Dulles Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Herndon, Virginia.
- Location
- 2978 Centreville Road, Herndon, Virginia 20171
- CMS Provider Number
- 495174
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Dulles Health & Rehab Center during CMS and state inspections, most recent first.
Multiple residents had care plan failures involving incontinence care, bathing, oxygen therapy, contact precautions, anticoagulation monitoring, and TED hose use. Surveyors observed missing ADL documentation, inconsistent showers, oxygen delivered at the wrong flow rate, an uncovered nebulizer mask, a CNA entering a contact isolation room without PPE, and no evidence of anticoagulation monitoring or a care plan for TED hose use.
Failure to Monitor Anticoagulant Therapy: The facility failed to document monitoring for residents receiving anticoagulants. A resident receiving Enoxaparin and three residents receiving Apixaban/Eliquis had MAR-TARs showing the medications were given as ordered, but the records did not show evidence of routine monitoring for bleeding or bruising. An LPN stated anticoagulant monitoring should include observing for these side effects because it is a patient safety issue.
Unsafe Food Storage and Utensil Handling in Kitchen: The kitchen had a carton of thickened apple juice with a use-by date in dry storage, stacked meatloaf pans with visible debris, steam tray pans with visible moisture on the outside, and a thickener bin with a scoop resting inside the product. The FSD stated the vendor-sent juice should have been rejected and that the scoop should be stored on top of the bin rather than inside the thickener.
Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Call Light Not Kept Within Reach: A resident with severe cognitive impairment and right-sided non-functioning was observed in a wheelchair with the touch pad call bell clipped to the bed on the resident’s right side, out of reach of the left hand. The resident indicated the call bell could not be reached until an LPN moved it to the wheelchair tray, where it became accessible. The resident’s care plan included keeping personal items within reach, and the facility policy stated call lights should be available to allow residents to call for assistance.
A resident admitted with cellulitis and chronic lower extremity ulcers was ordered IV Daptomycin for 28 days, but one scheduled dose was not administered because the medication had not arrived from the pharmacy. The record documented that the dose was waiting for pharmacy arrival, but there was no evidence that the physician was notified or that the missed dose was documented as required.
Failure to Provide Written Transfer Notice: A resident was transferred to the hospital for fever, low O2, and a slow response, but the facility did not provide a written transfer notice to the resident, the resident representative, or the ombudsman. The DON/Social Services process described mailing notice to family, documenting it on a form, and sending weekly encrypted emails to the ombudsman, but no notice was found in the record or ombudsman binder.
Failure to implement baseline wound care on admission. A resident admitted with cellulitis and multiple wounds had a baseline care plan identifying pressure injuries to both buttocks and cellulitis wounds to both calves, but the clinical record did not show wound treatment being started right away. The eTAR showed treatment for the buttock wounds began later, followed by treatment for the calf wounds, after the wounds had already been documented on admission and during body audits.
Failure to provide ordered wound care and TED stockings. One resident admitted with cellulitis, chronic venous insufficiency, and bilateral lower-extremity wounds had wounds identified on admission, but the record did not show treatment before the wound orders began, despite staff stating wound treatment should be entered and documented when wounds are found. Another resident with edema and a history of venous thrombosis had physician-ordered TED stockings, but observations showed the stockings were not being worn and the care plan did not document their use.
A resident admitted with cellulitis and chronic leg ulcers had pressure injuries to both buttocks identified on admission and confirmed on body audit as DTIs with maroon/purple tissue. The record did not show wound treatment before the orders and eTAR entries began, despite staff stating that admission nurses should review discharge instructions, obtain orders if needed, and document treatment in the eTAR and care plan.
Failure to provide ordered GJ stoma site care for a resident with a feeding tube. The resident’s record showed tube feeding and a care plan for the insertion site, but the MD orders did not include stoma care orders. An LPN described changing the dressing and dating it, while an RN said stoma care was done daily and as needed and would follow MD orders; facility policy called for cleansing the peristomal area and applying a dressing per provider order.
