Woodstock Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodstock, Virginia.
- Location
- 803 South Main St, Woodstock, Virginia 22664
- CMS Provider Number
- 495315
- Inspections on file
- 22
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Woodstock Valley Health And Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not provide required supervision or safety devices for two residents with cognitive impairment who smoked, allowing them unsupervised access to lighters and cigarettes, and failed to enforce the use of smoking aprons and proper disposal of cigarette butts. Additionally, a resident at risk for elopement had monitoring interventions discontinued without reassessment or documentation, despite ongoing risk factors.
A resident with a history of PTSD and chronic pain was not given her prescribed Fentanyl patch as ordered, leading to complaints of pain and withdrawal. When she voiced her concerns, the DON escalated the situation by threatening removal under a TDO, involving police and EMS, and removing the resident's personal signs without consent. The resident was not assessed by the DON, was not included in care decisions, and experienced significant psychosocial harm as a result.
Facility staff did not provide evidence of a current hospital transfer agreement, as the only agreement on file was with the previous owner and no updated contract had been established under the new ownership. This deficiency was identified through staff interviews and document review, potentially affecting all residents.
Facility staff did not ensure that an Infection Preventionist attended QAPI committee meetings for three consecutive quarters, as required by policy. Review of meeting sign-in sheets and staff interviews confirmed the absence of the Infection Preventionist from these meetings.
Facility staff did not notify physicians when multiple medications were not administered to two residents, nor did they inform emergency contacts of significant changes in condition, such as acute illness or elopement. In both cases, only the residents, who were their own responsible parties, were notified, contrary to facility policy and staff statements that next of kin should be informed during emergencies or when the resident's capacity is in doubt.
Staff failed to provide a clean and homelike environment, as evidenced by stained linens and bed pads, dirty privacy curtains, food debris and spill stains in resident rooms, and unrepaired wall damage. Multiple staff acknowledged these deficiencies, and facility policies requiring cleanliness and maintenance were not followed.
Staff failed to follow comprehensive care plans for six residents, including not providing required smoking aprons or supervision for two residents with cognitive impairment, missing multiple medication administrations for three residents, and not completing wound care treatments or weekly wound assessments for several residents with pressure injuries or surgical wounds. Documentation was incomplete or missing, and staff interviews confirmed lapses in following care plan interventions.
Facility staff failed to administer prescribed medications and wound treatments to three residents, despite medication and supply availability, as evidenced by blank entries and lack of documentation in medication and treatment records. Nursing staff confirmed that medications should be documented as given and obtained from in-house stock if not present on the cart, but this was not consistently done.
Facility staff failed to consistently provide and document ordered pressure ulcer treatments and weekly wound assessments for two residents with pressure injuries. Missed treatments and gaps in wound measurement documentation were identified, with staff interviews revealing that changes in wound care personnel contributed to lapses in care and record-keeping.
A resident with chronic pain did not receive Fentanyl patches as ordered, resulting in missed doses over multiple periods. Documentation and interviews confirmed gaps in administration and a lack of proper recordkeeping, despite a care plan and facility policy requiring consistent pain management and monitoring.
Facility staff did not maintain adequate CNA staffing on two resident units during evening shifts, resulting in inconsistent provision of HS snacks to residents. Staffing schedules and staff interviews confirmed that only one CNA was present at times when more were needed, and residents reported not receiving snacks as required. The facility's own assessment and policy standards for staffing were not consistently met.
Facility staff did not provide the required RN coverage for at least eight consecutive hours on multiple days, and the DON served as a charge nurse on several occasions when the resident census was above 60, both in violation of facility policy. These deficiencies were confirmed through schedule reviews and staff interviews.
Annual performance reviews for four out of five CNAs were not completed as required, with administrative staff unable to clarify responsibility for ensuring timely reviews. Facility policy mandates annual review of employee training and attendance records, but this process was not followed for several CNAs.
Facility staff did not ensure that prescribed medications were available and administered as ordered for two residents, resulting in multiple missed doses of antibiotics, pain medication, antipsychotics, and medication for anemia and prostate enlargement. Documentation and staff interviews confirmed that medications were often not available in the medication cart or Omnicell, and pharmacy delivery delays led to further missed doses.
Staff failed to serve residents the correct food portions as outlined in the facility's menu and production sheets, using incorrect serving utensils for Caesar salad, lasagna, and sliced carrots. The dietary manager confirmed that the portions served did not meet the documented requirements, and leadership was notified of the deficiency.
Staff did not serve palatable food on one unit, as a test tray of lasagna, carrots, green beans, and mashed potatoes was found to be below the expected serving temperature and described as not palatable by those who sampled it. Food temperatures ranged from 112°F to 127°F, and the issue was observed and confirmed by surveyors and a dietary manager.
Staff failed to consistently provide HS snacks to residents on two units, resulting in over 14 hours between dinner and breakfast. Two residents confirmed snacks were not offered at night, and staff interviews revealed inconsistent snack distribution due to staffing issues. Dietary staff prepared and delivered snacks, but nursing staff did not always pass them out, as confirmed by internal communications and photographic evidence.
