Old Dominion Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Newport News, Virginia.
- Location
- 4 Ridgewood Parkway, Newport News, Virginia 23602
- CMS Provider Number
- 495204
- Inspections on file
- 13
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Old Dominion Rehabilitation And Nursing during CMS and state inspections, most recent first.
Failure to Protect Residents from Sexual Abuse: The facility failed to protect vulnerable residents from sexual abuse involving a resident with dementia and severe cognitive impairment, a POA, and other residents with sexual behaviors. Records and interviews showed prior abuse and sexual incidents, yet the resident’s care plan was not updated with protections after the abuse, and another resident was found with his hand under a female resident’s shirt. Staff acknowledged the resident could not consent and that prior incidents had occurred.
A cognitively intact resident was misappropriated when the BOM used the resident’s personal credit card for rent and numerous online purchases without consent, totaling more than $10,000. The incident was discovered through the facility’s investigation and involved the wrongful use of the resident’s money and belongings.
The facility failed to complete the required water management risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and staff did not consistently follow contact precautions for a resident with MSSA bacteremia. The resident had ESRD on intermittent dialysis, was ordered to remain on contact precautions, and was observed with a contact sign and PPE cart outside the room, but no separate trash cans for PPE or linens were present and an LPN entered the room without PPE.
Failure to Timely Report Alleged Abuse Incidents: The facility did not report multiple alleged abuse incidents involving residents within the required 2-hour timeframe. In one case, a CNA observed one resident in another resident’s room with inappropriate contact, but the report was not sent to the SA until the next day. In other incidents, allegations of sexual abuse and abuse between residents were reported many hours or days late, and the DON confirmed the reports were not submitted on time.
Failure to Provide Written Transfer and Bed Hold Notices The facility did not provide written transfer notices and bed hold notices for several residents who were sent to the hospital. One resident was transferred after becoming extremely drowsy and altered from baseline, another called 911 for an ER transfer, a third was sent out after hypotension during dialysis, and a fourth was transported after staff found him slumped over and hard to arouse. Staff and leadership could not find documentation showing the required notices were given, and one resident stated she never received any paperwork related to the transfer or bed hold.
A resident who could feed herself waited with her meal tray in front of her for tray set-up after it was delivered, and another resident reported that dining room residents were not served at the same time because staff left to serve the hallway before finishing the room. A CNA said the process was not right, and the DM and RD confirmed that dining room residents should be served together and tray set-up should occur when the meal is delivered.
The facility failed to complete a thorough investigation of a resident-to-resident abuse incident involving a resident with bipolar disorder, GAD, delusional disorders, and convulsions. The resident threatened another resident, threw water on the resident, cursed at the resident, and used racial slurs while staff intervened. The FRI showed no evidence that other residents were asked whether they felt safe or feared any resident, and the Administrator, DOO, and SSD confirmed those questions were not asked.
Inaccurate PASARR screening was completed for two residents with mental health diagnoses. One resident admitted with bipolar disorder had a PASARR Level I that did not identify the diagnosis, despite EMR documentation showing bipolar disorder and psychotropic medications. Another resident admitted with schizophrenia had an older PASARR that the DON said was inaccurate and should have been redone, but no updated screening could be located.
Incomplete Assessment and Transfer Documentation: A resident with dementia, CAD, HF, and DM had a BIMS score of 3/15 and required extensive assistance with ADLs. The record later noted a boggy heel/deep tissue injury and left foot drop, but when the resident was found unresponsive on the floor and sent to the ER, the transfer record lacked an assessment, rationale, vital signs, and baseline status. The DON stated the documentation was unacceptable and that a comprehensive assessment should have been completed before transfer.
Failure to provide foot care for a resident with impaired mobility and dependent personal hygiene needs. The resident was observed in bed with dry, flaking skin on both feet, and the resident stated the feet felt scratchy and had not been lotioned. A weekly skin review documented the skin as intact and not dry, while later observations and an LPN and CNA confirmed the dry, flaking condition. The facility policy required foot care and skin inspection during bathing.
