Lynn Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Front Royal, Virginia.
- Location
- 1000 Shenandoah Avenue, Front Royal, Virginia 22630
- CMS Provider Number
- 495316
- Inspections on file
- 20
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Lynn Care Center during CMS and state inspections, most recent first.
Multiple residents experienced repeated physical abuse from other residents, primarily on a memory care unit, including being struck in the face, head, shoulder, arm, and mouth, having hair pulled, and being knocked to the floor. These altercations typically occurred in common areas while residents were wandering or seated, often when one resident became agitated about personal space or perceived a need to protect staff. Many involved residents had cognitive impairment and could not recall the events, though staff and other residents sometimes witnessed the incidents and documented assessments showing either no injury or minor findings such as bruising or redness. Despite these documented episodes and staff acknowledgment that such conduct constitutes abuse under the facility’s abuse policy, the comprehensive care plans for the abused residents did not include information about the incidents or individualized approaches to address the abuse or prevent recurrence, resulting in an immediate jeopardy determination.
Facility staff failed to provide adequate supervision to two high-risk residents, one with severe dementia and a long history of unpredictable physical aggression who repeatedly assaulted other cognitively impaired residents on the memory care unit, causing facial and eye injuries, and another with severe cognitive impairment, poor standing balance, and documented need for substantial to maximal assistance who was left alone on the toilet by a CNA and subsequently found on the bathroom floor with a hip fracture and intracranial hemorrhage, despite a care plan directing staff not to leave the resident alone in the room.
The facility failed to revise comprehensive care plans for four residents who were repeatedly abused by the same resident on a memory care unit. Facility documentation and nursing notes described multiple episodes in which one resident, who became agitated when others entered her personal space or touched staff, struck other residents in the face or mouth with her hand or objects, sometimes leaving visible marks or bruising. Although psychosocial support visits were documented and the residents often had no recall of the events, their existing care plans contained no information about these abuse incidents. Interviews with the social services director, an RN, and a unit manager LPN confirmed that care plans should be updated for any victim of abuse, and facility policy required review and updating of care plans when needs or preferences change, but this was not done for the affected residents.
Sanitary Food Handling and Equipment Cleaning Deficiencies: Surveyors observed kitchen aides placing resident lunch trays while one aide was not wearing a hair net and another did not have his mustache covered. They also found prepared food items in refrigerators without dates and a food processor with leftover food debris, while the dietary manager stated hair restraints should always be worn, food should be dated, and equipment should be checked after washing to ensure it was clean.
Failure to Preserve Resident Dignity During Feeding Assistance: A resident with swallowing difficulties and severe cognitive impairment was observed receiving breakfast assistance from a CNA who was standing next to the bed. The CNA later acknowledged she should have been sitting while helping with the meal and stated it was not dignified for the resident to stand and feed them.
A facility failed to maintain a clean, homelike environment for two residents. One resident had a fan in the room with dust fibers and dried residue inside the cage while it was being used at bedside, and staff said housekeeping only cleaned the outside unless maintenance took it apart. Another resident’s room smelled strongly of urine on admission, with a stained carpet and repeated attempts by EVS to scrub the room, but the odor remained and the room was described as not homelike.
Failure to timely report resident-to-resident altercations: A resident was involved in two altercations with another resident, including one where the roommate reported being punched in the face and another where the resident struck a peer in the face with a padded sewing box. The facility’s abuse policy required reporting abuse allegations within 2 hours, but state agency notification was documented the next day for both events. Staff interviews confirmed they knew these incidents had to be reported immediately and within 2 hours, and the DON stated the incidents were probably not brought to her attention until the next day.
Failure to Timely Report Abuse Allegations: A resident was involved in two resident-to-resident altercations in which one roommate reported being punched and another resident was struck in the face with a padded sewing box. Facility records showed the abuse allegations were not reported to the state agency within the required 2-hour timeframe, and the DON stated the incidents were probably not brought to her attention until the next day.
A resident was discharged home with family, alert and oriented and without acute distress, but the facility did not notify the LTC ombudsman of the discharge. The DOSS stated she only sent monthly ombudsman notifications for residents transferred or discharged to the hospital and did not send notices for residents discharged or transferred elsewhere, saying she was not aware this was required.
Facility staff failed to obtain a Level I PASARR before admission for two residents. One resident was Medicare admitted and cognitively intact with a BIMS of 15/15, but the record did not show the required screening was completed. Another resident admitted with cerebral atherosclerosis and unspecified dementia also had no documented Level I PASARR, and staff could not provide one when requested. The DON and social services staff described that admissions normally obtained the PASARR from the hospital and used a checklist to verify completion.
Respiratory care was not provided in a sanitary manner for two residents. One resident who required trach care and EBP was observed receiving trach care from a respiratory therapist who wore gloves but no gown or mask, and who did not change gloves or sanitize hands between dirty and clean steps. Another resident with CPAP for sleep apnea had a nasal mask repeatedly left uncovered in the bed or on the bedside table instead of being stored in a bag, and an LPN stated it needed to be bagged to prevent contamination.
