, atrial fibrillation, osteoarthritis, and muscle weakness, with a BIMS score of 15. For Resident #84, who had diagnoses including chronic respiratory failure with hypoxia, atherosclerotic heart disease, history of TIA, CHF, COPD, morbid obesity, bilateral hip osteoarthritis, shortness of breath, and muscle weakness, the clinical record did not contain evidence of an admission Nursing Collection Tool or any baseline care plan. The resident had a BIMS score of 6, indicating severe cognitive impairment. The survey findings documented that the facility did not complete the required baseline care plan process for this resident.
Incomplete Comprehensive Care Planning and Resident Participation
Penalty
Summary
The facility staff failed to include Resident #50 and/or the resident representative in reviews and/or revisions of the comprehensive person-centered care plan. Resident #50 had diagnoses including depression, obstructive and reflux uropathy, COPD, cardiomegaly, tachycardia, metabolic encephalopathy, weakness, and chronic respiratory failure with hypoxia. The resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness, and during interview the resident could not recall being invited to care plan meetings. The clinical record did not show evidence that the resident and/or representative had been invited to participate in care plan reviews, and social work staff stated the last documented invitation was in May 2025. The facility also failed to develop and implement a care plan for self-administration of medications for Resident #116. The resident’s record included diagnoses related to respiratory conditions and a physician order allowing Flonase and Chloroseptic to be kept at bedside. The resident’s MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. The comprehensive care plan did not contain a self-administration of medications focus, and the resident stated that Flonase and Chloroseptic were kept in the top drawer of the nightstand. For Resident #11, the facility failed to develop a comprehensive care plan for PTSD. The resident’s diagnoses included PTSD, anxiety disorder, and depression, and the quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. Review of the comprehensive care plan showed no focus area for PTSD. For Resident #32, the facility failed to develop a comprehensive care plan for self-administration of medications. The resident had diagnoses including acute and chronic respiratory failure, chronic diastolic CHF, and diabetes, and the quarterly MDS showed a BIMS score of 12, indicating moderate impairment in cognitive skills for daily decision making. During observation, a bottle of Systane eye drops was seen on the over-bed table, and the record included an order allowing the eye drops to be kept at bedside, but there was no evidence the resident had been assessed for self-administration or that this had been included in the comprehensive care plan.
Failure to Provide Nail Care and Bathing Assistance
Penalty
Summary
The facility failed to provide activities of daily living care, specifically nail care and, for some residents, shower/bathing care, for multiple residents identified during survey. The report states that staff failed to provide ADL care for 7 of 25 residents: Resident #6, #84, #42, #51, #62, #67, and #116. The findings were based on observation, resident interviews, staff interviews, clinical record review, and facility document review. Resident #6 was observed with long, jagged fingernails with debris under the nails. The resident, who had diagnoses including sepsis and chronic pulmonary edema and was assessed as moderately impaired in cognition with substantial/maximal assistance needed for personal hygiene, stated the nails were too long and that staff had said they would cut them but had not done so. Resident #6’s care plan included reminders to use the call light for assistance with ADLs, and the facility policy stated nail care includes daily cleaning and regular trimming. Resident #84, who had multiple chronic diagnoses including chronic respiratory failure with hypoxia, CHF, COPD, morbid obesity, and severe cognitive impairment, stated they missed a shower due to a room change and wanted one. Shower/bathing records showed only two showers during the reviewed period and no documentation of refusals, bed baths, or partial bed baths. An email from a CNA stated baths were not documented on certain days and that when the resident did not feel up to a shower, the CNA would wipe the resident down with a wet soapy rag. The facility policy required at least two full baths or showers per week and documentation of refusals or alternative bathing care. Resident #42 reported not getting showers on time and sometimes going a week without one, and toenails were observed curling over the ends of the toes. Resident #51 had long toenails and stated podiatry had not been in since June 2025, with toenails sometimes cutting into the adjacent toe. Resident #62 was asking for toenail trimming because the nails were long and hurting, and the nails were observed to be long, thick, and ragged; the resident stated the toenails had not been cut in close to a year. Resident #67 was observed with extremely long, ragged toenails and long, ragged fingernails with dark debris under and around the nail bed, and stated the toenails needed to be cut. Resident #116 also had long toenails and stated they usually went to podiatry but missed the last appointment because they were in the hospital. For these residents, the DON stated nail care was the responsibility of the ADON, CNA, shower team, or nurses depending on the task, and the facility policy stated routine nail care may be performed by nursing staff and/or qualified activity team members and includes daily cleaning and regular trimming.