Norfolk Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norfolk, Virginia.
- Location
- 901 East Princess Anne Road, Norfolk, Virginia 23504
- CMS Provider Number
- 495210
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Norfolk Health Care Center during CMS and state inspections, most recent first.
A resident with stroke, chronic systolic HF, left-sided hemiparesis, aphasia, and moderate cognitive impairment (BIMS 7) was allowed to leave on an LOA with a person identified as a cousin, after being signed out and assisted by a CNA who was not trained on the LOA process. Staff, including an LPN and the Manager on Duty, believed the resident was going to a cookout and would return later that day, but the resident did not return and remained away for about three days without the knowledge of nursing staff or family. The resident’s daughter learned he was missing only when contacted by staff, and a missing person report was filed with local law enforcement. Although facility policy required prompt reporting of unusual incidents and submission of a 5‑day investigative report to the state agency, no such reports were made; instead, the state agency received an anonymous complaint and later a call from the resident. The facility’s internal investigation was incomplete and did not include all relevant statements or a full chronology of events.
Staff failed to follow and competently implement the LOA process, allowing a cognitively impaired, functionally dependent resident with multiple comorbidities to leave with a cousin for several days without the knowledge of nursing staff or family. A CNA who had not been trained on LOA assisted the resident in leaving, and an LPN relied on second-hand information that the resident would return later that evening, without confirming or documenting the required LOA details or medications. The resident did not return as expected, and his absence was only recognized the next day when an LPN noted missed medications and contacted the resident’s daughter, who reported that the family had not taken him. The facility’s LOA policy requirements for nurse notification, estimated time of return, medication provision, and documentation were not met, and no required report of the incident was submitted to the state agency.
Staff failed to follow written menus and individual meal tickets for several residents, including one with stroke and heart failure on a fluid‑restricted diet who received a biscuit instead of the ordered cornbread, another with a tracheostomy and diabetes on a mechanical advanced/chopped diet who was served an unchopped pork loin and a biscuit instead of the ordered dinner roll, and a resident with dysphagia and cerebral palsy who did not receive the cornbread portion listed on the meal ticket despite expressing a desire for more food to gain weight. The Dietary Manager reported that ordered bread items were unavailable due to missed food deliveries and that substitutions were not updated in the menu/meal ticket software.
A resident with multiple comorbidities and intact cognition was discharged home with physician orders for a bedside commode, front‑wheeled walker, and HH services including nursing and PT. The resident reported that the ordered DME did not arrive for several days and HH services did not start for about a week, leaving her to use a bedpan despite limited mobility and reporting increased weakness and flaccidity in one leg. The Director of Social Services and Director of Rehabilitation confirmed the delays in DME delivery and HH initiation, and the Administrator acknowledged the time frames were not acceptable. Discharge planning notes documented the resident’s complaints about missing DME, the inability of a PCA company to provide services, and subsequent contacts with the DME supplier and multiple HH agencies, confirming that the resident’s ordered equipment and HH services were not provided in a timely manner after discharge.
Multiple residents did not receive beverages with their lunch meals as listed on menus, meal tickets, or physician orders. Cognitively intact and impaired residents with conditions such as dysphagia, cerebral palsy, malnutrition, stroke, renal failure, heart failure, tracheostomy, diabetes, and PVD were served full meals without the hot coffee, tea, milk, or measured fluid-restricted beverages specified for them. In some cases, a resident verbally requested the missing beverage from an LPN, who did not return with it, while CNAs relied on bedside water pitchers instead of following the meal ticket. The Dietary Manager reported that beverages had been removed from trays due to spills and sent separately, and also noted a software error listing milk at lunch, but was unaware that residents were not consistently receiving the required 8 oz and 6 oz beverages with meals.
Staff failed to post required enhanced barrier precaution (EHB) signage for a resident with a tracheostomy and feeding tube who had an active physician order for EHB every shift and documented cognitive impairment. During multiple days of surveyor observation, no EHB sign was present on the resident’s door or wall, even though EHB signs were posted for other residents throughout the facility. A CNA and an RN confirmed that residents with trachs, feeding tubes, PICC lines, or dialysis should be on EHB precautions and that staff had been in-serviced to follow posted signs for high-contact care activities. The RN acknowledged that the resident should have been on EHB precautions and attributed the missing signage to the resident’s recent room change, during which new signage was not put up.