The facility failed to complete annual performance evaluations for two CNAs reviewed. Records showed the most recent evals for both CNAs were outside the required annual timeframe, and HR stated that employee performance evaluations should be completed annually and that she was trying to get all evaluations up to date. The facility policy required job performance reviews at least annually after the 90-day probationary period.
Missing Contract for Wound Care Consultant: Facility staff failed to maintain a written agreement for the contracted wound care company. During contract review, the wound care agreement could not be located, and the regional director of operations stated the facility normally keeps signed agreements on site but was unable to find this one. The issue was discussed with the administrator, DON, and regional leadership.
Failure to follow infection control procedures during tracheostomy care for a resident on EBP and standard precautions. A respiratory therapist wore gloves but did not don a gown or mask, then removed soiled gauze and continued care without removing gloves or sanitizing hands before cleansing the stoma and replacing clean gauze. Staff interviews and facility policy stated that EBP requires gown and glove use, and trach care requires a mask when splashing or spraying of body fluids is likely.
Facility staff failed to provide required resident rights training for a dietary contract employee whose education record showed only abuse training. HR stated contract staff receive an orientation packet with required trainings before starting work, but the record review confirmed the resident rights training was not completed.
A dietary contract employee’s education record did not show the required QAPI training. HR staff stated the employee had only received abuse training, while the regional HR director said contract staff receive an orientation packet with required trainings completed before work begins. After record review, HR staff acknowledged the QAPI training was missing.
A dietary contract employee did not have evidence of required infection control training in the personnel record. HR staff stated the employee only received abuse training, while the regional HR director said contract staff receive an orientation packet with required trainings completed before starting work.
A dietary contract staff member did not have documentation of the required compliance and ethics training in the education record reviewed by the surveyor. HR stated the staff member only received abuse training, while the regional HR director said contract staff are supposed to receive an orientation packet with required trainings completed before starting work. The missing training was confirmed during the record review, and facility leadership was notified.
A dietary contract employee did not have evidence of the required behavioral health training in the personnel record. HR stated the employee only received abuse training, while the regional HR director said contract staff receive an orientation packet with required trainings completed before starting work. After record review, HR confirmed the required behavioral health training had not been completed.
Two residents did not receive multiple prescribed medications at scheduled times due to unavailability following their admissions. Staff documented that medications were on order or not available in the facility's Omnicell system, and the process for obtaining medications from an out-of-state pharmacy led to delays. Required notifications and documentation were inconsistently completed, resulting in missed doses for both residents.
Facility staff did not notify physicians or responsible parties when multiple residents missed scheduled medication doses due to unavailability, despite documentation in the MAR and progress notes indicating the medications were on order or not available. Nursing staff interviews confirmed the expectation to communicate and document such events, but records showed this was not done.
Staff failed to administer prescribed medications and supplements to two residents as ordered, documenting them as unavailable or on order from the pharmacy, even though interviews and observations confirmed that Banatrol and Ferrous Sulfate were stocked and accessible in the facility.
The facility failed to update the care plans for two residents after they were moved to a secured dementia unit. The care plans, which were outdated, did not reflect the residents' current living situations or needs. Interviews with facility staff confirmed that the care plans should have been updated, as required by the facility's policy.
A resident's physician order for compression wraps was not clarified, leading to improper application. The order lacked specificity on the type of wrap, causing confusion among LPNs, who used different wraps, some of which were not compression wraps. The facility's policy requires clarification of such orders, but this was not done.
Three residents with cognitive impairments eloped from a facility due to inadequate supervision and unsecured exits. One resident fell outside, another was found in a garden area, and a third reached a private residence. The facility's failure to secure doors and properly assess elopement risks contributed to these incidents.