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess 2 of 25 residents for self-administration of medications, including Resident #32 and Resident #116. The facility policy stated that staff and the practitioner would assess each resident’s mental and physical abilities and choice to determine whether self-administering medications and/or treatments was clinically appropriate, and that a more specific skill assessment would be performed for residents who self-administered medications. For Resident #32, the clinical record included an order for Systane eye drops to be kept at bedside, and the resident had diagnoses including acute and chronic respiratory failure, chronic diastolic congestive heart failure, and diabetes. The quarterly MDS showed a BIMS score of 12, indicating moderate impairment in cognitive skills for daily decision making. During observation and interview, Systane eye drops, Voltaren cream, and Neosporin ointment were seen on the resident’s over-the-bed table, and the resident stated she had to order the medications herself and that the Voltaren was for her hip. The record did not include orders for Voltaren or Neosporin ointment, and no evidence of a self-administration assessment was found in the record. For Resident #116, the record included orders to keep Flonase nasal spray and Chloraseptic throat spray at bedside, and the resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. The eMAR for February 2026 contained no documentation related to Flonase or Chloraseptic, and no self-administration assessment was located in the record when reviewed. When interviewed, the resident stated that she kept her Flonase and Chloraseptic in the top drawer of her nightstand. A self-administration assessment was later provided by the DON and was dated after the review period.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate beneficiary notices to 2 of 3 residents reviewed, Residents #36 and #42, regarding Medicare coverage and potential liability for services not covered. Resident #36 had diagnoses of sepsis and acute respiratory failure, and the admission MDS with an ARD of 01/19/26 showed a BIMS score of 15, indicating the resident was cognitively intact. Resident #42 had diagnoses of chronic systolic congestive heart failure and diabetes, and the quarterly MDS with an ARD of 02/03/26 showed a BIMS score of 15, also indicating cognitive intactness. On 02/25/26, the surveyor requested notices provided to both residents regarding discharge from Medicare Part A. During an interview on 02/26/26, the Social Worker stated that Residents #36 and #42 were not given the appropriate notices, that Resident #36 should have received an ABN, and that Resident #42 should have received a NOMNC. The Social Worker also stated that Resident #36 was provided an ABN on 02/26/26.
Failure to Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
Facility staff failed to notify the office of the state long-term care ombudsman of a resident transfer/discharge for Resident #13, who was transferred/discharged to a higher level of care. Resident #13 had diagnoses including psoas muscle abscess, sepsis due to streptococcus, atrial fibrillation, chronic kidney disease-stage 3, infrarenal abdominal aortic aneurysm, muscle weakness, and malnutrition. The most recent MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. An order progress note documented that the resident may be sent to the ER for evaluation and treatment related to Hgb 7 and severe left-sided abdominal pain. On interview, SW#2 provided a January 2026 transfer/discharge list and stated it was printed that day, and Resident #13 was listed. SW#2 stated the fax confirmation form was not kept and agreed there was no evidence the list was sent to the state long-term care ombudsman. The facility did not provide evidence of notification or a transfer/discharge policy before exit.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up on pharmacist recommendations for 2 of 25 residents, Resident #5 and Resident #72. For Resident #5, the clinical record showed diagnoses including personal history of traumatic brain injury, major depressive disorder, and metabolic encephalopathy. The most recent MDS dated 12/14/25 coded the resident with a BIMS score of 3 out of 15, indicating severe cognitive impairment, and showed use of an antipsychotic, antidepressant, and antibiotic. Resident #5's record contained a Pharmacy/Pharmacy Consultant Note dated 09/23/25 stating that a medication regimen review was completed and recommendations were written to the provider, but the related pharmacy report could not be located. The DON was informed of the missing pharmacy report but could not locate it. The facility policy entitled Medication Regimen Review stated that the consultant pharmacist will perform an MRR for every resident, report irregularities to the attending physician, medical director, and DON, and provide a written report with the resident's name, relevant drug, and identified irregularity. For Resident #72, the clinical record listed diagnoses including unspecified dementia, delusional disorders, psychotic disorder, and major depressive disorder. The most recent MDS dated 11/25/25 coded the resident with a BIMS score of 3 out of 15, indicating severe cognitive impairment, and showed use of antipsychotics, antianxiety medications, antidepressants, opioids, and anticonvulsants. The resident's care plan included a psychoactive medication plan related to anxiety disorder, depression, and insomnia. The record contained a Pharmacy/Pharmacy Consultant Note dated 09/22/25 stating that a medication regimen review was completed and recommendations were written to the provider, but the related pharmacy report could not be located. The DON was informed of the missing pharmacy report but could not locate it.
