Lancashire Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Kilmarnock, Virginia.
- Location
- 287 School Street, Kilmarnock, Virginia 22482
- CMS Provider Number
- 495345
- Inspections on file
- 12
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Lancashire Post Acute during CMS and state inspections, most recent first.
Failure to Prevent and Treat Pressure Ulcers: A resident admitted without pressure injuries and with significant mobility impairment developed multiple pressure ulcers during the stay, including a stage 4 heel ulcer, a stage 3 ankle ulcer, and several unstageable wounds. The record showed pressure-injury prevention measures, nutrition recommendations, and wound care orders were not consistently documented as implemented, and staff interviews confirmed the resident required extensive assistance with turning/repositioning and developed wounds while in the facility.
Failure to Provide Scheduled Showers: Four residents with significant ADL needs, including stroke, paralysis, cerebral palsy, and other chronic conditions, did not receive showers according to their assigned schedules. One resident reported having to yell to get a shower, another said she had received at most two showers since admission, and two others stated they had gone weeks without showers. Records showed missed, refused, or absent shower documentation despite care plans and task schedules calling for bathing assistance.
Insufficient staffing affected resident care and daily services. The facility’s staffing sheets did not show any shift fully staffed per the facility’s own staffing pattern, and residents reported long waits for help, missed showers, and delayed response to call lights. A CNA was observed leaving a resident with food on bedding after lunch, and multiple CNAs, the Staff Coordinator, and the DON acknowledged frequent call-offs and not having enough aides to complete care tasks.
Staff failed to perform hand hygiene between resident contacts while passing lunch trays and assisting residents with eating. CNA4, CNA18, and the ADON touched residents during meal service without sanitizing hands between residents, and one CNA gave bites to two residents without hand hygiene in between. A CNA also handled dirty linen with a gloved hand in the hall and touched the gate and soiled utility door code before removing gloves and cleaning hands.
Failure to Inform Family Member of Psychiatric Visits: A resident with Alzheimer’s disease, dementia, and severe cognitive impairment received bi-weekly psychiatric NP visits, but the record showed no documentation that the FM was informed or consulted. The FM stated she was not aware of the visits and would not have agreed to them, and both the DON and Administrator stated the FM should have been notified.
A resident with cerebral palsy, paraplegia, and malignant colon cancer was verbally abused by a CNA during shower care when the resident had a bowel movement on the shower floor. The resident, who had a BIMS of 15 and was always incontinent of bowel, stated the CNA called him an "A-hole," and a roommate confirmed the abuse. The DON was notified, and the facility later documented that the CNA could not be reached for a statement.
Failure to thoroughly investigate an allegation of verbal abuse involving a cognitively intact resident who was incontinent and required extensive care. A CNA reported that another CNA allegedly used profanity during shower care after the resident had a bowel movement, but the facility had no documentation of interviews with other residents or staff, and the Administrator could not identify or interview the reporting CNA. The facility policy required immediate reporting and a thorough written investigation of alleged abuse.
The facility failed to transmit MDS assessments to CMS within the required timeframe for two residents. One resident’s quarterly MDS was overdue by 15 days and the other resident’s admission MDS was overdue by 9 days; the MDSC confirmed both were late. The residents had diagnoses including COPD, CKD, heart disease, and pressure ulcers.
Failure to refer two residents for PASARR Level II review after new MH diagnoses were identified. One resident had diagnoses including bipolar disorder, psychotic disorder, schizophrenia, MDD, and dementia, while another had depression, anxiety, and later PTSD listed on MDS. The RDSW stated documentation could not be found showing either resident was referred for Level II PASARR evaluation, despite facility policy requiring referral when Level I screening indicates possible MD, ID, or related disorder.
A resident with diabetes and CHF sustained a fall while transferring from wheelchair to bed and was diagnosed with a closed R wrist fracture after ER evaluation. The Fall Care Plan included pain control, sling use, therapy, and ortho follow-up, but it was not updated to reflect that the resident was independent in applying and removing the wrist brace; staff later observed the resident removing the splint and RN confirmed this independence.
Failure to Monitor Fractured Wrist: A resident with a closed R wrist fracture after a fall had a soft splint in place, but later removed it independently. The wrist was observed with bruising and swelling, and the MAR/TAR contained no documentation that nursing staff monitored the wrist for changes in swelling or bruising. The RN confirmed there was no EMR monitoring, and the DON stated the wrist should have been monitored.
A resident with COPD, ESRD, and Type 2 DM was observed using a nasal cannula with the oxygen concentrator set at 4 LPM even though the EMR showed no current physician order for oxygen. The care plan did not address oxygen, and an LPN, RN, and DON all confirmed the resident should not have been receiving oxygen without an active order; the DON stated it had been overlooked.
