Woodmont Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fredericksburg, Virginia.
- Location
- 11 Dairy Lane, Fredericksburg, Virginia 22405
- CMS Provider Number
- 495246
- Inspections on file
- 20
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Woodmont Center during CMS and state inspections, most recent first.
Staff failed to consistently develop and implement comprehensive care plans for multiple residents, resulting in undocumented or omitted interventions for pain management, catheter care, fluid restriction, transfers, activities, dialysis communication, mobility, and bathing. Cognitively intact and impaired residents with pain did not have non-pharmacological interventions documented as required. Residents with indwelling catheters and ESRD lacked complete intake/output, catheter care, and fluid restriction monitoring despite physician orders and care plan directives. Other residents who required maximal assist or mechanical lifts for transfers were not consistently documented as being transferred, and one resident reported not being offered to get out of bed daily. A resident who valued voting and religious practice was not assisted to vote and had to request chaplain visits, while another on dialysis lacked consistent dialysis communication documentation. One resident with an OT-ordered hand splint had no corresponding care plan entry, and another dependent resident received fewer showers than the twice-weekly schedule specified in the care plan and described by staff. Staff interviews confirmed that care plans are intended to guide care, that missing documentation means care was not provided, and that the interdisciplinary team is responsible for updating and implementing care plans.
Staff failed to consistently provide and document ADL care, including bathing, transfers, and grooming, for several dependent residents. One resident who required assistance with bathing received far fewer showers than the twice-weekly schedule, despite being in the facility most days. Another cognitively intact resident who depended on a mechanical lift was rarely transferred out of bed over several months, while documentation often showed "not applicable" or no transfer entries. A third resident needing maximal assist for transfers had numerous days across all shifts with missing transfer documentation, which a CNA acknowledged meant the care likely did not occur. A dependent resident with advanced MS and keloids was observed with significant facial hair and reported waiting for a family member to bring an electric shaver, while therapy notes and staff interviews showed ongoing distress and lack of grooming assistance. Another severely cognitively impaired, fully dependent resident was observed in bed throughout multiple survey observations and was not transferred to a wheelchair, with the assigned CNA citing time constraints and a mistaken belief that therapy had said the resident did not need to get up.
Facility staff failed to follow professional standards for food storage, preparation, and sanitation in the kitchen and on a resident hallway. Surveyors observed dirty food-contact equipment, improperly stored dry goods, and wet pans stacked and dripping in clean storage areas. Hot foods were held and served below the facility’s stated minimum of 135°F. Expired milk cartons were placed on breakfast trays and in the milk supply on a hallway, with both dietary and nursing staff not identifying the out-of-date product. In the kitchen, a pizza cutter that had fallen to the floor and other utensils, trays, and dome lids were inadequately sanitized, with submersion times far below the one-minute contact time required by the sanitizer manufacturer, and some items not fully submerged. A dietary staff member also used a soiled utility cart and contaminated gloves to handle both dirty and clean dishware without cleaning the cart between uses, contrary to facility policy.
Facility staff failed to provide or offer scheduled showers or bed baths to a cognitively intact resident who required partial/moderate assistance with bathing. Although the shower schedule listed bathing on specific weekdays during the day shift, ADL documentation over multiple days showed entries coded as not applicable or not attempted, with some shifts left blank, and no evidence that bathing was provided or offered. A CNA who routinely cared for the resident confirmed the scheduled shower days and, upon review of the ADL records, acknowledged not knowing why the resident did not receive showers or bed baths and that there was no documentation that these were offered.
A resident with DM, Parkinson’s disease, dementia, adult FTT, severe cognitive impairment, and dependence for bed mobility and transfers was care planned as at risk for falls, with interventions including bed rails as an enabler and two-staff assistance for repositioning in bed. An agency CNA who had been at the facility about a week provided care without ensuring the low air loss mattress was in static mode, and the resident subsequently fell from bed and complained of left knee pain. Imaging showed a possible subtle distal femoral fracture. The DON described the resident as a one-person assist who held onto the bedrail and was alert but confused, and the facility’s falls policy required individualized interventions based on risk factors, which were not properly implemented in this instance.
Facility staff failed to follow care plans requiring a two-person assist for a resident with a below-the-knee amputation, resulting in a fall and serious injury. Additionally, after two separate falls involving another resident, staff did not update care plans or implement new interventions to prevent future incidents. Documentation and investigation procedures were not followed as required by facility policy.
