Harrisonburg Hlth & Rehab Cntr
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisonburg, Virginia.
- Location
- 1225 Reservoir Street, Harrisonburg, Virginia 22801
- CMS Provider Number
- 495093
- Inspections on file
- 26
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Harrisonburg Hlth & Rehab Cntr during CMS and state inspections, most recent first.
Staff failed to maintain a safe, clean, and homelike environment throughout the facility, with multiple resident rooms found cluttered with hoarded items, spoiled food, soiled linens, and stained privacy curtains, and one resident observed lying on a heavily soiled bed partially unclothed. Shower rooms and hallways had black buildup, broken tiles, trip hazards, and grime, while dining and dirty linen rooms contained dirty surfaces, overflowing soiled linens, and unsecured sharps and chemicals accessible near cognitively impaired and ambulatory residents. Housekeeping and laundry services were severely understaffed, resulting in excessive piles of soiled and wet laundry, minimal clean linen on unit carts, and residents lacking adequate bedding and room cleaning for extended periods, as confirmed by a resident, an LPN, and facility records of grievances and Resident Council concerns.
Staff failed to maintain clean, properly supplied rooms, protect personal property, and process laundry in a timely manner. A resident with complex medical needs did not consistently receive correctly sized fitted sheets for a bariatric mattress, despite an adequate central supply and 24‑hour access to laundry, and staff sometimes used whatever sheets were available instead of obtaining the proper ones. Another resident with severe cognitive impairment remained in a room with damaged walls, visible drips and spatters, trash on the floor, and a persistently dirty floor, while housekeeping and maintenance were unaware or unable to keep up with daily cleaning expectations. Two residents experienced missing personal items, including a shaving mirror and multiple laminated family photos, with incomplete or absent property inventories and grievances that were entered but never investigated or resolved. Multiple residents reported that personal clothing took more than two weeks to be returned from laundry and was often mixed up, and surveyors observed a significant backlog of soiled and clean laundry in the department, with the EVS director acknowledging delays and infrequent handling of lost‑and‑found items.
Facility staff did not follow physician orders for two residents, resulting in one resident not receiving a newly recommended glaucoma medication for over a month due to a missed consultation report, and another resident missing three doses of a prescribed antibiotic after admission because of delays in order entry and verification. These deficiencies were linked to lapses in communication, documentation, and adherence to medication administration policies.
A resident with multiple chronic conditions and bowel incontinence, who was cognitively intact but unable to sense bowel movements due to numbness, did not have a care plan addressing bowel incontinence. Staff interviews confirmed regular checks for incontinence, but review of the clinical record showed that a care plan for this issue was not developed.
Two residents with significant medical conditions and frequent incontinence did not receive timely incontinence care during an overnight shift. Both were found at the start of the day shift with soiled briefs and, in one case, wet bed linens. Staff interviews and facility documentation confirmed that required checks and changes were not performed as outlined in their care plans.
Staff failed to serve palatable and properly heated meals to two residents, as observed during a meal service where food was served lukewarm and described as bland. A test tray confirmed that food temperatures were significantly lower than when prepared in the kitchen, and a resident reported that meals were never served hot. The dietary manager acknowledged that food temperatures dropped while waiting to be served, contrary to facility policy requiring appetizing temperatures.
Three residents did not receive their documented meal preferences, including requests for baked potatoes, dessert, and milk, during a lunch service. Interviews confirmed that these preferences were routinely unmet, and a CNA was unable to explain the omissions despite facility policy requiring accommodation of resident preferences.
A resident did not receive prescribed doses of niacin and oxycodone-acetaminophen because the medications were not available in the facility. Staff documented the unavailability, notified the provider and responsible party, and explained that delays in ordering and pharmacy authorization contributed to the missed doses. The emergency medication supply did not contain the required medications, and facility policies for medication unavailability were not fully effective in preventing the deficiency.
A resident experienced prolonged discomfort and safety concerns due to unresolved maintenance issues, including a non-functioning air conditioning unit, broken closet doors, and a loose ceiling tile. Despite repeated reports to staff and open maintenance work orders, these deficiencies were not addressed in a timely manner, and the facility lacked an effective system for tracking and resolving maintenance requests.
Staff failed to supervise and secure hazardous items, resulting in a resident with dementia ingesting body wash left on her bedside table, leading to severe medical complications. The facility also lacked protocols to monitor hot liquid temperatures, causing the same resident to sustain a coffee burn. Additional observations found unsecured hazardous items accessible to cognitively impaired residents, with staff confirming inconsistent storage practices.
Multiple residents experienced neglect when staff failed to provide timely incontinence care and respond to call bells, resulting in prolonged exposure to urine and feces, skin injury, and psychosocial harm. One resident with quadriplegia was left in feces for over fifty minutes, another was left in feces for two hours leading to significant skin redness and burning, and a third was found by a family member in a saturated brief that had not been changed for eight hours, resulting in moisture-associated skin damage.
Facility staff failed to provide timely incontinence care to three residents who were dependent on staff, resulting in psychosocial harm and the development of incontinence-associated dermatitis. Delays in responding to call lights and incontinence needs led to residents remaining in soiled briefs for extended periods, causing skin breakdown, discomfort, and emotional distress. Staff interviews and documentation confirmed inconsistent practices and lack of timely care.
A resident with a history of severe weight loss and on a full liquid diet continued to lose substantial weight after admission due to the facility's failure to implement timely nutritional interventions, accurately assess malnutrition risk, and promptly arrange a gastroenterology consult. Meal trays were repetitive and sometimes missing prescribed items, and there was a lack of interdisciplinary follow-up despite ongoing weight loss and the development of wounds.
The facility did not maintain an effective pest control program for all units, with a lapse in professional pest control services for two months due to a change in providers. During this period, staff documented sightings of cockroaches in resident areas, and the facility's policy requiring monthly inspections and treatments was not followed.