Failure to document vaccine refusal education was cited after staff did not record that residents or representatives were informed of the risks and benefits of influenza and pneumococcal vaccines when the vaccines were declined. Three residents with varying cognitive status had MDS records showing the vaccines were offered and refused, but the IP stated they were unaware documentation was required. The facility policy stated that when vaccines are refused, the date and stated reason for refusal must be documented in the medical record.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions and wound care for a resident admitted with Alzheimer's disease, urinary and fecal incontinence, autonomic nervous system degeneration, osteoarthritis of the hip, right hip pain, and generalized muscle weakness. On admission, the resident had no pressure injuries, but the MDS showed substantial to maximal assistance was needed for bed mobility and the Braden assessment identified the resident as at risk for pressure sores. The care plan included interventions such as assistance with positioning, encouragement to reposition, skin barrier cream, an air mattress or air overlay, use of pillows, pads, or wedges, turning and repositioning, and pressure-reducing surfaces. During the stay, skin checks initially documented no new areas, but later notes described discoloration to both heels and feet, very poor bed mobility, and frequent resting of the feet on the footboard. The resident then developed multiple wounds after admission, including wounds to the left heel, right heel, right ankle, and left lateral foot. The wounds progressed from discoloration and intact skin to unstageable pressure injuries and deep tissue injuries, with later documentation showing a stage 4 pressure ulcer of the left heel and a stage 3 pressure ulcer of the right ankle. A right buttock wound also developed and was documented as unstageable with deep tissue injury. The record also showed that ordered interventions and recommendations were not documented as implemented. Nutrition recommendations from the dietary assessment, including vitamin C, zinc, double protein portions, and LiquaCel, were not documented as carried out. The specialty wound physician’s recommendations on 02/18/25, including specific dressing regimens, off-loading boots, protein supplementation, thyroid testing, vitamin C, zinc, and an upgraded Roho chair cushion, were also not documented as implemented in the MAR or TAR. Interviews with the WCN, an LPN, and the DON confirmed that the resident developed pressure wounds during the stay, required two staff for turning and repositioning, and that the DON stated there was no reason the dietitian’s recommendations were not implemented.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide assistance with ADLs by not ensuring showers were given according to the residents’ shower schedules and preferences for four residents. R4, who had a history of stroke with left-sided paralysis and was dependent on staff for bathing, reported that she did not receive showers on her scheduled days and stated she had to yell to get a shower. The record showed she was scheduled for two showers per week, but documentation reflected only one shower in the prior 30 days. R18, who had diagnoses including seizures, diabetes, and an irregular heart rhythm, had a BIMS score of 10 and required moderate assistance with bathing. She stated she had received at most two showers since admission. Her task record showed she was scheduled for two showers per week, but the documentation showed one shower marked no and another documented as refused, with no further shower documentation after that. R59, who had cerebral palsy and paraplegia and was totally dependent on staff for bathing, stated it had been over a month since her last shower. Her task record showed she was scheduled for two showers weekly, but after one refusal there was no further shower documentation. R56, who had hemiplegia, osteoarthritis, and type 2 diabetes and required moderate assistance with bathing, stated she had not had a shower in weeks and that staff told her they did not have time or that it was not her shower day. The facility policy stated staff were to assist residents as necessary and provide assistance to improve quality of life.
Insufficient staffing and delayed resident care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of 108 residents. The facility’s undated Facility Assessment listed a base staffing pattern of 2 RNs on the 7-3 shift, 2 LPNs on the 7-3 shift, 2 RNs on the 3-11 shift, 2 LPNs on the 3-11 shift, 3 LPNs on the 11-7 shift, and CNAs at 11 on 7-3, 8 on 3-11, and 5 on 11-7. Review of Daily Staffing Sheets and daily nursing schedules for 01/15/25 through 02/28/25 showed an average daily census of 80 residents, and no shift could be located that was fully staffed per the Facility Assessment staffing guidelines. Residents and staff described delays and missed care tied to the staffing shortages. R56 reported not having a shower in weeks and said CNAs told her they did not have time and kept changing her shower day. R46 was observed with oily hair and sloppy joe meat on her sheet and blanket after lunch, and a CNA stated she was busy and had to make rounds. R4, R18, and R59 each reported long waits for assistance and call lights not being answered, with R18 stating waits of 45 minutes to an hour and R59 stating waits of more than 30 minutes, especially on the 3-11 shift. Multiple CNAs stated the facility was short-staffed, had frequent call-offs, and that they could not complete charting or all resident care tasks, while the Staff Coordinator and DON acknowledged ongoing staffing concerns and a lack of enough aides.