Staff were observed hand drying meal trays and placing them on the tray line before serving meals to residents. The trays, which should have been air dried to prevent contamination, were then used to serve food and delivered to resident units. This practice was confirmed by dietary management as not meeting sanitary standards.
Facility staff did not have an updated contract with the respiratory equipment provider, as the existing agreement was still under the previous owner's name, which no longer exists. This affected seven residents who received respiratory equipment services, and the executive director confirmed delays in updating contracts after a change in facility ownership.
A resident with severe cognitive impairment and swallowing difficulties was observed being fed by a CNA who stood next to the bed, rather than sitting, during feeding assistance. The resident was fully dependent on staff for eating, and the CNA acknowledged that standing while feeding was not dignified. This action did not align with the facility's policy on respecting resident dignity.
A resident with multiple medical and mental health conditions had handmade signs removed from her door by the DON without her permission, despite not being cognitively impaired. The removal was abrupt and done without prior discussion, causing the resident significant distress. Staff confirmed the resident was upset, and facility policy on resident rights was not followed, as there was no evidence the signs posed an immediate health or safety risk.
Staff failed to secure a resident's clinical record when an LPN, after being asked by another LPN and with involvement from a former staffing coordinator, printed and handed over a progress note related to backdated medication orders. The document was later destroyed by the receiving LPN, but the incident resulted in a breach of confidentiality, contrary to facility policy.
A resident was discharged without documented evidence that written instructions were provided, home medications were arranged in advance, or information on home health provider options and quality measures was given. Staff interviews revealed inconsistent practices regarding discharge documentation and medication arrangements, and the facility did not follow its policy to present comparative provider data to the resident or family.
Facility staff did not develop a baseline care plan within 48 hours for a newly admitted resident with complex needs, including a PICC line, incontinence, multiple wounds, a colostomy, and insulin therapy. Staff interviews confirmed the absence of the required care plan, and the administrator acknowledged it was not completed as per facility policy.
Staff failed to follow professional standards by administering pain medications without current physician orders for one resident, relying on medication cards rather than active orders, and later entering backdated orders without direct physician authorization. For another resident, staff did not administer prescribed heart failure medications when the resident was sleeping, made no further attempts to give the medications, and did not notify the physician, despite the absence of orders to hold the medications. These actions did not comply with facility policy or accepted nursing practice.
Facility staff did not obtain a physician's order for an incentive spirometer for a resident and failed to store the device in a sanitary manner, leaving the mouthpiece uncovered on the nightstand. An LPN confirmed that orders and proper storage are required, but no policy was provided by the facility.
A resident was administered tramadol and oxycodone by an RN without a current physician's order after returning from a hospital stay. The nurse relied on medication cards in the cart instead of verifying active orders in the MAR or computer system, resulting in the administration of unnecessary medications.
A resident was administered tramadol and oxycodone without a valid physician order after returning from a hospital stay, as previous orders had been discontinued. An RN assumed the medications were still prescribed based on medication cards and administered them without direct physician consultation, later entering backdated orders into the system. The physician did not recall approving these orders, and other staff members were not directly involved or aware of the late entries.
Staff did not maintain accurate medical records for three residents, including documenting assessments after discharge, recording medication administration that did not occur, and failing to document critical interventions during a resident's change in condition. These actions resulted in incomplete and inaccurate records, contrary to facility policy.
Staff did not follow infection control protocols when an LPN performed wound care on a resident with a stage four pressure injury without wearing a gown, despite clear facility policy and posted CDC guidance requiring enhanced barrier precautions for such high-contact care activities.
The facility did not accurately post daily nurse staffing information, as required, for an entire month. The postings failed to specify the total number and actual hours worked by RNs, LPNs, and CNAs per shift, instead only listing licensed and unlicensed staff totals. Additionally, the posted information was sometimes outdated, and staff interviews confirmed the process did not meet policy requirements.
Failure to Supervise Smoking and Elopement Risk Residents
Penalty
Summary
Facility staff failed to provide adequate supervision, monitoring, and use of safety devices, and did not fully implement their smoking policy for two residents. One resident, with moderate cognitive impairment and nicotine dependence, was observed independently accessing a lighter from a personal bag, lighting cigarettes for themselves and another resident, and smoking outside without a required smoking apron or proper receptacles for cigarette butts. The resident's care plan and smoking evaluation indicated the need for a smoking apron and supervision, but these interventions were not in place at the time of the incident. Staff interviews confirmed that smoking materials were not securely stored, and residents could access cigarettes and lighters outside of designated times and areas, contrary to facility policy. Another resident, with severe cognitive impairment and dementia, was observed holding and storing partially smoked cigarettes in personal belongings, smoking unsupervised, and discarding cigarette butts in unsafe areas such as mulch with dried leaves. This resident's care plan and smoking evaluation identified them as an unsafe smoker requiring direct supervision and a smoking apron, but these interventions were not provided. Staff interviews revealed that the resident often picked up cigarette butts from the ground and smoked them, and that staff did not consistently monitor or control access to smoking materials or enforce the use of safety equipment. Additionally, the facility failed to maintain interventions for a resident assessed as being at risk of elopement. The resident, with cognitive impairment and a history of exit-seeking behavior, had a WanderGuard device ordered and care plan interventions for monitoring, but these were discontinued without documented reassessment or justification. The resident was later observed ambulating in the facility without a WanderGuard and was not located on the secure unit, despite ongoing risk factors. Facility policy required ongoing assessment and communication of interventions for residents at risk of elopement, but these procedures were not followed.
