Holston Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wytheville, Virginia.
- Location
- 990 Holston Rd, Wytheville, Virginia 24382
- CMS Provider Number
- 495349
- Inspections on file
- 16
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holston Health And Rehabilitation during CMS and state inspections, most recent first.
Facility staff failed to administer ordered medications, such as insulin and Gabapentin, and did not consistently obtain or document daily weights for residents with physician orders. In one case, a resident with diabetes did not receive their bedtime insulin, resulting in a critically high blood sugar and hospital transfer. Another resident missed doses of Gabapentin despite its availability in the facility, and a third resident's daily weights were not consistently obtained or recorded, with staff signing off without performing the task.
A resident with severe cognitive impairment and a history of hip fracture experienced frequent, inadequately managed pain due to inconsistent pain assessments, lack of timely follow-up on pain interventions, and delays in adjusting pain medications. Staff did not consistently document pain levels or nonpharmacological interventions, and communication lapses led to delays in implementing new pain management orders, resulting in the resident's pain not being effectively addressed.
Staff did not provide written information or assistance regarding advance directives to multiple residents, despite facility policy requiring this. Documentation referenced an 'Advance Directive Handbook' that did not exist, and no evidence of advance directive education or offers of assistance was found.
Facility staff did not ensure that a baseline care plan was developed and provided to residents and their representatives within 48 hours of admission. Staff interviews and record reviews confirmed that baseline care plans were completed electronically but not shared or reviewed with residents or families, and key staff were unaware of the requirement to provide these plans promptly.
Staff failed to properly assess a resident after a fall resulting in a hip fracture, did not document a registered nurse's assessment at the time of a resident's death, and documented daily weights and medication administration for another resident when these actions were not performed. These deficiencies involved failures in assessment, documentation, and adherence to professional standards by nursing staff and administration.
The DON worked as a floor nurse and CNA on multiple occasions, contrary to regulations requiring the DON to serve in a full-time administrative role. Staff interviews and facility records confirmed that the DON provided direct resident care on 14 occasions, and both the DON and Administrator acknowledged this practice occurred when necessary to maintain resident care.
Staff failed to maintain accurate clinical records for two residents, including incomplete documentation of behavioral episodes for one resident and missing provider orders for lab studies performed on another. The MAR and progress notes were inconsistent with facility policy requiring thorough documentation of services and changes in resident condition.
Facility staff did not provide required behavioral health training to five sampled CNAs, as evidenced by a lack of documentation in their in-service records. Although the facility assessment and policies specified the need for such training to address the needs of residents with behavioral health conditions, only trauma-informed care training was completed by most of the CNAs. At the time of the survey, two residents with PTSD/trauma were identified as needing this level of care.
Facility staff shortages resulted in the DON and UMs frequently working floor shifts, which hindered their ability to oversee critical processes such as lab monitoring. This led to failures in timely lab test completion, communication of abnormal results, and prompt implementation of provider orders for several residents, resulting in an immediate jeopardy finding.
An LPN was employed without a valid Virginia nursing license, as required by state law. The LPN held only a single state license from West Virginia, and facility records showed no evidence of a Virginia license or a multi-state license during the period of employment. The issue was discovered after the LPN was no longer working at the facility, and the facility's hiring policy required license verification.
A resident with chronic respiratory conditions was found to have an Albuterol inhaler and over-the-counter medications in their possession without documentation of an assessment for self-administration. The resident was cognitively intact and had a provider order for Albuterol as needed, but staff failed to document administration or assess the resident's ability to self-administer medications, contrary to facility policy.
Facility staff did not notify the medical provider when a resident with multiple complex diagnoses experienced a significant change in condition, including altered mental status and hypotension, which led to a hospital transfer and ICU admission. Review of records and staff interviews confirmed there was no documentation of physician notification, despite facility policy requiring such notification in these circumstances.
Facility staff did not provide a required SNF Advanced Beneficiary Notice of Non-coverage (ABN) to a resident discharged from a Medicare Part A stay, and were unable to locate or produce any related documentation when requested by surveyors. Leadership confirmed the absence of the required notice and documentation during the survey process.
Facility staff did not provide required notifications to the ombudsman or written notices to residents and their representatives during transfers or discharges to hospitals. In several cases, residents with varying levels of cognitive impairment were transferred without proper documentation or notification, and staff interviews revealed a lack of awareness of these requirements.
Facility staff did not provide or document sufficient preparation and orientation for a resident with multiple complex diagnoses and moderate cognitive impairment before transfer to a higher level of care. The clinical record lacked required details about the transfer process, and the DON confirmed that discharge documentation was incomplete, contrary to facility policy.
Facility staff did not provide a resident and/or the resident's representative with the required written bed-hold policy notification when the resident, who had multiple serious medical conditions and moderate cognitive impairment, was transferred to a hospital. No documentation of the notification was found in the clinical record, and the DON confirmed its absence during the survey.