Facility staff did not consistently implement or document comprehensive care plans for three residents, resulting in unmet care needs such as inadequate assistance with bed mobility leading to a fall and fracture, missed incontinence and wound care, lack of contracture management, and improper handling of a urinary catheter. Staff interviews and documentation reviews confirmed that care plans and physician orders were not followed as required.
Facility staff did not review or revise the comprehensive care plans for multiple residents after documented falls, despite clinical records and staff interviews confirming that care plans should be updated following such incidents. The care plans remained unchanged after each fall, contrary to facility policy and standard practice, as confirmed by staff and documentation review.
Staff failed to provide and document required ADL care for two residents, including incontinence care for a dependent, cognitively impaired resident and twice-daily oral hygiene for another resident needing assistance. Documentation was incomplete or incorrectly marked as 'not applicable,' and staff interviews confirmed that care was not provided as required.
Staff failed to maintain sanitary food service practices, including using a dirty floor fan that blew air onto clean dishware, not covering facial hair during food preparation, and not changing gloves between tasks such as handling food and touching unclean surfaces. Management acknowledged these lapses did not meet facility policy.
Facility staff did not ensure privacy for a resident with an indwelling catheter, as the catheter collection bag was repeatedly left uncovered and visible to anyone entering the room. The resident, who was alert with some forgetfulness and had a diagnosis of urinary retention, reported being bothered by the lack of privacy. This action was inconsistent with the facility's policy to treat residents with dignity and respect.
A resident was found lying in bed with the call bell on the floor and out of reach, and reported that staff only respond when the call bell is accessible. An LPN confirmed the call bell should be within reach and acknowledged it was not at the time of observation. The issue was reported to administrative staff, with no further information provided before survey exit.
Facility staff did not notify a resident's responsible party when a physician-ordered IV antibiotic for a serious foot infection was unavailable for administration. Although the nurse practitioner was informed and the pharmacy was contacted, there was no documentation that the responsible party was notified, as required by facility policy.
Staff did not maintain a clean and comfortable environment for a resident, as fall mats and floors in the resident's room were observed to have spilled liquids, debris, and dirt. Environmental services staff confirmed the cleaning protocols were not followed, resulting in unsanitary conditions despite facility policy requiring a clean and homelike environment.
Facility staff did not document or resolve a written grievance submitted by a resident's responsible party concerning wound care and other care issues. Despite being told the concerns were under review, the responsible party received no follow-up or resolution, and the grievance was not found in facility records. The resident was severely cognitively impaired and dependent on staff for ADLs, with a family member as their health care representative. Staff interviews confirmed a lack of documentation and uncertainty about the grievance process for this incident.
Facility staff did not submit a required admission MDS assessment within the federally mandated timeframe for a resident. The assessment was marked as in progress without a documented completion or submission date, and the MDS coordinator confirmed that some assessments had fallen behind due to staffing issues.
Facility staff did not develop a baseline care plan for oral hygiene for one resident and failed to implement ordered wound care for another, despite both needs being identified in their baseline care plans. Interviews and record reviews confirmed that required care planning and interventions were not completed or documented as per facility policy.
The facility did not ensure that a resident received proper care for pressure ulcers and failed to implement adequate preventive measures, resulting in the development or worsening of pressure ulcers.
A resident with an indwelling catheter for urinary retention was observed with their catheter collection bag lying on the floor, despite care plan interventions and physician orders requiring the bag to be kept off the floor. This failure to maintain proper catheter care was identified during a survey and reported to facility administration.
Staff failed to maintain an accurate medical record for a resident by documenting a progress note after the resident had expired and was no longer in the facility. The note, which described an advanced care planning discussion with the responsible party and DON, was not properly identified as a late entry, resulting in an inaccurate record.