Failure to Prevent and Care Plan Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, primarily on the memory care unit, over an extended period. Resident-on-resident altercations repeatedly occurred in which one resident struck, hit, pulled hair, or otherwise physically contacted another resident, often involving the same aggressor. For example, one resident repeatedly struck other residents in the face, head, shoulder, arm, and mouth, and pulled another resident’s hair while they were seated in the dining room. In many of these events, staff documented that the aggressor resident became agitated or combative, particularly when other residents were in her personal space, when she perceived staff as needing protection, or immediately after receiving care. The clinical records and final event synopses show that affected residents were typically seated in common areas such as the dining room or wandering on the memory care unit when they were struck or otherwise physically abused. In several cases, staff or other residents witnessed the incidents and separated the residents, and progress notes documented assessments showing either no visible injury or minor findings such as a small red spot on the nose, bruising to the upper lip, or a fall to the floor after being hit on the shoulder. Many of the residents involved had cognitive impairment and were unable to recall the incidents when interviewed afterward, though one resident later described being “whacked” across the face. Staff interviews acknowledged that residents on the memory care unit wander, can become easily agitated, and are especially vulnerable due to cognitive status and limited ability to communicate symptoms. Across all cited residents, the comprehensive care plans in place at the time of the incidents did not contain information related to these episodes of resident-to-resident abuse. Care plans for residents who were struck, hit, or had their hair pulled lacked any documentation of the abuse incidents or individualized approaches addressing these behaviors or the residents’ vulnerability to further altercations. This absence of care plan interventions was noted for multiple residents who experienced one or more abusive encounters, including those who were struck on more than one occasion by the same aggressor. Facility staff, including nursing and social services personnel, stated in interviews that any willful striking, hitting, smacking, or hair-pulling by one resident toward another constitutes physical abuse and that residents have the right to be free from abuse, consistent with the facility’s written abuse policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. In addition to the repeated incidents involving a primary aggressor on the memory care unit, other residents were abused by different residents who became combative when their personal space was invaded. In these cases, staff witnessed residents being hit on the arm or chest and a resident being struck on the shoulder, causing a loss of balance and a fall. Progress notes documented that affected residents were assessed and often had no recall of the negative encounters. Despite these documented events and staff recognition that such conduct constitutes abuse, the corresponding care plans for the abused residents did not reflect the incidents or any related information. The pattern of resident-to-resident physical abuse, combined with the lack of care plan documentation addressing these events, formed the basis of the cited deficiency and led to a determination of immediate jeopardy for residents on the memory care unit.
Removal Plan
- Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
- Provide follow up psychosocial support from social services to Residents #58, #94, #25, #13, #41, and #68.
- Screen all residents for evidence of abuse and neglect.
- Complete an abuse questionnaire for residents who are interviewable (BIMS score of 8 or greater).
- Complete a head to toe physical assessment for non-verbal residents or residents with a BIMS score of 7 or below.
- Address any identified concerns according to the HVHC Abuse and Neglect Policy.
- Conduct an audit of all incident reports for the last 30 days to ensure that all events meeting the reporting requirements were reported to the appropriate parties.
- Reeducate all staff of the facility/agency on the HVHC Abuse and Neglect Policy, including abuse prevention, types of abuse, abuse reporting, and the Elder Justice Act specifically pertaining to resident to resident altercations.
- Require any staff not present for the education to receive mandatory education prior to the start of their next shift.
- Prohibit staff from returning to work until the mandatory education has been completed.
- Include this training in new hire orientation as part of the new hire process.
- Require all agency staff to complete this education prior to starting work in the facility.
- Provide reeducation to facility leadership (NHA, DON, social services, activities) on abuse reporting and investigating allegations of abuse and resident altercations.
Failure to Adequately Supervise Aggressive and High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and care to prevent accidents for residents with known behavioral and fall risks. One resident with non-Alzheimer’s dementia, depression, severe cognitive impairment, and a long history of physical aggression toward others repeatedly assaulted other cognitively impaired residents on the memory care unit. Despite documented episodes of hitting, grabbing, throwing objects, wandering into other residents’ rooms, and striking residents with fists and objects, the resident continued to wander and interact with others on the unit without consistently implemented, sustained close supervision. Facility documentation showed multiple resident-to-resident altercations over many months, including incidents where the resident struck others in the face and head, sometimes causing visible injuries such as redness to an eye and bruising on the bridge of the nose. Clinical records, change-in-condition notes, and psychiatry progress notes described this resident as having recurrent, sometimes unprovoked, violent outbursts triggered by perceived threats to possessions, food, or personal space, and as being unpredictable and increasingly aggressive toward both staff and residents. Staff statements indicated that the resident could ambulate independently but required someone to walk with them due to fall risk, and that the resident had a history of hitting other residents. However, supervision practices on the memory care unit were described as having staff stationed in the common area and CNAs rounding on rooms every couple of hours, rather than continuous or 1:1 supervision for this resident despite the pattern of aggression. Nursing staff acknowledged that repeated resident-to-resident assaults constituted abuse and that repeated incidents indicated residents were not being adequately supervised. A second deficiency involved another resident with dementia, severe cognitive impairment, poor standing balance, and high fall risk who sustained a fall with serious injury. This resident’s MDS, therapy evaluations, and fall risk assessments documented substantial to maximal assistance needs for sit-to-stand and transfers, poor standing balance, impulsivity when standing, and a fall risk score above the facility’s threshold for being at risk. The resident’s care plan included an intervention instructing staff not to leave the resident alone in the room. On the night of the incident, a CNA assisted the resident onto the toilet in the resident’s bathroom, then left the resident alone on the toilet with the bathroom door closed while physically redirecting the roommate to another bathroom. When the CNA returned after this brief absence, the resident was found on the bathroom floor complaining of right hip and elbow pain, with contusions noted to the right elbow and side of the head. Hospital evaluation confirmed a right hip fracture and intracranial hemorrhage. This sequence of events demonstrates that the resident was left unsupervised during a high-risk toileting transfer despite known fall risk and documented need for close assistance, resulting in a fall and serious injury.