Failure to Perform Hand Hygiene Between Resident Contacts and During Dirty Linen Handling
Penalty
Summary
The facility failed to perform hand hygiene between contact with residents while serving lunch trays for 28 of 108 residents. During an observation on 02/17/26 from 12:29 PM until 1:28 PM, CNA4, CNA18, and the ADON were serving lunch trays and assisting residents with sanitizing hand wipes before eating, but the three staff members were observed touching residents while helping them sit down, distracting residents until trays were served, or touching residents' arms or shoulders without performing hand hygiene between resident contacts. CNA4 was also observed giving one resident a bite to eat and then going to another resident and giving that resident a bite to eat without performing hand hygiene between residents. The facility also failed to remove gloves and perform hand hygiene prior to carrying bagged dirty linen in the hall. During an observation on 02/17/26 at 3:00 PM, CNA18 carried a plastic bag of dirty linen with a gloved hand down the hall to the dirty utility room, touched the gate to open it, and entered the code on the soiled utility room door. CNA2 was observed brushing her hair out of her face with her hands and picking up her cell phone off the floor without performing hand hygiene while assisting a resident with eating. The DON stated staff should sanitize hands between touching residents and that dirty linens should be bagged and carried to the soiled utility room with one gloved hand, followed by hand hygiene. Facility policy stated hand hygiene is indicated immediately before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal.
Failure to Inform Family Member of Psychiatric Visits
Penalty
Summary
The facility failed to provide information and choices to the family member of a resident regarding psychiatric visits. Resident 13 was admitted with diagnoses including Alzheimer's disease, atrial fibrillation, and dementia, and the significant change MDS showed a BIMS score of 99, indicating severe cognitive impairment. The record review found psychiatric visits dated 01/27/26 and 02/13/26 by the psychiatric NP, but there was no mention of consultation with the family member in those notes. Review of the Progress Notes showed no documentation that the family member was informed of the risks and benefits or made aware that psychiatric visits were being provided bi-weekly. During interview, the family member stated she had not been consulted and said she would not have agreed to the visits because the resident had been completely uncommunicative for months and rarely opened her eyes. The DON and Administrator both stated the family member should have been notified.
Verbal Abuse by CNA During Resident Care
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by staff. The resident was admitted with cerebral palsy, paraplegia, and malignant colon cancer, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact and always incontinent of bowel. According to the Administrator Statement, the DON received a report that a CNA had used profanity while providing care when the resident had a bowel movement on the shower floor during a shower and the CNA called the resident an "A-hole." The resident later stated that the CNA wheeled him into the shower, he had a bowel movement that went all over the floor, and the CNA called him an "A-hole," which made him feel terrible. The resident reported the incident to the DON, and the roommate was present during the interview and confirmed that the CNA had verbally abused the resident. The Administrator stated that the CNA was not scheduled when the report was received, management had been unable to reach the CNA for a statement after multiple attempts, and the CNA was removed from the schedule and terminated. The facility policy titled Resident Abuse Policy and Procedure stated that residents are to be free from abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving one resident. The resident was admitted with cerebral palsy, paraplegia, and malignant colon cancer, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact and always incontinent of bowel. According to the Administrator Statement, the DON received a report from a CNA that the resident said another CNA used profanity during shower care after the resident had a bowel movement on the shower floor and the CNA allegedly called the resident an "A-hole." The staff member accused of the profanity was not scheduled when the report was received, could not be reached for a statement after multiple attempts, and was terminated. During interview, the Administrator stated there was no documentation showing that other residents on the unit were interviewed about possible verbal abuse by the CNA, and no documentation of staff interviews was available. The Administrator also stated she did not know who the unknown CNA was that reported the allegation and that person was not interviewed for the investigation. The facility policy required all alleged violations involving abuse to be reported immediately and for the facility to complete a thorough written investigation while preventing further potential abuse during the investigation.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to electronically transmit MDS assessments to CMS within the required timeframe for two residents in a sample of 32. For one resident, the quarterly MDS with an ARD of 10/26/25 was 15 days overdue for transmission; the resident’s admission record listed diagnoses of chronic obstructive pulmonary disease, chronic kidney disease, and heart disease. For a second resident, the admission MDS with an ARD of 02/03/26 was nine days overdue for transmission; the resident’s admission record listed diagnoses that included pressure ulcers. During interviews on 02/19/26, the MDS Coordinator confirmed that both assessments were overdue for transmission to CMS.