Failure to Develop and Implement Comprehensive Care Plans Across Multiple Care Areas
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for multiple residents across pain management, catheter care, fluid restriction, transfers, activities, dialysis communication, mobility, and bathing. For two residents with pain, staff did not follow care plan directions for non-pharmacological interventions. One cognitively intact resident with frequent severe back pain received PRN acetaminophen and oxycodone, but nursing progress notes from early April showed no documentation of non-pharmacological pain interventions in numerous opportunities, despite the care plan requiring evaluation of pain characteristics and use of such measures. Another resident with chronic pain and moderate cognitive impairment received PRN hydromorphone for moderate to severe pain, but the eMAR and nursing notes lacked evidence of non-pharmacological interventions at multiple documented administration times, contrary to the pain-focused care plan. For residents with urinary catheters and renal conditions, staff did not consistently implement care plan interventions or related physician orders. One resident with an indwelling catheter and an order for daily intake and output monitoring, with instructions to report urinary output below a specified amount, had multiple shifts with no recorded urinary output on the TAR, despite a care plan directive to monitor catheter output for odor, color, consistency, and amount. Another resident with ESRD and a neurogenic bladder had a care plan requiring catheter care twice daily and recording of output, and physician orders for catheter care every shift and regular emptying of the drainage bag; the TAR showed missing documentation of catheter care and output on several day and night shifts. The same ESRD resident also had physician orders for a specific daily fluid restriction total, divided between dietary and nursing-provided fluids, but there was no evidence on the MAR/TAR of fluid restriction monitoring, and the care plan for impaired renal function did not include fluid restriction monitoring as an intervention. Staff also failed to implement care plans related to transfers, activities, dialysis communication, mobility, and bathing. One resident requiring maximal assistance of one to two staff for transfers had numerous missing entries in ADL documentation for transfers across multiple dates and shifts, with a CNA stating that if care was not documented, it did not happen. Another resident, cognitively intact and dependent for mobility, had a care plan stating it was important to engage in meaningful routines, including voting and religious activities; the resident reported no one approached her about voting in a recent election and that she had to ask to see the chaplain more often, despite care plan interventions noting the importance of voting and religious engagement. A resident with a left-hand splint ordered by OT had no corresponding care plan update addressing limited range of motion or the splint, and the same resident on hemodialysis had a care plan intervention to send and review a dialysis communication book each treatment, but dialysis communication records were missing for several dialysis dates. Additional failures involved assistance out of bed and bathing frequency. One cognitively intact resident, dependent on staff for transfers and requiring a total mechanical lift with two-person assist, reported not getting out of bed every day and only being offered to get up when enough staff were available; ADL documentation over several months showed the resident was transferred out of bed only a small number of times, with many days marked as not applicable or not attempted, even though staff interviews indicated residents should be offered to get out of bed daily and refusals documented and reported. Another resident, severely impaired for decision-making and dependent for ADLs, had a care plan stating it was important to choose between a shower or bed bath and that extensive assistance for bathing would be provided, with showers scheduled twice weekly. ADL records showed this resident received only one shower in one month and five showers in the following month, despite the stated expectation of twice-weekly showers, and staff confirmed showers were scheduled twice weekly and refusals should be documented and reported. Throughout the report, multiple LPNs, a CNA, and the MDS Coordinator acknowledged that the purpose of the care plan is to guide and assist staff in providing appropriate care and that the interdisciplinary team is responsible for implementing and updating care plans. They also confirmed that missing documentation indicates care was not provided and that specific interventions, such as fluid restriction monitoring, dialysis communication, and daily transfer offers, should be reflected in and carried out according to the care plans. The Administrator and DON were notified of each set of findings, and no additional information was provided prior to exit.
Failure to Provide and Document Required ADL Care for Multiple Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, including bathing, transfers, and grooming, to multiple dependent residents as documented in clinical records, observations, and interviews. One resident who was severely cognitively impaired and required partial/moderate assistance for showering was care planned to receive assistance with bathing and to choose between a shower or bed bath. ADL documentation over two separate months showed this resident received only one shower in one month and five showers in the following month, despite facility staff stating that showers are scheduled twice weekly and refusals are to be documented and reported. Census records showed the resident was out of the facility on only one day during this period, and the facility’s ADL policy required necessary care and services to maintain grooming and personal hygiene. Another resident, cognitively intact and dependent on staff for transfers using a total mechanical lift, reported not getting out of bed every day and stated staff only offered to get them up when enough staff were available. Observations over multiple days showed this resident in bed, and ADL documentation over three months reflected very limited transfers out of bed, with many days coded as not applicable or not attempted due to medical condition or safety concerns. Staff interviews indicated that not applicable should only be used when a resident is not in the building or is not allowed to get out of bed, and that all residents should be offered to get out of bed daily with refusals documented and reported to the physician and responsible party. A third resident, cognitively intact and requiring maximal assistance for mobility, transfers, bathing, dressing, and hygiene per MDS and care plan, had numerous dates across all three shifts with missing ADL transfer documentation. A CNA confirmed that transfers are documented in the electronic record and that if there is no documentation, it means the care did not occur. Another resident, dependent on staff for transfers, mobility, and