Removal Plan
- Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
- Conduct an audit of Point of Care behavior documentation to ensure that residents identified with aggressive behaviors have interventions and care plans in place to provide adequate supervision.
- Reeducate all staff of the facility/agency on the HVHC Safety and Supervision of Residents Policy.
- Require all staff to complete mandatory education prior to the start of their next shift.
- Do not allow any staff member to return to work until the mandatory education has been completed.
- Include this training in new hire orientation as part of the new hire process.
- Require all agency staff to complete this education prior to starting work in the facility.
Failure to Revise Care Plans After Repeated Resident-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans for multiple residents after substantiated resident-to-resident abuse incidents involving the same aggressor. Facility records, including final synopses of events and progress notes, documented that one resident repeatedly struck or otherwise physically contacted other residents on the memory care unit, typically when others entered her personal space or touched staff she was interacting with. Despite these documented abuse events and follow-up psychosocial support visits, the comprehensive care plans for the abused residents did not contain any information related to the incidents or any updated approaches following the altercations. For one resident, an event synopsis dated in February described that she was struck on the right side of her face by another resident who became combative on the memory care unit. Staff who frequently cared for both residents reported that both wandered throughout the unit and that the aggressor could become agitated and combative when residents were in her personal space. A progress note documented a support visit related to the altercation, during which the abused resident was unable to recall the event but stated she felt safe and happy. However, review of her comprehensive care plan, dated the prior month, showed no information related to this abuse incident. Another resident experienced multiple separate incidents with the same aggressor in April. Facility synopses and nursing notes documented that the aggressor allegedly struck this resident in the face and nose after the resident got into the aggressor’s personal space and food, and on another occasion punched her in the upper lip after the resident grabbed a CNA’s arm. Notes described small red marks and later separation of the residents, but the comprehensive care plan, dated in February, contained no entries related to these abuse incidents. Similarly, a third resident was documented as being hit on the right side of her face by the same aggressor after the aggressor became combative in the bathroom area; progress notes described assessment and a follow-up visit related to a negative encounter with another resident, but her care plan, dated in March, lacked any abuse-related information. A fourth resident had at least two documented abuse incidents with the same aggressor. In June, progress notes recorded that she was sitting in her wheelchair when the aggressor approached and hit her in the face with a comb; assessment at that time showed no injuries, and a support visit later that day documented that she had no recall of the encounter and stated she felt safe. In November, another incident was documented in which the aggressor hit her in the face with a padded box after she gently touched the aggressor’s arm; subsequent notes recorded bruising to the upper lip and a follow-up visit where the resident did not recall the negative encounter or provide information about her comfort level among others. Review of her comprehensive care plan, dated the previous December, revealed no information related to any of these abuse incidents. Interviews with facility staff confirmed that the care plans for these abused residents were not updated after the incidents. The director of social services stated she is responsible for following up on psychosocial needs after resident-to-resident altercations and that the abused resident’s care plan should be updated after any such event. A registered nurse explained that the care plan is used to ensure all care team members provide appropriate care and that it should be updated for any victim of abuse, noting that unit managers ordinarily update care plans. A unit manager LPN stated that care plans should be updated after an incident of abuse because such an event could trigger a trauma response, and that floor nurses do not typically update care plans. The facility’s own policy on comprehensive person-centered care planning stated that the interdisciplinary team is responsible for reviewing and updating care plans when there has been a significant change in condition or when goals, needs, and preferences change, yet the care plans for the four residents remained unrevised regarding the documented abuse events.
Sanitary Food Handling and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to prepare, store, and serve food in a sanitary manner in the kitchen. During observation of the tray line, two kitchen aides were placing resident lunch trays, but one aide was not wearing a hair net and the other did not have his mustache covered. In the reach-in refrigerator, surveyors observed two trays containing 78 cups of pasta salad with no date showing when the salads were prepared. In the dairy refrigerator, a container with about six ounces of pureed turkey and another with about eight ounces of sliced ham were also found without dates. Surveyors also observed a food processor on a preparation table with the lid sitting upside-down on the bowl, and both the lid and inside of the bowl had leftover food debris. When asked how to determine whether the food processor was clean and ready for use, the dietary manager stated the lid would be turned upside-down on the bowl, but after the debris was observed she stated it was not clean and directed a kitchen aide to remove it for washing. The dietary manager later stated that hair nets and beard or mustache coverings should always be worn in the kitchen, that prepared and leftover food should be dated, and that the food processor should have been checked after washing to ensure it was clean.