Removal Plan
- Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials.
- The responsible party for both Resident #10 and Resident #11 were notified of the incidents.
- The current smoking area on the locked dogwood unit is no longer designated as a smoking area.
- Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit.
- If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.].
- A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit.
- The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container.
- Current residents will be re-educated on the facility smoking policy.
- Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy.
- If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy.
- The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record.
- Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times.
- Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking.
- The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents.
- All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift.
- A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke.
- The Executive Director or designee will make visual observations of the smoking times on Rosewood to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol.
- The Executive Director or designee will make observations of the courtyard on the locked Dogwood unit to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area.
- Findings of the observations will be monitored by the RVPO or RDCS.
- The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance.
- Findings of the above audits will be reported to the QAPI Committee for additional oversight.
Failure to Protect Resident from Mental Abuse and Neglect
Penalty
Summary
Facility staff failed to protect a resident from mental and verbal abuse, resulting in psychosocial harm. The resident, who was cognitively intact and had a history of PTSD, depression, and chronic pain, did not receive her prescribed Fentanyl patch as ordered, leading to complaints of pain and withdrawal symptoms. When the resident voiced her concerns and posted signs about her rights and lack of medication, the DON escalated the situation by threatening to have the resident removed from the facility under a temporary detention order (TDO) and involved police and EMS, despite the resident not exhibiting behaviors that warranted such action. The DON also removed the resident's personal signs from her door without consent, further agitating the resident and exacerbating her PTSD symptoms. Multiple staff interviews and documentation confirmed that the resident was not assessed by the DON or other medical personnel prior to the involvement of law enforcement. The resident was not given the opportunity to participate in decisions about her care or to refuse treatment before the escalation. Staff and the Ombudsman reported that the DON's actions were intimidating, retaliatory, and not based on an accurate assessment of the resident's condition. The resident was left feeling scared, embarrassed, and experienced ongoing psychosocial distress, including increased anxiety and night terrors related to the incident. The facility's own investigation, as well as reports from the Ombudsman and Adult Protective Services, substantiated that the resident's rights were violated and that there was neglect in the timely administration of pain medication. The DON's actions, including the threat of a TDO, removal of personal property, and lack of direct assessment, were identified as the primary factors leading to the resident's psychosocial harm and the deficiency cited in the report.
Lack of Updated Hospital Transfer Agreement
Penalty
Summary
Facility staff failed to provide evidence of an updated hospital transfer agreement, as required for ensuring residents can be transferred quickly to a hospital when necessary. Document review showed that the only available agreement was with the previous owner, a company that no longer exists, and there was no current contractual agreement with a hospital under the new ownership. During staff interviews, the executive director explained that the process of updating contracts with all vendors, including hospitals, had been slow due to the recent acquisition of multiple facilities by the new company. No updated agreement was presented prior to the survey exit, potentially affecting all 86 residents in the facility. No specific residents or their medical conditions were mentioned in the report, and the deficiency was identified through staff interviews and document review.
Infection Preventionist Absent from QAPI Committee Meetings
Penalty
Summary
Facility staff failed to ensure that the required Infection Preventionist attended the Quality Assurance and Performance Improvement (QAPI) committee meetings for three consecutive quarters, covering the periods from October 2024 through June 2025. Review of QAPI meeting sign-in sheets for these quarters did not show the signature of an Infection Preventionist, as required by facility policy. During interviews, the executive director confirmed that an Infection Preventionist was supposed to attend these meetings and acknowledged that there was no documentation to show their attendance during the specified timeframes. The facility's policy states that the QAPI committee must be interdisciplinary and include, at a minimum, the Infection Preventionist, and must meet at least quarterly.
Failure to Notify Physician and Emergency Contacts of Changes in Condition and Missed Medications
Penalty
Summary
Facility staff failed to notify the emergency contact of changes in condition and the physician of medications not administered for two residents. For one resident, staff did not inform the physician when multiple medications, including antibiotics, antidiabetics, and heart failure medications, were not administered over several months due to reasons such as unavailability or the resident being asleep. Documentation in the electronic medication administration record (eMAR) did not show evidence of physician notification for these missed doses, nor were there parameters in the physician orders for holding medications under certain conditions, such as when the resident was sleeping or had low blood pressure. Additionally, the same resident experienced significant changes in condition, including lethargy, labored breathing, confusion, and low oxygen saturation, as well as another episode of labored breathing and pallor. In both instances, only the resident, who was their own responsible party, was notified, and there was no documentation that the next of kin or emergency contacts were informed, despite facility policy requiring such notification in emergencies or when the resident may not be able to understand the situation. For another resident, who was also their own responsible party, staff failed to notify the next of kin after the resident was found outside the facility, which was considered a change in condition. The resident was returned inside, a wander guard was applied, and safety checks were initiated, but only the resident was notified. Staff interviews confirmed that, according to facility policy, the next of kin should have been notified in these situations, especially when the resident's ability to act as their own responsible party was in question during an emergency.