Staff did not maintain comfortable temperatures in two units when boilers malfunctioned, resulting in residents experiencing cold conditions for several days. A resident and her family reported discomfort and concern, and documentation showed that room temperatures dropped as low as 60°F before temporary heating solutions were implemented.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on several occasions because the medication was not available, despite active physician orders. Interviews with LPNs revealed that medication unavailability was sometimes due to staff not ordering the medication or agency staff being unaware of overstock supplies. Facility policy required staff to notify providers and use backup pharmacy procedures, but these steps were not effectively followed, resulting in missed doses.
Staff failed to follow infection control protocols for handling soiled linen and disposing of incontinent briefs, with observations of dirty linen being transported without bags or gloves, and soiled items left on floors or in unlined trash cans. Interviews confirmed these actions were not in line with facility policy, which requires contaminated laundry to be bagged and handled with protective equipment.
Staff failed to maintain sanitary and comfortable conditions in multiple resident rooms and bathrooms, with persistent soiling, mold, and damaged walls left unaddressed despite daily cleaning policies. Residents reported ongoing concerns about cleanliness, lack of supplies, and communication barriers with housekeeping. Maintenance issues were exacerbated by staffing shortages and unfulfilled renovation promises, resulting in unsanitary and uncomfortable living conditions.
A review of staff records and facility documentation found that five employees had not received required behavioral health training, despite the facility's assessment indicating the need for such competencies to support residents with mental health and behavioral needs. Facility leadership confirmed the absence of training records for these staff members.
Facility staff did not notify the Department of Health Professions (DHP) of abuse or neglect allegations involving two certified nursing assistants, despite reporting these incidents to APS, the ombudsman, and VDH. The administrator acknowledged not following the facility's policy, which requires DHP notification within 24 hours for incidents involving licensed or certified staff.
Staff failed to promptly report allegations of abuse and neglect for two residents. In one instance, a resident was left in a soiled brief for an extended period, with evidence provided by a family member, but the incident was not escalated to management or authorities in a timely manner. In another case, a resident reported being left in feces for hours, resulting in skin irritation and emotional distress, yet the allegation was not promptly reported by the ADON. Both cases demonstrate lapses in timely reporting of suspected abuse and neglect.
Facility staff did not conduct comprehensive investigations into two separate allegations of neglect and possible abuse. In one case, a resident with severe dementia was hospitalized after presumed ingestion of body wash, with multiple staff observing symptoms consistent with ingestion, but only two staff were interviewed and the incident was deemed unsubstantiated. In another case, a resident was found in a wet brief for an extended period, with staff and photographic evidence confirming the neglect, yet the investigation was limited and concerns were dismissed. Both cases show the facility did not follow its own investigation protocols.
Staff did not update a resident's care plan to include nonskid strips as a fall intervention after a fall incident, despite documentation in progress notes and device assessments. Interviews with LPNs and CNAs revealed inconsistent awareness of the intervention, and facility policy required such interventions to be added to the care plan and reviewed by licensed nurses.
A resident with severe cognitive impairment and multiple health issues did not receive required grooming and shower care, despite being dependent on staff for ADLs. Staff accounts and documentation conflicted, with some indicating care was provided and others, including family, observing the resident was not groomed or showered. The facility lacked a policy for ADL care, contributing to the deficiency.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on two occasions, as confirmed by MAR review and resident interview. Facility staff, including LPNs and the DON, indicated issues with medication availability and lack of awareness among agency staff regarding medication storage. Required documentation explaining the missed doses was not present, and the facility's policy for medication administration and documentation was not followed.
Facility staff failed to accurately complete a hot liquid safety evaluation for a resident with behavioral issues and did not properly document or provide clear evidence of a shower for another dependent resident. In both cases, clinical records were incomplete or inconsistent, and staff interviews and documentation did not align, resulting in deficiencies in maintaining accurate resident records.
A review of employee records revealed that two CNAs did not have documented abuse training, as required. When asked, facility leadership confirmed they could not provide evidence of completed training for these staff members.
Two certified nursing assistants did not have documented evidence of receiving mandatory infection control training, as required by the facility's infection prevention and control program. This was identified during a review of employee records, and facility leadership confirmed the absence of training documentation.
The facility failed to maintain a clean and sanitary environment, with observations of feces, mold, and dirt in resident areas and the dining room. Residents reported infrequent cleaning, and staff confirmed a shortage of housekeeping personnel. Equipment and supplies were improperly stored in hallways, creating potential hazards. The maintenance director acknowledged some responsibility but had not addressed the issues.
The facility failed to provide appetizing and palatable meals to residents on the West unit. Observations and interviews revealed that meals were often cold and unappealing by the time they reached residents. Despite appropriate temperatures at the steam table, delays in delivery led to lukewarm meals. Residents consistently complained about the food's quality and temperature, as documented in Resident Council Meeting Minutes and confirmed by the activities director and dietary manager.