Failure to Preserve Resident Dignity During Feeding Assistance
Penalty
Summary
Facility staff failed to promote the dignity of Resident #45 during feeding assistance. Resident #45 had diagnoses including swallowing difficulties and, on the most recent comprehensive MDS with an ARD of 11/07/2025, scored 3 out of 15 on the BIMS, indicating severe cognitive impairment for daily decision-making. GG0130 Self-Care coded the resident as requiring moderate assistance for eating. On 01/06/2026 at approximately 9:15 a.m., an observation showed CNA #3 standing next to the resident's bed while assisting with breakfast. During an interview later that morning, CNA #3 stated she was standing while feeding the resident and that she should have been sitting while assisting with the meal, adding that it was not dignified for the resident to stand and feed them.
Unclean Room Conditions and Dirty Fan
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents. For one resident who was severely impaired in making daily decisions, staff observed an approximately 20-inch floor fan in the room that was being used while the resident was in bed. The fan cage had dust fibers and a dried brown/gray substance on the inside, and the condition remained the same during repeated observations. An LPN stated nursing did not clean the fan and that housekeeping was responsible, while the environmental services supervisor stated housekeeping only wiped the outside of the fan and did not clean the inside cage or blades unless maintenance took it apart. A work order to clean the inside of the fan was created later, and no prior evidence of cleaning was provided. For another resident admitted on a Saturday, the resident’s son filed a grievance that the room smelled of urine all weekend and that staff addressed it by opening windows, leaving the resident cold. The grievance record noted the room issue was investigated and that affected carpet would be removed, the floor bleached, and an area rug applied. The environmental services supervisor stated the roommate had been urinating on the carpet, the room smelled very strongly of urine when the resident and family arrived, and the carpet stain was not new. She said she scrubbed the carpet, removed curtains, scrubbed the walls, and briefly opened the window, but the odor remained and the room was not a homelike environment.
Failure to Timely Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse policy for timely reporting of abuse allegations involving Resident #99. The policy stated that alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made when the event involves abuse or results in serious bodily injury. Clinical record review showed that on 10/24/2025 at 9:30 PM, a change in condition note documented that another resident stated R99 was going through her drawers and was aggressive toward her when she asked R99 to stop. A nursing note at the same time documented that the roommate stated R99 punched her in the face. The facility synopsis of events listed an initial report date of 10/25/2025, and the fax confirmation showed the state agency was notified at 8:35 AM on 10/25/2025. The record also showed a second resident-to-resident altercation on 11/2/2025 at 8:56 PM, when R99 was documented as hitting another resident in the face with a padded sewing box after the other resident reached out and gently touched her. Both residents were assessed and no injuries were noted, and all parties were notified. The facility synopsis of events listed an initial report date of 11/3/2025, with fax confirmation showing state agency notification at 10:50 AM on 11/3/2025. During interviews, an LPN stated resident-to-resident altercations were to be immediately separated, assessed, and reported because they had to be reported. A CNA stated such incidents were to be reported to the charge nurse immediately and that she knew they had to be reported within 2 hours. The DON stated staff were supposed to report within 2 hours and said the incidents on 10/24/2025 and 11/2/2025 were probably not brought to her attention until the next day.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report an abuse allegation to the state agency within the required time frame for one resident involved in resident-to-resident altercations. Documentation showed that on 10/24/2025, a roommate reported that the resident was going through her drawers and became aggressive when asked to stop, with a nursing note stating the resident punched the roommate in the face. On 11/2/2025, another resident-to-resident altercation was documented in which the resident hit another resident in the face with a padded sewing box after the other resident reached out and gently touched her; both residents were assessed and no injuries were noted. Facility records showed the initial reports were dated the day after each incident, with fax confirmations sent at 8:35 AM on 10/25/2025 for the first event and 10:50 AM on 11/3/2025 for the second event. Interviews with staff indicated that resident-to-resident altercations were to be immediately separated, assessed, and reported up the chain of command, and that such incidents were supposed to be reported within two hours. The DON stated the incidents on 10/24/2025 and 11/2/2025 were probably not reported to her until the next day.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility staff failed to notify the long-term care ombudsman of the discharge of Resident #119. The clinical record documented that the resident was discharged to home via the family’s car, was alert and oriented at the time of discharge, had no acute distress noted, and left the facility accompanied by family with all belongings taken. Review of the record did not show evidence that the ombudsman was notified of the discharge. During interview, the director of social services stated that monthly notifications were sent to the ombudsman for residents transferred or discharged to the hospital, but notifications were not sent for residents discharged or transferred to other facilities, and she stated she was not aware that this was required.
Failure to Complete PASARR Level I Screening Before Admission
Penalty
Summary
Facility staff failed to obtain a Level I PASARR prior to admission for two residents. For one resident, the most recent MDS annual assessment with an ARD of 12/11/2025 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for daily decisions. The resident had been admitted under Medicare, but the clinical record did not show that a Level I PASARR was completed before admission. When asked on 01/12/2026, the regional director of clinical services stated the PASARR Level I had not been completed for this resident. For a second resident, the clinical record also did not evidence a completed Level I PASARR prior to admission. The resident was admitted with diagnoses including cerebral atherosclerosis and unspecified dementia. Staff were unable to provide a Level I PASARR when requested, and the regional director of clinical services stated it was not available. The director of social services stated the hospital should complete the Level I PASARR before admission and that admissions normally obtained it from the hospital and used a checklist to verify completion, but if it was not done before admission, she could complete it.
