Southampton Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 7246 Forest Hill Ave, Richmond, Virginia 23225
- CMS Provider Number
- 495423
- Inspections on file
- 23
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Southampton Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents dependent on assistance with ADLs, medication administration, and in one case dialysis, were discharged from the facility to an unlicensed independent living setting that provided no direct care, despite being repeatedly described by facility staff as a group home. For one resident with multiple chronic conditions, moderately impaired cognition, and a court-appointed guardian, there was no physician-documented basis for discharge, no discharge care plan, no IDT involvement, no documented guardian consent, and key chronic-condition medications and education on Trulicity self-injection were missing from the discharge summary. For the second resident with hemiplegia, ESRD on dialysis, and documented need for nursing home level of care, the record lacked evidence of discharge planning for medication administration, dialysis access management, equipment, or confirmed home health services. In both cases, the SW did not verify the destination’s services or level of care, did not visit the site, and relied on assumptions that it was a staffed group home, while the NP and nursing staff believed 24-hour care and medication administration would be provided, leading surveyors to identify an immediate jeopardy deficiency in discharge planning.
Facility staff discharged a resident with multiple chronic conditions and moderately impaired cognition to a group home without providing written notice to the court-appointed legal guardian, despite a court order granting the guardian authority over all placement decisions. The clinical record lacked a physician-documented rationale for discharge, a documented discharge plan, or evidence of guardian involvement or consent, and only contained social services notes referencing discussions with the resident and the group home. The discharge summary listed the group home address and claimed medication reconciliation was completed, but omitted several medications that a NP had documented should be continued for conditions such as CHF, diabetes, hyperlipidemia, vitamin deficiency, and prior cerebral infarction, and there was no clear evidence that discharge instructions were provided to the resident, representative, or receiving provider.
Facility staff failed to review and revise care plans and to conduct required quarterly interdisciplinary care plan reviews for two residents who were discharged from the facility. One resident with multiple chronic conditions was discharged to a group home, but the care plan continued to state the resident wished to remain LTC and was never updated to include discharge-related problems, goals, or interventions, and no care plan meetings were documented after an earlier date despite subsequent quarterly MDS assessments. Another resident with complex cardiac, neurologic, diabetic, and ESRD conditions had an active care plan focus stating a wish to remain LTC up to discharge, and although the provider documented the resident was stable for discharge to a group home with home health PT/OT, the record lacked evidence that the care plan was revised to include discharge planning, discharge location, or related education and service arrangements.
Facility staff failed to provide adequate medically related social services and discharge planning for two residents with complex medical and cognitive needs who were discharged to independent living settings. One resident, adjudicated incapacitated with a legal guardian and requiring assistance and cueing for ADLs and medication administration, was discharged to an independent apartment setting that provided no direct care, without a documented discharge plan, IDT involvement, or guardian consent, and without verification of services at the destination or education on self‑administration of medications such as Trulicity. Another dialysis-dependent resident with significant comorbidities and a care plan goal to remain LTC was discharged to an independent living facility despite provider documentation referencing a group home with home health PT/OT; the record lacked evidence of discharge planning for medication management, dialysis access care, home health arrangements, or equipment needs beyond a hospital bed, and staff interviews showed they believed the resident was going to a staffed group home rather than independent living.
Facility staff did not attempt or document non-pharmacological pain interventions before administering PRN tramadol to a resident on multiple occasions, despite facility policy and staff expectations that such measures should be tried and recorded prior to giving as-needed pain medication.
Facility staff did not consistently monitor or document blood pressure before administering Midodrine to two residents, despite physician orders and facility policy requiring vital sign checks prior to each dose. This resulted in multiple instances where the medication was given without confirming blood pressure was within prescribed parameters.
Two residents were not treated with dignity when staff prevented one from placing personal items on a window shelf, despite no safety or fire hazard, and delayed meal assistance for another resident who required total help with eating. Both residents were cognitively intact, and staff interviews confirmed the failures to honor their rights to self-determination and timely care.
A resident who was cognitively intact reported concerns about not having enough linens for care. Multiple staff, including CNAs, LPNs, and RNs, confirmed frequent linen shortages, and observation of the linen cart showed insufficient supplies for the number of residents. Staff lacked access to additional linens after the laundry aide's shift, and the facility's policy for maintaining a homelike environment with clean linens was not met.
A resident who was cognitively intact and able to make her own decisions was served grits for breakfast despite a documented dislike for this food. The resident reported frequently receiving food she dislikes, and staff interviews confirmed that food preferences are supposed to be entered into a meal tracker system and followed during meal preparation, but this process was not adhered to in this case.