Widespread Environmental Uncleanliness, Hoarding, and Inadequate Linen and Housekeeping Services
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment across all three nursing units, public spaces, and the building as a whole. During an initial tour and subsequent observations over several days, multiple resident rooms were found crowded with boxes, food items, personal items, and plastic storage containers placed in front of and on top of air conditioning/heating units, restricting air flow. Rooms contained balled-up clothing in beds with soiled linens, soiled clothing scattered around, and large open containers of sauces and spices spilled over overbed tables and bedside cabinets. Privacy curtains in semi-private rooms had stains and brown smears causing them to stick together, and partially eaten cornbread squares with visible blue mold were present. Various food and drink items in cups and plastic glasses were mixed and unidentifiable, none were refrigerated, and rooms had a sour spoiled food smell combined with a strong urine odor. One resident was observed lying on a soiled bed encrusted with spilled food, wearing a black sweatshirt with a large dried food/liquid stain on the front and no clothing from the waist down, partially covered by a soiled sheet. The roommate’s side of the semi-private room appeared similarly unclean and cluttered. Several rooms were noted to have hoarding conditions, and the administrator acknowledged awareness of the hoarding but stated he had not cleaned certain areas to avoid upsetting residents. Throughout the survey, shower rooms were observed with a black substance along corners and caulking, broken tiles, used soap and hair in drain covers, and hallway floors with holes creating trip hazards. Baseboards were knocked down in places, and main hallways and resident room floors had black track marks, a sticky substance, food crumbs, wrappers, and built-up crusts of dirt and black grime in corners. Housekeeping and laundry services were found to be inadequate for the 180-bed facility. On one day, only one housekeeper was present, who reported being unable to complete all necessary work, and the environmental services director confirmed she was also the only laundry attendant. The laundry room contained excessive accumulations of soiled clothing and linens, including piles stacked over five feet high, overflowing bins, bags of wet laundry piled halfway up the laundry room doors, and washers and dryers full of linen and clothing sitting idle. Linen carts on all three units contained only a few sheets, pillowcases, towels, and gowns, with no washcloths or blankets, and resident rooms lacked facility-provided bedspreads, with some residents using personal blankets instead. A resident reported not having enough linen for his bed, lacking a bedspread, and that his room had not been cleaned for about two weeks; his room was observed with trash under both beds, black scuff marks on the floor, and cobwebs in corners. Grievances and Resident Council minutes documented repeated concerns about rooms not being cleaned and personal items missing. Additional observations included dirty dining room tables and floors with paint spatters and greasy black substances, stained chairs stacked in the dining room, dirty linen rooms with soiled items overflowing onto floors, and unsecured rooms containing sharps containers with blood, biohazardous waste in red bins, and chemicals accessible near cognitively impaired and ambulatory residents.
Failure to Maintain Clean, Homelike Environment and Safeguard Residents’ Personal Property and Laundry
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and to protect residents’ personal property. One cognitively intact resident with multiple chronic conditions, including polyarthritis, chronic respiratory failure, diabetes, Crohn’s disease, and bipolar disorder, did not consistently receive properly sized fitted sheets for a bariatric mattress. Surveyors observed an ill‑fitting sheet that did not cover the entire mattress, and the resident reported that the correctly sized orange‑trimmed bariatric sheets were often unavailable on the unit. Staff interviews confirmed that the resident had voiced concerns about sheet availability, that the unit linen room sometimes lacked the needed sheets, and that CNAs sometimes used whatever sheet was available at shower time instead of obtaining the correct size from the laundry, despite 24‑hour access to clean linen and an adequate central inventory of the correct sheets. Another resident with COPD, mood disorder, chronic pain syndrome, major depressive disorder, and severely impaired cognition was found in a room where housekeeping was not maintained. Over multiple days, surveyors observed scraped and damaged drywall, missing sections of wall, brown/tan drips and spatters on the wall, paper trash and candy wrappers on the floor beside and under the bed, and a dirty floor with black/gray film, drips, footprints, and black/brown specks near the toilet. A family member reported having to pick up trash from the floor and stated that housekeeping "could be better." The maintenance director was unaware of the wall damage and reported no work order had been entered, while the housekeeping supervisor and housekeeper acknowledged that rooms and bathrooms were supposed to be cleaned daily but that room changes and deep cleans sometimes prevented the housekeeper from getting to all rooms each day, resulting in some rooms only being cleaned every other day. The facility also failed to protect residents’ personal property and to process laundry in a timely manner. One resident with moderately impaired cognition reported that pictures and other personal items were lost during room changes, particularly laminated pictures of family and pets, and that grievances had been filed without any response or apparent search for the items. Records showed two room changes and two grievances documenting missing glasses, fingernail clippers, hats, a fan, and multiple laminated pictures, with no investigation, findings, or actions recorded. Interviews with the administrator, housekeeping supervisor, social services director, and unit manager revealed that no personal belongings inventory had been completed on admission, no department had been assigned to investigate the grievances, and personal items left in a room for pest treatment were not accounted for. Another cognitively intact resident reported a shaving mirror missing for about six months; the property list did not specifically list the mirror, lacked the resident or responsible party signature, and had no dates or signatures for items added or removed, contrary to facility policy. In addition, multiple residents reported problems with timely return of personal clothing from laundry, stating that laundry sometimes took more than two weeks to be returned, was not returned in the order sent, and that they received items that were not theirs while not receiving items sent earlier. A tour of the laundry department revealed large amounts of mixed soiled facility and resident laundry in bags at the bottom of the chute, multiple bins of soiled laundry awaiting washing, tables piled high with clean facility linen to be folded, and a long rack of clean resident clothing awaiting return to units. The EVS director acknowledged that laundry sometimes became backed up, that delays occurred, and that unlabeled items were placed in lost and found, which was only brought to units about once every two months, despite a stated goal of returning resident laundry within three days.
Failure to Administer Medications as Ordered and Implement Physician Recommendations
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and care coordination. For one resident with a history of glaucoma and multiple other diagnoses, an eye physician recommended the addition of Dorzolamide-Timolol eye drops to the resident's existing glaucoma treatment. The recommendation was made during an on-site consultation, but the report was sent to an outdated email address and was not received by current facility staff. As a result, the new medication order was not reviewed or implemented, and the resident did not receive the recommended eye drops for over 30 days. Interviews with staff revealed a lack of awareness regarding the new recommendation, and the facility's process for updating consultant contact information was not followed, leading to the oversight. In a separate incident, another resident was admitted with physician orders for an antibiotic to be administered four times daily. Upon review, it was found that the antibiotic was not initiated until the following day at noon, resulting in three missed doses. The delay was attributed to the late entry and verification of the medication orders in the electronic system, despite the medication being available in the facility's backup supply. The DON and Regional Director of Clinical Services were unable to clarify why certain doses were missed after the orders were entered into the system. Facility policies require that medications be administered according to prescriber orders and that consultation reports be reviewed and implemented as indicated. In both cases, failures in communication, documentation, and timely order entry led to residents not receiving prescribed treatments as ordered by their physicians.