Respiratory equipment and tracheostomy care were not maintained in a sanitary manner
Penalty
Summary
The facility failed to provide respiratory care and services in a sanitary manner for two residents. One resident was in a persistent vegetative state and required an invasive mechanical ventilator and tracheostomy care. During observed tracheostomy care, a respiratory therapist donned gloves before entering the room but did not wear a gown or mask. The therapist removed soiled gauze with gloved hands and did not remove the gloves or sanitize hands before cleansing around the stoma or replacing clean gauze. The resident also had an order for enhanced barrier precautions. Facility staff interviews stated that enhanced barrier precautions require gloves and a gown, and that tracheostomy care also requires a mask because of the risk of bodily fluids being sprayed into the air. Staff further stated that gloves should be changed and hands sanitized between handling dirty and clean gauze around a tracheostomy. The facility policy for tracheostomy care stated that a mask and eyewear will be worn if splashes, spattering, or spraying of blood or body fluids is likely, and that soiled gloves should be removed before applying clean gloves to clean the stoma and apply clean gauze. For another resident with sleep apnea who was ordered CPAP at bedtime, the CPAP nasal mask was repeatedly observed lying uncovered in the bed or on the bedside table, and no storage bag was present. An LPN observed the uncovered mask and stated it was not covered and needed to be placed in a bag to prevent contamination. The resident’s MDS coded the resident as cognitively intact and as having a non-invasive mechanical ventilator.
Annual CNA Performance Evaluations Not Completed
Penalty
Summary
The facility failed to complete annual performance evaluations for two of five CNA records reviewed, CNA #5 and CNA #6. Facility staff did not provide evidence of a required annual performance evaluation within the past 12 months for either employee. CNA #5's most recent performance evaluation was dated 11/27/2024, and CNA #6's most recent performance evaluation was dated 03/05/2024. On 01/09/2026, the surveyor requested the most recent performance evaluations for CNA #5 and CNA #6, and the records were reviewed on 01/12/2026. During a telephone interview on 01/12/2026, OSM #11, human resources, stated that employee performance evaluations should be completed annually and that she was trying to get all performance evaluations up to date. The facility policy stated that the job performance of each employee shall be reviewed and evaluated at least annually, with evaluations completed after the 90-day probationary period and at least annually thereafter.
Missing Contract for Wound Care Consultant
Penalty
Summary
The facility failed to maintain written agreements for contracted wound care services. During document review, staff were asked to provide contracts for hospice, dialysis, mobile X-ray, mobile laboratory, dental, podiatry, ophthalmology/optometry, wound care, and psych services, but the review of facility contracts did not reveal an agreement for the contracted wound care company. The facility's policy stated that written, signed, and dated agreements are to be maintained for each consultant or consulting group. During an interview, the regional director of operations stated that when services are initiated with an outside company, the facility has the company sign an agreement and keeps it at the facility, but he was unable to locate the wound care contract. On the same day the findings were discussed, the administrator, DON, regional director of clinical services, and regional director of operations were made aware of the missing agreement, and no further information was provided prior to exit.
Failure to Follow Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to follow infection control procedures for one resident who was coded on the most recent MDS as being in a persistent vegetative state and as requiring an invasive mechanical ventilator and tracheostomy care. During observed tracheostomy care, a respiratory therapist donned gloves before entering the room and began care without putting on a gown or mask. He used gloved hands to remove soiled gauze around the resident’s tracheostomy and did not remove those gloves or sanitize his hands before cleansing around the stoma or replacing clean gauze around the opening. The resident had a provider order dated 9/22/25 for enhanced barrier precautions. Facility staff interviews stated that enhanced barrier precautions require gloves and a gown, and that tracheostomy care also requires a mask because of the risk of bodily fluids being sprayed into the air. The facility policy for tracheostomy care directed staff to wear a mask and eyewear if splashes, spattering, or spraying of blood or body fluids was likely, and to remove old dressings, discard soiled gloves, apply clean gloves, clean the stoma, and then apply a fenestrated gauze pad. The facility policy for enhanced barrier precautions stated that gown and glove use are to be used with standard precautions during high-contact resident care activities for residents with wounds and/or indwelling medical devices.
Missing Resident Rights Training for Contract Dietary Staff
Penalty
Summary
Facility staff failed to provide required resident rights training for one of five staff records reviewed, OSM #8, a dietary contract employee. On 01/09/2026, the surveyor requested OSM #8's education records, and on 01/12/2026 the record review showed no evidence of the required resident rights training. During a telephone interview on 01/12/2026, human resources staff stated that OSM #8 was a contract employee and only received abuse training, while the regional director of human resources stated that all contract employees receive an orientation packet from the facility's HR department that contains the required trainings and that the training is completed before the employee starts working. After reviewing the record, human resources staff acknowledged that OSM #8 had not received the required resident rights training. Later that day, the administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.