requiring maximum assistance with hygiene and bathing, was observed with a large amount of facial hair and reported waiting for a family member to bring an electric shaver due to keloids and an inability to use facility razors. Therapy notes documented the resident’s repeated statements about waiting for a shaver, her distress about her appearance, and her refusal to participate in certain therapy activities because of her unshaven face, while a CNA described her as totally dependent and stated she believed the resident was waiting for someone to come and shave her and that the resident refused a lot. A fifth resident, severely cognitively impaired and completely dependent on staff for transfers from bed to wheelchair, was observed lying in bed multiple times over two survey days and was never seen out of bed during surveyor presence. The resident’s representative expressed concerns about whether staff were assisting the resident out of bed. The CNA assigned to the resident on one of those days stated the resident was completely dependent for all ADLs and admitted she did not transfer the resident out of bed because she arrived late to the unit as a float CNA, had other residents to care for, and believed, based on what she said a therapy staff member told her, that the resident did not need to get up that day. The therapy assistant later stated she had not instructed any CNA that the resident did not need to get out of bed and explained that it was beneficial for the resident to be up in the wheelchair as much as tolerated each day and that he had previously been up much of the time each day before his most recent readmission. Across these five residents, the survey findings showed failures to provide scheduled showers, to consistently offer and perform transfers out of bed, to document transfers as required, and to assist with grooming needs such as shaving, despite care plan directives, MDS assessments indicating dependence for ADLs, and facility policy requiring provision of necessary ADL care to maintain grooming and personal hygiene. Staff interviews repeatedly confirmed that care should be offered and documented, that refusals should be recorded and reported, and that lack of documentation indicates care was not provided, yet the records and observations did not support that these ADL services were consistently delivered.
Food Storage, Sanitation, and Temperature Control Deficiencies in Dietary Services
Penalty
Summary
Facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and on one resident hallway. During a kitchen observation, surveyors noted multiple soiled or improperly cleaned food-contact items, including a cutting board with dried red debris, ladles with yellow debris and a noodle attached, baking sheets with thick white debris, and a cake mixer guard and stand with white debris and the electrical cord stored inside the mixing bowl. Clean dish storage was also deficient: steam pans were stacked while still wet, and baking sheets on a rack were dripping water onto the floor. In the refrigerator, an unlabelled, undated 2‑quart container with a thick yellow substance identified by the dietary manager as butter was found. In dry storage, an open, undated bag of potato chips was not closed after opening, a blue bag of parboiled rice was left open inside a 25‑lb box, and a container of chicken base was found with the lid off on a cart. These conditions were inconsistent with the facility’s written policies requiring utensils and food-contact surfaces to be clean and sanitized after each use and dry goods to be properly sealed and date marked. Hot food holding and service temperatures were also not maintained according to professional standards and facility policy. Immediately prior to lunch tray preparation, surveyors measured five hot food items below the facility’s stated acceptable serving temperature of 135°F: mashed potatoes at 123.5°F, puréed peas at 133.3°F, gravy at 134.4°F, puréed burger at 110.0°F, and ground beef hamburger at 127.0°F. Despite these readings, staff proceeded to serve the lunch meal with the temperatures as recorded. The facility’s Dining Services policy specified that all foods would be held at appropriate temperatures greater than 135°F for hot holding, but this was not followed during the observed meal service. On a resident hallway, staff distributed expired milk and failed to ensure proper sanitization of utensils and warewashing. During breakfast tray distribution, 12 individual milk cartons on resident trays and in the ready-to-distribute supply were observed with an expiration date of the previous day. A CNA reported that dietary staff place milk in an ice-filled container on the tray cart and CNAs add milk to trays per resident request, and that dietary staff are responsible for checking expiration dates, while nursing staff are responsible for double-checking before serving. The Dining Services Director later confirmed that she and dietary aides are responsible for checking milk dates and acknowledged that expired milk had been placed in the hallway milk bucket and not identified by dietary or nursing staff. Surveyors also observed improper sanitization of a pizza cutter and other utensils and equipment at the three-compartment sink. After a pizza cutter fell to the floor, a dietary district manager briefly dipped it in the wash, rinse, and sanitizer sinks, leaving it in the sanitizer for less than three seconds before returning it for use in lunch service, contrary to the Dining Services Director’s statement that utensils should be immersed in sanitizer for at least 60 seconds. Additional observations showed a dietary staff member washing plastic tongs and submerging them in sanitizer for only 2–3 seconds before placing them in a drying rack. Later, corporate and facility dietary staff washed trays and dome covers, with observed sanitizer contact times ranging from approximately 3.38 to 40.83 seconds, and some dome covers not fully submerged in the sanitizer solution. Manufacturer instructions for the Oasis 146 Multi‑Quat sanitizer required exposure of food-contact surfaces to the sanitizing solution for at least one minute. Further, staff did not maintain separation between soiled and clean items and did not follow glove-use and cart-cleaning practices described in facility policy. A dietary staff member collected used plates and dome covers from meal carts onto a black utility cart while wearing one glove, picked up a plastic juice cup from the floor with the gloved hand, and then moved all items to the sink area. Without cleaning the cart, the staff member then used the same cart to receive washed dome lids from the sanitizer sink and stacked them on the visibly wet and debris-contaminated cart surface before transporting them to a storage rack in the kitchen. The dietary manager later stated that carts were supposed to be cleaned daily and after dirty items were placed on them, and that dishes had to go into sanitizer and then air dry, but she also stated there was no required time they had to sit in the sanitizer, which conflicted with the manufacturer’s instructions and the facility’s manual warewashing policy.