Failure to Develop Care Plan for Bowel Incontinence
Penalty
Summary
Facility staff failed to develop a care plan addressing bowel incontinence for one resident, despite the resident being assessed as bowel incontinent on the most recent MDS and having diagnoses including diabetes, congestive heart failure, respiratory failure, and peripheral vascular disease. The resident, who was cognitively intact, reported numbness from the waist down and an inability to sense bowel movements, requiring frequent checks by staff. Interviews with a CNA and the MDS coordinator confirmed that the resident was regularly checked for incontinence and that a care plan for bowel incontinence should have been in place but was missed. Review of the clinical record and care plan revealed no documentation of a bowel incontinence care plan for this resident.
Failure to Provide Timely Incontinence Care for Two Residents
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents who were unable to perform activities of daily living independently. One resident, with diagnoses including quadriplegia and spinal cord compression, was assessed as cognitively intact and frequently incontinent of bowel and bladder. On the early morning in question, the resident was found soaked at the start of the day shift, indicating that incontinence care had not been provided during the previous shift. The resident did not recall receiving care during the night and reported sleeping through most of it. Staff interviews and facility documentation confirmed that the resident was not checked or changed prior to the day shift, despite care plan interventions requiring frequent checks and changes. Another resident, with a history of COPD, diabetes, BPH, congestive heart failure, and dementia, was also assessed as cognitively intact and frequently incontinent. This resident was found with a heavily soiled brief and wet bed linens at the start of the day shift. The resident's roommate reported that the assigned CNA did not provide a brief change during the last round of the shift. Staff interviews and facility investigation corroborated that incontinence care was not provided as required by the resident's care plan, which called for frequent checks and changes. In both cases, the lack of timely incontinence care was identified through staff and resident interviews, review of facility documentation, and clinical record review. The findings were discussed with facility leadership, and the facility's own investigation supported the evidence of failure to provide care as outlined in the residents' care plans. No skin issues were identified for either resident following the incidents.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
Facility staff failed to serve palatable and appropriately heated meals to two residents out of a sample of eleven. During a lunchtime meal service observation, several residents were noted not eating, and one resident specifically complained that her food was not served hot, which she preferred. A test tray conducted during the same meal service revealed that the baked ham, scalloped potatoes, and mixed vegetables were served at lukewarm temperatures (121.6°F, 138.4°F, and 129.7°F, respectively), despite being much hotter in the kitchen prior to service. The vegetables and potatoes were also described as bland and lacking seasoning. The dietary manager acknowledged that food temperatures dropped significantly due to hot plates sitting and waiting to be served on the cart. Resident interviews confirmed dissatisfaction with meal temperatures, with one resident stating that her meals were never served hot. Facility documentation reviewed indicated a policy requiring food to be palatable, attractive, and served at a safe and appetizing temperature. The dietary manager stated that food should be served below 150°F to prevent scalding, but acknowledged the temperature drop before service. The deficiency was brought to the attention of facility leadership during an end-of-day meeting.
Failure to Honor Resident Meal Preferences During Service
Penalty
Summary
During a lunchtime meal service, three residents did not receive their stated meal preferences as documented on their meal tickets. Specifically, two residents had requested baked potatoes and milk with their meals, while another resident preferred dessert and milk. These preferences were not honored during the observed meal service. Resident interviews confirmed that one resident consistently did not receive dessert or milk without specifically asking, another did not receive milk or condiments, and a third seldom received milk or the requested baked potato. A Certified Nursing Assistant (CNA) reviewed a meal ticket and was unable to explain why the baked potato was not served, indicating a lack of awareness or communication regarding resident preferences. Facility documentation stated that menus are to be served as written unless changes are made in response to resident preference, unavailability, or for special meals. Despite this policy, the observed meal service did not accommodate the residents' documented preferences, resulting in a failure to provide meals according to individual needs and requests.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
Facility staff failed to provide ordered medications for a resident, specifically niacin and oxycodone-acetaminophen, as prescribed by the medical provider. The clinical record review showed that the resident had active orders for oxycodone-acetaminophen for pain management and niacin as a supplement. The medication administration records indicated missed doses of both medications over several days, with documentation codes referencing unavailability and progress notes explaining that the medications were not on hand, were in transit, or awaiting delivery from the pharmacy. The emergency medication supply (Omnicell) did not contain the required strength of oxycodone-acetaminophen or niacin. Interviews with nursing staff revealed that when medications were not available, they notified the provider and responsible party, and documented the situation in the medical record. Staff explained that over-the-counter medications like niacin were typically ordered through a supply company with less frequent deliveries, and that the pharmacy required an authorization form to dispense such medications. Delays in returning the authorization form contributed to the delay in obtaining niacin for the resident. The pharmacy confirmed that they did not receive the necessary authorization to dispense niacin until several days after the initial order, resulting in a gap in administration. Facility policy required staff to search for missing medications, contact the pharmacy, and use the emergency kit if necessary. The policies also required provider notification and documentation when medications were unavailable. Despite these policies, the resident did not receive the ordered medications as scheduled, and there was a lack of documentation explaining the hold on niacin for certain days. The deficiency was identified through interviews, record reviews, and review of facility documentation, which confirmed that the facility did not have the medications available for administration as ordered.
Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
Facility staff failed to provide a safe, functional, and comfortable environment for a resident who reported multiple unresolved maintenance issues in his room. The resident expressed concerns about a non-functioning air conditioning unit, which had not been operational for several weeks despite rising temperatures and his pre-existing breathing issues. He also reported that the closet doors were broken, making the drawers inaccessible, and that a ceiling tile was out of place and appeared as if it could fall. The resident stated he had reported these issues to staff multiple times, but no corrective action had been taken. Direct observation by the surveyor confirmed the air conditioning unit was not working, the closet doors posed a safety hazard, and the ceiling tile was not properly secured. A review of facility maintenance work orders revealed that requests for repairs to the air conditioning unit and closet doors had been entered but remained open and unresolved for an extended period. Interviews with the maintenance director and staff indicated a lack of an effective system for tracking and addressing maintenance requests, with reliance on verbal reports and handwritten notes rather than the facility's electronic system. The maintenance director acknowledged that the electronic system was not being monitored and that many issues were prioritized informally, leading to delays in addressing non-urgent repairs. These actions and inactions resulted in the resident continuing to live in an environment that was not safe, functional, or comfortable.