Improper IV Antibiotic Administration: An RN administered oral meds, eye drops, and an injection to a resident while wearing the same gloves, then accessed the resident’s central venous access and connected IV Daptomycin without changing gloves or re-sanitizing hands. The resident had an order for daily IV Daptomycin for a wound infection, and an LPN stated gloves should be changed and hands sanitized before accessing a central venous access; the facility’s hand hygiene policy also stated gloves do not replace hand hygiene.
A resident with respiratory failure and COPD did not receive oxygen at the ordered 3 L/min via NC; the O2 concentrator was observed set between 2.5 and 3 L/min on multiple occasions. Staff also left the resident’s nebulizer mask uncovered on the bedside table when not in use, rather than storing it in a sanitary manner. An LPN acknowledged the oxygen setting should match the order and that the nebulizer mask should be protected from contamination.
A resident with ESRD, CVA, hemiplegia/hemiparesis, and DM had an order for dialysis transport on M/W/F and a care plan calling for coordination and regular communication with the dialysis center. The dialysis communication book was missing multiple pre/post weight entries, and an LPN confirmed the documentation was incomplete and that weights are to be documented; the facility policy also identified pre- and post-weights as part of dialysis communication.
Expired liquid cimetidine for a resident was found in the medication refrigerator, and an LPN left two residents’ medication cups unattended on top of a med cart during med pass. The LPN stated the meds should have been placed inside the cart and not left where someone could take them.
Dietary preferences were not honored when a resident’s meal tray included fish even though fish was listed on the dislike list. The resident was cognitively intact with DM, CHF, and MI, and the care plan and dietary note indicated that food preferences were discussed and relayed to the kitchen. Staff described a process for matching meal tickets to trays before delivery, but the tray still contained the disliked item.
Inaccurate Skilled Nursing Documentation: A resident with cellulitis wounds, pressure injuries, and anticoagulant therapy had skilled notes that incorrectly stated the resident was not on anticoagulants, not receiving infection-related care, and had no wounds being monitored or treated. The resident’s record also showed IV antibiotics, apixaban for DVT, and documented wounds to both lower extremities and buttocks, while an RN later stated the notes could not be considered accurate.
Infection control practices were not followed for two residents on contact precautions and during medication administration for another resident. A CNA entered a room under contact precautions without gown or gloves, and a staff member entered another contact precautions room without hand hygiene or PPE before handling meal trays. In addition, an RN administered oral meds, eye drops, and an injection without changing gloves or sanitizing hands between tasks, despite facility policy requiring hand hygiene and glove changes.
Multiple Care Plan Implementation Failures
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for multiple residents, including care related to incontinence, bathing, oxygen therapy, contact precautions, anticoagulation monitoring, and TED hose use. Surveyors identified missing documentation and observed care not being carried out as planned for residents with significant medical needs, including residents with bowel and bladder incontinence, severe cognitive impairment, quadriplegia, anoxic brain injury, dementia, COPD, respiratory failure, CVA, ESRD, and other diagnoses. In several cases, the care plans contained interventions such as toileting assistance, showering, oxygen administration, or monitoring for bleeding, but the record and observations did not show those interventions were consistently implemented. For one resident who was frequently incontinent of bowel and bladder and dependent on staff for toileting, the ADL record did not show toileting hygiene on two night shifts. Another resident with quadriplegia and anoxic brain damage was assessed as always incontinent and dependent for toileting hygiene, and the resident’s agent reported concern that the resident appeared to have a wet brief for hours. A resident with dementia and dependence for bathing received only two showers in a two-week period despite a care plan calling for bathing and hygiene assistance as required. For two residents with severe cognitive impairment and dependence for ADLs, the ADL records showed multiple missing entries for incontinence care, turning, and positioning on numerous dates and shifts. Surveyors also observed failures in treatment-related care. A resident ordered to receive oxygen at 3 L/min continuously was observed on multiple occasions receiving oxygen at a lower flow rate of between 2.5 and 3 L/min, and the resident’s nebulizer mask was repeatedly observed uncovered on the bedside table rather than stored in a sanitary manner. Another resident on contact precautions for CRE was observed when a CNA entered the room and turned off the call light without donning gown or gloves. In addition, residents on anticoagulation therapy had no evidence of anticoagulation monitoring documented in the MAR-TAR, and one resident ordered to wear TED hose had no care plan developed to address that intervention.