Staff failed to ensure accurate MDS assessments for a resident, documenting lower extremity functional impairment inconsistently with other records and without supporting documentation. The resident, who had severe cognitive impairment, was assessed as having lower extremity limitations on two MDS assessments, despite other assessments indicating no such impairment.
Surveyors found that staff failed to create and implement complete care plans for two residents—one requiring oxygen therapy and another with PTSD. For the resident on oxygen, there was no care plan addressing oxygen use despite physician orders and direct observation of oxygen administration. For the resident with PTSD, the care plan did not identify triggers or include specific interventions, and the interdisciplinary team did not address the diagnosis during care planning. Facility policy requires comprehensive, person-centered care plans, but these were not followed in both cases.
Staff did not update the care plans for two residents after changes in their clinical status. One resident's care plan continued to reference CPAP use despite discontinuation, and another's care plan listed tube feeding dependence even though the resident was no longer receiving tube feedings. Facility policy required timely care plan updates, but these were not completed.
Facility staff did not document the amount of gastric residuals when checking a resident's tube feeding residuals, despite physician orders and facility policy requiring this information. Although checks were marked as completed on the MAR, the actual amounts were missing from the clinical record, as confirmed by the DON.
Staff did not follow the physician's order for oxygen administration for a resident with chronic respiratory failure, providing oxygen at 5 LPM via nasal cannula instead of the ordered 2 LPM. The discrepancy was observed and confirmed before the order was updated to match the higher flow rate.
Facility staff did not properly assess or address trauma-informed care needs for a resident with PTSD, failing to identify or mitigate triggers such as nightmares and hallucinations in the care plan, despite ongoing symptoms and relevant diagnoses. Staff interviews and record reviews confirmed that trauma assessments and appropriate interventions were not implemented as required by facility policy.
A resident's medication and consult orders were entered by non-prescribing staff as 'Prescriber written' in the electronic record, which did not require provider signature, resulting in multiple orders remaining unsigned by the medical provider. Facility policy required provider review and countersignature for such orders, but this was not followed due to incorrect order entry.
Staff failed to accurately document the administration of controlled medications for two residents, as LPNs did not sign out Oxycodone and Gabapentin in the narcotics book at the time of preparation or after administration, contrary to facility protocols.
A resident with multiple complex diagnoses and severe cognitive impairment did not have a pharmacist's medication regimen review recommendation regarding antipsychotic use reported to or acted upon by the medical provider in a timely manner. The recommendation was not acknowledged or reviewed by the provider until several months after it was made, contrary to facility policy requiring timely physician response and documentation.
Facility staff failed to ensure residents were free from significant medication errors, including incorrect transcription and delayed administration of an IV antibiotic for a resident with a UTI, and improper administration of cardiac medications to two residents despite provider orders to hold the medications based on vital signs. These incidents involved residents with severe cognitive impairment and complex medical histories.
A surveyor observed an unattended, unlocked medication cart on a nursing unit. When approached, an LPN confirmed responsibility for the cart and locked it after being notified. Facility policy requires medication carts to be locked when out of the nurse's view.
Facility staff failed to obtain timely laboratory tests for two residents who exhibited symptoms requiring urinalysis, resulting in delays in diagnosis and treatment. In both cases, provider orders or documented plans for urinalysis were not processed or carried out as required, with staff and providers later indicating issues with order entry or follow-through. The facility's policy to process and arrange laboratory tests was not adhered to, and no further explanation was provided to surveyors.
A resident with chronic renal failure and other urological conditions experienced a significant delay in UTI treatment because abnormal urinalysis and culture results were not promptly communicated to the ordering provider. Despite repeated lab findings indicating infection, nursing staff did not notify the NP, and the NP was unaware of the results due to issues with lab integration and lack of staff communication. Facility policy requiring prompt notification of abnormal results was not followed, leading to delayed care.
A resident with multiple chronic conditions experienced a delay in receiving a chest x-ray after it was ordered to rule out a respiratory infection. Although the facility's policy and contract required 24/7 radiology services, the x-ray was not obtained for two days, and staff could not provide a reason for the delay.
An LPN failed to follow infection prevention and control practices during medication administration by stacking medication cups for two residents, carrying both into a resident's room, and not maintaining separation between medications. The LPN also handled medications and discarded items without changing gloves or sanitizing the medication cart, contrary to facility policies.
Surveyors identified that a CNA did not have documented evidence of completing required effective communication training, as outlined in the facility's assessment and training protocols. This was confirmed through review of training records and discussion with facility leadership.
