Nans Pointe Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Suffolk, Virginia.
- Location
- 200 West Constance Road, Suffolk, Virginia 23434
- CMS Provider Number
- 495247
- Inspections on file
- 18
- Latest survey
- April 25, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Nans Pointe Rehabilitation And Nursing during CMS and state inspections, most recent first.
Facility staff failed to maintain the fire alarm system in fully operational condition and did not implement Fire Watch according to policy, leading to an Immediate Jeopardy finding. Surveyors observed non‑working exit lights, a fire alarm panel in trouble mode, and no credible evidence of required annual testing, while the facility had been on Fire Watch for months without a dedicated, trained Fire Watch person. Multiple CNAs, LPNs, and other staff could not clearly explain why the facility was on Fire Watch, who was responsible, or the full scope of required surveillance, and Fire Watch rounds were largely limited to hallways and the building exterior rather than all risk areas. The Administrator and maintenance staff were unable to produce timely documentation of inspections, testing, or risk assessments for the fire alarm system, and the facility continued to accept new admissions while on Fire Watch, contrary to expectations outlined during the survey.
Facility leadership failed to ensure proper oversight of the fire alarm system and Fire Watch, with no evidence of fire alarm panel testing or inspections for several months while the facility remained on Fire Watch. The Administrator, newly in the role, confirmed that nursing staff primarily performed Fire Watch rounds and later identified a receptionist as the dedicated Fire Watch person but could not provide her full identification or documentation of vendor verification that the fire panel was functioning. There were no records of fire alarm functionality audits, system inspections, or maintenance program records, and the facility lacked a full-time maintenance director and a policy on administrative duties. The ongoing fire panel and smoke detector malfunctions and extended Fire Watch status were not reported to the QAPI committee, despite QAPI materials listing maintenance and fire safety items for review.
The governing body failed to ensure effective oversight and implementation of policies related to the fire alarm system and Fire Watch, resulting in prolonged Fire Watch across all units without clear documentation or monitoring. The Administrator, who was newly appointed, could not initially explain the exact fire panel issue, provide vendor service reports, or show evidence of fire alarm testing, inspections, or maintenance records, and the fire alarm panel was observed in trouble mode for multiple units. The facility lacked a full‑time maintenance director, and the ongoing fire alarm and smoke detector problems, as well as the extended Fire Watch status, were not brought to the QAPI committee despite maintenance and life safety items being listed on the QAPI agenda. There was no documented process or evidence of communication between the Administrator and the governing body regarding these life safety issues or of the governing body’s involvement in QAPI oversight as required by facility policy.
Staff failed to involve the QAPI committee in identifying and overseeing serious life safety deficiencies related to a malfunctioning fire alarm system and prolonged Fire Watch on all units. The facility had been on Fire Watch for months, with staff making frequent rounds to look for smoke or fire, yet the Administrator could not clearly explain the long-standing issue, provide maintenance or vendor documentation, or show that the fire panel, smoke detectors, and exit signage problems were evaluated through QAPI. Although monthly QAPI meetings were reportedly held, there was no evidence that these fire safety issues were discussed, monitored, or tracked, and the Administrator acknowledged they should have been reported to QAPI but were not.
Facility staff did not post the most recent survey results in an accessible location, instead keeping the report in a drawer by the receptionist and only providing a sign stating it was available upon request. This deficiency was confirmed through observation and staff interviews.
A resident with an infected diabetic foot ulcer did not receive any doses of a prescribed IV antibiotic despite the medication and IV access being available. The initial dose was missed without explanation, and subsequent doses were not given due to a dislodged IV that was not promptly replaced. The antibiotic was discontinued before administration, and facility leadership did not comment on the incident.
A resident with an infected diabetic foot ulcer had abnormal wound culture results indicating multiple pathogens, but staff did not promptly notify the NP as required. The results were available in the electronic system and should have been identified during routine chart checks, but the oversight was not recognized for several days, delaying practitioner notification and subsequent medical intervention.
A resident with significant neurological impairments and dependence in daily activities did not receive timely OT, PT, and ST evaluations as ordered by a physician. Facility staff failed to initiate therapy evaluations within the required timeframe due to miscommunication about therapy orders and insurance coverage, resulting in delayed treatment and increased risk for decline.
Staff did not follow infection prevention protocols by failing to post Enhanced Barrier Precautions signage for a resident with a PEG tube who was sharing a room with another resident on Contact Precautions for an infected diabetic foot ulcer. The required precautions and cohorting practices were not implemented until after the issue was identified during a survey.