Unsafe Discharges to Independent Living Without Adequate Planning or Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe, appropriate discharge planning and execution for two residents who were discharged from the facility to independent living settings that did not provide the level of care they required. For the first resident, who had resided in the facility for over three years and had multiple diagnoses including muscle wasting, diabetes, congestive heart failure, atrial fibrillation, cerebral infarction, major depressive disorder, and moderately impaired cognition, the facility discharged the resident to an apartment setting that provided no direct supervision, ADL assistance, or medication administration. The clinical record contained no documented basis from a physician or provider for the discharge, no discharge care plan with goals or identified care needs, and no evidence of interdisciplinary team involvement or care plan review related to discharge. The resident’s MDS indicated the resident did not wish to be asked about returning to the community, and the last comprehensive care plan review months earlier documented no plans to discharge. The first resident had a court-appointed legal guardian authorized to make all decisions, including living arrangements, yet there was no documentation of guardian involvement or consent for the discharge. Facility documents repeatedly referred to the destination as a “group home,” but the location was actually an unlicensed independent living apartment where residents were expected to be independent with all ADLs and where only pill reminders and optional meal preparation were offered. The social worker reported relying on information from the housing owner and did not visit or verify the setting or services, did not document guardian contact, and did not send written notice. The NP and nursing staff believed the resident was going to a licensed group home with a provider and medication administration, and the NP stated the resident required assistance with medications, cueing for hygiene, and could not effectively manage money. The discharge summary omitted several chronic-condition medications previously ordered to continue and contained no documented education on self-administration of Trulicity, despite the resident never having self-administered medications in the facility. The second resident, who had diagnoses including NSTEMI, hemiplegia and hemiparesis after cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, ESRD requiring dialysis, heart failure, and significant ADL and mobility deficits, was also discharged to the same owner’s independent living setting. The resident’s care plan and MDS documented dependence or need for assistance with toileting, bathing, transfers, mobility, dressing, grooming, and bowel incontinence, and a UAI and Medicaid authorization form indicated a need for nursing home level of care. The care plan also documented the resident’s wish to remain long-term at the facility. The discharge summary from the NP stated the resident was stable for discharge to a group home with home health PT/OT, but the clinical record contained no documented discharge planning addressing medication administration, medication education or training, dialysis access management, medical equipment needs, or confirmation that home health services were arranged. For the second resident, the social worker documented only that the resident was interested in discharging to a group home and had met with the group home representative, with no discharge date initially in place, and later noted the discharge was postponed. The social worker did not verify the level of care or services at the destination, did not visit the site, and acknowledged not knowing what services were provided, having assumed it was a group home. The owner of the receiving setting confirmed it was independent living, not licensed, with no staff providing care or medication administration, only pill reminders and meal preparation if desired. The NP and nursing staff believed the resident was going to a staffed group home with CNAs and nurses providing 24-hour care and medication administration, and the NP stated the resident could not manage medications or dialysis-related needs independently and required 24-hour care. These actions and omissions resulted in residents dependent on assistance with ADLs, medications, and in one case dialysis, being discharged to unsupervised independent living without verified support systems, documented discharge planning, or appropriate involvement of the interdisciplinary team and, for the first resident, without the legal guardian’s knowledge or consent. The surveyors determined that these failures constituted an immediate jeopardy situation related to the facility’s obligation to ensure safe, appropriate discharge planning and execution for residents transferring to lower levels of care.
Removal Plan
- Pause all discharges to a lower level of care pending interdisciplinary team (IDT) review.
- Social Services, Assistant Administrator, and Assistant Director of Nursing completed a retrospective review of all residents discharged to a lower level of care, including verifying that medication administration (including injectables) needs and ADL needs were met; residents identified at risk were contacted, reassessed, and supports/services were arranged or offered as appropriate.
- Implement a Discharge Planning Protocol requiring ongoing IDT collaboration to establish a discharge plan; a physician order aligned with the actual discharge location; resident/representative participation and consent; assessment of functional status and care needs; confirmation of medication access and ability to administer medications; and confirmed follow-up appointments and services.
- Require that residents needing assistance with ADLs, dialysis, medications, or supervision may not discharge to a lower level of care without documented support systems.
- Educate all IDT members (Administrator, Assistant Administrator, DON, ADON, Unit Managers, Business Office, Social Services, Therapy, Licensed Nurses, CNAs, and Providers) on appropriate discharge planning using the Transfer and Discharge Policy and F627 requirements, including IDT collaboration, physician order alignment with actual discharge location, resident/representative participation and consent, functional/care needs assessment, medication access/administration confirmation, and confirmed follow-up appointments/services.