Failure to Administer Ordered Treatments and Document Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and care according to provider orders, resident preferences, and goals for multiple residents. In one instance, a resident with diabetes did not receive their ordered bedtime insulin upon admission, and there was no documentation of administration. The resident subsequently experienced a critically high blood sugar level, requiring emergency intervention and transfer to the hospital. Additionally, the same resident did not have their before-meal insulin ordered for the evening meal on the day of admission, resulting in a gap in diabetic management. Another resident with a physician's order for Gabapentin to be administered at bedtime for pain did not receive the medication on two separate days, despite the medication being available in the facility's backup medication dispensing system. Documentation indicated the medication was not available from the pharmacy, but the DON later confirmed it was accessible in the Cubex system and should have been administered as ordered. The order was discontinued after several missed doses. A third resident with orders for daily weights due to congestive heart failure did not have weights consistently obtained or documented. The electronic medication administration record (eMAR) lacked a designated area for weight documentation until several months after the order was in place, and staff were signing off on weights without actually performing them. Progress notes indicated multiple refusals by the resident, but the weight record showed infrequent documentation of actual weights, and the DON confirmed that nurses were not consistently obtaining the weights as ordered.
Failure to Provide Consistent and Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with multiple complex diagnoses, including a recent right hip fracture, Alzheimer's disease, and chronic pain conditions. The resident, who had severe cognitive impairment and was frequently experiencing pain, was noted to have pain levels as high as 6 out of 10 and exhibited behaviors such as calling out, moaning, and shouting for help. Despite these signs and the care plan's directive to notify the physician of unrelieved pain, documentation showed inconsistent pain assessments, lack of follow-up on pain interventions, and delays in adjusting pain management strategies. Progress notes and provider documentation revealed that the resident continued to experience pain even after receiving PRN narcotic pain medication, with staff sometimes only placing the resident on a rounding list for future provider evaluation rather than seeking immediate intervention. Orders for pain assessment were not consistently followed, as staff simply checked off pain monitoring without documenting pain scales or nonpharmacological interventions. There was also a lack of follow-up pain assessments after medication administration, and gaps in pain medication administration were noted despite ongoing reports of pain. Communication issues further contributed to the deficiency, as there were delays in clarifying and implementing new pain medication orders, confusion regarding medication allergies, and lack of timely documentation regarding hospice involvement and medication changes. Interviews with staff and providers indicated uncertainty about expectations for pain assessment frequency and appropriate escalation when pain was not controlled. Facility policy required regular pain reassessment and documentation, but these standards were not met, resulting in inadequate pain management for the resident.
Failure to Provide Written Advance Directive Information and Assistance
Penalty
Summary
Facility staff failed to provide written information regarding the right to formulate an advance directive to 11 out of 30 sampled residents. Clinical record reviews showed that these residents had signed an acknowledgment of receipt of admission information, which included a reference to an 'Advance Directive Handbook.' However, interviews with the administrator revealed that no such handbook existed, and there was no evidence that advance directive education had been provided to the residents. The administrator also confirmed that the facility did not currently offer assistance to residents in formulating advance directives, despite this being referenced in the facility's policy. The facility's own Advance Directive policy requires that residents be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, as well as a description of the facility's policies and applicable state law. The policy also states that staff should offer assistance in establishing advance directives and document the offer and the resident's decision in the medical record. No documentation or evidence was found to show that these requirements were met for the affected residents.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to implement a process to ensure that a baseline care plan was developed for every resident within 48 hours of admission and that a summary of this care plan was provided to the resident and their representative. Clinical record reviews for seven residents showed no evidence that either the residents or their representatives received a baseline care plan. Staff interviews revealed that the MDS coordinator completed baseline care plans in the computer system but did not print, provide, or review them with residents or their families. The MDS coordinator also indicated a lack of awareness regarding the requirement to provide the baseline care plan within 48 hours of admission. The facility's policy stated that a baseline plan of care should be developed within 48 hours of admission and that a summary should be provided to the resident and their representative. However, during interviews and document reviews, it was confirmed that this process was not consistently followed. The DON was unable to find evidence that baseline care plans had been provided to residents, and the issue was discussed with facility leadership during the survey.
Failure to Follow Professional Standards in Assessment, Documentation, and Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice in several instances involving three residents. In one case, a resident with severe cognitive impairment experienced a fall resulting in a right hip fracture. The resident was found on the bathroom floor and was unable to bear weight on her right leg. Despite this, the resident was moved to a wheelchair and monitored at the nurses' station before being sent to the emergency room. Documentation did not show that a proper assessment was performed prior to moving the resident, nor was there evidence of how long the resident remained in the wheelchair before transfer. The facility's own falls management policy and staff interviews confirmed that a post-fall assessment should have been conducted before moving the resident, but this was not documented or performed. In another instance, staff failed to follow professional standards regarding the pronouncement of death for a resident with moderate cognitive impairment. The clinical record included a progress note from an LPN stating the resident had no signs of life and that the DON was notified and pronounced the resident dead. However, there was no documentation of a registered nurse's assessment at the time of death, and a late entry was made by the RN much later. Additionally, the facility could not provide a policy guiding the pronouncement of death, and the LPN's assessment and findings leading to the call to the DON were not documented in the clinical record. A third deficiency involved a resident with multiple chronic conditions, including CHF and COPD, for whom staff documented daily weights and medication administration that did not occur. The electronic medication administration record (eMAR) was initialed as if daily weights were obtained, but there was no area to document the actual weights until a later date, and the weight record showed weights were not taken daily as ordered. Staff also initialed the administration of an inhaler medication that was not available in the facility, as confirmed by progress notes and the DON. Facility policies required documentation of all services provided and that medication administration be documented immediately after administration, but these standards were not followed.