Failure to Prevent Resident Access to Hazards and Inadequate Hot Liquid Safety
Penalty
Summary
Facility staff failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in multiple incidents of resident harm. One resident with severe dementia ingested an unknown amount of body wash that had been left accessible on her bedside table. This resident was known to be impulsive, grab at objects, and was not oriented, requiring total care. Staff interviews and clinical documentation confirmed that the body wash was left within reach after a bed bath, and the resident subsequently ingested it, leading to respiratory distress, hospitalization, intubation, and the need for a tracheostomy and feeding tube. The incident was not directly witnessed, but multiple staff and the resident's roommate confirmed the presence of the body wash and the resident's symptoms following ingestion. Additionally, the facility did not have a system or protocol in place to monitor the temperature of hot liquids served to residents. This failure resulted in another incident where the same resident spilled hot coffee on herself, causing redness and requiring medical attention. Review of the resident's hot liquid safety evaluation revealed inaccuracies and omissions, as the assessment did not reflect the resident's documented agitation, impulsivity, and behavioral symptoms. Staff interviews confirmed that coffee temperatures were not routinely checked, and observations during the survey found that coffee was being served at temperatures exceeding safe limits. Further observations during the survey revealed that hazardous items, such as toiletry products and cleaning supplies, were left unsecured in resident rooms and common areas, including shower rooms with open doors and accessible gallon jugs of shampoo and body wash. Residents with cognitive impairment and poor safety awareness were found to have access to these items, and staff interviews confirmed a lack of consistent practice regarding the storage of potentially hazardous materials. These deficiencies were found to have the potential to affect multiple residents across all nursing units.
Failure to Provide Timely Incontinence Care and Call Bell Response Resulting in Neglect and Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care and respond to call bells for multiple residents, resulting in neglect, skin injury, and psychosocial harm. One resident, who was cognitively intact and completely dependent on staff for all activities of daily living due to quadriplegia, was left sitting in feces for over fifty minutes after activating the call light. The resident reported feeling humiliated and unimportant, and was observed to be emotionally distressed. The resident's care plan indicated a high risk for pressure ulcers and required prompt incontinence care, but staff did not respond in a timely manner, and the call bell system showed the call had been active for over fifty minutes before staff entered the room. Another resident, who was dependent on staff for toileting and had no cognitive impairment, reported being left in feces for approximately two hours. The resident described that after activating the call bell and informing a CNA of the need for incontinence care, the CNA turned off the call light and did not return. The resident was eventually assisted by another CNA, who found fecal material on the resident's thighs, bed pad, and sheets, and observed significant skin redness and burning. The resident reported the incident to staff and Adult Protective Services, and photos documented the extent of the soiling and skin injury. A third resident, with severe cognitive impairment and dependent on staff for care, was found by a family member in a saturated brief and wet bedding. The family member marked the brief and found it unchanged eight hours later. Staff interviews confirmed that incontinence rounds were expected every two hours, but the resident's brief was not changed as required, resulting in moisture-associated skin damage. Staff acknowledged that the resident was wet enough to require a change, and documentation showed redness and treatment for skin damage following the incident.
Failure to Provide Timely Incontinence Care Resulting in Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care to multiple residents who were dependent on staff for activities of daily living, resulting in psychosocial and physical harm. One resident with quadriplegia, who required total assistance, was observed to have his call light engaged for over 50 minutes before staff responded to his request for incontinence care. The resident reported routinely waiting extended periods for care, which led to feelings of anger, humiliation, and being unimportant. Clinical records indicated that this resident developed incontinence-associated dermatitis (IAD) on both buttocks, with wound care documentation confirming new skin breakdown attributed to delayed incontinence management. Another resident, who was dependent for toileting and had no cognitive impairment, reported being left in feces for approximately two hours after notifying staff of the need for a brief change. The resident described significant discomfort, burning, and emotional distress as a result of the delay. Observations and interviews confirmed that the resident's skin was red and irritated, and photographic evidence showed feces on the resident's thighs, bed pad, and sheets. Staff interviews corroborated the delay, and the resident reported the incident to multiple facility leaders, who were unaware of the situation until informed by surveyors. A third resident, with severe cognitive impairment and a history of urinary tract infection, was found to have remained in the same brief for eight hours, as confirmed by staff interviews and photographic evidence provided by the resident's daughter. The resident's brief was saturated, and skin assessments documented redness and moisture-associated skin damage to the coccyx and groin areas. Staff interviews revealed inconsistent practices regarding the frequency of incontinence care and reliance on visual indicators rather than direct assessment, contributing to prolonged exposure to moisture and subsequent skin breakdown.
Failure to Timely Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
Facility staff failed to ensure that a resident with a history of significant weight loss maintained acceptable nutritional status. Upon admission, the resident had already experienced a 40-pound weight loss due to self-imposed starvation and was placed on a full liquid diet per hospital discharge instructions. Despite this, the resident lost an additional 18 pounds in the first nine days at the facility and a total of 24 pounds over five weeks. Observations revealed that the resident's meal trays were repetitive and sometimes missing prescribed items, such as ice cream, which the resident expressed a preference for and was ordered to receive. The facility did not implement timely interventions to address the resident's ongoing weight loss. There was a delay in initiating nutritional supplements, with the first supplement order not placed until nearly a month after admission. The registered dietician's initial malnutrition screening inaccurately assessed the resident as low risk and did not account for the significant weight loss. There was also a lack of documented follow-up or reassessment by the dietician until several weeks later, during which time the resident continued to lose weight and developed wounds. Additionally, the facility failed to promptly arrange a necessary gastroenterology appointment to address the resident's underlying condition of achalasia, which restricted dietary advancement. Staff interviews revealed confusion and lack of communication regarding the scheduling of this appointment, with no evidence of attempts to secure an earlier consultation until several weeks after admission. The facility's own policies required timely weight monitoring, interdisciplinary review, and provider notification for significant weight changes, but these procedures were not followed, resulting in the resident's continued decline.