- Ensure any staff not present for immediate education are educated prior to working their next scheduled shift.
- Issue phone contacts and/or letters to all residents discharged to a lower level of care.
- Implement a documented discharge protocol that includes a mandatory checklist of required items to be completed prior to any discharges to a lower level of care.
Failure to Notify Legal Guardian and Incomplete Medication Reconciliation at Discharge
Penalty
Summary
Facility staff failed to provide written notice to a court-appointed legal guardian prior to or at the time of a resident’s discharge to a group home, and failed to accurately complete medication reconciliation on the discharge summary. The resident had multiple significant diagnoses, including muscle wasting/atrophy, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, compulsive sexual behaviors, atherosclerotic heart disease, cerebral infarction, and vitamin and magnesium deficiencies. The MDS documented moderately impaired cognitive skills, need for set-up/touch assistance with ADLs, and occasional incontinence, and Section Q indicated the resident did not want to be asked about returning to the community. The clinical record also contained a court order adjudicating the resident incapacitated and appointing a guardian with authority over all decisions, including living arrangements and placement. The resident’s clinical record documented a discharge to a group home, but there was no documented involvement, consent, or notification of the legal guardian regarding this discharge. There was no documented basis or rationale from a physician or other provider for the discharge to a lower level of care, no documented discharge plan, and no documented request from either the resident or the guardian to leave the facility. Social services notes referenced discussions with the resident and the group home and identified a planned discharge date, later postponed by one day, but did not document any notification to the guardian. The discharge summary listed the group home address and included the guardian’s name and phone number, yet contained no evidence that the guardian was notified or provided written notice of the discharge, including reasons, anticipated date, or destination. The discharge summary stated that pre- and post-discharge medications had been reconciled, but it did not list all medications that were to be continued after discharge. Specifically, aspirin, atorvastatin, ferrous sulfate, spironolactone, and Trulicity were omitted from the discharge medication list, despite a nurse practitioner note indicating these medications were to be continued for treatment of cerebral infarction, hyperlipidemia, vitamin deficiency, congestive heart failure, and diabetes. It was unclear from the record whether the resident, the resident’s representative, or the receiving provider received copies of the discharge instructions. Interviews with the guardian confirmed she was unaware of the discharge until notified by a hospital social worker after the resident was found in the community, and interviews with facility staff confirmed there was no written letter or documented written notice to the guardian, and no documented discharge plan beyond the discharge summary.
Failure to Revise Care Plans and Conduct Quarterly Interdisciplinary Reviews for Discharging Residents
Penalty
Summary
Facility staff failed to review and revise comprehensive care plans and to conduct required interdisciplinary care plan reviews for multiple residents. For one resident with multiple chronic conditions including muscle wasting/atrophy, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, and prior cerebral infarction, the care plan last revised in April documented that the resident wished to remain in the facility long term, with goals stating the resident would remain LTC and interventions directing the social worker and care navigation to meet quarterly and as needed regarding the resident’s wishes to remain LTC. The resident was later discharged to a group home, but the care plan was never updated to reflect problems, goals, or interventions related to discharge to the community, despite this change in status. The same resident’s record showed that the last documented interdisciplinary care plan meeting occurred in January, while quarterly MDS assessments were completed in April and July. There was no documentation of care plan review meetings at the time of those quarterly MDS assessments. During interviews, the social worker, who was responsible for updating care plans for discharge status and scheduling care plan meetings, and the assistant administrator confirmed there were no care plan review meetings for this resident after January, and the social worker could not explain why quarterly meetings were not held. The ADON stated that care plan review meetings were supposed to be conducted quarterly around the time of required MDS assessments and that discharge plans were expected to be revised when discharge status changed, but this did not occur for the resident. For a second resident with diagnoses including NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive chronic kidney disease with stage 5 CKD or ESRD, the care plan contained an active focus area stating the resident wished to remain LTC at the facility up to the time of discharge. The discharge summary from the medical provider documented the resident was stable for discharge to a group home with home health PT and OT. However, the clinical record contained no documented evidence that the care plan was reviewed or revised to include discharge planning or the discharge location, and there was no documentation of planning for medication administration or education, dialysis access site management, medical equipment needs, or arrangement of home health services as referenced in the provider documentation. Social work notes only reflected that the resident was interested in discharging to a group home and that the discharge date was postponed, and the unit manager could not recall any care plan meeting to discuss discharge planning for this resident.