DON Served as Charge Nurse and CNA in Violation of Staffing Requirements
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse, as required. Based on staff interviews and facility document review, it was found that the DON worked as a floor nurse on nine occasions and as a certified nursing assistant (CNA) on five occasions between January and April, for a total of 14 instances. The facility has 107 certified beds with an average daily census of 98 residents. During interviews, the DON acknowledged working the medication cart at times and stated that when she or the Unit Managers were assigned to direct care duties, it was difficult to keep up with facility processes. The Administrator confirmed awareness of the issue, indicating that having the DON work on the floor was considered a last resort to ensure resident care.
Incomplete Clinical Documentation and Missing Provider Orders for Lab Studies
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident, the medication administration record (MAR) indicated two episodes of behaviors during specific shifts, but the clinical documentation did not specify what those behaviors were. Additionally, the MAR included a section for monitoring and documenting specific behaviors, which was inconsistently completed; the nurse documented 'N' for no behaviors observed, which did not clarify the nature of the behaviors previously recorded. Facility policy required documentation of all services, changes in condition, and events involving the resident, but this was not followed in this instance. For another resident, staff did not ensure that the clinical record included a provider order for laboratory studies that were performed. Although a progress note indicated that a provider requested a urinalysis due to concerns about cloudy urine, and results for both urinalysis and urine culture were present in the record, there was no formal provider order documented in the system. The DON confirmed the absence of a provider order for these laboratory studies, despite the tests being completed and results available.
Failure to Provide Behavioral Health Training to CNAs
Penalty
Summary
Facility staff failed to provide behavioral health training for all five sampled Certified Nursing Assistants (CNAs). Review of in-service training records for these CNAs showed no evidence of completed behavioral health training, with only the trauma-informed care portion being completed by four of the five CNAs. The facility's own assessment and policy documents indicated that staff should be trained in recognizing psychological distress, implementing and monitoring care plan interventions relevant to behavioral health diagnoses, and following protocols for mental disorders, trauma, and substance use disorders. The facility assessment documented that the facility regularly cares for residents with behavioral health needs, including those with PTSD/trauma and substance use disorders. At the time of the survey, the resident matrix identified two residents with PTSD/trauma. Despite this, the facility was unable to provide evidence that the sampled CNAs had received the required behavioral health training as outlined in their own policies and facility assessment.
Insufficient Licensed Nursing Staff Leads to Immediate Jeopardy
Penalty
Summary
Facility staff failed to provide sufficient licensed nursing staff to meet the needs of all residents, as required. The Director of Nursing (DON) and Unit Managers (UMs) were frequently required to work as floor nurses or CNAs due to staffing shortages, which limited their ability to monitor and maintain essential facility processes, including laboratory services. The facility's own assessment indicated an average daily census of 98 residents, and CMS Payroll Based Journal data showed a one-star staffing rating for the previous four quarters. During the survey, it was found that the facility averaged only two to three licensed nurses on night shift, below their stated goal of four per shift, and relied on agency staff and management to fill gaps. As a result of these staffing issues, surveyors identified concerns for four residents related to failures in timely laboratory test completion, communication of abnormal results to medical providers, ensuring provider response, and timely implementation of orders for abnormal results. These failures led to the identification of an immediate jeopardy situation. Both the DON and the Administrator acknowledged that the need for management to cover floor shifts contributed to the breakdown in facility processes, particularly regarding laboratory services.
Failure to Verify Valid State Nursing License for LPN
Penalty
Summary
Facility staff failed to ensure that a licensed practical nurse (LPN) employed at the facility held a valid license to practice in accordance with state laws. The LPN was hired with an active single state license from West Virginia, as verified in the employee file, but did not possess a Virginia LPN license at any point during their employment. Documentation in the employee file included a note indicating an application for a multi-state license, but there was no evidence that such a license was ever obtained. The LPN's employment spanned from early March to the end of December, with no breaks in service. Interviews with facility staff revealed that the current human resources manager was not employed at the time of the LPN's hire and described a process for license verification that would have excluded applicants with only a single state license. The administrator became aware of the licensing issue only after the LPN was no longer employed. The facility's hiring policy required verification of certifications and licenses, but no further information regarding compliance with this policy at the time of the LPN's hire was provided to the survey team.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident for self-administration of medications, despite the resident having an Albuterol inhaler in their possession. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and heart failure, was found to be cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included interventions for respiratory conditions, but there was no documentation indicating an assessment for self-administration of medications. The resident was observed keeping the inhaler in their pocket and stated they used it as needed for shortness of breath. Additionally, over-the-counter medications were found in the resident's bedside drawer, which were not on the medication list. A review of the clinical record revealed a provider order for Albuterol as needed, but there was no documentation on the medication administration record for its administration during the month in question. Facility policy required that residents be assessed by the interdisciplinary team for self-administration of medications and that unauthorized medications found at the bedside be given to the charge nurse. Despite these requirements, there was no evidence that the resident had been assessed for self-administration, and the issue was confirmed during a meeting with facility administrators.