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to monitor residents receiving anticoagulant medications for side effects and signs of bleeding or bruising, resulting in a deficiency for unnecessary drugs. For Resident #2, the clinical record showed an order for Enoxaparin sodium injection every 12 hours, and the MARs showed the medication was administered as ordered each day, but the record did not show evidence of monitoring for side effects. An LPN stated that residents receiving anticoagulants have a higher risk of bleeding or bruising and that nursing staff should monitor for these side effects each shift and document the monitoring on the MAR. For Resident #8, the record showed a diagnosis history including CVA, hemiplegia/hemiparesis, DM, and ESRD, with a quarterly MDS indicating no cognitive impairment and extensive assistance needs for mobility and self-care. The care plan identified anticoagulant therapy as a focus and directed staff to report signs or symptoms of new or unusual bleeding or bruising, and the physician ordered Apixaban for atrial fibrillation. The MAR-TAR showed Apixaban was administered as ordered, but there was no evidence of anticoagulation monitoring documented during the reviewed period. For Resident #10, the record showed diagnoses including osteoarthritis, dementia, atrial fibrillation, and COPD, with severe cognitive impairment and dependence for multiple activities of daily living. The physician ordered Apixaban for unspecified atrial fibrillation, and the MAR-TAR showed the medication was administered as ordered, but there was no evidence of anticoagulation monitoring. For Resident #1, the record showed diagnoses including DM, CHF, and MI, with no anticoagulant care plan until later in the review period; the physician ordered Eliquis for atrial fibrillation, the MAR-TAR showed administration as ordered, and there was no evidence of anticoagulation monitoring documented.
Unsafe Food Storage and Utensil Handling in Kitchen
Penalty
Summary
Food was not served in a safe and sanitary manner in the kitchen. During observation with the food service director, a 46 fluid ounce carton of thickened apple juice was found in dry storage with a documented use-by date. In the kitchen, a wire shelving rack held six stacked meatloaf pans that the director said were clean and available for use, but two of the pans had visible debris adhering to the inside. Another wire shelving rack in the cooking area held two stacks of steam tray pans, one stack of four and one stack of three, and the director stated they were clean and available for use; however, one pan in each stack had visible water droplets on the outside. A 22-quart bin labeled thickener was observed on the countertop containing approximately 14 quarts of product, with a plastic scoop resting inside the thickener. During interview, the food service director stated she had pulled the thickened apple juice off the shelf because it should have been rejected by the vendor, that the meatloaf pans had been re-washed to remove debris, that staff had been educated on air drying pans before stacking them, and that the thickener scoop should be kept on top of the bin rather than inside the product for infection control purposes. The administrator, DON, and ADON were informed of the findings.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to accommodate the needs and preferences of one resident by not keeping the call light within reach. During an observation, the resident was seated in a wheelchair beside the bed, and the touch pad call bell cord was clipped to the edge of the bed with the TV remote control on the resident’s right side. The resident was unable to reach the call bell across the body with the left hand and indicated that the call bell was not reachable. The resident was admitted with diagnoses including epilepsy, traumatic brain injury, schizophrenia, and psychotic delusions, and the most recent MDS coded the resident as severely cognitively impaired with dependence for locomotion, transfer, dressing, toileting, and hygiene. The resident was documented as non-functioning on the right side. The care plan included an intervention to place personal items and water within reach, and the facility’s policy stated that call lights should be available at the bedside, toilet, and bathing area to allow residents to call for assistance. When an LPN observed the situation, he confirmed the resident could not reach the call bell in its original location and moved it to the wheelchair tray, where the resident could then reach it. The LPN stated it was a safety issue if the resident could not call for assistance.