Failure to Provide Scheduled Showers/Bed Baths and ADL Support
Penalty
Summary
Facility staff failed to ensure that a resident did not lose the ability to perform activities of daily living (ADLs) by not providing or offering showers or bed baths as scheduled. The resident was admitted with diagnoses including muscle weakness and, on the most recent MDS admission assessment with an ARD of 03/19/2026, scored 15/15 on the BIMS, indicating intact cognition for daily decision-making. Section GG of the MDS coded the resident as requiring partial/moderate assistance for showering/bathing. The facility’s 200 Wing Shower List showed the resident was scheduled for showers on Mondays and Thursdays during the 7:00 a.m. – 3:00 p.m. shift. However, review of the ADL documentation for March and April 2026 revealed multiple dates on which showering/bathing was coded as not applicable or not attempted, and there was no documentation that the resident received or was offered a shower or bed bath on those days. Specifically, the March 2026 ADL sheet showed that on 03/06/2026 the day shift was coded “09” (not applicable – not attempted and the resident did not perform this activity prior to the current illness), the evening shift “88” (not attempted due to medical condition or safety concerns), and the night shift “09.” On 03/23/2026, the day shift entry was left blank, and the evening and night shifts were both coded “09.” The April 2026 ADL sheet showed that on 04/13/2026 the day shift was coded “98,” the evening shift “88,” and the night shift “09,” and on 04/20/2026 all three shifts were coded “09.” During an interview on 04/23/2026, CNA #5, who provided care and showers to the resident and confirmed the scheduled Monday/Thursday shower days, stated she did not know why the resident did not receive showers or bed baths on the identified dates and acknowledged the resident should have been offered them. Upon review of the ADL sheets, CNA #5 confirmed there was no evidence that showers or bed baths were offered on those dates.
Failure to Ensure Safe Bed Environment Resulting in Resident Fall and Injury
Penalty
Summary
Facility staff failed to provide a safe environment and adequate supervision for a resident with significant cognitive and functional impairments, resulting in a fall from bed. The resident had diagnoses including DM, Parkinson’s disease, dementia, and adult FTT, and was assessed on the most recent MDS as severely cognitively impaired with a BIMS score of 04/15. The MDS Section GG documented that the resident was dependent for bed mobility, transfers, hygiene, and bathing, and required supervision for eating. The comprehensive care plan identified the resident as at risk for falls due to Parkinson’s disease, dementia, poor safety awareness, and general weakness, and included interventions such as use of bed rails as an enabler and requiring two staff to assist with repositioning/turning in bed. Despite these identified risks and interventions, the resident experienced a fall from bed. On the date of the incident, a CNA reported that the resident fell out of bed, after which the resident complained of left knee pain. The resident was unable to verbalize what occurred other than stating she fell out of bed. Subsequent evaluation and imaging showed a possible subtle distal femoral fracture of the left knee. A root cause analysis documented that the CNA, an agency staff member who had been working at the facility for about a week, failed to ensure that the low air loss mattress was placed in static mode prior to providing care. The DON stated that the resident was considered a one-person assist who would hold onto the bedrail and was described as alert but confused. The facility’s Falls Management policy required implementation and documentation of patient-centered interventions according to individual risk factors and adjustment of interventions as the patient’s condition changed, but the failure to properly set the mattress contributed to the unsafe environment and the resulting fall.
