South Roanoke Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Roanoke, Virginia.
- Location
- 3823 Franklin Rd, Sw, Roanoke, Virginia 24014
- CMS Provider Number
- 495002
- Inspections on file
- 12
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at South Roanoke Nursing And Rehabilitation during CMS and state inspections, most recent first.
A food service aide with visible facial hair was observed preparing food without a beard net, in violation of facility policy requiring hair restraints during food preparation. The acting director of food and nutrition was present and confirmed the requirement for beard coverage.
Facility staff did not have written procedures to ensure the availability of both drinkable and non-drinkable water in the event of a loss of normal water supply. The Administrator described a verbal plan for water provision, but this was not documented, and emergency water storage was insufficient. The agreement with a water delivery company did not guarantee supply during high demand and did not address non-drinkable water needs.
Staff failed to accurately complete MDS assessments for several residents, including not documenting PRN pain medication use, unplanned weight loss, hospice care, and functional limitations, as well as incorrectly coding restraint use. These errors were identified through record review and staff interviews, revealing discrepancies between clinical documentation and MDS coding.
Facility staff did not consistently develop or implement care plans that reflected residents' documented preferences, such as declining oral suction and oxygen, nor did they ensure required safety interventions like Dycem for fall prevention or two-person assist for mechanical lift transfers were followed. These deficiencies affected residents with varying cognitive abilities and medical complexities, resulting in unmet needs and unaddressed safety measures.
Facility staff did not document required discussions or education with residents or their representatives regarding refusal of treatments such as oral suction and oxygen, as indicated on advance directive forms. Additionally, staff failed to complete advance directive forms according to instructions, using checkmarks or Xs instead of initials for 21 residents.
Facility staff did not provide written notification of the reason for transfer or discharge to a resident with severe cognitive impairment and their representative prior to a hospital transfer, as required. Documentation confirming that the notification was given could not be located when requested by surveyors.
Facility staff did not accurately identify or assess a significant change in a resident's condition, specifically failing to document a 6.1% unplanned weight loss in the MDS assessment. Despite clinical records noting the weight loss, the MDS was incorrectly coded, and the issue was confirmed during staff interviews and record review.
A resident with severe cognitive and physical impairments, dependent on staff for transfers, was transferred by a CNA using a mechanical lift without a second staff member and with the wrong size lift pad. This failure to follow the care plan and facility policy resulted in the resident slipping from the lift pad and falling to the floor.
Facility staff did not perform or document neuro-checks and vital signs as ordered by a medical provider for a resident with severe cognitive impairment after a fall. The required assessments were missed during one interval, with staff noting the resident was sleeping, and no assessment data was available for that time.
Staff failed to provide adequate supervision and appropriate assistive devices for two residents with significant cognitive and physical impairments. One resident was transferred using an incorrectly sized lift pad and without the required second staff member, resulting in a fall, while another resident did not have the prescribed Dycem non-slip material in the wheelchair and was observed transferring independently despite being care planned for assistance.
Staff did not consistently provide or document oxygen therapy as ordered for a resident with advanced respiratory conditions. The resident's oxygen was administered at varying flow rates, and staff followed hospice instructions to titrate oxygen without ensuring proper documentation in the clinical record. There were also gaps in recording oxygen usage and flow rates, leading to a deficiency in respiratory care.
Failure to Ensure Consistent Use of Beard Nets During Food Preparation
Penalty
Summary
Facility staff failed to consistently prevent hair from contacting food in the kitchen, as observed during food preparation. Specifically, a food service aide with visible facial hair was seen preparing residents' food trays without wearing a beard net, despite the presence of the acting director of food and nutrition. When questioned, the director acknowledged that the aide should have had their facial hair covered and instructed the employee to apply a beard net at that time. The facility's policy on employee hygiene and sanitary practices requires that hair nets or beard restraints be worn when cooking, preparing, or assembling food to prevent hair from contacting exposed food, clean equipment, utensils, and linens. The deficiency was identified through direct observation and confirmed by staff interviews and review of facility policy documents. No information about residents' medical history or condition was included in the report.
Lack of Written Procedures for Emergency Water Supply
Penalty
Summary
Facility staff failed to develop and maintain written procedures to ensure the availability of water in the event of a loss of the normal water supply. During the survey, it was found that there were no documented processes addressing both drinkable and non-drinkable water needs for the facility. The Administrator verbally reported a plan to provide 64 ounces of water per day for three days for all residents and staff, but this plan was not documented. Observations revealed that the facility's emergency water storage consisted of only 60 gallons, and while there was an agreement with a water delivery company, the documentation from the company did not guarantee supply during high demand and did not address non-drinkable water needs. The surveyor reviewed the facility's emergency preparedness program and found it lacked written policies detailing how water needs would be met during a water outage. The documentation provided by the water delivery company only estimated purified drinking water needs and did not include recommendations for non-drinkable water. During a meeting with facility leadership, the absence of a written process for both drinkable and non-drinkable water provision in the event of a water supply loss was discussed.