Failure to Notify Physician When Ordered IV Antibiotic Was Not Given
Penalty
Summary
The facility failed to notify the physician that Resident #182 did not receive the ordered Daptomycin intravenous dose on 3/21/2026 at 5:00 PM. Resident #182 was admitted with diagnoses including cellulitis and chronic lower extremity ulcers, and the physician order documented Daptomycin 600 mg intravenously in the evening for cellulitis for 28 days, with a start date of 3/21/2026. The eMAR showed the 5:00 PM dose was coded as 9, with chart code .9 indicating other/see nurses notes. The progress notes documented that the resident arrived to the facility on 3/20/2026 with a central line in the right upper chest and was receiving IV Daptomycin for cellulitis. On 3/21/2026, a note stated that the Daptomycin was waiting for pharmacy arrival. The clinical record did not show that the physician was notified that the dose was not administered. During interviews, an LPN stated that if a medication had not arrived from the pharmacy, the nurse should call the physician and document that the physician and resident were notified. An RN stated that if a medication had not arrived, the physician should be notified to determine whether treatment should be extended, and that this would be documented in the medical record.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for Resident #6 when the resident was transferred to the hospital on 2/28/26 for fever, low oxygen, and a slow response. Review of the clinical record and a facility binder containing ombudsman notices did not show that a written transfer notice was provided to the resident, the resident's representative, or the ombudsman. During an interview on 3/24/26, the Director of Social Services stated that when a resident is transferred to the hospital, she sends written notification to the resident's family by mail, documents the date on a written notification form, and sends a weekly encrypted email of all transfers to the ombudsman. She also stated that she provides the written notification form to the resident if and when the resident returns to the facility. She stated she was on leave when Resident #6 was transferred and her social services team was new. The Administrator and Director of Nursing were informed of the concern on 3/24/26. The facility policy titled Notification of Discharge stated that discharge notices for emergent discharges will be provided to the patient/representative as soon as practicable and that copies of notices for emergency transfers must also be sent to the ombudsman.
Failure to Implement Baseline Wound Care on Admission
Penalty
Summary
The facility failed to implement the baseline care plan for a resident admitted with cellulitis and chronic lower extremity ulcers. The baseline care plan, initiated on 3/20/2026 and revised on 3/23/2026, documented that the resident was at risk for or had actual skin breakdown, including pressure injuries to both buttocks, cellulitis wounds to both calves, and redness under both breasts. The care plan also directed staff to assess the skin thoroughly and implement precautions and/or treatment as indicated. On admission, the nursing assessment documented cellulitis on both lower extremities, wounds to both lower extremities, excoriation to the sacrum, and open areas on both buttocks. A body audit on 3/20/2026 documented the same findings. A subsequent body audit on 3/21/2026 described a deep tissue injury to the right buttock and left buttock, necrotic tissue with purulent drainage in the left posterior calf wound, and granulation tissue with moderate serous drainage in the right posterior calf wound. The physician orders for wound care were not entered until 3/23/2026, with start dates of 3/23/2026 for the left buttock pressure injury and 3/24/2026 for the calf wounds. Review of the eTAR showed treatment to the buttock pressure injuries beginning on night shift 3/23/2026 and treatment to the calf wounds beginning on evening shift 3/24/2026. The clinical record did not evidence treatment to the wounds prior to those dates.