Unsecured Medications Left in Residents' Rooms
Penalty
Summary
Drugs and biologicals were not safely stored in a locked and secure manner for 2 residents. For Resident #4, who had diagnoses including Parkinson's disease, respiratory failure, and epilepsy, the quarterly MDS showed a BIMS score of 10, indicating moderate impairment in cognitive skills for daily decision making. During the initial tour, survey staff observed a white cream in a clear plastic medicine cup sitting on top of an extended outlet box in the resident's room. An LPN stated the cream was hydrocortisone and that she had placed it there. The resident's record included an order for hydrocortisone cream to be applied to the right lower leg twice daily for 5 days, and the DON later stated the hydrocortisone should not have been left in the room. For Resident #32, who had diagnoses including acute and chronic respiratory failure, chronic diastolic CHF, and diabetes, the quarterly MDS showed a BIMS score of 12 out of 15, indicating moderate impairment in cognitive skills for daily decision making. Survey staff observed Systane eye drops, Voltaren cream, and Neosporin ointment on the resident's over-the-bed table unattended. The resident stated she had to order the medications herself and that the Voltaren was for her hip. The clinical record included an order for Systane eye drops twice daily with permission to leave at bedside, but there were no orders for Voltaren or Neosporin ointment at the time of the observation; the order for Diclofenac (Voltaren) Sodium External Gel 1% was entered later that day.
Food Service Complaints Not Adequately Addressed
Penalty
Summary
The facility failed to adequately address resident complaints about food services, including concerns about taste, temperature, condiments, and the availability of snacks. During resident interviews, multiple residents reported that the food was cold, the eggs and vegetables were watery, trays lacked condiments, and snacks were not available at night. Resident Council Minutes documented repeated complaints that voicing concerns to dietary was a waste of time, that snacks were still not being provided, and that residents were waiting for alternate meal calls to be answered and for soda to be returned. Surveyors also observed that a requested test tray on 2/25/26 was the last tray off the cart at 1:10 PM and was described as palatable and at a temperature that would have been enjoyed. However, on 2/26/26 the four unit pantries were observed to contain several out-of-date items with limited snacks available or safe for resident consumption. An LPN stated kitchen staff were supposed to stock snack carts but did not do so often, forcing CNAs to go to the kitchen for snacks, and that nursing staff kept some snacks in the office and had even brought in their own food items at one point to make sandwiches for residents. The administrator acknowledged that food concerns had been raised in Resident Council but did not have notes or documentation from the prior dietary manager regarding the complaints.
Infection Control Practices Not Followed During Medication Pass and Resident Care
Penalty
Summary
The facility failed to follow established infection control procedures during medication administration and resident care observations. During a medication pass and pour, RN #2 was observed dispensing medication from a medication card into her bare hand and placing the medication into a cup. The nurse also removed a capsule from the medication cup with her bare hand, opened it, and poured the contents into a cup of pudding. The facility provided a medication administration policy stating that if tablets must be broken, hands are to be washed with soap and water and gloves applied prior to handling tablets. Additional infection control concerns were observed with linens and respiratory equipment. Linens were seen on the floor in room B-6, and a wet washcloth was observed on the floor in room A-6. An incentive spirometer was observed under the head of Resident #42's bed on multiple observations. Resident #92's CPAP mask was observed lying uncovered on the nightstand on multiple observations. The ADON stated that linens should not be left on the floor and that respiratory equipment should be bagged when not in use. Facility policies provided for linen handling required soiled linen to be placed directly into a covered laundry hamper, and the respiratory care policy stated that respiratory equipment not in use should be stored in a safe manner and that CPAP/BiPAP equipment should be cleaned, disinfected, and stored in a clean environment.
Dietary Staff Lacked Training and Proper Food Safety Practices
Penalty
Summary
The facility failed to provide adequate training and skill sets for dietary staff to safely and effectively carry out food and nutrition services. During observation of the lunch tray line in the kitchen, other staff #3 was preparing resident trays with visible facial hair and was not wearing a beard net. When asked about it, the regional director of dining services requested a beard net, and OS#3 then placed one over his facial hair. Later, other staff #4, #5, and #6 entered the kitchen to begin their shift and went to the hand-washing sink without hair restraints; OS#6 also had visible facial hair and no beard net was visible. Staff stated there were no hair restraints outside the kitchen door, that this was how they had been entering the kitchen, and that OS#6 had never been educated on hair nets or beard restraints since starting in February 2026. Additional observations showed the cook, OS#2, handling food while wearing gloves covered by oven mitts, then removing the mitts and changing gloves without performing hand hygiene. The regional director of dining services reminded OS#2 to change gloves, and later asked OS#2 to wash hands after a break for water because hand hygiene had not been performed before putting on new gloves. OS#2 was again observed using oven mitts over gloves while adding egg noodles to the serving station and then changing gloves without hand hygiene. The administrator stated the dietary manager had quit on 2/6/26, several other dietary staff quit soon afterward, and the facility had hired new dietary staff, including a new cook and dietary aide. The administrator also stated an offer to a new dietary manager was about to be made and that the regional director of dining services was in the process of establishing training for dietary employees.