Failure to Implement Fall Prevention Interventions and Inadequate Post-Fall Response
Penalty
Summary
Facility staff failed to implement required interventions for fall prevention for two residents, resulting in deficiencies related to accident hazards and supervision. In one case, a resident with a right below-the-knee amputation and multiple comorbidities, including heart failure, diabetes, and muscle weakness, was assessed as requiring a two-person assist for all activities of daily living (ADLs), including bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to the resident rolling off the bed and sustaining a right distal femoral fracture. Documentation confirmed that the care plan and CNA Kardex both specified a two-person assist, but this was not followed. Additionally, there was no evidence of a thorough investigation into the fall with serious injury, as required by facility policy. Staff interviews revealed inconsistent communication and understanding of care requirements for new admissions and readmissions. While some staff stated that care plans and Kardexes are used to inform CNAs of resident needs, the involved CNA did not follow the two-person assist directive. Witness statements and interviews indicated that the incident was not properly documented in the risk management system, and the required accident report was not completed. The facility's fall management policy mandates assessment, documentation, and implementation of individualized interventions, but these steps were not adequately performed in this case. In a separate incident, another resident experienced two falls within a four-month period. After each fall, there was no evidence in the clinical record or care plan that staff addressed or implemented new interventions to prevent future falls. Interviews with staff confirmed that interventions such as increased monitoring and toileting should be implemented post-fall, but the records did not reflect any such actions. The lack of follow-up and failure to update care plans or implement preventive measures contributed to the ongoing risk of falls for this resident.
Failure to Implement and Document Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for three residents, resulting in unmet care needs and adverse outcomes. For one resident with a right below-knee amputation, the care plan and CNA Kardex specified a two-person assist for bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to a fall from bed and a fracture of the distal right femur. Documentation and staff interviews confirmed that the care plan was in effect at the time of the incident and should have been followed. Another resident, assessed as severely cognitively impaired and fully dependent for ADLs, did not receive incontinence care and wound treatments as outlined in their care plan and physician orders. Multiple dates showed missing or inappropriate documentation for incontinence care, with staff confirming that such care should always be documented for a resident who is always incontinent. Additionally, wound care treatments were not administered or documented on several dates, and there was no evidence of resident refusal. The care plan also failed to address contracture management, despite the resident having a diagnosis and orders for splints and braces, as well as therapy recommendations for contracture prevention. A third resident with an indwelling urinary catheter had a care plan intervention to keep the catheter bag off the floor. However, observation revealed the catheter collection bag lying flat on the floor next to the bed. Staff interviews confirmed that the care plan should be implemented for resident safety. In all cases, the facility's own policies required timely development and implementation of individualized, measurable care plans, but these were not consistently followed or documented.
Failure to Review and Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following documented falls. For one resident, after a fall was observed and documented by nursing staff, there was no evidence that the care plan, which had been created months prior, was reviewed or updated to address the incident. Interviews with staff confirmed that care plans are expected to be updated after such events, but this was not done in these cases. Another resident experienced multiple falls, each documented in the clinical record, but the care plan remained unchanged after each event. Staff interviews reiterated the expectation that care plans should be updated after falls, but documentation did not support that this occurred. The facility's own policy requires care plans to be reviewed and revised after assessments and as needed to reflect changes in the resident's condition or response to care. Additional residents also experienced falls, with clinical records and fall investigations documenting the incidents and subsequent assessments, but without evidence of care plan review or revision. In each case, staff interviews confirmed the expectation for care plan updates following such events, and facility policies supported this requirement. Despite this, the care plans did not reflect the necessary reviews or changes after the falls, as confirmed by both documentation review and staff statements.
Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide required activities of daily living (ADL) care for two residents who were dependent on staff assistance. For one resident with severe cognitive impairment and total incontinence of bowel and bladder, documentation showed multiple instances across several months where incontinence care was not provided or not documented as provided on various shifts. The resident's care plan specified the need for incontinence care to maintain dignity and prevent complications, yet ADL records were either left blank or marked as 'not applicable' on days when care should have been given. Staff interviews confirmed that such documentation was inappropriate for a resident who was always incontinent and dependent on staff. For another resident, who was cognitively intact but required set-up or clean-up assistance with oral hygiene, the facility failed to provide oral care twice daily as required. Review of the ADL tracking sheets for this resident revealed missed oral hygiene care on several consecutive days, with documentation either left blank, marked as 'not applicable,' or coded without explanation for why care was not provided. Staff interviews confirmed that the resident did not receive oral hygiene care as required during these periods. Facility policy required that ADL care, including hygiene and elimination, be documented accurately and reflect the care provided by nursing staff. The deficiencies were identified through clinical record review, staff interviews, and examination of facility documentation, which consistently failed to show evidence of required care being provided or properly documented for these dependent residents.
Sanitary Food Service Deficiencies in Kitchen Operations
Penalty
Summary
Facility staff failed to maintain sanitary food service practices in the kitchen, as observed during multiple site visits. A floor fan was found on the dish room floor, blowing air across clean plate bases and covers, with visible debris and grease on the fan guard. The dietary manager acknowledged the fan was dirty and removed it after the observation. Additionally, a kitchen aide was seen plating pureed cake and assembling dinner trays without a cover over his mustache and facial hair, contrary to facility policy requiring facial hair to be restrained. The aide confirmed that his mustache should have been covered during food preparation. Further observations revealed a cook wearing gloves while performing multiple tasks, including opening and closing the walk-in refrigerator, wiping hands on a dirty apron, handling resident sandwiches, stacking dinner plates, and plating food, without changing gloves between tasks. The dietary manager confirmed that gloves should be changed between tasks to maintain sanitation. Interviews with dietary management staff indicated awareness of these issues and acknowledged that the observed practices were not sanitary and did not align with facility policy.
Failure to Provide Privacy for Catheter Collection Bag
Penalty
Summary
Facility staff failed to promote the dignity of a resident with urinary retention who had an indwelling catheter. On two separate occasions, surveyors observed the resident's catheter collection bag hanging uncovered on the lower portion of the bed, with the contents clearly visible. The resident was alert with some forgetfulness, as documented in the facility's clinical admission assessment. The physician's order specified the use of an indwelling catheter with straight drainage due to urinary retention. During an interview, the resident expressed discomfort and stated that it bothered him that anyone entering the room could see the urine in the collection bag. The facility's policy on resident rights requires that each resident be treated with respect and dignity, and that care be provided in a manner that promotes or enhances quality of life. Despite this policy, the lack of privacy for the catheter collection bag was not addressed prior to the survey exit.
Failure to Maintain Call Bell Within Resident's Reach
Penalty
Summary
Facility staff failed to accommodate the needs of a resident by not ensuring the call bell was within the resident's reach. The resident was observed lying in bed with the call bell on the floor, out of reach, and reported that staff only respond to the call bell when it is accessible. During an interview, an LPN confirmed that the call bell should be placed next to or clipped on the resident when in bed, and acknowledged that the call bell was not within reach at the time of observation. The issue was brought to the attention of the administrator and interim director of nursing, but no additional information was provided before the survey exit. The deficiency was identified through direct observation, resident interview, and staff interview, specifically noting the failure to maintain the call bell within reach for the resident while in bed.
Failure to Notify Responsible Party of Unavailable Medication
Penalty
Summary
Facility staff failed to notify the responsible party when a physician-ordered medication, Daptomycin, was not available for administration to a resident with a left foot infection and gangrene. The resident was alert with some forgetfulness, and the medication was ordered to be given intravenously every other day for 23 days. On the scheduled administration date, the medication was not available, and the nurse's note indicated that the pharmacy would deliver it during the next run and that the nurse practitioner was aware. However, there was no documentation that the responsible party was informed of the missed dose. Staff interviews confirmed that the facility's procedure requires notifying the responsible party when a medication is unavailable, and this notification should be documented in the progress notes. Review of the clinical record and facility documentation did not show evidence that the responsible party was notified as required. The facility's policy also mandates immediate notification of the patient's representative when there is a need to alter treatment significantly, such as when a medication is not available.
Failure to Maintain Clean and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to maintain a clean and comfortable environment for one resident, as evidenced by observations of the resident's room. During two separate visits, surveyors noted that the fall mats on both sides of the resident's bed had visible evidence of spilled liquids, causing the surveyor's shoes to stick to the mats. Additionally, there were bits of paper on both sides of the bed and dirt and debris behind the bed and nightstand. These conditions were present despite the facility's stated cleaning protocols. Interviews with the director of environmental services and another environmental services staff member confirmed that all resident rooms are supposed to be cleaned daily, including lifting and cleaning fall mats. However, both staff members acknowledged that the fall mats in this resident's room were in need of cleaning at the time of observation. The facility's own policy requires a safe, clean, and comfortable environment for residents, but this standard was not met for the resident in question.