Failure to Provide Ordered Wound Care and TED Stockings
Penalty
Summary
The facility failed to provide ordered treatment for a resident with bilateral venous wounds identified on admission. The resident was admitted with diagnoses including cellulitis, chronic venous insufficiency, and chronic lower extremity ulcers. Admission documentation and body audits identified cellulitis wounds on both posterior calves, including necrotic tissue and purulent drainage on the left calf wound and granulation tissue with moderate serous drainage on the right calf wound. The physician later entered wound care orders for cleansing and dressing changes, but the clinical record did not evidence treatment to the wounds before the orders began on the evening shift of 3/24/2026. The resident stated that compression wraps had slipped down at home and that the resident had developed cellulitis in the lower legs and was at the facility for a 28-day course of antibiotics. Facility staff interviews indicated that when a wound was identified on admission, the nurse should review hospital discharge instructions for wound treatment orders and, if none were present, contact the physician for orders. Staff also stated that the admission nurse normally entered initial treatment and that wound treatment should be documented in the eTAR. However, the record failed to show treatment for the bilateral calf wounds prior to 3/24/2026 despite the wounds being identified on admission and included on the baseline care plan. The facility also failed to apply TED stockings according to physician orders for another resident. The resident had diagnoses including embolism and thrombosis of superficial veins of the left lower extremity and was cognitively intact. The physician ordered TED stockings to be worn during the day and removed in the evening for edema, but observations on two separate occasions showed the resident’s lower legs without TED stockings. During an observation with an LPN, the resident was not wearing TED stockings on either leg, and the LPN stated they were used to prevent swelling. The care plan did not include documentation for the use of TED stockings, and the facility policy stated stockings are to be applied in accordance with physician orders and checked daily.
Failure to Initiate Pressure Injury Treatment
Penalty
Summary
The facility failed to implement treatment for pressure injuries identified on admission for one resident who was admitted with diagnoses including cellulitis and chronic lower extremity ulcers. The admission/readmission skin assessment documented excoriation to the sacrum and open areas on both buttocks, and a body audit the next day documented a deep tissue injury to the right buttock and a deep tissue injury to the left buttock with dark maroon/purple tissue, no drainage, and surrounding skin redness. The clinical record showed physician orders for zinc oxide paste and cleansing of the left and right buttock pressure injuries beginning on 3/23/2026, and the eTAR documented treatment to the left and right buttock pressure injuries beginning on night shift 3/23/2026. Review of the record did not show treatment to the wounds before 3/23/2026, despite the wounds being identified on admission and during the subsequent body audit. Staff interviews indicated that when a wound was identified on admission, the nurse was expected to review hospital discharge instructions for wound treatment orders and contact the physician if no orders were present. Staff also stated that the admission nurse typically entered initial treatment, the wound nurse assessed the resident the next day, and wound treatment would be documented in the eTAR. The facility policy stated that interventions for a pressure injury would be documented in the care plan and that compliance with interventions would be documented in the medical record.
Failure to Provide Ordered GJ Stoma Site Care
Penalty
Summary
The facility failed to provide care for Resident #17’s gastrojejunostomy (GJ) stoma site consistent with professional standards of practice. The resident’s most recent MDS annual assessment, with a reference date of 2/5/2026, documented that the resident had a feeding tube and received 51% or more of calories from enteral feeding. The physician’s orders documented tube feeding and water flushes, but did not include orders for GJ stoma site care. The resident’s discharge instructions from 12/12/2025 stated that the skin around the tube and under the skin disk should be cleansed daily with soap and water and dried thoroughly. The comprehensive care plan stated that the insertion site would be free of signs and symptoms of infection and that stoma site care would be provided per MD order or facility policy, with reference to the TAR. During interviews on 3/25/2026, an LPN stated that she changed the dressing and wrote the date on it, and that night shift usually changed the dressing. An RN stated that stoma care was done daily at 6:00 AM and as needed and that he would follow the doctor’s orders. The facility policy for care of a patient with a feeding tube stated that the stoma area would be cleaned and a dressing applied by a licensed nurse as indicated in accordance with the medical provider’s order, and that the peristomal area may be cleansed with soap and water using a spiral pattern.
Improper IV Antibiotic Administration
Penalty
Summary
The facility failed to administer parenteral medications in a sanitary manner for a resident receiving an IV antibiotic through a central venous access. During observation, an RN prepared medications on a medication cart, sanitized her hands, donned gloves, and then touched the medication cart surfaces and lock before taking the tray to the resident. Without changing gloves, she administered oral medications, eye drops, and an injection, then removed the cap from the resident’s central venous access, cleaned the access with alcohol, and connected the tubing for Daptomycin before unclamping it to begin infusion. The resident’s record showed an order for Daptomycin Sodium Chloride Intravenous Solution 620 mg IV daily for wound infection for 6 weeks. An LPN interviewed after the observation stated that gloves should be changed and hands sanitized if gloves become contaminated, and that gloves should be removed and hands sanitized before donning new gloves and attaching an antibiotic to a central venous access. The facility policy on Hand Hygiene stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them; the IV Access Device Care policy did not address the concern.