Failure to Notify Physician of Change in Condition and Hospital Transfer
Penalty
Summary
Facility staff failed to notify the medical provider of a significant change in condition for one resident, which resulted in the resident being transferred to a higher level of care. The resident had multiple complex diagnoses, including heart failure, atherosclerotic heart disease, chronic respiratory failure with hypoxia, atrial fibrillation, myocardial infarction, type 2 diabetes mellitus, cardiomyopathy, presence of a prosthetic heart valve, presence of a cardiac pacemaker, transient ischemic attack, and anxiety disorder. The resident was assessed as moderately impaired in cognition. On the evening in question, the resident experienced altered mental status, hypotension with blood pressure as low as 68/49, tachycardia, and tachypnea, leading to a transfer to the hospital and subsequent admission to the ICU for a stroke workup. A review of the clinical record and facility documentation revealed no evidence that the physician was notified of the resident's change in condition or of the transfer/discharge. The facility's policy requires nursing staff to notify the attending physician or physician on call in the event of a significant change in the resident's condition or when a transfer to a hospital is necessary. The director of nursing confirmed that there was no documentation of physician notification for this incident.
Failure to Provide Required SNF ABN Notification
Penalty
Summary
Facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification to one of three residents selected for SNF Beneficiary Notification Review. During the survey, the administrator supplied a list of Medicare beneficiaries discharged from a Medicare Part A stay with benefit days remaining, from which three residents were chosen for review. For one resident, documentation showed that the SNF ABN was not provided, with a hand-written note indicating uncertainty and inability to locate the document in the file. Interviews with the administrator confirmed that staff could not find any beneficiary documentation for this resident. The issue was discussed with facility leadership, but no further information or documentation was provided before the survey concluded.
Failure to Notify Ombudsman and Provide Written Transfer/Discharge Notices
Penalty
Summary
Facility staff failed to provide timely and appropriate notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman prior to or at the time of transfer or discharge for multiple residents. In several cases, there was no evidence that the ombudsman was notified when residents were transferred to local hospitals or higher levels of care. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman, and documentation supporting such notifications was not provided to surveyors upon request. For one resident with intact cognition, there was no documentation that the ombudsman was notified of the resident's transfer to a hospital. Another resident, who was severely cognitively impaired, was sent to an acute care hospital without evidence of ombudsman notification, and the social worker confirmed she was unaware of the notification requirement. Additionally, a resident with severe cognitive impairment was transferred to a hospital, and again, no evidence of ombudsman notification was found. In another instance, a resident and their representative did not receive written notice of the reason for transfer/discharge, nor was the ombudsman notified. The facility's own policy indicated responsibilities for informing appropriate parties of transfers or discharges, but staff interviews and document reviews showed these procedures were not followed. The survey team discussed these deficiencies with facility leadership, but no further evidence of compliance was provided before the survey exit.
Failure to Document and Prepare Resident for Safe Transfer/Discharge
Penalty
Summary
Facility staff failed to provide and document adequate preparation and orientation for a resident prior to transfer or discharge to a higher level of care. The clinical record lacked sufficient documentation to demonstrate that the resident was properly prepared or oriented for the transfer, as required by facility policy. The only progress note available for the transfer was brief and did not include necessary details about the preparation or orientation provided to the resident. The resident involved had multiple significant diagnoses, including heart failure, chronic respiratory failure, atrial fibrillation, and anxiety disorder, and was assessed as moderately cognitively impaired. The DON confirmed that the family requested the transfer due to increased confusion, but acknowledged that the nurse responsible did not accurately document the discharge process. Facility policy requires thorough documentation of all services, changes in condition, and communication with family or other staff, which was not met in this instance.
Failure to Provide Bed-Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide a resident and/or the resident's representative with the facility's bed-hold policy upon the resident's transfer to a higher level of care. Specifically, for one sampled resident with multiple significant diagnoses, including heart failure, chronic respiratory failure, and cognitive impairment, there was no documented evidence that the required written notification regarding the bed-hold policy was given at the time of transfer to the hospital. A review of the clinical record confirmed the absence of this documentation, and the DON was unable to locate any evidence that the bed-hold policy had been provided. This deficiency was identified through staff interviews, clinical record review, and facility document review, and was discussed with facility leadership during the survey process.