Failure to Maintain Functional Fire Alarm System and Proper Fire Watch Implementation
Penalty
Summary
The deficiency involves the facility’s failure to maintain the fire alarm system in fully operational condition and to implement Fire Watch in accordance with its own policy and Life Safety Code requirements. During a Life Safety Inspection, surveyors observed three non‑operational exit lights, a fire alarm panel in trouble mode, and no credible evidence of annual fire alarm system testing. The acting maintenance director reported that the alarm trouble condition had been ongoing for about a week. The facility had been on Fire Watch since at least late January, but there was no dedicated Fire Watch person assigned at the time of the Life Safety Inspection; instead, nursing staff were informally making rounds. The Administrator later acknowledged that the facility had been on Fire Watch for months and that the fire alarm system had been “touch and go” since the end of the prior year. Staff interviews from multiple departments showed inconsistent understanding of Fire Watch, its purpose, and who was responsible for it. Several CNAs, LPNs, and other staff members stated that Fire Watch meant someone walked around every 15 minutes or so to look for smoke or fire, but many did not know who was currently on Fire Watch or why the facility was on Fire Watch. Staff reported they had not received formal training specific to Fire Watch, and some said they were only told to be more alert and to walk the halls and outside the building. The Director of Social Services and the MDS RN also confirmed that nursing staff had been performing Fire Watch because they were present 24/7, but they did not know the exact reason for Fire Watch. The Maintenance Assistant stated that the fire panel was malfunctioning and beeping frequently, that the facility had been on Fire Watch for a long time, and that replacement of the fire panel would not occur until mid‑summer. The Administrator, who had recently started in his role, confirmed that the facility was on Fire Watch and that nursing staff had been performing the rounds while also carrying out their regular duties. He was unsure of the exact issue with the fire alarm system and could not initially provide credible evidence of fire alarm inspections, testing, or maintenance records when requested. Review of the fire maintenance binder showed Fire Watch logs dating back to late January, but the Administrator could not explain why Fire Watch had been in place that long. He also stated that the facility did not have a full‑time maintenance director and that he was not aware of any risk assessment being completed on the malfunctioning fire panel, despite a facility policy requiring risk assessments for building systems. During observation with the Maintenance Assistant, the fire panel was seen in trouble mode for multiple units, and the Maintenance Assistant silenced the beeping without taking further action or indicating any steps to investigate the trouble conditions. The facility’s written Fire Watch policy required continuous and systematic surveillance by trained personnel, with duties including searching diligently for fires, controlling ignition sources, ensuring egress routes and fire protection features were available and functioning, and documenting patrols. However, interviews and observations showed that Fire Watch activities were limited mainly to walking hallways and the building exterior, without consistent attention to areas such as laundry, kitchen, resident rooms, cook surfaces, dryers, smoking materials, and janitor closets with flammable liquids. Staff were often unaware of the full scope of Fire Watch responsibilities described in the policy. The facility continued to accept new admissions while on Fire Watch, and there was no evidence that the malfunctioning fire panel or prolonged Fire Watch status had been brought to the facility’s QAPI committee. The surveyors determined that failure to maintain a functional fire alarm system and to conduct Fire Watch according to policy created a hazardous environment and resulted in an Immediate Jeopardy determination, later reduced in scope and severity after immediacy was addressed. Further review showed that the facility had remained on Fire Watch for approximately three months without evidence of re‑inspection or testing of the fire panel until a fire alarm system inspection and test were performed near the end of the survey period. A third‑party event history record later provided by corporate plant operations leadership showed ongoing communication between the fire panel and the monitoring company, but this information, along with earlier vendor service reports and Fire Watch notices from local fire authorities, had not been available or presented to surveyors during the initial investigations. The lack of a full‑time maintenance director and the newness of the Administrator were cited by corporate representatives as reasons why these documents were not produced when first requested. Throughout this period, interviews and document review demonstrated that Fire Watch was not consistently implemented in accordance with the facility’s own ASHE Fire Watch Procedure, and not all staff had been educated on Fire Watch procedures, emergency procedures, and response expectations at the time of the initial Immediate Jeopardy determination.