Failure to Provide Adequate Social Services and Discharge Planning for Two Residents Discharged to Independent Living
Penalty
Summary
Facility staff failed to provide medically related social services for discharge planning for two residents, resulting in discharges to independent living settings without adequate planning, IDT involvement, or guardian participation. For the first resident, who had multiple complex medical diagnoses including muscle wasting/atrophy, diabetes, CHF, atrial fibrillation, prior cerebral infarction, major depressive disorder, and moderately impaired cognition, the record showed the resident had lived in the facility for over three years and had been adjudicated incapacitated with a court‑appointed guardian authorized to make all decisions, including living arrangements. The MDS documented that the resident did not wish to be asked about returning to the community, and the comprehensive care plan last reviewed eight months before discharge indicated no plans to discharge. Despite this, the resident was discharged to what was documented as a "group home" without a documented discharge plan, without documented rationale for discharge, without a physician/provider order or basis for discharge, and without documented consent or involvement of the legal guardian. Clinical and facility documentation for this resident showed that the psychiatric NP and LCSW noted the resident talking about moving to a group home, but the physician’s recertification shortly before discharge stated the resident was appropriate for nursing home care and required significant help with ADLs, with no mention of community discharge. The social worker documented brief notes indicating discussion of discharge with the resident and the "group home" and set a discharge date, but there was no evidence of IDT care plan review or a written discharge plan identifying post‑discharge care needs, services, or goals. The discharge summary listed a group home address, noted medication reconciliation, and assigned the resident responsibility for scheduling follow‑up with a primary care provider, but left the provider’s contact information incomplete and contained no documentation of education on self‑administration of Trulicity or any other medications, despite the resident not having been assessed or trained to self‑administer injections or other medications in the facility. There was no documentation addressing access to a phone, money management, or specific community supports. Interviews with the guardian, NP, LPN, and social worker revealed that the guardian was not notified or consulted, the NP and nursing staff believed the destination was a licensed group home with medication administration and structured services, and the social worker had not verified the level of care or services at the destination, had not visited the site, and had no written description of services provided. Further investigation with the owner of the discharge destination for the first resident established that the setting was independent living apartments, not a licensed group home, and that residents were required to be independent with all ADLs, with no direct care or medication administration provided, only pill reminders and some meal prep if requested. The NP stated the resident required cueing for hygiene, assistance with medication administration, and could not effectively manage money, and that independent living was not appropriate. The guardian reported learning of the discharge only after being contacted by a hospital social worker when the resident was found on the street with belongings and brought to the ED, and stated she had never been contacted by the facility about the discharge and would have evaluated the location herself if informed. The administrator acknowledged that the guardian should have been involved and that there was no separate documented discharge plan beyond the discharge summary. The facility’s social worker job description, as reviewed by surveyors, required participation in discharge planning, development and implementation of the social care plan, involvement of the resident/family in planning goals, and regular review of discharge plans, which were not reflected in the documentation for this resident. For the second resident, who had resided in the facility for approximately three and a half years, diagnoses included NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive CKD with stage 5 CKD/ESRD requiring dialysis. The care plan contained an active focus area indicating the resident wished to remain long‑term care at the facility. The NP’s discharge summary stated the resident was stable for discharge to a group home with home health PT/OT. However, the clinical record contained no documented discharge planning addressing the resident’s needs prior to discharge, no documentation of arrangements for medication administration post‑discharge, no evidence of medication education or training, and no documented plan for management of the dialysis access site/port. There was no documentation of medical equipment needs beyond later evidence of a hospital bed setup, no evidence that home health services referenced by the provider were actually arranged, and no IDT involvement in discharge planning other than a care plan meeting note on the day of discharge. The only social services documentation for the second resident consisted of two brief notes: one indicating the resident was interested in discharging to a group home after meeting with a group home representative, and another postponing discharge to a later date, with no details on the destination, services, or identified needs. The only document listing the discharge address was an IDT care plan meeting review form on the day of discharge, which also indicated the level of care as long‑term care and showed only nursing and social services present with the resident. The owner of the receiving facility reported that the setting provided apartments and rooms as independent living, with no assistance with daily care, no medication administration, only medication reminders and some meal prep if requested, and that the facility was not licensed as any type of medical facility. Interviews with the social worker, NP, and LPN showed that the social worker stated the resident requested discharge and that she ensured dialysis transport and owner awareness, but could not provide documentation of broader discharge planning; the NP believed the resident was going to a group home described as a small nursing home with CNAs and nurses and stated she was not aware it was independent living and felt the resident needed a group home; and the LPN unit manager believed the resident was discharging to a group home with 24‑hour care. The Director of Social Services confirmed that discharge planning was a social work responsibility and should be documented in the clinical record, which was not evident for this resident.