Failure to Document and Resolve Family Grievance Regarding Resident Care
Penalty
Summary
Facility staff failed to demonstrate efforts to resolve a written grievance submitted by a resident's responsible party in November 2024. The grievance, which was related to wound care procedures and other care concerns, was sent to the former administrator. Although the responsible party was informed that the administration was investigating the concerns, there was no documented follow-up or resolution provided to the responsible party. Review of facility grievance records from January 2024 onward did not show any documentation of the November 2024 grievance, and staff interviews revealed uncertainty about whether an official grievance was completed or properly tracked. The resident involved was assessed as being severely impaired in making daily decisions and was dependent on staff for activities of daily living, with a family member designated as the responsible party and health care representative. Interviews with current and former administrative staff indicated a lack of clear documentation and follow-up regarding the grievance, and the facility's grievance log did not reflect the reported concern. The facility's policy required the administrator to oversee and track grievances through to their conclusion, but this process was not followed in this instance.
Failure to Submit Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to submit a required Minimum Data Set (MDS) admission assessment within the federally mandated timeframe for one resident. Clinical record review showed that the resident was admitted on a specific date, but the admission MDS assessment, while marked as in progress, did not have a documented completion or submission date within the required 14 days. This omission was confirmed through review of the resident's facesheet and MDS records. During an interview, the MDS coordinator, an LPN, acknowledged that the admission MDS was completed and submitted before the fourteenth day, but also stated that some MDS assessments had fallen behind due to staffing issues. The deficiency was brought to the attention of the administrator and acting DON, and no further information was provided prior to the survey exit.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans for two residents within 48 hours of admission, as required by facility policy. For one resident, who was admitted with muscle weakness and was cognitively intact, the baseline care plan did not address oral hygiene needs. The MDS coordinator confirmed that a baseline care plan for this resident was not developed, despite the facility's policy mandating a person-centered care plan be created within 48 hours of admission. For another resident, staff failed to implement the baseline care plan intervention for pressure injury treatment as ordered by the physician. The baseline care plan identified the resident as being at risk for skin breakdown and included an intervention to provide wound treatment as ordered. However, review of the electronic treatment administration record did not show evidence that the wound care was completed on a specified date, and there was no documentation of treatment refusal. Staff interviews confirmed that wound care should have been provided and documented according to the care plan.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents at risk for pressure ulcers did not consistently receive necessary interventions such as regular repositioning, skin assessments, or timely wound care. As a result, some residents developed new pressure ulcers or experienced worsening of existing wounds due to inadequate preventive and treatment practices.
Failure to Maintain Proper Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate care and services for an indwelling catheter for one resident. Specifically, the staff did not keep the resident's catheter collection bag off the floor, as observed during the survey. The collection bag was found lying flat on the floor next to the resident's bed, contrary to the care plan intervention that required the catheter to be kept off the floor. The resident had a diagnosis of urinary retention and was alert with some forgetfulness at the time of admission. The physician's order specified the use of a 16FR indwelling catheter with a 10cc balloon to bedside straight drainage for urinary retention. The comprehensive care plan, initiated upon admission, included an intervention to keep the catheter off the floor. Despite these documented requirements, the deficiency was observed and brought to the attention of administrative staff, with no additional information provided prior to the survey team's exit.
Failure to Maintain Accurate Medical Record Documentation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident. The clinical record for this resident documented a discharge date, but a progress note was entered with a date after the resident had already expired and was no longer in the facility. The note described an advanced care planning discussion with the resident's responsible party and the DON, referencing the resident's ongoing decline, multiple hospitalizations, and poor prognosis. However, the nurse practitioner who authored the note confirmed in an interview that the entry was made after the resident's death and should have been documented as a late entry, which it was not. The administrator reviewed the progress note and confirmed that the resident was not present in the facility on the date indicated in the documentation, acknowledging the inaccuracy of the medical record. Facility policy requires that documentation be completed at the time of service or during the shift in which care occurred, and that any late entries be clearly indicated as such. The failure to properly document the timing and nature of the entry resulted in an incomplete and inaccurate medical record for the 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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