Inaccurate MDS Assessments for Pain Management, Weight Loss, Hospice, Restraint, and Range of Motion
Penalty
Summary
Facility staff failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents, resulting in several deficiencies. For one resident with multiple chronic conditions and severe cognitive impairment, staff did not accurately code the administration of PRN pain medication and failed to document a significant unplanned weight loss on the MDS, despite clear evidence in the medical record and medication administration records. Another resident receiving hospice care was not coded as such on the admission MDS, even though provider orders and the care plan indicated active hospice services. Additionally, a resident was incorrectly coded as using a limb restraint on a quarterly MDS assessment, although no restraint was observed and staff confirmed this was an error. In another case, two MDS assessments for a resident with severe cognitive impairment inaccurately documented functional limitations in lower extremity range of motion, which was inconsistent with other assessments and not supported by clinical findings. These deficiencies were identified through review of clinical records, medication administration records, and staff interviews. The surveyors found that the facility staff did not follow the Centers for Medicare & Medicaid Services Resident Assessment Instrument (RAI) guidelines for accurate MDS coding, leading to discrepancies between the residents' actual clinical status and what was documented in the MDS assessments.
Failure to Implement Comprehensive, Person-Centered Care Plans and Interventions
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans that addressed residents' specific preferences and needs, as documented in their advance directives and clinical records. Several residents had clearly stated wishes to decline certain treatments, such as oral suctioning and oxygen, particularly in end-of-life care situations. Despite these documented preferences, the care plans for these residents did not include interventions reflecting their choices. For example, multiple residents with advance directives explicitly refusing oral suction and oxygen did not have these preferences incorporated into their care plans, even though their cognitive status and ability to participate in care planning varied from severely impaired to cognitively intact. In addition to failures in care planning related to advance directives, the facility did not ensure that specific safety interventions were implemented as outlined in residents' care plans. One resident, identified as high risk for falls, had an intervention for Dycem (a non-slip material) to be used in their wheelchair, but repeated observations showed the Dycem was not present. Staff were unaware of the missing intervention and speculated that the resident may have been removing it, but no alternative intervention was documented or implemented at the time of the survey. Another resident, dependent on staff for transfers and requiring a two-person assist with a mechanical lift, experienced a fall during a transfer when only one staff member was present. The care plan clearly stated the need for two staff during mechanical lift transfers, and facility policy reinforced this requirement. The staff member involved admitted to performing the transfer alone due to perceived staffing shortages, which was contradicted by staffing records. These failures demonstrate a lack of adherence to individualized care plans and facility policies, resulting in unmet resident needs and unaddressed safety risks.
Failure to Document Advance Directive Discussions and Properly Complete Forms
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for 21 of 24 sampled residents, specifically regarding documentation of advance directives and related communications. In multiple cases, staff did not document verbal communication with residents or their representatives about the reasons for refusing treatments such as oral suction and oxygen, as indicated on advance directive forms. Additionally, there was no documentation that education was provided to residents or their representatives about the consequences or potential outcomes of refusing these treatments, despite facility policy requiring such documentation. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, had an advance directive indicating refusal of oral suction and oxygen. However, there was no evidence in the clinical record of staff assessment or documentation of the reasons for this refusal, nor of any education provided to the resident or representative about the implications of these choices. Similar deficiencies were found for other residents, including those who were cognitively intact, where staff failed to document the required discussions and education related to advance directive decisions. Furthermore, the facility staff did not ensure that advance directive forms were completed according to the form's instructions. Instead of having the individual providing the information initial the desired areas, staff marked the forms with checkmarks or Xs. This failure to follow documentation procedures was identified for 21 residents. These deficiencies were confirmed through interviews with residents, family members, and staff, as well as reviews of clinical records and facility policies.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
Facility staff failed to provide written notification of the reason for transfer or discharge to a resident and the resident's representative prior to a hospital transfer. The deficiency was identified through staff interviews, clinical record review, and facility document review, which revealed that no evidence of written notification was present for the transfer that occurred on 4/3/25. When requested by the surveyor, administrative staff confirmed that they could not locate documentation showing that the required notification had been given. The resident involved had multiple diagnoses, including osteoarthritis, Alzheimer's disease, hypertension, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease stage 3, and a history of digestive system surgery. The most recent assessment indicated severe cognitive impairment, with a BIMS score of 6 out of 15. Despite these factors, there was no documentation that the resident or their representative received written notification regarding the transfer, as required.