Failure to Attempt Non-Pharmacological Pain Interventions Before PRN Medication
Penalty
Summary
Facility staff failed to implement a complete pain management program for one resident who required such services. Specifically, the staff did not attempt or document non-pharmacological interventions prior to administering PRN tramadol on multiple occasions in July and August 2024. The resident had a physician's order for tramadol 50mg every six hours as needed for pain, and the medication was administered on several dates without evidence that alternative pain management strategies were tried first. A review of the resident's clinical record, including medication administration records and nurses' notes, did not show that non-pharmacological interventions were offered or attempted before giving the as-needed pain medication. Staff interviews confirmed that such interventions, including touch, relaxation, exercise, or music, should be attempted and documented prior to administering PRN pain medication. The facility's own policy also outlined various non-pharmacological approaches that may be appropriate alone or with medications, but there was no documentation that these were utilized for the resident in question.
Failure to Monitor Blood Pressure Prior to Midodrine Administration
Penalty
Summary
Facility staff failed to monitor and document blood pressure readings prior to administering Midodrine, a medication used to treat low blood pressure, for a resident with a physician's order specifying to hold the medication if systolic blood pressure exceeded 140. The order required blood pressure checks before each dose, but clinical record review showed that on multiple occasions, blood pressure was not obtained prior to administration at scheduled times. This included several missed checks for both morning and afternoon doses across different dates. Staff interviews confirmed that blood pressure should have been checked before each administration to ensure the medication was given within the prescribed parameters. Facility policy also required verification of vital signs prior to medication administration when necessary. Despite these requirements, documentation and monitoring were not consistently performed, resulting in the administration of medication without the necessary assessment.
Failure to Promote Resident Dignity and Timely Care
Penalty
Summary
Facility staff failed to promote the dignity of two residents by not honoring their rights to self-determination and timely care. For one resident with a diagnosis including major depressive disorder and who was cognitively intact, staff instructed her not to place personal items, such as bottles of water and a stuffed animal, on a shelf in front of her room window. The resident reported being told by staff that this was not allowed, citing safety and fire hazard concerns. However, the director of maintenance confirmed that the shelf was attached to the wall and that items would not rest on the air conditioning unit, and the regional director of clinical services stated it was not a fire hazard and that residents were allowed to place items in their windows. For another resident with swallowing difficulties and a history of stroke, who was also cognitively intact and required total assistance with activities of daily living, staff failed to provide a meal in a timely manner. The resident was observed with a lunch tray on the over-bed table, stating he had not eaten and was waiting for assistance. Staff interviews revealed that meal trays for residents needing assistance were left on the cart to stay warm and distributed after other residents were served. The CNA assigned to feed the resident was delayed due to other care tasks and assumed someone else had assisted the resident when the tray was not found on the cart. Both incidents were brought to the attention of facility leadership, including the administrator, director of nursing, assistant administrator, regional director of clinical services, and regional vice president. The facility's policy affirms residents' rights to be treated with respect, kindness, and dignity, which was not upheld in these cases.
Failure to Provide Adequate Linens for Resident Care
Penalty
Summary
Facility staff failed to provide a comfortable and homelike environment for one resident by not ensuring an adequate supply of linens for resident care. The resident, who was cognitively intact and resided on the third floor, expressed concern about the insufficient availability of linens. Multiple staff members, including CNAs, LPNs, and RNs, confirmed that there was often a shortage of linens on the unit, with some stating this occurred daily. Observations of the linen cart revealed that the number of available linens was insufficient for the number of residents on the floor, and staff did not have access to additional linens after the laundry aide left for the day. The linen delivery schedule and actual cart contents showed a discrepancy between what was delivered and what was available for use, with several items in short supply. Staff interviews indicated that only laundry aides and the receptionist had keys to the laundry room, but the receptionist did not actually have access, and the laundry aide locked the room when not present. The facility's policy required clean bed and bath linens in good condition to maintain a homelike environment, but this standard was not met due to the recurring linen shortages.
Failure to Honor Resident Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's documented food dislike, specifically serving grits to a resident who had clearly indicated a dislike for this food item. The resident's annual MDS assessment showed that she was cognitively intact and capable of making her own daily decisions. Despite this, her breakfast tray was observed to contain grits, and her meal ticket also documented her dislike for grits. The resident reported that she receives food she dislikes almost every day. Interviews with dietary staff revealed that resident food dislikes are collected upon admission and entered into a computerized meal tracker system, which is supposed to generate alternative food items on the meal ticket. Staff are expected to follow these meal tickets when preparing trays. However, in this instance, the process was not followed, resulting in the resident receiving a food item she disliked. The facility's policy states that individual food preferences are to be assessed and communicated to the interdisciplinary team, but this was not effectively implemented for this resident.
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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