Inaccurate MDS Assessment of Lower Extremity Range of Motion
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident, specifically regarding the assessment of lower extremity functional range of motion. The resident's MDS assessments with assessment reference dates of 2/19/25 and 11/19/24 documented impairment in both lower extremities, which was inconsistent with other MDS assessments for the same resident that indicated no functional limitations. The resident was assessed as able to make self understood and to understand others, with a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. During the survey, the Administrator-in-Training was unable to provide documentation supporting a decline in the resident's lower extremity functional range of motion as recorded in the MDS assessments. The discrepancy in the MDS documentation was identified through observation, staff interviews, and clinical record review, revealing that the assessments did not accurately reflect the resident's actual condition at the time.
Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and PTSD
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies identified during the survey. For one resident with chronic respiratory failure, morbid obesity, and obstructive sleep apnea, the clinical record and physician's orders indicated the use of oxygen therapy. Despite documentation of oxygen use in the resident's records and direct observation of oxygen administration, there was no corresponding care plan addressing oxygen usage. The MDS coordinator confirmed that oxygen usage should have been included in the care plan, and facility policy requires that care plans describe all services necessary to meet residents' needs. For another resident diagnosed with post-traumatic stress disorder (PTSD) and other significant medical and psychiatric conditions, the care plan failed to identify potential triggers for PTSD. Although the resident's diagnosis and risk for PTSD-related symptoms were documented, the care plan did not include specific interventions or triggers. Interviews with administrative staff and the administrator revealed that the interdisciplinary team did not address or discuss the resident's PTSD during care plan meetings, and staff acknowledged the lack of appropriate assessment and intervention planning for trauma-informed care. Facility policies reviewed by the surveyor emphasized the need for comprehensive, person-centered care plans developed by the interdisciplinary team, incorporating risk factors and targeted interventions based on thorough assessments. The deficiencies were discussed with facility leadership, and no additional information was provided prior to the survey team's exit.
Failure to Update Care Plans Following Changes in Resident Status
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents following changes in their clinical status. For one resident with chronic respiratory failure, morbid obesity, and obstructive sleep apnea, the care plan continued to reference CPAP use and resistance to CPAP, despite the resident no longer having a CPAP order due to ongoing refusals. The resident confirmed that the CPAP had not been picked up and was not in use, and the MDS coordinator acknowledged that the care plan should have been updated to reflect this change. For another resident with congestive heart failure, diabetes mellitus type 2, and dysphagia, the care plan indicated dependence on tube feeding, even though the resident's current physician orders reflected a regular puree diet and only maintenance flushes for the PEG tube. The MDS coordinator confirmed that the care plan should have been revised to indicate that the resident was no longer dependent on tube feedings. In both cases, the facility's policy required care plans to be updated when outcomes were not met and at least quarterly, but this was not done.
Failure to Document Tube Feeding Residual Amounts
Penalty
Summary
Facility staff failed to document the amount of gastric residuals when checking a resident's tube feeding residuals, as required by physician orders and facility policy. The resident in question had an order to check gastric residual volume prior to feeding, with instructions to hold feeding and notify the physician if the residual exceeded a specified amount. The care plan and medication administration record (MAR) both indicated that gastric residuals were to be checked three times daily, and the MAR showed that these checks were consistently performed. However, the actual amounts of gastric residuals were not documented in the resident's clinical record, despite facility policy requiring this information to be recorded. This omission was confirmed by the Director of Nursing. The resident involved had moderate cognitive impairment and was receiving enteral nutrition due to an inability to eat or drink, making accurate documentation of tube feeding residuals critical for their care.
Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with the physician's order for one resident diagnosed with chronic respiratory failure with hypoxia, morbid obesity, and obstructive sleep apnea. The resident's clinical record included a physician's order for oxygen administration via nasal cannula at 2 liters per minute (LPM) during the day shift, to be used when oxygen saturation dropped or the resident was unable to breathe. Documentation in the electronic medication administration record indicated that oxygen was administered as ordered each day. However, during surveyor observations on two separate occasions, the resident was found receiving oxygen at 5 LPM, not the 2 LPM specified in the physician's order at that time. The resident confirmed that the oxygen was supposed to be at 5 LPM, but the clinical record and orders had not been updated to reflect this until after the surveyor's inquiry. The facility's policy required verification and documentation of the physician's order and the oxygen flow rate, but this was not followed prior to the order being changed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Facility staff failed to provide appropriate trauma-informed care for one resident diagnosed with post-traumatic stress disorder (PTSD), among other medical and psychiatric conditions. The resident was cognitively intact and had a documented history of PTSD, anxiety, depression, and hallucinations. Despite this, the clinical record lacked any trauma-informed care assessments, and the comprehensive person-centered care plan did not identify or address specific triggers related to the resident's PTSD. Psychiatry progress notes indicated ongoing symptoms and identified nightmares and hallucinations as potential triggers, but these were not incorporated into the care plan interventions. Interviews with facility staff and administration revealed that the interdisciplinary team did not discuss or address the resident's PTSD during care plan meetings, and staff were not adequately educated on trauma-informed care. The facility's own policy required trauma assessment and identification of triggers, but these steps were not followed for the resident in question. The deficiency was confirmed through staff interviews, clinical record review, and facility document review, with no further relevant information provided to the survey team prior to exit.