Failure to Provide Ordered Respiratory Care and Maintain Nebulizer Mask Sanitation
Penalty
Summary
Facility staff failed to provide respiratory care and services for Resident #161 by not administering oxygen according to the physician’s order. The resident was admitted with diagnoses including respiratory failure and COPD, and the most recent MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for daily decisions. The physician ordered oxygen at 3 L/min via nasal cannula continuously for respiratory failure related to COPD, and the care plan directed staff to provide oxygen as ordered. During multiple observations, the resident was seen receiving oxygen by nasal cannula, but the oxygen concentrator flow meter was set between two-and-a-half and three liters per minute rather than the ordered 3 L/min. When questioned, an LPN stated the flow meter should be read with the liter line passing through the middle of the float ball and acknowledged that the resident’s oxygen flow rate should have been 3 L/min. The manufacturer’s manual for the oxygen concentrator stated that the flow should be adjusted to the prescribed setting by centering the ball on the line marking the specific flow rate. Facility staff also failed to store the resident’s nebulizer mask in a sanitary manner when not in use. On multiple observations, the nebulizer mask was found laying uncovered on top of the bedside table. The resident had an order for formoterol fumarate inhalation nebulization solution twice daily for COPD. When the uncovered mask was observed with an LPN, she stated that the mask should be placed in a plastic bag when not in use to prevent contamination.
Missing Dialysis Communication and Weight Documentation
Penalty
Summary
The facility failed to provide evidence of communication with the dialysis facility for a resident with ESRD who was admitted with diagnoses including CVA, hemiplegia/hemiparesis, DM, and ESRD. The resident’s most recent MDS quarterly assessment coded the resident as cognitively intact with a BIMS score of 15 out of 15 and requiring maximal assistance for locomotion, transfers, dressing, toileting, and hygiene. The physician’s order directed dialysis pickup at 6:45 AM on Mondays, Wednesdays, and Fridays, and the care plan identified the resident’s renal disease requiring dialysis and a left arm shunt, with interventions to coordinate with the dialysis center and communicate regularly via pre/post treatment notes. A review of the resident’s dialysis communication book showed missing pre/post weight documentation for multiple dialysis dates, including 2/20, 2/23, 2/25, 2/27, 3/2, 3/6, 3/9, 3/13, and 3/16. During interview, an LPN described the expected dialysis care process, including checking the fistula for bruit and thrill, sending a snack or meal depending on dialysis time, and monitoring the site for bleeding, and stated the documentation was not complete and that weights are to be documented. The facility’s dialysis policy stated that communication with the dialysis center may include pre- and post-weights.
Expired Medication Stored in Refrigerator and Medications Left Unattended on Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when the facility kept a bottle of liquid cimetidine for Resident #132 in the Chesapeake unit medication refrigerator after its labeled expiration date of 3/15/26. The resident had a physician’s order dated 10/21/25 for cimetidine 300 mg/5 mL, to give 2.5 mL twice daily for gastroesophageal reflux disease. During observation on 3/24/26, the bottle was still present in the refrigerator with the expired date on the label, and an LPN later stated that expired medications should have been discarded and that nurses should check the medication refrigerator daily for expired medications. Medication storage was also not maintained securely when an LPN left two residents’ medication cups on top of medication cart #1 on the Chesapeake Unit during medication administration. The cups contained several pills and tablets and were covered only by upside-down clear plastic drinking cups while the LPN walked away from the cart and entered resident rooms, leaving the medications unattended and out of sight. During interview, the LPN stated the medications should not have been left on top of the cart and should have been placed inside the cart, and said someone could come by and take them.