Failure to Maintain Consistent Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program across all three units. Although a tour of the nursing units did not reveal immediate concerns, interviews and document reviews showed that the facility did not have pest control services in place for the months of January and February 2025. The administrator confirmed that pest control was not present during these months due to a change in service providers, acknowledging that this lapse was an oversight. During the period without pest control coverage, work orders documented the presence of cockroaches in a resident's nightstand and sightings of roaches in a resident's bathroom. The facility's policy required monthly inspections and treatments by a corporate-approved contractor, which was not followed during the lapse. Staff interviews indicated that pest sightings were reported and addressed internally, but the absence of professional pest control services during the specified months led to the deficiency.
Failure to Maintain Safe and Comfortable Temperatures Due to Boiler Malfunction
Penalty
Summary
Facility staff failed to maintain a comfortable and safe environment for residents by not ensuring adequate internal temperatures in two of three units due to malfunctioning boilers. The east and west wings experienced significant heating issues when the primary boilers were not operating properly. Residents and their family members reported that it was cold in the facility, with one resident stating she had to use multiple sheets and still felt cold, and her family member expressing concern to the point of requesting a welfare check from the police department. Documentation and interviews revealed that the facility's boilers had ongoing mechanical problems, including frequent shutdowns, water leaks, and malfunctioning recirculating pumps. Service logs indicated repeated failures and the need for manual resets to restore heat. The administrator and maintenance staff confirmed that the boilers would often trip and require intervention, and that parts were difficult to obtain due to the manufacturer no longer being in business. During this period, the facility resorted to using portable heaters and spot coolers to provide some heat, but temperature monitoring showed that several resident rooms remained below comfortable levels, with some rooms measuring between 60-67°F. The deficiency was further substantiated by service technician reports, which described a cracked heat exchanger and the inability of staff to consistently reset the boiler to maintain adequate temperatures. The lack of a reliable heat source persisted until a temporary boiler was installed, but prior to this, residents in affected wings were exposed to uncomfortably low temperatures for an extended period. The facility's failure to maintain a safe and comfortable environment directly impacted residents' well-being during the time the boilers were inoperable.
Failure to Provide Ordered Glaucoma Medication Due to Unavailability
Penalty
Summary
Facility staff failed to ensure that a resident received Latanoprost eye drops for glaucoma as ordered by the physician. The medication order, active since 2/14/24, required the drops to be administered at bedtime in both eyes. Clinical record review and interviews revealed that the resident did not receive the eye drops on multiple occasions, specifically on 1/16/25, 3/2/25, and 3/4/25, due to the medication not being available. Documentation indicated that the drops were reordered or that the pharmacy was contacted, but the medication was still not administered as prescribed. Interviews with two LPNs indicated that medication unavailability could be due to staff not ordering the medication or agency staff being unaware of overstock supplies stored in the medication room refrigerator. Facility policy required nurses to notify the provider and discuss alternatives or activate backup pharmacy procedures when medications were unavailable. Despite these policies, the resident's medication was not consistently available or administered as ordered, and the issue was brought to the attention of the facility administrator and DON.
Failure to Follow Infection Control Standards for Soiled Linen and Brief Disposal
Penalty
Summary
Facility staff failed to adhere to infection control standards regarding the handling of soiled linen and disposal of incontinent briefs across all three units. Multiple observations revealed staff transporting dirty linen without using bags, carrying it against their bodies, and not wearing gloves. Dirty linen was found on the floor in shower rooms and resident rooms, and soiled incontinent briefs were disposed of in trash cans without liners. Staff interviews confirmed that these practices were not in accordance with facility policy, which requires contaminated laundry to be bagged at the site of generation and handled with appropriate personal protective equipment. Further observations showed that during resident care, staff placed soiled linen directly on the floor rather than in designated bags or carts. Some staff acknowledged the improper handling when questioned and indicated awareness of the correct procedures. Facility documentation reviewed stated that contaminated laundry must be bagged and handled with protective gear, but these protocols were not consistently followed as evidenced by the surveyor's findings.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to maintain a sanitary, clean, and comfortable environment in multiple resident rooms and bathrooms across several units. Observations revealed brownish/black substances on bathroom walls and trashcans, persistent soiling and sticky floors, and missing or damaged wall plaster with visible mold and musty odors. In several instances, these unsanitary conditions remained unaddressed over multiple days, despite daily cleaning schedules outlined by facility policy. Staff interviews confirmed that cleaning was not consistently performed as required, with some staff unaware of ongoing issues and others acknowledging that bathrooms had been in poor condition for extended periods. Residents reported ongoing concerns about the cleanliness of their rooms and bathrooms, with some expressing fear of using the facilities due to the level of filth and lack of cleaning. One resident noted a lack of paper towels for several days, requiring family to bring supplies from outside. Staff interviews further revealed communication barriers between residents and housekeeping staff, and a lack of follow-through on promised renovations and repairs, particularly in bathrooms where mold and water damage were present. Maintenance staff were not always aware of the problems, and the maintenance department had open positions, including a vacant director role, which contributed to delays in addressing these issues. Facility documentation confirmed that daily cleaning tasks were not being completed as required, with specific failures to clean toilets, sinks, floors, and to remove visible stains and debris. The administrator and corporate staff were made aware of these deficiencies during the survey, and acknowledged the poor state of repair and cleanliness in resident areas. The lack of consistent cleaning and maintenance resulted in unsanitary and uncomfortable living conditions for residents on multiple units.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
Facility staff failed to provide behavioral health training to five out of eight employees reviewed during an extended survey. The survey included a review of staff interviews, staff records, and facility documentation, which revealed that there was no credible evidence that these employees had received the required behavioral health training. The facility assessment, last reviewed on 8/6/25, indicated that the facility serves residents with mental health and behavioral needs and outlined the necessity for staff competencies in managing psychiatric symptoms, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. Despite being asked to provide evidence of behavioral health training for the selected employees, the facility was unable to produce documentation showing that the identified staff had completed such training. The administrator, DON, and corporate staff confirmed that they could not locate the required training records for these employees. The facility's own assessment highlighted the need for behavioral health competencies, particularly for memory care units, but the training records for the reviewed staff did not reflect completion of this requirement.