Facility staff failed to maintain a sanitary, clean, and comfortable environment on both the 200-unit and 400 floor. On the 200-unit, corridors were littered with debris and uncleaned spills, rooms had dirty floors, missing trash can liners, used gloves on the floor, heavily soiled and damaged fall mats, and clutter including broken items and dust under beds; one resident also reported that another resident’s TV remote controlled his television. An EVS staff member stated she mops around items on the floor rather than moving them and was unable to fully clean some fall mats, though she reported these issues to her supervisor. On the 400 floor, surveyors noted recurring strong urine odors and dirty, debris-covered floors on some tours, contrasted with periods when the area appeared clean and odor-free, with only a few housekeepers present when odors were again detected; facility leadership acknowledged environmental concerns.
The facility failed to ensure RN coverage and competent tracheostomy care on a specialized unit, resulting in missed medication doses, inadequate assessment, and improper interventions by LPNs for residents with complex needs. These deficiencies led to critical events, including two resident deaths and one resident found deceased without RN oversight, with staff reporting inadequate training and support.
A resident with intact cognitive abilities and at risk for pressure ulcers reported waiting for hours for incontinence care, preventing participation in activities. The care plan required timely cleaning and moisture barrier application, but staff failed to adhere, as observed by a heavily saturated brief. A CNA acknowledged the delay, and an LPN considered the resident okay since the urine was contained, leading to the deficiency.
Failure to Implement Abuse and Unusual Occurrence Reporting Policies for Unauthorized LOA
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse and unusual occurrence reporting policies when a cognitively impaired resident left the facility on a leave of absence (LOA) and remained away for approximately three days without the knowledge of nursing staff or the resident’s family. The resident had diagnoses including stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and a recent MDS with a BIMS score of 7/15 indicating moderate cognitive impairment, with a need for assistance with all ADLs. At the time of the incident, the resident was his own decision maker, as the POA documents were not executed until after his return. On the day of the incident, the resident left the facility around 2:00 p.m. with a person identified as a cousin, who signed the resident out on the LOA sheet; staff, including an LPN and the Manager on Duty, understood that the resident was going to a cookout and would return later that evening. The report states that a CNA, who was not trained on the LOA process, helped the resident leave, which the Administrator later identified as an error. The resident did not return that evening as expected. The following day, an LPN became concerned when the resident was not back in the building to receive medications and called the resident’s daughter, who then learned for the first time that the resident was missing and that no family member had removed him. The facility’s abuse/neglect/misappropriation/crime policy required reporting unusual incidents or occurrences to the State Survey Agency, including events likely to result in legal action or involving law enforcement, and specified time frames for initial reporting and submission of investigative findings. Despite the resident being gone for approximately 72 hours and a missing person report being filed with local police, the facility did not submit an initial report or a 5‑day follow‑up report to the state agency as mandated by its abuse policy. The state agency instead received an anonymous complaint two days after the incident, with an addendum indicating that the resident himself later contacted the state agency after learning he had been deemed a missing person and expressed a desire to discharge and make his own decisions. The facility’s internal investigation was incomplete at the time of review; it lacked statements from residents and all involved individuals and did not clearly document the chronology of events leading to the incident. The Administrator and DON reported no additional information when interviewed, and the failure to follow the abuse and unusual occurrence reporting policy, along with allowing an untrained CNA to assist with the LOA, constituted the core deficiency.
Failure to Ensure Competent LOA Process Resulting in Unmonitored Resident Absence
Penalty
Summary
Facility staff failed to maintain competency in the nursing aide proficiency related to leaves of absence (LOA), resulting in a resident leaving the facility for approximately three days without the knowledge of family or nursing staff. The resident involved had a history of stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and had a BIMS score of 7/15 indicating moderate cognitive impairment. He required assistance with all activities of daily living and, prior to the incident, was his own decision maker, as the power of attorney (POA) documents were not executed until after his return. On the day of the incident, the resident left the facility at approximately 2:00 p.m. with a person identified as a cousin, who signed the resident out on the facility’s LOA sign-out sheet. CNA staff assisted the resident in leaving, despite not having been trained on the LOA process. The Manager on Duty observed the resident leaving with the family member and was told by both the cousin and the resident that he had been signed out and would be going to a cookout and returning later that evening. LPN staff were informed, via another CNA, that the resident would return around 7:00 p.m., and this information was passed in shift report, but no further verification or follow-up occurred when the resident did not return as expected. The facility’s LOA policy required that the patient or responsible party notify a licensed nurse prior to leaving, provide an estimated time of return, receive medications, and have the LOA documented in the medical record, with additional notification to administrative staff if the resident would not return the same day. In this case, the resident left with a family member without medications and without a documented plan consistent with policy requirements. The resident’s departure was not recognized as a problem until the following day when an LPN noted that he had not returned to receive medications and contacted the resident’s daughter, who reported that the family had not removed him and was unaware of his whereabouts. No initial or 5‑day follow‑up report of the incident was submitted by the facility to the state agency as required by law.