Failure to Provide Required QAPI Training
Penalty
Summary
Mandatory training on the facility’s QAPI program was not provided for one of five staff records reviewed, specifically OSM #8, a dietary contract employee. During review of OSM #8’s education record, surveyors found no evidence of the required QAPI training. In interviews, HR staff stated that OSM #8 was a contract employee and had only received abuse training, while the regional HR director stated that all contract employees receive an orientation packet containing required trainings completed by HR before they start work. After the record review, HR staff acknowledged that OSM #8 had not received the required QAPI training. The administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.
Missing Infection Control Training for Contract Dietary Staff
Penalty
Summary
The facility failed to provide required infection control training for one of five staff records reviewed, OSM #8, a dietary contract employee. On 01/09/2026, the surveyor requested OSM #8's education records, and on 01/12/2026 the record review showed no evidence of the required infection control training. During interviews on 01/12/2026, human resources staff stated that OSM #8 was a contract employee who only received abuse training, while the regional director of human resources stated that all contract employees receive an orientation packet from the HR department containing required trainings completed before work begins. After review of the record, human resources staff acknowledged that OSM #8 had not received the required infection control training. The administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.
Missing Compliance and Ethics Training for Contract Dietary Staff
Penalty
Summary
Facility staff failed to provide the required training on compliance and ethics for one of five staff records reviewed, OSM #8, a dietary staff member and contract employee. On 01/09/2026, the surveyor requested OSM #8's education records, and on 01/12/2026 the record review showed no evidence of the required compliance and ethics training. During a telephone interview on 01/12/2026, OSM #11, HR, stated that OSM #8 was a contract employee and only received abuse training, while OSM #7, regional director of HR, stated that all contract employees receive an orientation packet from the facility's HR department containing the required trainings and that HR completes the training before the employee starts working. After the record was reviewed, OSM #11 stated that OSM #8 had not received the required training on compliance and ethics. Later that day, ASM #1, administrator, ASM #2, DON, ASM #3, regional director of clinical services, and ASM #4, regional director of operations were informed of the findings.
Missing Required Behavioral Health Training for Contract Dietary Staff
Penalty
Summary
Behavioral health training was not provided for one of five staff records reviewed, OSM #8, a dietary contract employee. During record review, the surveyor requested OSM #8's education records and found no evidence of the required behavioral health training. In interviews, human resources staff stated that OSM #8 was a contract employee who only received abuse training, while the regional director of human resources stated that contract employees receive an orientation packet containing required trainings completed by HR before they start work. After review of the record, human resources staff confirmed that OSM #8 had not received the required behavioral health training. The administrator, DON, regional director of clinical services, and regional director of operations were informed of the findings.
Failure to Ensure Timely Availability of Medications for New Admissions
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident, multiple medications including Pantoprazole, Amantadine, Diltiazem, Docusate, Levetiracetam, Oxybutynin, Vimpat, Tizanidine, and Propranolol were not available for scheduled administration times following admission. Documentation in the medication administration record (MAR) and nurse's notes indicated that these medications were on order, not available in the facility's Omnicell system, or awaiting delivery from the pharmacy. The resident was admitted in the afternoon, and the medications were expected to arrive during the night, but several doses were missed as a result of the delay. For another resident, staff did not ensure the availability of Sennoside, Budesonide, Humulin 70/30, and Glycopyrrolate for scheduled administration. The MAR and progress notes documented that these medications were on order and not available at the time they were due. The resident arrived at the facility in the evening, and several doses of the prescribed medications were not administered over multiple days due to unavailability. Interviews with an LPN revealed that the process for obtaining medications for new admissions involved entering orders into the computer system, which then sent them to an out-of-state pharmacy. If medications were not available at the time of administration, staff were expected to check the Omnicell, contact the pharmacy, and, if necessary, reach out to the provider for alternative orders or to hold the medication. The facility's policy required staff to notify the attending physician and document all actions taken. Despite these procedures, the medications were not available for timely administration, and the required notifications and documentation were inconsistently completed.
Failure to Notify Physician and Responsible Party of Missed Medication Administration
Penalty
Summary
Facility staff failed to notify physicians and responsible parties when prescribed medications were not available and subsequently not administered to multiple residents. For one resident with a G-tube and complex medical needs, including gastrostomy status, seizures, hypertension, constipation, and bladder spasms, several medications were missed over multiple days. Documentation in the medication administration record (MAR) indicated the medications were not given and referenced progress notes, which showed the medications were on order or unavailable. However, there was no documentation that the physician or responsible party was informed of these missed doses, despite facility policy requiring such notification. Another resident, who required medications for diarrhea and anemia, also experienced missed doses due to unavailability. The MAR and nurse's notes documented that the medications were not available and had been ordered from the pharmacy, but again, there was no evidence that the physician or responsible party was notified of the missed administrations. In one instance, a nurse practitioner was notified, but there was no documentation of communication with the responsible party. A third resident, with orders for medications related to bowel regimen, respiratory failure, diabetes, and secretions, also did not receive several scheduled doses due to medication unavailability. The MAR and nurse/respiratory therapist notes indicated the medications were on order or not available, but there was no documentation of notification to the physician or responsible party. Interviews with nursing staff confirmed the expectation to notify both the provider and responsible party and to document these actions, but this was not reflected in the records reviewed.