Failure to Report Abuse Allegations to DHP as Required by Policy
Penalty
Summary
Facility staff failed to implement their abuse policy regarding timely reporting of allegations involving licensed staff to the Department of Health Professions (DHP) for two residents out of a sample of 26. In both cases, allegations of abuse or neglect involving certified nursing assistants were reported to Adult Protective Services (APS), the ombudsman, and the Virginia Department of Health (VDH), but there was no evidence that DHP was notified as required by facility policy. Documentation for one incident showed confirmation of notifications to APS, ombudsman, and VDH, but not to DHP. In the other case, similar notifications were made, but again, DHP was not notified. During interviews, the administrator initially claimed to have sent the report to DHP, but upon review, the documentation provided was addressed to VDH, not DHP. The administrator later admitted to not faxing allegations to DHP unless they were substantiated, contrary to the facility's written policy, which requires notification within 24 hours for incidents involving licensed or certified staff. No additional information was provided prior to the survey exit.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
Facility staff failed to timely report allegations of abuse and neglect for two residents. In the first case, a resident's daughter discovered her father had not been changed for approximately eight hours, as evidenced by a marked brief and photographs. The resident was found with a saturated brief, red and irritated skin, and poor grooming. Although the incident was reported to a charge nurse and later discussed with a unit manager, neither staff member escalated the allegation to upper management or regulatory authorities in a timely manner. Documentation and witness statements were delayed, and the issue was not brought to the administrator's attention until days after the incident. In the second case, a resident reported to a CNA and later to the ADON that she had been left in a soiled brief with feces for nearly two hours, resulting in skin irritation and visible soiling of her bed and body. The resident expressed emotional distress over the incident and provided photographic evidence. The ADON acknowledged being informed but did not immediately report the allegation to appropriate authorities. The administrator was not made aware of the situation until after the resident had already been visited by Adult Protective Services. In both cases, the facility failed to follow timely reporting protocols for suspected abuse and neglect.
Failure to Conduct Thorough Investigations into Allegations of Neglect and Abuse
Penalty
Summary
Facility staff failed to conduct a thorough investigation into two separate allegations of neglect and possible abuse involving two residents. In the first case, a resident with severe dementia was presumed to have ingested a body wash, resulting in hospitalization for acute hypoxic and hypercapnic respiratory failure. Multiple staff members observed symptoms consistent with soap ingestion, such as foaming at the mouth, pink-tinged bubbles, and respiratory distress. Despite these observations and statements from several staff and the resident's roommate, the facility's internal investigation was limited to interviews with only two staff members and a review of hospital records. The facility concluded the incident was unsubstantiated due to lack of direct witness, despite substantial circumstantial evidence and staff testimony indicating otherwise. In the second case, the facility failed to thoroughly investigate an allegation of neglect regarding timely incontinent care for another resident. The resident's daughter reported that her father had not been changed for an extended period, and staff witness statements, as well as photographic evidence, confirmed the resident was found in a wet brief that had been marked earlier in the day. Staff interviews revealed inconsistencies in care documentation and a lack of timely intervention. The administrator, who also served as the abuse coordinator, acknowledged the situation but did not conduct a comprehensive investigation, relying instead on limited staff interviews and dismissing the daughter's concerns. Both incidents demonstrate a failure by facility staff to follow their own abuse and neglect investigation policies, which require immediate and thorough internal investigations, including collecting evidence and interviewing all relevant witnesses. The lack of comprehensive investigations in both cases was directly observed and documented by surveyors, who noted that the facility did not meet its own standards for responding to allegations of abuse and neglect.
Failure to Revise Care Plan with Fall Interventions
Penalty
Summary
Facility staff failed to review and revise the care plan to include fall interventions for one resident. Specifically, after a fall incident, a progress note indicated that nonskid strips should be placed by the resident's bedside as a new intervention. However, this intervention was not added to the resident's care plan, despite documentation in a device assessment that it had been. Multiple staff interviews revealed inconsistent knowledge about whether nonskid strips were in place for the resident, and staff relied on care plans and other documentation to implement interventions. Housekeeping staff were responsible for removing nonskid strips after resident discharge, but there was no clear record of the intervention being implemented for the resident in question. A review of facility policies showed that interventions identified after falls or through device assessments were to be incorporated into the care plan and reviewed by licensed nurses. The care plan for the resident did not reflect the intervention for nonskid strips, even though it was documented elsewhere as necessary. The deficiency was identified through observation, staff interviews, and review of clinical records and facility documentation, and was communicated to facility leadership.
Failure to Provide ADL Care and Grooming
Penalty
Summary
Facility staff failed to provide adequate activities of daily living (ADL) care, specifically grooming and showering, for one resident who was dependent on staff for these needs. The resident, who had severe cognitive impairment and multiple diagnoses including urinary tract infection, muscle weakness, and underweight status, did not receive a shower or proper grooming on the day in question. Staff statements conflicted regarding whether a shower was provided, with one CNA documenting that a shower was given, while both an LPN and a physical therapist assistant indicated the resident was not showered and remained in bed for much of the morning. The resident's daughter also reported that her father was not groomed and appeared unshowered, with greasy hair. Review of facility documentation showed inconsistencies between staff statements and recorded care, as the CNA had documented both a bed bath and a shower, but other staff and family observations contradicted this. The facility did not have a policy for ADL care, and the incident was confirmed through interviews and record reviews. The lack of consistent and accurate care documentation, as well as the absence of a clear ADL policy, contributed to the failure to provide necessary hygiene and grooming for the resident.