Failure to Employ Qualified Infection Preventionist and Ensure Proper Precautions
Penalty
Summary
Facility staff failed to employ a qualified infection preventionist (IP) with the required training prior to assuming the role, as evidenced by staff interviews and document review. On multiple occasions, surveyors observed residents requiring enhanced barrier precautions (EBP) and/or transmission-based precautions (TBP) without proper notification, signage, or personal protective equipment (PPE) available to staff, residents, or visitors. During an interview, the interim administrator and interim director of nursing confirmed that the previous IP left employment and that they were acting as IPs without the necessary certification. Although an LPN on staff held an IP certification from 2022, she did not perform the IP role at the facility. The facility provided evidence of staff education on infection control procedures and a job description for the IP position, which only required the ability to obtain certification, but no further information was provided.
Failure to Respond Timely to Resident Call Bell
Penalty
Summary
Facility staff failed to provide a reasonable accommodation of needs for one resident by not responding to the resident's call bell in a timely manner. The resident, who had diagnoses including chronic obstructive pulmonary disease, dysphagia, and major depressive disorder, was cognitively intact according to the most recent assessment. The resident reported to the surveyor that call bell response times had been an ongoing issue, discussed at resident council meetings without improvement, and stated they had waited up to an hour for assistance in the past. During the surveyor's visit, the resident's call bell had been on for about five minutes, and the surveyor observed the call light active over the resident's door. Multiple staff were present at the nurse's station and walked by the resident's room without acknowledging the call bell, which remained unanswered for at least 20 minutes. Facility leadership, including the ADON and DON, provided differing expectations for call bell response times, with the ADON stating approximately five minutes and the DON stating 20 minutes or less. The facility's policy on answering call lights did not define a specific response time but emphasized that any staff member could answer a call light and that response should be appropriate to the situation. Despite these guidelines, staff failed to respond to the resident's call bell in a timely manner, as observed by the surveyor and confirmed through staff and resident interviews.
Failure to Administer Ordered Medication
Penalty
Summary
Facility staff failed to administer Cyclobenzaprine, an oral muscle relaxant, as ordered by the medical provider for one resident. The resident had multiple diagnoses, including encephalopathy, hemiplegia, hemiparesis, congestive heart failure, epilepsy, and several fractures, and was assessed as cognitively intact. The clinical record included a provider order for Cyclobenzaprine 10 mg by mouth three times daily for muscle spasms. Review of the September 2024 Medication Administration Record (MAR) showed an omission of the medication on a specific date and time, with no documentation that it was given. When interviewed, the Interim Administrator confirmed the medication was not signed off and assumed it was not administered. No additional information regarding the omission was provided to the survey team before the exit conference.
Failure to Implement Infection Control Precautions and PPE Use
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols for three residents requiring either Enhanced Barrier Precautions (EBP) or Transmission-Based Precautions (TBP). For one resident with a history of urinary tract infections and colonization with a multidrug-resistant organism (MDRO), staff did not don required personal protective equipment (PPE), specifically gowns, during incontinence care. The resident’s care plan and physician orders specified EBP, but staff were unaware of the precautions, and appropriate signage and PPE were not consistently available in the resident’s area. Interviews with the involved certified nurse aides revealed a lack of knowledge regarding the resident’s EBP status and the need for gowns, and the resident confirmed that staff did not wear gowns during care. Another resident with a urinary tract infection and a Foley catheter had orders and a care plan indicating the need for EBP. However, there was no visual indicator, such as a colored sticker or signage, in the resident’s room to alert staff to the required precautions. Additionally, PPE was not available on the linen carts as outlined in facility policy. The absence of these measures was confirmed by both observation and staff interviews, indicating a failure to implement the facility’s EBP process for this resident. A third resident with an active Acinetobacter infection in the urine and a provider order for contact isolation did not have appropriate TBP signage or PPE available outside the room. Staff, including CNAs and LPNs, entered and exited the room without donning PPE, and there was confusion among staff regarding the type of precautions required. The facility’s policy required signage and PPE availability for residents on TBP, but these were not in place at the time of surveyor observation. The deficiencies were discussed with facility leadership, but no additional information was provided prior to the survey exit.
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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