Failure to Escort Resident to Appointment: A resident with hemiplegia/hemiparesis, respiratory failure, wheelchair use, and limited upper and lower extremity function was sent to a GI appointment without an escort. Records showed the resident was cognitively intact and alert/oriented, but family reported he was left outside the office and not dressed appropriately for cold weather. Staff confirmed the resident went alone, and interviews showed the facility lacked a policy for appointment transportation or escorts.
A resident with a history of stroke, vascular dementia, and right above-knee amputation had bilateral side rails in use for safety and repositioning, but the record did not show that alternatives were tried first, that the risks and benefits were reviewed with the resident or representative, or that informed consent was obtained. Staff stated the resident used the rails to turn and reposition, and the DON confirmed there were no documented risks or benefits addressed for the side rails.
Medication administration errors exceeded the allowed rate, with 3 errors in 27 opportunities. An RN gave G-tube meds without checking residual or tube placement despite orders for both, an LPN administered carvedilol without checking BP even though the order said to hold if systolic BP was below 120, and an RN gave Humalog Kwikpen insulin without priming the pen after attaching the needle. The DON, UM, and ADON confirmed the expected order requirements were not followed.
Meal Substitution and Pureed Diet Not Followed: A resident on a pureed diet did not receive the meal posted on the menu and was instead served an unposted substituted meal. The CNA was unsure of the items served, while the DM confirmed she used substitutions and did not puree pasta because of its texture. The RD stated she was unaware the DM was not pureeing the pasta and confirmed the resident should have received the menu meal.
Food Served at Improper Temperatures: A dietary review found that meals were not consistently served at palatable temperatures. A resident reported trays arriving cold and overcooked food, another said hot items were cold and cold items were warm, and a third said food did not smell good and was often cold. The RD confirmed hot foods should be hot and cold foods cold, and the DM measured cold pasta and juice at 62 degrees F on a test tray.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse for two of nine residents reviewed for abuse. One resident with dementia and severe cognitive impairment was sexually abused by her power of attorney in the facility, and the facility also had prior knowledge of sexual abuse and sexual behavior involving other residents but did not put measures in place to protect her and other vulnerable residents. The report states the resident had a history of sexually inappropriate behaviors and was unable to make decisions regarding her care or finances. The resident was found in bed with another resident with no clothes on, and the facility investigation documented that the resident’s cognition did not allow her to provide proper consent. The record also showed a prior incident in which the same resident was sexually abused by her power of attorney in the facility, with statements indicating oral sex occurred. The facility’s records did not show that the resident’s care plan was updated with interventions to protect her after that incident. The facility also failed to protect another resident who was sexually abused by a different resident. That resident was found in the victim’s room with his hand under her shirt, and the facility substantiated the incident. The victim had Parkinson’s disease, dementia with behavioral disturbance, neurocognitive disorder with Lewy bodies, and depression, and required extensive assistance with bed mobility and transfers. The report further describes another incident involving a resident with cognitive impairment who was found engaged in sexual activity with the first resident, and the facility’s interviews showed staff awareness that the first resident had a history of sexual behaviors and could not consent.
Misappropriation of a Resident’s Credit Card by Business Office Manager
Penalty
Summary
The facility failed to protect a cognitively intact resident from misappropriation of property when the Business Office Manager used the resident’s personal credit card for personal expenses without consent. The resident’s quarterly MDS showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. The report states the BOM used the resident’s credit card to pay her rent for three months and to make numerous Amazon purchases, totaling over $10,000, which was identified through the facility’s incident investigation. The incident was reported by the BOM to the previous Administrator, and the report notes that the resident was reimbursed later. The facility’s abuse policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent. The survey findings identified this as a deficiency involving the wrongful use of the resident’s money and belongings.