Failure to Follow Menus and Meal Tickets for Diet Orders and Portions
Penalty
Summary
Facility staff failed to serve meals according to the written menu and individual meal tickets for multiple residents. One resident with stroke, renal failure, and heart failure, who had moderately impaired cognition and required setup assistance for eating, was observed at lunch receiving roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The resident’s menu and personal meal ticket specified that cornbread, not a biscuit, should be served, and the meal ticket also documented a regular diet with a fluid restriction of 1200 milliliters per day and one 8‑ounce beverage. The Dietary Manager later stated that cornbread was not available because the food delivery did not occur as scheduled and that the substitute item was not updated on the menu or meal tickets due to software difficulties. Another resident with tracheostomy, diabetes, peripheral vascular disease, and heart failure, who had intact cognition and required setup assistance with eating, was ordered a mechanical advanced/chopped diabetic diet. The meal ticket for this resident specified chopped roasted pork loin, diced beets, mashed potatoes, a dinner roll, margarine, apple crisp, 2% milk, and hot coffee or tea. During observation of the lunch meal, the resident was served a whole slice of roasted pork with gravy instead of chopped pork, and a biscuit instead of the dinner roll listed on the ticket. The Dietary Manager acknowledged that the pork loin not being chopped was an error and again reported that dinner rolls were unavailable due to a missed food delivery and that the substitute item was not reflected on the menu or meal tickets. A third resident with dysphagia, mechanically altered PO intake, and cerebral palsy, who had intact cognition and was able to use utensils to eat once the meal was placed before him, reported wanting more food to gain weight and stated he was not receiving extra portions despite asking. Observation of this resident’s lunch tray showed roasted pork loin, pork gravy, diced Harvard beets, creamy mashed potatoes, a biscuit, and apple crisp. The resident’s meal ticket listed the same items but included cornbread, which was not present on the tray. The resident commented that the tray “comes like that sometimes” but reiterated his desire to gain weight. The Dietary Manager later stated there was no cornbread mix available, so a biscuit was served instead.
Failure to Ensure Timely Provision of DME and Home Health Services After Discharge
Penalty
Summary
Facility staff failed to ensure timely provision of ordered durable medical equipment (DME) and home health (HH) services for one resident who was discharged home. The resident, cognitively intact per a discharge MDS BIMS score of 15, had diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, morbid obesity due to excess calories, end stage renal disease, and muscle weakness. Upon discharge home, physician orders were in place for a bedside commode and a front‑wheeled walker to be delivered to the resident’s home, as well as HH services including nursing and physical therapy. The resident reported that these DME items were not delivered until several days after discharge and that HH services did not begin until approximately one week after arrival home. During this period, the resident stated she had to use a bedpan for four days and, due to limited mobility, this was very difficult on her body and mental state, and she reported that her body became weaker and one leg became flaccid. Interviews with facility staff corroborated the delays in DME and HH service initiation. The Director of Social Services confirmed that the resident was discharged home and that the bedside commode and front‑wheeled walker were not delivered until several days later, and that HH services did not begin until about a week after discharge, acknowledging this was an issue and not typical. The Director of Rehabilitation stated she had provided a bedpan prior to discharge because the bedside commode would not be at the home when the resident arrived and later went to the resident’s home to set up the bedside commode after the DME provider did not do so. The Administrator stated it was not acceptable that the DME was delivered and HH services started after such delays. Discharge planning notes documented the resident’s calls reporting that DME had not been delivered and that a personal care aide company could not cover services, as well as subsequent contacts with the DME provider and multiple HH agencies, confirming that the ordered equipment and HH services were not in place in a timely manner following discharge.