Dietary Preferences Not Honored on Meal Tray
Penalty
Summary
The facility failed to honor a resident’s dietary preferences by serving fish to a resident whose meal ticket listed fish as a dislike. The resident was admitted with diagnoses including DM, CHF, and MI, and the most recent MDS coded the resident as cognitively intact with a BIMS score of 15 out of 15. The comprehensive care plan addressed altered nutritional needs related to class II obesity and DM and included an intervention to discuss food preferences with the resident/family and honor food requests as possible. A dietary progress note documented that food preferences were discussed with the resident and relayed to the kitchen. During the initial resident screening, the resident stated that everything was great except for food on meal trays that was on the dislike preference list. The lunch tray ticket for the resident listed no fish among the dislikes, yet the resident’s lunch tray included fish. Staff described the tray delivery process as checking the meal ticket against the food on the tray before giving it to the resident, and the dietary manager stated that trays are made in the kitchen based on the meal ticket and aides are to compare the tray with the ticket before delivery.
Inaccurate Skilled Nursing Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident by documenting incorrect information in the daily skilled observation and assessment notes on 3/22/2026, 3/23/2026, and 3/24/2026. The resident was admitted with diagnoses including cellulitis of both lower limbs, chronic lower extremity ulcers, and long-term anticoagulant use. The nursing admission/readmission assessment documented cellulitis with wounds on both lower extremities, open areas on both buttocks, and anticoagulant therapy, and the body audit documented wounds to both posterior calves with necrotic tissue, purulent drainage, granulation tissue, and measurable wound dimensions. Physician orders showed the resident was receiving apixaban every 12 hours for DVT, daptomycin IV in the evening for cellulitis, and piperacillin-tazobactam IV every 8 hours for cellulitis. The baseline care plan also documented the resident as at risk for or having actual skin breakdown, with pressure injuries to both buttocks, cellulitis wounds to both calves, redness under both breasts, and anticoagulant therapy placing the resident at risk for bleeding/bruising. Despite this documented condition and treatment, the daily skilled notes for the three dates recorded that the resident was not on anticoagulants, was not receiving care related to recent or ongoing infection, and did not have impaired skin or a wound being monitored or treated. During interview, RN #2 stated that nurses completed the skilled notes, that the computer prompted some of the documentation, and that the notes needed to be accurate because they were used to keep everyone informed on the resident’s progress; after reviewing the notes, he stated he could not say they were accurate.
Infection Control Practices Not Followed During Contact Precautions and Medication Administration
Penalty
Summary
The facility failed to implement infection control practices for two residents on contact precautions and for one resident during medication administration. For one resident with a physician order for Contact Isolation due to CRE, a CDC contact precautions sign was posted outside the room directing staff to clean hands and wear gloves and a gown before room entry. While the resident was lying in bed and the call light was ringing, a CNA entered the room and turned off the call light without donning a gown or gloves. The CNA later stated that staff should wear a gown and gloves when touching a resident or items in the room but could not explain why she did not do so in this instance. For another resident on contact precautions for a UTI, a sign outside the room instructed staff to wash hands and don gown and gloves before entering. A staff member entered the room without washing hands or donning gown or gloves, went to the bedside table to pick up the breakfast tray, then went to the roommate’s bedside, retrieved the roommate’s breakfast tray, and delivered both trays to dietary staff. The staff member sanitized hands only after leaving the room. Interviews with RN and CNA staff confirmed that gown and gloves were required for entry into a contact precautions room and that this applied regardless of the task being performed. During medication administration for a third resident, an RN prepared medications on a tray, sanitized hands, and donned gloves. After handling the medication cart and administering oral medications, the RN administered olopatadine eye drops and then gave an enoxaparin injection without changing gloves or sanitizing hands between tasks. An LPN stated that gloves should be changed and hands sanitized between oral medications, eye drops, and injections, and that this was basic nursing care to prevent contamination. The facility policy stated that gloves do not replace hand hygiene and that hand hygiene should be performed before donning gloves and immediately after removing them, with gloves changed when moving from a contaminated body site to a clean body site.
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Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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