Unsigned Provider Orders Due to Incorrect Order Entry
Penalty
Summary
Facility staff failed to ensure that medical provider orders entered into a resident's clinical record by non-prescribing staff were signed or cosigned by the ordering provider. Specifically, several medication and consult orders for a resident with intact cognition were entered by staff as 'Prescriber written' rather than as verbal or telephone orders, which in the facility's electronic record system did not require or allow for provider signature or cosignature. This resulted in the orders for medications such as pantoprazole, famotidine, and insulin, as well as a urology consult, remaining unsigned by the medical provider. Facility policies required that physician orders and progress notes be maintained in accordance with OBRA regulations and that verbal or telephone orders be reviewed and countersigned by the practitioner during their next visit. The Assistant Director of Nursing confirmed that the orders were not signed due to incorrect entry in the electronic record system, which bypassed the requirement for provider signature. The deficiency was identified through interviews, clinical record review, and facility document review.
Failure to Accurately Record Controlled Drug Administration
Penalty
Summary
Facility staff failed to maintain accurate records of controlled drugs for two of thirty sampled residents during a medication pass and pour observation. On two separate occasions, LPNs prepared and administered controlled medications—Oxycodone 5/325 mg for one resident and Gabapentin 100 mg for another—without signing the medications out in the narcotics book at the time of preparation or after administration. These actions were directly observed by the surveyor, and the facility's policy on controlled substance medication orders was reviewed, which indicated that applicable protocols are to be followed closely. No additional information was provided to the survey team prior to exit.
Delayed Medical Provider Review of Pharmacist Medication Regimen Recommendation
Penalty
Summary
Facility staff failed to ensure that a medication regimen review (MRR) completed by a licensed pharmacist was reported to and acted upon by the medical provider in a timely manner for one resident. The pharmacist completed the MRR and made recommendations regarding the resident's antipsychotic medication, specifically suggesting an evaluation and possible dose reduction of Olanzapine. However, the recommendation report was not found in the resident's clinical record, and there was no evidence that the medical provider had acknowledged or reviewed the recommendation until three months after the MRR was completed. The resident involved had multiple complex diagnoses, including hypertension, Alzheimer's disease with early onset, chronic respiratory failure, cerebrovascular disease, diabetes, epilepsy, depression, anxiety, dementia, chronic kidney disease, and schizoaffective disorder. The resident was also noted to have severe cognitive impairment. Facility policy required timely physician response to pharmacist recommendations, and documentation of review in the medical record, but these steps were not followed in this instance.
Significant Medication Errors Due to Failure to Follow Provider Orders
Penalty
Summary
Facility staff failed to ensure residents were free from significant medication errors, as evidenced by three separate incidents involving three residents. In one case, a resident with a history of urinary tract infections and severe cognitive impairment was readmitted with a hospital discharge order for IV Ceftriaxone Sodium (Rocephin) to treat an acute UTI. Instead, staff transcribed and administered Ceftazidime, not the ordered medication, and there was a delay in starting the antibiotic, with the first dose given several days after readmission. The resident never received the prescribed Ceftriaxone Sodium. In another instance, staff did not follow provider orders for the administration of Carvedilol, a medication for heart failure and hypertension, for a resident with severe cognitive impairment and multiple cardiac diagnoses. The provider's order specified to hold the medication if the pulse was less than 60, but staff administered Carvedilol on two occasions when the resident's pulse was documented as 59. A third incident involved a resident with paroxysmal atrial fibrillation and multiple myeloma, who was prescribed Metoprolol Tartrate with instructions to hold the medication if systolic blood pressure was less than 110. Staff administered the medication twice when the resident's systolic blood pressure was documented as 109, contrary to the provider's order. These events demonstrate failures in medication transcription, administration, and adherence to provider orders.
Unattended and Unlocked Medication Cart Observed
Penalty
Summary
Facility staff failed to ensure the safe and secure storage of medications and biologicals as required by professional standards. During an observation, a surveyor found an unattended and unlocked medication cart on the nursing unit. When questioned, an LPN confirmed the cart was hers and subsequently locked it after being informed of the observation. The facility's own policy requires medication carts to be securely locked at all times when out of the nurse's view. No additional information was provided to the survey team prior to their exit.