Failure to Maintain Clean, Homelike Environment and Room Repairs
Penalty
Summary
Facility staff failed to maintain a clean, comfortable, and homelike environment for residents, as evidenced by multiple observations and staff interviews. One resident's bed was found with a large brown stain on the blanket over several days, and three reusable bed pads in the laundry room were observed to have large brown and yellow stains despite being washed. Staff interviews confirmed that stained linens were a recurring issue, and the executive director acknowledged that the stained bed pads were not suitable for use. The account manager for environmental services reported ongoing problems with linen supply and laundering, including issues with bleach dispensing in washing machines. In several resident rooms, privacy curtains were found to be dirty and stained, despite the facility's stated practice of monthly cleaning and as-needed laundering. The account manager for environmental services confirmed that the curtains were not clean and agreed they did not present a homelike environment. Additionally, one resident room was observed to have food debris and spill stains next to and under the beds on multiple occasions, and the environmental services manager acknowledged awareness of the unacceptable room condition. Further observations revealed that some resident rooms were not maintained in good repair, with gouges in the walls exposing plasterboard and unpainted plaster patches. The plant operator and maintenance director stated that repairs were typically made when reported by staff, but walk-throughs to check for needed repairs were inconsistent. He agreed that the rooms required repair and did not present a homelike environment. Facility policy requires the provision and maintenance of clean, good-condition linens and a sanitary, orderly, and comfortable environment, which was not met in these instances.
Failure to Implement Comprehensive Care Plans and Required Interventions
Penalty
Summary
Facility staff failed to implement comprehensive care plans for six residents, resulting in multiple deficiencies related to the delivery of care and safety interventions. For two residents with cognitive impairment and nicotine dependence, staff did not provide required smoking aprons or direct supervision while the residents smoked, despite care plans and facility policy specifying these interventions. Observations showed these residents smoking independently, without protective equipment or staff oversight, and using personal lighters, contrary to documented care plan interventions. For three residents, staff did not administer medications as ordered or document reasons for missed doses. Medication administration records (MARs) and electronic MARs (eMARs) revealed blank entries or notes indicating medications were not available, but there was no evidence of physician notification or follow-up documentation. This included missed doses of antipsychotic, antihypertensive, antiplatelet, diabetic, and pain medications, as well as intravenous antibiotics and other critical therapies. In some cases, nurse interviews confirmed that the care plan was not consistently followed or that documentation was incomplete. Additionally, staff failed to provide wound care treatments and complete required weekly wound assessments for several residents with pressure injuries or surgical wounds. Treatment administration records (TARs and eTARs) showed missed wound care on multiple dates, and there was a lack of documentation regarding the missed treatments or wound measurements. Interviews with nursing staff and administrators indicated lapses in wound tracking and assessment processes, particularly following staff turnover and the departure of a wound care nurse practitioner.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
Facility staff failed to administer medications and treatments according to physician orders for three residents. For one resident, multiple doses of gabapentin, insulin glargine, and spironolactone were not administered as ordered, as evidenced by blank entries or notes such as "on order" or "pharmacy to send" in the electronic medication administration record (eMAR). The facility's Omnicell inventory indicated that these medications were available in stock at the time. Interviews with nursing staff confirmed that medications should be documented as given in the eMAR, and if not available on the cart, staff were expected to check the Omnicell stock. The facility's policy required medications to be administered as ordered by the physician. Another resident did not receive multiple prescribed medications, including atorvastatin, clopidogrel, Edarbyclor, Miralax, Mirapex, montelukast, gabapentin, magnesium oxide, and insulin lispro, during two evening medication passes. The medication administration record (MAR) was blank for these times, and there was no documentation in the nurse's notes explaining the missed doses. The resident's care plan included interventions to administer these medications as ordered for conditions such as hypertension, diabetes, hyperlipidemia, constipation, and pain management. Additionally, this resident did not receive wound care treatments for an abdominal wound as ordered every three days, with several missed treatments documented as blank on the treatment administration record (TAR) and no corresponding nurse's notes. A third resident did not receive melatonin as ordered for insomnia on multiple dates, as shown by blank spaces on the MAR. The facility's supply list confirmed that melatonin was available in-house. Nursing staff interviews indicated that if a medication was not on the cart, it should be obtained from the facility's stock or Omnicell. The executive director and other administrative staff were made aware of these concerns during the survey, and no further information was provided prior to exit.