Failure to Refer Residents for PASARR Level II Review After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, R8 and R97, for Level II PASARR evaluation and determination after each was identified with a new diagnosis of mental illness. Record review showed R8 was admitted with diagnoses including dementia, cognitive communication deficit, bipolar disease, major depressive disorder, and schizophrenia, and the facility’s screening dated 12/06/19 indicated R8 did not have a current serious mental illness. A later quarterly MDS with an ARD of 09/15/25 listed bipolar disorder, psychotic disorder, and schizophrenia. R97 was admitted with diagnoses of depression, anxiety disorder, and nightmare disorder, and the facility’s screening dated 02/28/23 indicated R97 did not have a current serious mental illness. A later MDS with an ARD of 12/05/25 listed PTSD. During interview, the Regional Director of Social Work stated documentation could not be found to support that a PASARR Level II referral was made for either resident. The facility policy stated that residents are screened for mental disorders, intellectual disabilities, or related disorders and, if the Level I screen indicates possible criteria, they are referred for Level II screening.
Fall Care Plan Not Updated for Wrist Brace Independence
Penalty
Summary
The facility failed to ensure the Fall Care Plan was updated to include interventions related to a fractured wrist for one resident, R20, in a sample of 32. R20 was admitted with diabetes and congestive heart failure. The record showed that on 01/06/26 the resident attempted to transfer from a wheelchair to bed, lost balance, and was found on the floor yelling that her wrist hurt. She was unable to complete range of motion because of extreme pain to the right arm, and the physician ordered transfer to the ER for evaluation and treatment. After returning to the facility, the resident had x-rays of the right elbow and right wrist and was diagnosed with a closed fracture of the right wrist. The resident was instructed to leave the splint in place until seeing orthopedics. The Fall Care Plan listed the right wrist fracture and included interventions such as pain management, sling use, therapy consult, and follow-up orthopedic appointment, but it did not include the resident’s independent ability to apply and remove the right wrist brace. During observations, the resident was seen with the wrist splint on but with the Velcro ties not connected, and later was observed removing the splint and stating that she removes it and puts it back on when she wants to. RN 1 confirmed the resident was independent in applying and removing the wrist brace, and the DON acknowledged the care plan should have been updated to include that information.
Failure to Monitor Fractured Wrist
Penalty
Summary
The facility failed to monitor a resident’s fractured right wrist for increased swelling and bruising after the resident fell while attempting to transfer from a wheelchair to bed and reported severe pain in the right arm. The resident was found on the floor yelling that her wrist hurt, could not complete range of motion due to extreme pain, and was sent to the ER after the physician was notified. Emergency medical technicians splinted the right arm before transfer. After the resident returned to the facility, records documented a closed fracture of the right wrist and instructions to leave the splint in place until orthopedic follow-up. During a later interview and observation, the resident had removed the soft splint independently; the wrist showed bruising and swelling on the back side of the wrist/forearm, and the resident denied pain. Review of the MAR and TAR showed no documentation that nursing staff monitored the wrist for increased or decreased swelling and bruising, and the RN confirmed there was no monitoring of the wrist or brace removal in the EMR. The DON stated the wrist should have been monitored.
Oxygen Given Without Current Physician Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure an active physician order for oxygen administration for one resident. The resident was admitted with chronic obstructive pulmonary disease, end stage renal disease, and Type 2 diabetes. Review of the resident’s significant change MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The care plan dated 10/06/20 and revised on 01/08/26 did not include oxygen, and the physician orders dated 01/08/26 showed no current order for oxygen. Despite the absence of a current oxygen order, observations on 02/17/26 at 1:15 PM and 02/18/26 at 8:35 AM showed the resident lying in bed using a nasal cannula with the oxygen concentrator set at 4 LPM. During interviews, an LPN and an RN both confirmed the resident was receiving oxygen and stated a resident should not receive oxygen without a physician order. The DON also confirmed the resident should not receive oxygen without a physician order and stated the resident had been in and out of the hospital and it must have been overlooked. No oxygen policy was provided by the facility.
Failure to Document Vaccine Refusal Education
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to document, when vaccines were declined, that the resident and/or representative had been educated on the risks and benefits of the influenza and pneumococcal vaccines for three residents reviewed. R2 was admitted with Alzheimer’s disease and dementia; the annual MDS showed a BIMS score of 99 and that the influenza vaccine was offered and declined. R19 was admitted with anxiety disorder and major depressive disorder; the quarterly MDS showed a BIMS score of 15 out of 15 and that both the influenza and pneumococcal vaccines were offered and declined. R20 was admitted with diabetes and heart failure; the annual MDS showed a BIMS score of 10 out of 15 and that the influenza and pneumococcal vaccinations were offered and refused. During interview, the Infection Preventionist stated they were not aware that documentation was needed when a resident or representative declines the vaccines. The facility policy titled, Pneumococcal Vaccine and Influenza Vaccine, dated August 2025, stated that the resident or representative has the right to refuse vaccines and that if refused, the date of and stated reason for the refusal are documented in the resident's medical record.
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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