Failure of Administrative Oversight for Fire Alarm System and Fire Watch
Penalty
Summary
Facility leadership failed to ensure effective systems were in place to maintain a safe, hazard-free environment and to integrate these issues into QAPI activities across all three units. During a complaint investigation and extended survey, staff could not provide evidence that fire alarm panel testing and inspections had been conducted since 1/30/26. The Administrator, who had been in the role since 3/30/26, confirmed the facility was on Fire Watch but was unsure of the exact reason, stating only that a Life Safety inspector had identified a malfunctioning fire panel during an inspection on 4/15/26. Fire Watch logs dating back to 1/30/26 showed the facility had been on Fire Watch for several months, yet the Administrator could not explain why it had been in place since January or provide documentation that the fire alarm system had been tested or inspected during that period. The Administrator reported that Fire Watch duties were primarily performed by nursing staff, who were already in the building 24/7, and that a Life Safety inspector had later instructed the facility to assign a dedicated person to Fire Watch who could not perform other tasks. At the time of the survey, the Administrator identified the receptionist by first name as the person currently on Fire Watch but could not recall her last name. He stated that the fire alarm vendor had recently verified the panel was functioning but could not provide any visit report or other credible evidence of this verification, and he had no records of fire alarm functionality audits, system inspections, or maintenance program records. The facility did not have a full-time maintenance director, and the Administrator acknowledged that the ongoing fire panel and smoke detector malfunctions and prolonged Fire Watch status had not been brought to the QAPI committee, despite the QAPI agenda including maintenance items such as fire drill logs, disaster drill logs, monthly fire alarm tests, and maintenance tracking. The facility also lacked a policy addressing administrative duties, and no additional information was provided at the exit meeting.
Governing Body Failed to Ensure Oversight of Fire Alarm System and Fire Watch
Penalty
Summary
The deficiency involves the governing body’s failure to ensure effective leadership, policy implementation, and operational systems to maintain a safe, hazard‑free environment on all three units while the facility was on Fire Watch. Surveyors found that the facility had been on Fire Watch since 1/30/26 due to issues with the fire alarm system, yet the Administrator, who started on 3/30/26, could not clearly explain the exact problem with the fire panel or provide contemporaneous documentation of the malfunction or its monitoring. During an interview, the Administrator stated that Fire Watch consisted of someone making rounds every 15 minutes, primarily nursing staff, and acknowledged that the facility did not have a full‑time maintenance director. When surveyors requested evidence on 4/24/26 of the fire panel’s functionality, fire alarm system inspections, testing, or maintenance records, the Administrator was unable to produce any such documentation, including vendor service reports or audit records. He also could not initially provide documentation from the fire safety vendor verifying that the panel was functioning, and he did not present any evidence of communication from the local Fire Marshal or Fire and Rescue Department regarding Fire Watch. The fire alarm panel was observed in trouble mode for specific units, and the explanation given by regional leadership later was that the issue related to sensitivity and the age of the system, but this information and supporting documents were not available or presented at the time of the initial surveyor request. The governing body’s policies required it to be legally responsible for establishing and implementing policies for management and operation of the facility, including appointment and oversight of the Administrator and accountability for QAPI. However, there was no evidence that the governing body was involved in QAPI activities related to the ongoing fire panel and smoke detector issues or the prolonged Fire Watch status since January. The Administrator confirmed that the fire alarm and Fire Watch issues had not been brought to the QAPI committee, despite the QAPI agenda format including maintenance items such as fire drills, disaster drills, monthly fire alarm tests, and use of the TELS system. No evidence was provided to show a defined process of communication between the Administrator and the governing body regarding these life safety problems or that the Administrator was being held accountable for reporting and managing these operational issues.
Failure to Use QAPI to Address Prolonged Fire Alarm Malfunction and Fire Watch
Penalty
Summary
Facility staff failed to use the Quality Assurance and Performance Improvement (QAPI) committee to identify and oversee serious safety deficiencies related to a malfunctioning fire alarm system and prolonged Fire Watch on all three units. During a complaint investigation and extended survey, surveyors determined that the facility had been on Fire Watch since 1/30/26 due to fire alarm panel and related system malfunctions, yet there was no credible evidence that these issues were reported to or addressed by the QAPI committee. The Administrator, who began in the role at the end of March, confirmed the facility was on Fire Watch but was unsure of the exact cause, stating only that a Life Safety inspector had identified a malfunctioning fire panel during a mid-April inspection. Interviews and document reviews showed that Fire Watch rounds had been documented since 1/30/26, with staff making rounds approximately every 15 minutes to look for signs of smoke or fire. Initially, nursing staff performed Fire Watch duties while also carrying out their regular responsibilities, and only later was a dedicated person assigned to Fire Watch per the Life Safety inspector’s directive. The Administrator could not clearly explain why Fire Watch had been in place since January, reported that the fire alarm system had been “touch and go” since late 2025, and stated that the vendor had recently verified the panel was functioning, but he was unable to provide any visit reports, audit records, or maintenance program documentation to substantiate this. Further review of QAPI activities revealed that, although monthly QAPI meetings were reportedly held and attendance sheets existed for several recent meetings, there was no evidence that the malfunctioning fire panel, nonfunctioning smoke detectors, exit signage issues, or the ongoing Fire Watch had been discussed or monitored by the QAPI committee. The Administrator produced a QAPI action plan for a broken exit door and a blank agenda/minutes form listing maintenance-related items such as fire drill logs and fire alarm tests, but he had no supporting documentation showing that identified tasks were completed or that the fire alarm deficiencies were addressed. He also lacked evidence of quarterly QAPI meetings or medical director participation, and he acknowledged that the fire panel and Fire Watch issues should have been reported to QAPI but were not.