Failure to Provide and Document Pressure Ulcer Care and Assessments
Penalty
Summary
Facility staff failed to provide ordered pressure ulcer treatments and appropriate documentation for two residents with pressure injuries. For one resident, there were multiple instances in January and February where prescribed wound care treatments, including cleansing, application of medicated ointments, and dressing changes, were not documented as completed in the electronic treatment administration record (eTAR). The clinical record did not contain explanations or documentation regarding these missed treatments. The resident's care plan noted multiple Stage 2 and Stage 3 pressure injuries present on admission, with contributing factors such as decreased mobility, incontinence, poor nutrition, and non-compliance with treatment. For another resident, staff did not consistently provide or document pressure injury treatments on several dates across July, August, and September. Additionally, there was a lack of weekly wound assessments, including measurements and descriptions of wound progress, for an unstageable pressure injury that later progressed to Stage 4. The care plan required weekly documentation of wound measurements and characteristics, but the clinical record showed gaps in this documentation. Interviews with staff revealed that changes in personnel, including the departure of a wound care nurse practitioner and an assistant director of nursing, contributed to lapses in wound tracking and assessment. Both residents had care plans that included interventions for pressure injury management, such as administering treatments as ordered and monitoring wound healing. However, the facility failed to ensure that treatments were consistently provided and documented, and that required wound assessments were completed as specified in the care plans. There was no evidence in the clinical records to account for the missed treatments or assessments on the identified dates.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication as ordered for a resident with chronic pain, resulting in missed doses of a Fentanyl transdermal patch. The resident, who was cognitively intact and able to make daily decisions, reported experiencing withdrawal symptoms such as nausea and diarrhea after not receiving her pain patch as prescribed. Documentation revealed that the Fentanyl patch was not administered for a 12-day period in March, and additional missed doses occurred in September, with gaps of up to six days between administrations. Medication administration records, narcotic sign-off sheets, and nurse's notes confirmed these missed doses, and there was a lack of documentation explaining the omissions on certain dates. The resident's care plan specified the need for analgesic medication to be administered as ordered and for monitoring of side effects and effectiveness every shift. Despite this, the facility did not ensure consistent administration of the Fentanyl patch according to physician orders. Interviews with staff and review of records verified the missed doses and lack of documentation for some scheduled administrations. The facility's pain management policy required provision of pain management services consistent with professional standards and the resident's care plan, but this was not followed in the resident's case.
Insufficient Nursing Staff Resulting in Missed Resident Care Needs
Penalty
Summary
Facility staff failed to maintain sufficient nursing staff to meet the needs of residents on both the Dogwood and Rosewood units, as evidenced by staffing schedules and interviews. On multiple occasions, only one CNA was scheduled for the 3:00 p.m. to 11:00 p.m. shift despite a facility census ranging from 71 to 79 residents per unit. Staff interviews confirmed that the usual practice was to have two CNAs per unit during this shift, but there were times when only one CNA was present for several hours. The former staffing coordinator reported that she was not permitted to use agency staff to fill gaps, and efforts to call in additional staff were not always successful. The facility's own assessment tool indicated a need for 4-6 CNAs per unit for evening and night shifts, but this standard was not consistently met. Resident interviews revealed that snacks were not consistently provided during the night shift, with both resident council presidents from each unit stating that residents were not offered snacks. Staff interviews corroborated this, with CNAs and administrative staff acknowledging that the distribution of HS (hours of sleep) snacks was inconsistent due to insufficient staffing. The dietary department prepared and delivered snacks to the nurse's stations, but it was the responsibility of the nursing staff to distribute them, which did not always occur. The facility's policy requires sufficient staff to ensure resident safety and meet care needs, but documented staffing levels and staff accounts demonstrated that this requirement was not met on several occasions.
Failure to Maintain Required RN Coverage and Improper Assignment of DON as Charge Nurse
Penalty
Summary
Facility staff failed to provide required registered nurse (RN) coverage for at least eight consecutive hours per day on multiple dates, as evidenced by a review of nursing schedules and staff interviews. Specifically, there was no RN coverage for eight consecutive hours on five separate days, and the director of nursing (DON) confirmed that only one other RN was employed at the facility besides herself. The facility's own policy requires RN coverage for at least eight consecutive hours per day, seven days per week, but this standard was not met for 16 out of 31 days reviewed. Additionally, the DON served as a charge nurse on several occasions when the resident census exceeded 60, which is contrary to facility policy stating that the DON may only serve as a charge nurse when the average daily occupancy is 60 or fewer residents. Nursing schedules and staffing postings confirmed that the DON acted as charge nurse on multiple dates despite the higher census. The DON acknowledged that she was aware of the policy but felt compelled to serve as charge nurse due to staffing shortages.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
Facility staff failed to complete annual performance reviews for four out of five certified nursing assistants (CNAs) as required. Specifically, the performance reviews for these CNAs were not conducted on an annual basis according to their hire dates. The director of nursing, who was newly appointed and had no prior experience in the role, was unaware of who was responsible for ensuring the completion of CNA performance reviews. The facility's policy requires that employee attendance and completion records for mandatory in-service trainings be reviewed at least annually, typically at the time of the performance review. No additional information or documentation was provided to address this concern prior to the survey exit. Staff interviews and facility document reviews confirmed the deficiency, with administrative staff unable to clarify responsibility for the process, resulting in missed or delayed annual reviews for multiple CNAs.
Failure to Ensure Availability and Administration of Prescribed Medications
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident with sepsis, anemia of chronic disease, and joint pain, multiple doses of Daptomycin, Epoetin Alfa-epbx, and Pregabalin were not administered on several dates in February and March. Documentation in the electronic medication administration record (eMAR) indicated that medications were either not available, on order, or awaiting delivery from the pharmacy. Progress notes reflected missed doses due to unavailability, and staff interviews confirmed that when medications were not found in the medication cart or Omnicell, the pharmacy was contacted, and the physician was to be notified if a medication was not given. Another resident with schizophrenia and an enlarged prostate did not receive multiple doses of Ziprasidone and Flomax over several dates from July through September. Review of medication administration records showed missed morning and bedtime doses of Ziprasidone and daily doses of Flomax, with staff confirming that these medications were not available in the Omnicell and were not administered as ordered. The facility's policy required medications to be administered as ordered and in accordance with professional standards, but the records and staff interviews demonstrated that this was not consistently achieved.