Failure to Identify and Assess Significant Weight Loss
Penalty
Summary
Facility staff failed to accurately identify and assess a significant change in a resident's physical condition using the Resident Assessment Instrument (RAI) process. Specifically, a resident with multiple diagnoses, including osteoarthritis, Alzheimer's disease, hypertension, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease stage 3, and a history of digestive system surgery, experienced a 6.1% weight loss over thirty days. Despite this, the comprehensive Minimum Data Set (MDS) assessment did not reflect the significant weight loss, as Section K0300 was coded to indicate no weight loss of 5% or more in the last month. A nurse's progress note documented the significant weight loss, but this information was not incorporated into the MDS assessment. During a staff interview, an LPN acknowledged that the MDS should have been coded as a significant change assessment due to the unplanned weight loss and that the weight loss should have been recorded. The deficiency was identified through clinical record review, staff interview, and facility document review, and was discussed with facility leadership prior to survey exit.
Failure to Follow Mechanical Lift Protocols Resulting in Resident Fall
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for one resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, dementia, generalized muscle weakness, and a history of falls, was assessed as severely cognitively impaired and dependent on staff for transfers. The resident's care plan specified that transfers should be performed using a mechanical lift with the assistance of two staff members and the correct size lift pad. However, during a transfer from chair to bed, a CNA used a lift pad with four loops instead of the required medium/purple six-loop pad and performed the transfer alone, contrary to facility policy and the resident's care plan. As a result of these actions, the resident slipped through the lift pad and fell to the floor. Staff interviews confirmed that the CNA did not wait for a second staff member and used the incorrect lift pad size. Documentation and staff statements indicated that the correct lift pad size was listed at the nurse's desk and that the unit was not short-staffed at the time of the incident. Facility policy required two staff for mechanical lift transfers and proper sling sizing, but these procedures were not followed, leading to the resident's fall.
Failure to Complete and Document Ordered Neuro-Checks and Vital Signs
Penalty
Summary
Facility staff failed to perform and document neuro-checks and vital signs as ordered by a medical provider for one resident following a fall. The resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, had provider orders for neuro-checks and vital signs every four hours. Documentation on the medication administration record (MAR) showed that these assessments were not completed at the 4:00 a.m. interval, with staff noting the resident was sleeping instead. No assessment findings or data for this missed check were found or provided to the surveyor. Facility policy required that neuro-checks be performed and documented as ordered, including specific neurological and vital sign assessments. During interviews, the Director of Nursing confirmed that the resident should have been woken up to complete the required assessments. The failure to complete and document the neuro-checks and vital signs as ordered was discussed with facility leadership during surveyor meetings.
Failure to Prevent Accidents Due to Inadequate Supervision and Assistive Devices
Penalty
Summary
Facility staff failed to ensure that two residents received appropriate assistance and assistive devices to prevent accidents. For one resident with hemiplegia, dementia, generalized muscle weakness, and a history of falls, staff used an incorrectly sized mechanical lift pad and performed a transfer with only one staff member instead of the required two. During the transfer, the resident slipped from the lift pad and fell to the floor. The staff member then moved the resident from the floor to the bed before a nurse could assess for injuries, contrary to facility policy. The resident was dependent on staff for transfers and was care planned for two-person assistance with a mechanical lift and the correct size lift pad, but these interventions were not followed at the time of the incident. Another resident, who had diagnoses including traumatic subdural hemorrhage, Parkinsonism, dementia, and repeated falls, did not have Dycem non-slip material in the wheelchair as specified in the care plan. This resident was severely cognitively impaired, dependent on staff for transfers, and had a recent history of multiple falls. During multiple observations, the resident was seen transferring independently and walking without assistance, and the required Dycem was not present in the wheelchair. Staff were unaware of the missing Dycem and could not provide an explanation at the time of the survey. Facility policies required at least two staff for mechanical lift transfers and the use of properly sized lift pads, as well as individualized fall prevention interventions. In both cases, staff did not follow established protocols and care plan interventions, resulting in preventable incidents involving residents at high risk for falls and injury.
Failure to Consistently Provide and Document Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to consistently provide and document respiratory care for a resident with multiple respiratory diagnoses, including lung cancer, COPD, emphysema, and respiratory failure. The resident was cognitively intact and had a physician's order for oxygen at 8 LPM via nasal cannula, with instructions to remove for ADLs. The care plan and electronic medication administration record reflected this order. However, observations revealed the oxygen concentrator was set at varying levels (3, 5, and 6 LPM) rather than the prescribed 8 LPM, and staff reported following hospice guidance to titrate oxygen down, though no corresponding order was found in the clinical record at the time of survey. Documentation in the resident's clinical record was inconsistent, with oxygen flow rates and usage not always recorded, and gaps in data for several weeks. Hospice notes indicated attempts to decrease oxygen, but the official order to titrate oxygen was not entered into the facility's record until after the surveyor's inquiry. Staff interviews revealed confusion about the current orders, with reliance on verbal or faxed instructions from hospice that were not properly documented. This lack of consistent documentation and adherence to physician and hospice orders led to the identified deficiency.
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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