Failure to Provide Ordered and Menu-Listed Beverages With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages as listed on menus, as ordered, or per resident preferences during meals for multiple residents. For one resident with dysphagia, mechanically altered PO intake, and cerebral palsy, the lunch meal ticket specified hot coffee or hot tea, but no beverage was served with the meal. The resident, who had intact cognitive abilities and could use utensils to bring food and liquid to the mouth, reported not receiving anything to drink with lunch and indicated he would drink from his personal water bottle instead. Facility leadership later acknowledged that the meal ticket should have been followed and that beverages should have been available. Another cognitively intact resident with a diagnosis including moderate protein calorie malnutrition reported poor service from nursing and dietary staff. At lunch, the resident’s meal ticket listed hot tea or coffee, but no beverage was present on the tray other than what was already on the bedside table. The resident was heard asking an LPN for his tea or coffee; the LPN shrugged, left the room, and did not return with a beverage. The Dietary Manager later stated that the residents should have received their beverages. Two additional residents did not receive beverages in accordance with the menu and their personalized meal tickets. One resident with stroke, renal failure, and heart failure, and with moderately impaired cognition, had a lunch meal served without any fluids, despite the menu specifying an 8 oz and a 6 oz beverage at lunch and the resident’s ticket allowing one 8 oz beverage due to a 1200 ml/day fluid restriction. The following day, this resident again received a lunch meal with no fluids served. Another resident with tracheostomy, diabetes, PVD, and heart failure, and intact cognition, was served lunch meals on two consecutive days without any fluids, even though the menu called for an 8 oz and a 6 oz beverage and the meal ticket specified 2% milk (8 oz) and hot coffee or tea (6 oz). The Dietary Manager explained that beverages had been removed from trays due to spilling and were being sent separately, and that he was unaware residents were not consistently receiving beverages as planned. Across these cases, surveyors observed that residents did not receive beverages as listed on the menu or meal tickets, or as ordered, during lunch meals. Staff interviews confirmed that meal tickets should have been followed and that beverages were expected to be provided with meals. The Dietary Manager acknowledged that drinks were being sent separately from trays due to spill concerns and that there was an error in the menu software offering milk at lunch, while also stating that no concerns had been raised to him about residents not receiving beverages according to the menu, preferences, and physician orders.
Failure to Post Enhanced Barrier Precaution Signage for Resident With Tracheostomy
Penalty
Summary
Facility staff failed to implement the ordered enhanced barrier precautions (EHB) for a resident with a tracheostomy. The resident, admitted with diagnoses including tracheostomy status and a feeding tube, had a physician’s order for "Enhanced Precaution r/t Trach every shift" active since 11/04/25. The discharge MDS documented short-term memory loss and moderately impaired cognitive abilities for daily decision-making. During surveyor rounds from 1/12/26 through 1/14/26, no EHB signage was observed on the door or wall of the resident’s room, despite the active order and the presence of a tracheostomy and enteral feeding at the bedside. Staff interviews confirmed that EHB precautions were required for residents with tracheostomies, feeding tubes, PICC lines, or dialysis, and that staff had been in-serviced on following posted EHB signs for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care, and wound care. A CNA described the need to follow EHB signage for such residents, and an RN acknowledged that the resident with a tracheostomy should have been on EHB precautions and that signage should have been posted, explaining that the resident had been moved to another room the previous day and no new signage was put up. Throughout the survey, EHB signs were observed on all floors for other residents, but not for this resident, and facility leadership did not provide additional information to refute the absence of signage.