Failure to Serve Correct Food Portions According to Menu Requirements
Penalty
Summary
Facility staff failed to provide residents with the correct portion sizes of food as specified by the facility's menu and production sheets. Observations in the kitchen revealed that staff used incorrect serving utensils to plate Caesar salad, lasagna, and sliced carrots, resulting in residents receiving less than the required amounts. Specifically, a beige/off-white handle scoop holding three ounces was used for Caesar salad instead of the required one-cup portion, a grey handle scoop holding four ounces was used for lasagna instead of the required eight ounces, and a red handle scoop holding two ounces was used for sliced carrots instead of the required half-cup portion. The facility's menu and production count clearly documented the required serving sizes, and a disher size reference sheet was available in the kitchen. During interviews, the district manager for dietary confirmed that the serving utensils used did not match the required portion sizes and acknowledged that residents did not receive the correct amount of food for dinner. The executive director, vice president of operations, and regional director of clinical services were informed of these findings. No further information was provided prior to the survey exit.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
Facility staff failed to serve palatable food on the Rosewood Unit, as observed during a survey. On the evening of 09/22/2025, a test tray containing lasagna with meat sauce, sliced carrots, green beans, and mashed potatoes was sent from the kitchen to the Rosewood Unit. The tray was followed by a surveyor and a dietary district manager, who observed the process. Upon arrival, the last dinner tray was served to a resident, and the food temperatures were measured: lasagna at 127°F, green beans at 117°F, carrots at 113°F, and potatoes at 112°F. The food was then sampled by two surveyors and the dietary district manager, who stated that the food could have been warmer and was not palatable, noting it should have been at least 130°F. The executive director, vice president of operations, and regional director of clinical services were informed of these findings, and no further information was provided before the survey exit.
Failure to Provide HS Snacks Results in Prolonged Fasting Periods
Penalty
Summary
Facility staff failed to provide HS (hours of sleep) snacks to residents on both the Dogwood and Rosewood units, resulting in a prolonged interval of over 14 hours between the evening meal and breakfast. The facility's meal delivery schedule indicated that dinner was served between 4:30 p.m. and 5:15 p.m., and breakfast was not served until 7:30 a.m. to 8:00 a.m. the following day. Resident council presidents from both units confirmed that residents were not offered snacks during the night shift and that the council had not agreed to allow up to 16 hours between meals. Staff interviews revealed that snacks were not consistently provided due to staffing shortages, and dietary staff reported that while snacks were prepared and delivered to the nurse's stations, nursing staff did not always distribute them to residents. Further documentation and communication between dietary and administrative staff highlighted ongoing concerns about the failure to pass out snacks, with photographic evidence and emails indicating that snacks remained undistributed. Despite the dietary department fulfilling its responsibility to supply snacks, nursing staff did not consistently ensure residents received them. Multiple staff members, including CNAs and nurse managers, either did not recall being informed about the issue or acknowledged that snack distribution was inconsistent. No additional information was provided by facility leadership prior to the survey exit.
Unsanitary Food Tray Drying Practices Observed in Kitchen
Penalty
Summary
Facility staff failed to serve food in a sanitary manner in the kitchen. On 09/22/2025, an observation revealed that two dietary staff members, including the acting dietary manager and the district manager for dietary, were hand drying 20 resident meal trays and placing them on the tray line. The kitchen staff then slid these trays down the tray line, placed meals on them, and loaded them into food carts for delivery to the unit floors. During an interview, the district manager for dietary confirmed that the trays should have been air dried to prevent contamination. The executive director, vice president of operations, and regional director of clinical services were informed of these findings, and no further information was provided prior to exit.
Lack of Updated Contract for Respiratory Equipment Provider
Penalty
Summary
Facility staff failed to provide evidence of an updated contract with an outside provider for respiratory equipment services, affecting seven residents who received these services. A review of contracts revealed that the agreement with the respiratory equipment provider was still in the name of the previous owner, a company that no longer exists, and no current contractual agreement was in place under the new ownership. The executive director confirmed that, following the change in ownership, the process of updating contracts with all vendors had been slow due to the volume of facilities acquired and the need for legal review and negotiation with vendors. No further information was provided prior to the survey exit.
Failure to Promote Resident Dignity During Feeding Assistance
Penalty
Summary
Facility staff failed to promote a resident's dignity during feeding assistance. A resident with severe cognitive impairment, vascular dementia, a history of CVA, and swallowing difficulties was observed being fed by a certified nursing assistant (CNA) who stood next to the bed while providing assistance. The resident was dependent on staff for eating, as documented in the care plan, and required support due to significant self-care deficits. The CNA confirmed during an interview that she stood while feeding the resident and acknowledged that this was not a dignified approach. The facility's policy on resident rights includes the right to be treated with respect and dignity, and to receive services with reasonable accommodation of resident needs and preferences. Despite this, the staff member did not follow practices that would uphold the resident's dignity during feeding. The deficiency was identified through observation, staff interview, and review of the clinical record, and facility leadership was made aware of the findings.