Failure to Administer Physician-Ordered Eye Drops and Inadequate Documentation
Penalty
Summary
Facility staff failed to administer Latanoprost eye drops as ordered by the physician for a resident with glaucoma. The resident reported during an interview that he frequently did not receive his prescribed eye drops. Review of the clinical record and medication administration record (MAR) confirmed that the eye drops were not administered on two specific dates, with one date left blank on the MAR and the other marked as held, without any documentation explaining the omission. The physician's order for the eye drops had been active since February and remained so at the time of the survey. Interviews with the DON and two LPNs revealed that medication administration was inconsistent, particularly when medications were not available or when agency staff were unaware of where extra supplies were stored. The facility's policy required medications to be administered as ordered and documented immediately after administration, but this was not followed in the resident's case. No documentation was provided in the nursing progress notes to explain why the medication was not given, and the DON acknowledged that blanks on the MAR indicated the medication was not administered and should have been explained.
Failure to Accurately Complete Safety Evaluation and Maintain Clinical Records
Penalty
Summary
Facility staff failed to accurately complete and document a hot liquid safety evaluation for a resident with a history of agitation, restlessness, and impulsive behavior. Despite multiple progress notes indicating the resident was agitated and required lorazepam in the week prior to the evaluation, the hot liquid safety form did not reflect these behaviors. Required sections indicating risk factors were not properly checked, and the form was left incomplete, omitting the necessary indication that the resident was at risk for injury from hot liquids. Additionally, staff failed to maintain accurate clinical records for another resident who was dependent for activities of daily living and had severe cognitive impairment. There were conflicting accounts regarding whether the resident received a shower, with CNA documentation indicating a shower was given, while statements from other staff, including an LPN and a physical therapist assistant, indicated the resident was not showered. The resident's daughter also reported that her father did not appear to have been showered, providing photographic evidence of poor hygiene and soiled bedding. The facility did not have a policy for activities of daily living documentation, and the inconsistencies in staff statements and documentation led to uncertainty about the care provided. The lack of accurate and complete clinical records for both residents was confirmed through staff interviews, clinical record reviews, and supporting documentation.
Lack of Documented Abuse Training for Two CNAs
Penalty
Summary
Facility staff failed to provide credible evidence of abuse training for two certified nursing assistants out of eight employee records reviewed. During an extended survey, a sample of eight employees was selected, and the facility administrator was asked to provide documentation of staff training in abuse prevention and reporting. Upon review of the employee records, it was found that two CNAs did not have documentation indicating they had received the required abuse training. The facility administrator and corporate staff confirmed the absence of this documentation and were unable to locate records of the training for these staff members. No further information was provided before the exit conference.
Lack of Documented Infection Control Training for Two CNAs
Penalty
Summary
Facility staff failed to provide mandatory infection control training as part of their infection prevention and control program for two certified nursing assistants out of eight employee records reviewed. During an extended survey, a sample of eight employees was selected, and the facility administrator was asked to provide evidence of infection control training for these staff members. Upon review of the employee records, it was found that there was no credible evidence that the two certified nursing assistants had received the required infection control training. This finding was confirmed with the facility administrator, director of nursing, and corporate staff, who were unable to locate documentation of the training for these employees. No additional information or documentation was provided by the facility prior to the exit conference.
Facility Fails to Maintain Sanitary Environment and Proper Equipment Storage
Penalty
Summary
The facility staff failed to maintain a clean, sanitary, and comfortable environment for residents across all three nursing units and the dining room. Observations revealed feces on the floor in the shower room, black mold-like coloring around tiles, and heavily soiled shower mats. Several rooms had missing tiles, black and brown stains on floors and walls, and significant dirt build-up. The dining room was found with trash, cobwebs, and a severely soiled IV pole with a missing wheel. Residents reported that their rooms were not cleaned daily, and housekeeping staff were observed to be short-staffed and often on their cell phones. Interviews with residents and staff highlighted the lack of adequate cleaning due to insufficient housekeeping staff. Residents reported that their rooms were cleaned infrequently, with some areas never receiving a deep clean. The housekeeping manager confirmed the shortage of staff and the inability to complete deep cleaning as scheduled. The facility's cleaning policy was not being followed, as evidenced by the state of the rooms and common areas. Additionally, equipment and supplies were improperly stored in hallways and alcoves, creating potential hazards. A broken floor tile was observed in a hallway, and various items such as mattresses, wheelchairs, and a mechanical lift were stored inappropriately. The maintenance director acknowledged responsibility for some of these issues but had not addressed them. The therapy department manager noted that equipment should be stored out of resident use areas, but this was not being done.
Failure to Provide Appetizing and Palatable Meals
Penalty
Summary
The facility staff failed to provide appetizing food with palatable temperatures and appearance to residents on the West unit. Observations and interviews revealed that residents consistently received meals that were cold and unappealing. On July 1, 2024, Resident #4 expressed dissatisfaction with the meals, describing them as cold and unpleasant. The food temperatures were checked at the steam table, showing appropriate temperatures, but delays in delivery resulted in lukewarm meals by the time they reached the residents. Resident #5, a vegetarian, also complained about the limited choices and the unappealing appearance of the food. Resident Council Meeting Minutes from April to June 2024 documented ongoing complaints about the food being cold, bland, and dry. The activities director confirmed that residents consistently voiced these concerns, which were communicated to the administrator. The dietary manager acknowledged awareness of the issue, attributing it to delays in serving the food. Despite efforts to maintain appropriate temperatures at the steam table, the problem persisted, as noted by the administrator and director of nursing during the exit conference on July 2, 2024.
Latest citations in Virginia
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
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