Failure to Maintain Sanitary and Comfortable Environment on 200 and 400 Units
Penalty
Summary
Facility staff failed to maintain a sanitary, clean, and comfortable environment on the 200-unit. During a tour of the unit, surveyors observed the lower numeral corridor littered with debris, with many dark spots on the floor that appeared to be uncleaned spills, and cluttered with various medical equipment. In one room, the floor was described as simply dirty, the trash can had no liner, and a used glove was on the floor. The A bed resident’s fall mats at the bedside had holes and a dark substance on them, and the floor space under the head of the bed was filled with broken, useless items, a wheelchair leg rest, and a large amount of dust and dirt; the room overall was very cluttered. The resident in the B bed reported that the A bed resident’s television remote control changed the television channels on his side of the room. In another room, the room was dark and smelly, the floor was covered with dirt and debris, and the bathroom toilet was dirty and smelly; the corridor outside this room was extremely odorous, and the odor did not dissipate over time. An EVS staff member stated she worked hard to keep the unit clean, but reported that she does not move items on the floor when mopping, instead mopping around them, and that some fall mats could not be fully cleaned despite scrubbing; she stated she documented these issues in daily notes and gave them to her supervisor. On the 400 floor, staff also failed to provide a consistently sanitary and comfortable environment. During an initial tour, a strong urine odor was detected in the hallways, and the floors had visible dirt and debris, while a housekeeper was observed standing near her cart. On a subsequent tour, the floors appeared clean and no odor was present, and several housekeeping staff were observed cleaning rooms and mopping floors. However, on a later tour, a strong urine odor was again present on the 400 floor, and only a few housekeepers were observed on the unit. In a final interview with the Administrator, DON, Regional President, and Regional Nurse Consultant, facility leadership acknowledged agreement that there were environmental concerns.
Failure to Provide RN Coverage and Competent Tracheostomy Care
Penalty
Summary
Facility staff failed to provide competent professional nursing oversight, assessment, and administration of tracheostomy care for three residents on a specialized tracheostomy unit. The facility did not ensure that a Registered Nurse (RN) was present on every shift as required, resulting in lapses in care and medication administration. For one resident, there were multiple missed doses of IV and oral vancomycin following a hospital discharge for sepsis and pneumonia, with documentation showing that antibiotics were not administered as ordered for several days. The resident exhibited worsening symptoms, including fever and low blood pressure, without adequate assessment or intervention, and was ultimately sent to the hospital in critical condition and expired the same day. Staff interviews revealed that LPNs and CNAs often felt unprepared to care for tracheostomy residents and were unsure how to recognize signs of distress or perform safe suctioning. Another resident, who was at high risk for hemorrhage due to anticoagulation therapy, experienced a critical event when an LPN, without RN supervision, performed suctioning after the resident began coughing up blood and lung tissue. The resident's oxygen saturation dropped to a dangerously low level, and the resident was sent to the hospital with a tracheal tear and subsequently expired. The care plan for this resident lacked essential interventions for tracheostomy care, such as oxygen humidification, cannula management, and suction device settings. Staff interviews confirmed that RNs were not always present on the unit, and staff felt inadequately trained to manage tracheostomy care. A third resident, who was non-verbal and dependent on staff for all care, was found deceased on the unit during a shift when no RN was present. The scheduled RN, who was new and inexperienced with tracheostomies, left the facility after realizing she would be the only RN on the unit, and the DON refused to come in to provide coverage. Facility records confirmed that only LPNs were present on the unit at the time, and an RN from another floor had to be called to pronounce the resident's death. The facility's own assessment indicated awareness of the requirement for RN coverage on the tracheostomy unit, but this was not consistently implemented.
Removal Plan
- A Registered Nurse with documented tracheostomy competency training will be assigned to the tracheostomy unit every shift 7 days per week.
- Director of Nursing (DON) or designee will verify and document on assignment sheet the presence of an RN with documented tracheostomy training.
- The Regional Director of Specialty Care or designee will ensure all RN staff scheduled to work on the tracheostomy unit have completed reeducation and competency validation in care of tracheostomy patients, prior to assuming an assignment.
- A roster of RN's will be maintained by the DON or designee and provided to staffing scheduler to ensure immediate coverage in the event of call-off.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility's staff failed to provide timely incontinence care for a resident who was always incontinent of bladder and frequently incontinent of bowels. The resident, who had intact cognitive abilities and was at risk for pressure ulcers, reported waiting for hours to be cleaned up, which prevented participation in activities. The care plan for the resident included keeping the skin clean and dry, applying a moisture barrier, and cleaning the peri area with each incontinent episode. However, the staff did not adhere to these interventions, as evidenced by the resident's report and the observation of a heavily saturated brief. During an interview, a CNA acknowledged that the resident had been waiting a while to be changed and stated she would attend to the resident after assisting another. An LPN observed the resident's brief was heavily saturated but considered the resident okay since the urine was contained within the brief. These actions and inactions led to the deficiency, as the facility staff did not provide timely incontinence care, which was confirmed through resident and staff interviews, clinical record reviews, and observations.
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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