Failure to Honor Resident's Right to Retain Personal Belongings
Penalty
Summary
Facility staff failed to maintain a resident's right to be treated with respect and dignity, specifically the right to retain and display personal belongings. A resident, who was not cognitively impaired and had multiple medical diagnoses including diabetes, obesity, hypertension, sleep and mental health disorders, had handmade signs displayed on her door. On one occasion, the Director of Nursing (DON) removed these signs without the resident's permission, citing health department and infection control concerns. The removal was done abruptly, with the signs being ripped off the door, and without any prior discussion or consent from the resident. The resident expressed anger and distress over the removal of her personal items, stating that they were her belongings and that she was not asked for permission. Staff interviews confirmed that the resident was very upset by the incident and that the DON did not seek the resident's consent before removing the signs. Facility policy states that residents have the right to retain and use personal possessions unless doing so would infringe upon the rights or health and safety of others, but there was no documentation that the signs posed an immediate risk. The incident was also noted in an Ombudsman report, which highlighted the impact on the resident's mental well-being.
Failure to Maintain Confidentiality of Resident Clinical Records
Penalty
Summary
Facility staff failed to maintain the confidentiality of a resident's clinical record by printing and distributing a progress note without proper authorization. An LPN was asked by another LPN, through a CNA and with the involvement of a former staffing coordinator, to print a specific progress note related to backdated medication orders for a resident. The LPN expressed hesitation but proceeded to print and hand over the document, believing she had no alternative. The document was then given to the requesting LPN, who later admitted via text message to the director of nursing that she had destroyed the document after being questioned about its possession. Interviews with administrative staff revealed confusion regarding why the document was printed, as the requesting LPN should have had access to print it herself. The executive director and director of nursing both confirmed that the document was printed and distributed without proper oversight, and the facility's own policy states that residents have a right to secure and confidential personal and medical records. The incident involved multiple staff members and resulted in a breach of confidentiality for the resident's clinical information.
Failure to Ensure Safe and Informed Resident Discharge
Penalty
Summary
Facility staff failed to ensure that a resident's discharge needs were met, as evidenced by the lack of documentation that written discharge instructions were provided to the resident, failure to arrange home medications prior to discharge, and not supplying the resident with provider information that included standardized patient assessment data and quality measures for selecting a home health provider. The clinical record review showed that the resident was cognitively intact and was their own responsible party, with discharge planned to home with their spouse. Progress notes indicated ongoing discharge planning discussions with the resident and spouse, and referrals to home health and pharmacy were made, but there was no documentation of a discharge note or review of instructions and medications with the resident or family on the day of discharge. The discharge plan and instructions were electronically signed the day after discharge, and the nursing discharge summary was left blank. The social services discharge summary only briefly noted the discharge home and follow-up arrangements, but did not evidence that instructions were reviewed with the resident or family, nor that a copy was provided at discharge. Interviews with staff revealed inconsistent practices and uncertainty regarding the process for ensuring that prescriptions were signed and sent to the pharmacy prior to discharge, and that residents received their medications in a timely manner. Staff also indicated that while home health referrals were made, residents were not routinely given a selection of home health agencies or comparative data to make an informed choice, contrary to facility policy. Facility policy required that residents and their representatives be provided with information on post-acute care options, including quality and resource use data, and that all relevant discharge information be presented in an accessible format. However, the investigation found that this process was not followed for the resident in question. The lack of documentation and inconsistent staff practices led to a failure to ensure the resident was prepared for a safe discharge, with necessary instructions, medication arrangements, and provider choice information not properly provided or documented.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a baseline care plan within 48 hours of admission for one resident. The clinical record review showed that the resident was admitted with a PICC line, was always incontinent of bowel and bladder, had multiple wounds, a colostomy, and was taking insulin. Despite these complex care needs, there was no evidence in the clinical record that a baseline care plan was created within the required timeframe following admission. Interviews with staff confirmed that the baseline care plan is typically developed by the admitting nurse and should include essential information such as diet, mobility, behaviors, catheters, and colostomy care. However, staff were uncertain about including the PICC line in the baseline care plan. The administrator acknowledged that no baseline care plan was available for the resident in question. Facility policy requires a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident.
Failure to Follow Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to follow professional standards of practice in the administration and documentation of medications for two residents. For one resident, staff administered tramadol and oxycodone without current physician orders in place. The medications were given based on the presence of medication cards in the medication cart, and not on active orders in the electronic system. Subsequently, backdated orders were entered into the system several days later, with staff indicating that nursing management had claimed to have obtained physician approval, though the physician did not recall authorizing these orders. Facility policy required that physician orders be appropriately and timely documented and confirmed by the ordering physician, which was not followed in this instance. For another resident, staff failed to follow professional standards in the administration of Carvedilol and Entresto, both prescribed for heart failure and related conditions. On a specific date, the electronic medication administration record (eMAR) indicated that these medications were not administered because the resident was sleeping. There was no evidence of additional attempts to administer the medications later, nor was there documentation of physician notification regarding the missed doses. The physician orders did not include instructions to hold the medications if the resident was sleeping, and the nurse interviewed stated that important medications should be administered unless there was a specific order to hold them, and that the physician should be notified if medications are held. Both incidents were confirmed through staff interviews, clinical record reviews, and facility policy review. The failures included administering medications without proper authorization and not ensuring critical medications were administered or that the physician was notified when doses were missed. These actions did not meet professional standards of quality as required by facility policy and nursing best practices.