Failure to Publicly Post Survey Results
Penalty
Summary
Facility staff failed to post the most recent survey results in a location that was readily accessible to residents, family members, and legal representatives. During observations, a sign in the lobby indicated that the inspection report was available upon request, but no actual posting of the survey results was observed. Staff interviews revealed that the survey results book was kept in a drawer by the receptionist rather than being publicly displayed. These findings were confirmed during the survey and shared with facility leadership, with no additional information provided by staff.
Failure to Administer Ordered IV Antibiotic for Infected Foot Ulcer
Penalty
Summary
Facility staff failed to administer a prescribed intravenous (IV) antibiotic to a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with activities of daily living, had a deteriorating foot wound with increased edema and purulent drainage. After laboratory results identified multiple organisms in the wound, a wound care nurse practitioner ordered IV Linezolid to begin on a specific date, with the medication and IV access available at the scheduled start time. Despite these preparations, the resident did not receive any doses of the antibiotic as ordered. The initial dose was missed even though the IV access and medication were ready, and subsequent doses were not administered due to the IV being dislodged and not promptly replaced. Nursing notes indicated ongoing delays, and the antibiotic was ultimately discontinued on the recommendation of a consulting physician before any doses were given. Facility leadership was informed of these findings and did not provide comments or express concerns during the final interview.
Failure to Promptly Notify Practitioner of Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the ordering practitioner of abnormal laboratory results for a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with daily activities, had a wound specimen collected due to increased edema and purulent drainage. The laboratory results, which identified the presence of Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis in the wound, were sent to the facility but were not communicated to the nurse practitioner until several days later. The delay in notification occurred despite the facility's process for lab result review, which includes making results viewable on the Point-Click-Care system dashboard and requiring the overnight shift to conduct a 24-hour chart check to identify any oversights. The oversight was not recognized until several days after the results were received, at which point the practitioner was notified and appropriate medical interventions were ordered. The facility's policy requires prompt reporting of positive culture results to the practitioner, but this was not followed in this instance.
Delayed Therapy Evaluation Due to Missed Orders and Miscommunication
Penalty
Summary
Facility staff failed to provide a timely specialized therapy evaluation for a resident who was admitted with significant neurological impairments, including cerebral infarction and hemiplegia. The resident was dependent in multiple activities of daily living and had a physician's order for Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) evaluations upon admission. Despite this standing order, the initial therapy evaluations were not initiated until several weeks after admission, contrary to facility policy which required evaluations to be completed within two days of a referral. Interviews with staff revealed confusion and miscommunication regarding the resident's therapy orders and insurance status. The Director of Rehabilitation stated that no therapy orders were present initially, and therapy evaluations did not begin until nearly a month after admission. The Business Office Manager clarified that the resident had Medicare Part B as a therapy payor source, but there was a misunderstanding at admission regarding insurance coverage, which contributed to the delay in therapy services. The resident and her spouse reported that therapy services were not provided as expected, with the spouse stating that the facility social worker informed them that therapy could not be initiated due to insurance issues. The resident experienced significant pain and required assistance with mobility, as observed during the survey. Facility policy and staff interviews confirmed that the therapy evaluation order was missed, resulting in delayed treatment and placing the resident at higher risk for decline.
Failure to Implement Enhanced Barrier Precautions and Proper Cohorting
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by improper implementation of Enhanced Barrier Precautions (EBP) and cohorting practices. A resident with an infected diabetic foot ulcer, confirmed to be colonized with multiple organisms including Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis, was placed under Contact Precautions. However, the resident's roommate, who had a PEG tube and therefore met criteria for EBP, did not have appropriate EBP signage posted. This omission was observed during a facility tour, and staff interviews confirmed that the required precautions were not in place for the roommate. The Unit Manager acknowledged the error, stating that after consultation with the Infection Preventionist, it was determined that the two residents should not have been cohorted together. The roommate was subsequently moved, and EBP signage was posted, but these actions occurred only after the deficiency was identified. The facility's own infection prevention and control policy required all staff to follow established procedures, which was not adhered to in this instance, resulting in a lapse in infection control practices.
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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