Failure to Obtain Timely Laboratory Services for Residents
Penalty
Summary
Facility staff failed to obtain timely laboratory services for two residents, resulting in deficiencies in meeting their clinical needs. For one resident with chronic kidney disease, sepsis, and a history of urinary tract infections, a nurse practitioner ordered a urinalysis to evaluate symptoms consistent with a UTI. However, there was no evidence that the urinalysis was obtained as ordered on 4/25/25. The resident continued to experience symptoms, and a new order for a urinalysis was placed four days later, with the test finally collected on 4/29/25. The resident confirmed that no urine sample was collected prior to that date, and the nurse practitioner later stated the original order did not save in the electronic system. For another resident with multiple diagnoses including diabetes, hemiplegia, and mental health conditions, a provider's progress note indicated a plan to order a urinalysis due to increased urination. However, no corresponding order was found in the medical record, and no urinalysis was conducted at that time. The provider later stated she believed she had entered the order, but it did not appear in the system. The resident subsequently developed symptoms of dysuria and abdominal pain, prompting a new urinalysis order, which later confirmed a urinary tract infection. In both cases, the facility's policy required staff to process and arrange for laboratory tests as ordered by providers. The surveyors found that the staff did not follow through with obtaining the necessary laboratory tests in a timely manner, as evidenced by the lack of documentation and delayed testing despite provider orders or documented plans. No additional information or clarification regarding these failures was provided by the facility prior to the survey exit.
Failure to Promptly Notify Provider of Abnormal Lab Results Delays UTI Treatment
Penalty
Summary
Facility staff failed to promptly notify the ordering provider of laboratory results that were outside clinical reference ranges for one resident, resulting in a delay in treatment for a urinary tract infection (UTI). The resident had significant medical conditions, including chronic renal failure stage IV, benign prostatic hypertension, and obstructive and reflux uropathy, and was assessed as having moderate cognitive impairment. Orders for urinalysis with culture and sensitivity were placed, and results indicating a UTI were available in the clinical record, but the provider was not promptly informed. Despite multiple urinalysis and culture results showing evidence of infection, there was no documentation that the provider was notified of these abnormal findings. The nurse practitioner (NP) continued to order repeat tests and was unaware of the previous positive results, as the laboratory results were not integrated into the chart in a timely manner. Nursing staff did not communicate the abnormal results to the NP, and the NP reported being unable to obtain information about the labs from staff during visits. Facility policy required nursing staff to identify and promptly communicate abnormal laboratory results to the attending physician, especially when results were problematic or the resident's clinical status was unclear. However, the policy was not followed, and the abnormal results were not conveyed to the provider, resulting in a significant delay in the initiation of appropriate treatment for the resident's UTI.
Delay in Obtaining Timely Diagnostic X-ray Services
Penalty
Summary
Facility staff failed to obtain a chest x-ray (CXR) in a timely manner for a resident with multiple significant diagnoses, including Chronic Obstructive Pulmonary Disease, Multiple Myeloma, and Paroxysmal Atrial Fibrillation. The resident, who was cognitively intact, was seen by a nurse practitioner for mild fever and chills, and a CXR was ordered to rule out respiratory infection. The order for the CXR was entered on the same day as a urinalysis, but the CXR was not performed until two days later. Interviews with the Director of Nursing and the nurse practitioner revealed that the delay was not explained by facility staff, and the nurse practitioner stated that the facility was dependent on the radiology company. Review of facility policy and the contract with the mobile imaging provider confirmed that radiology services were to be available 24/7. No additional information was provided by facility leadership to explain the delay prior to the survey exit conference.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices during medication administration on one of two nursing units. During a medication pass, an LPN was observed stacking medication cups for two different residents, carrying both into one resident's room, and administering medications without maintaining separation between the residents' medications. The LPN then proceeded to administer the other resident's medication without following appropriate infection control protocols. Additionally, the LPN was observed donning gloves to prepare medications for another resident, handling and scoring a Lasix tablet while wearing the same gloves, and discarding a half-tablet in a resident's bathroom trash can. The LPN then retrieved the pill cup from the trash, placed it on the medication cart, and discarded the medication into the sharps container without sanitizing the cart. These actions were not in accordance with the facility's infection control and hand hygiene policies, which were reviewed by the surveyor.
Lack of Documented Communication Training for CNA
Penalty
Summary
Facility staff failed to provide evidence that a Certified Nursing Assistant (CNA) received effective communication training, as required by the facility's own assessment and training protocols. During a review of the CNA's in-service training record, surveyors found no documentation indicating that effective communication training had been completed. The facility's assessment document listed communication as a necessary training topic for direct care staff, but the CNA's records did not reflect participation in such training. This deficiency was confirmed through staff interviews and document review, and was discussed with facility leadership.
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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