Failure to Obtain Physician Order and Maintain Sanitary Storage for Incentive Spirometer
Penalty
Summary
Facility staff failed to provide appropriate respiratory care and services for one resident by not obtaining a physician's order for the use of an incentive spirometer. The resident's clinical record did not contain an order for the device, and the admission minimum data set assessment was incomplete. The resident was alert and oriented at the time of admission, and a clinical admission assessment was documented, but there was no documentation supporting the use of the incentive spirometer as ordered by a physician. During observation, the incentive spirometer was found on the resident's nightstand with the mouthpiece uncovered, and the resident confirmed using the device without staff providing a cover. An LPN interviewed stated that a physician's order is required for incentive spirometer use, including frequency, and that the device should be stored in a plastic bag for infection control. The facility did not provide a policy regarding incentive spirometer use, and no further information was presented before the survey exit.
Unnecessary Medication Administration Without Physician Order
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications by administering tramadol and oxycodone without a current physician's order. After the resident returned from a hospital stay, the previous orders for these medications were discontinued. Despite this, a registered nurse administered both tramadol and oxycodone to the resident on a specific date, relying on the presence of medication cards in the medication cart rather than verifying active orders in the computer system or on the medication administration record (MAR). A review of the clinical record and MAR confirmed that there were no active orders for these medications at the time they were given, and the orders were only backdated in the system several days later. The nurse involved acknowledged during an interview that she made an error by not confirming the existence of current physician orders before administering the medications. Facility policy requires that medications be administered only as ordered by a physician, and that staff review the MAR to identify medications to be administered.
Administration of Controlled Medications Without Valid Physician Order
Penalty
Summary
Facility staff failed to comply with state regulations by administering tramadol and oxycodone to a resident without a valid physician's order. The resident had previously been prescribed these medications, but the orders were discontinued upon the resident's return from a hospital stay. Despite the absence of current orders in the system, a registered nurse administered both medications on the same day, relying on the presence of medication cards in the medication cart and assuming the medications were still prescribed. The nurse did not directly consult with the resident's physician before administering the drugs. Subsequently, the nurse entered backdated orders into the electronic system several days after the medications were given, based on information from nursing management that the physician had approved the orders. However, the physician later stated he did not recall being asked or approving the administration of these medications. Interviews with other staff members, including the staff development coordinator and the director of nursing, revealed a lack of direct involvement or recollection regarding the late entry of orders. The executive director was informed of the issue, and no further information was provided before the survey exit.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for three residents. For one resident, documentation showed assessments dated after the resident had already been discharged, with staff acknowledging that these entries should have been marked as late entries but were not, resulting in an inaccurate record. Facility policy requires documentation to be completed at the time of service or, if late, clearly marked as such, which was not followed in this instance. Another resident's medication administration record (MAR) indicated a Fentanyl patch was administered, but the narcotic sign-off sheets and nurse's notes revealed the medication was not available and not given, indicating an error in documentation. Additionally, for a third resident who experienced a change in condition and was transferred to the hospital, the clinical record lacked documentation of the interventions performed, such as administration of Narcan, oxygen, and chest compressions, despite the nurse confirming these actions were taken. These failures resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement infection control practices for one resident who had a stage four pressure injury on the sacrum. The resident's clinical record included a physician's order for daily wound care, which required cleansing the wound, patting it dry, and applying medihoney and foam. The facility's policy and a CDC sign on the resident's door both indicated that enhanced barrier precautions, including the use of gloves and a gown, were required during high-contact care activities such as wound care for residents with wounds. However, there was no physician's order for enhanced barrier precautions in the resident's record. During an observation of wound care, an LPN performed the procedure without wearing a gown, despite the posted instructions and facility policy requiring this personal protective equipment. The LPN acknowledged during an interview that the sign on the door instructed staff to wear a gown during wound care, but she did not comply. Facility administrative staff were made aware of the incident, and the facility's policy clearly outlined the need for enhanced barrier precautions for residents with wounds.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to meet nurse staffing information posting requirements for all 31 days reviewed. Specifically, the postings did not include the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides directly responsible for resident care per shift. Instead, the postings only documented the total number and actual hours worked by licensed and unlicensed staff, without specifying the required categories. Additionally, on one occasion, the posted nurse staffing information was outdated, displaying a date several days prior to the observation. Interviews with facility staff revealed that the nurse staffing information postings were previously completed manually but had transitioned to being generated from an online scheduling system, which did not capture the required details. The staffing coordinator responsible for these postings had recently resigned, and the replacement from a related facility confirmed the current process and acknowledged the daily posting requirement. Facility policy also specified that the postings should include the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, but this was not followed during the review period.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