Failure to Administer Medications as Ordered Despite Availability
Penalty
Summary
Facility staff failed to administer medications and supplements as ordered by physicians for two residents. For one resident, Banatrol and Ferrous Sulfate were not given according to the prescribed schedule. The medication administration records (MAR) showed missed doses, with documentation codes indicating the medications were not available or other issues, and nurse's notes confirmed that the medications were reported as unavailable and on order from the pharmacy. However, interviews with staff revealed that both Banatrol and Ferrous Sulfate were actually available as floor stock or in storage areas, and observations confirmed the presence of these medications in the facility. For another resident, Banatrol was not administered as ordered. The MAR indicated missed doses, with codes for 'Other/See Progress Notes' and 'Hold See Progress Note.' Nurse's notes again cited the medication as being on order from the pharmacy. Staff interviews and observations confirmed that Banatrol was stocked in multiple locations within the facility and had not run out. The facility's policy requires that every effort be made to ensure medications are available to meet residents' needs. Despite this, the staff did not administer the medications as ordered, even though the medications were present in the facility. The deficiency was brought to the attention of the administrator, DON, and regional nurse consultant.
Failure to Update Care Plans for Residents in Secured Dementia Unit
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #2, the care plan was not updated when the resident was moved to a secured dementia unit. The existing care plan, dated nearly two years prior, identified the resident as an elopement risk and included interventions such as frequent rounding and the use of a wander guard. However, the care plan did not reflect the resident's new living situation in the secured unit, which was confirmed as an expectation by both the Director of Nursing and the unit manager during interviews. Similarly, for Resident #3, the care plan was outdated and did not address the resident's placement in a secured dementia unit. The care plan, last revised several months prior, noted the resident's history of wandering and resistance to care, as well as a risk for falls. Despite an incident where the resident was found outside in a vulnerable position, the care plan lacked updates to reflect the resident's current needs and environment. Interviews with facility staff confirmed that the care plan should have been updated to include the resident's placement in the secured unit. The facility's policy on care planning requires updates to care plans when there are significant changes in a resident's condition or environment, among other criteria. The failure to update the care plans for these residents was acknowledged by the facility's administrative staff, including the administrator and the regional director of clinical operations, during the survey process. No additional information was provided before the survey exit.
Failure to Clarify Physician's Order for Compression Wraps
Penalty
Summary
The facility staff failed to follow professional standards of practice for a resident by not clarifying a physician's order for the application of compression wraps. The resident, who was not cognitively impaired, had a physician's order dated July 5, 2023, for bilateral lower legs to be wrapped with compression wraps once a week for six months to address edema. However, the order did not specify the type of compression wrap to be used. Interviews with several LPNs revealed that there was confusion about the type of wrap to use, with some using kling wrap, which is not considered a compression wrap, and others suggesting the use of Kerlix or ace wraps. The facility's policy requires clarification of orders that do not specify details, but this was not done in this case. The deficiency was identified during a survey when interviews with LPNs and a review of the facility's documentation showed that the order for compression wraps was not clear and had not been clarified with the prescribing practitioner. The facility's administrative staff, including the administrator, director of nursing, and regional director of clinical operations, were made aware of the issue. Despite the facility's policy on clarifying incomplete orders, the lack of clarification led to the improper application of compression wraps for the resident, which was not in accordance with professional standards of practice.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent elopement for three residents, leading to incidents where residents left the facility unsupervised. Resident #2, who was severely impaired in making daily decisions, managed to exit the building and fell on the pavement outside. Despite having a wander guard, the resident was able to leave through a door that was opened by a visitor. The resident had a history of falls and was identified as an elopement risk, yet the interventions in place were insufficient to prevent the incident. Resident #3, also severely impaired in decision-making, was found outside in the garden area of the secured dementia unit after falling. The resident had a history of wandering and falls, and the garden doors were not consistently locked, allowing the resident to access the area unsupervised. The care plan noted the resident's tendency to wander and the need for supervision, but the lack of secured access to the garden area contributed to the incident. Resident #4, moderately cognitively impaired, left the facility and was found at a private residence across the parking lot. The resident was not previously identified as an elopement risk, and the door used for exit was not adequately secured, allowing the resident to leave unnoticed. The resident's care plan did not address elopement risk until after the incident, highlighting a gap in the facility's assessment and monitoring processes.
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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