Water Management Assessment Missing and Contact Precautions Not Followed
Penalty
Summary
The facility failed to complete an assessment of the building to determine where Legionella and other opportunistic waterborne pathogens could grow and spread. Review of the Water Management Binder showed that the required building assessment had not been completed. During interview, the Maintenance Director confirmed that no building assessment had been done and stated he monitored the water system by testing water temperatures, changing filters in the ice machine and hot water heater, and running water in sinks, showers, and empty-room toilets. He also stated he was not aware that an assessment was needed for the water management program. During interview, the Administrator verified that the blueprint of the building had been found but the assessment of the building where Legionella could grow and spread was not found. The Administrator stated the assessment was important to determine the areas of the building that needed to be monitored to ensure the quality of the water. The Infection Preventionist stated she was not aware that the assessment had not been completed, despite infection control meetings that included the Maintenance Director, and stated the assessment should have been completed to determine areas where Legionella could grow in the building. The facility policy titled Water Management Program required an annual risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The facility also failed to ensure staff adhered to Transmission Based Precautions for a resident with MSSA bacteremia. The resident was admitted with dependence on renal dialysis and had an Infectious Disease Physician note documenting end stage renal disease on intermittent dialysis and blood cultures positive for methicillin-susceptible Staphylococcus aureus. Orders required contact precautions with all services provided in the room for six weeks, and the care plan included MSSA bacteremia and maintaining contact precautions. Observation showed a contact precaution sign and PPE cart outside the room, but no separate trash cans for used PPE or linens were present. An LPN entered the room and handed the resident paperwork without wearing PPE, and the LPN confirmed PPE should have been worn. The DON confirmed the appropriate trash cans were not present, and the IP confirmed staff should always wear full PPE when entering a contact isolation room and that separate trash cans should be present for disposal of PPE and dirty linens.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged abuse violations within the required timeframe for five residents reviewed for abuse. A Facility Reported Incident documented an allegation of sexual abuse between two residents that occurred on 05/17/25 at 12:15 PM, but the report was not submitted to the State Agency until 05/18/25 at 10:50 PM, more than 34 hours later. Another allegation of abuse between the same two residents occurred on 07/02/25, and the FRI was not sent to the State Agency until 07/11/25, nine days later. During an interview, the Administrator stated the expectation was that abuse investigations should be turned into the state within two hours and confirmed these FRIs were not submitted within that timeframe. The report also documented an incident involving two other residents. A CNA observed one resident in another resident’s room with his right hand under the other resident’s shirt at 7:18 PM, and the facility did not report the abuse to the State Agency until 3:25 PM the next day. The Administrator confirmed the FRI should have initially been sent to the State Agency within two hours of discovery and acknowledged the report was sent the next day. The facility policy titled Abuse, Neglect, and Exploitation stated that all alleged violations involving abuse must be reported immediately, but not later than 2 hours after the allegation is made when the events involve abuse or result in serious bodily injury.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that residents and/or their resident representatives were provided written notices of transfer and bed hold notices for four of five residents reviewed for hospitalizations. The deficiency involved Residents 5, 8, 51, and 99, all of whom had hospital transfers documented in the record, but the survey found no documented evidence that the required written transfer notices or bed hold notices were given. The facility’s records and staff interviews showed that these notices were not available in the chart for the reviewed residents. Resident 5 was transferred to the Emergency Department after staff observed the resident acting outside of baseline, including extreme drowsiness, increased right-sided contractures, head leaning to the right, and inability to hold the head up. The resident’s representative was informed that the resident was being transferred, and EMS transported the resident with the face sheet, physician note, order summary, care plan, and e-interact transfer form. However, the Administrator stated she could not find the transfer form with the reason for transfer and appeal rights that were provided in writing, and also confirmed the bed hold notice in the admission packet did not specify the reserve bed payment per day. Resident 8, who had a BIMS score of 14 out of 15 and was cognitively intact, called 911 herself and requested transport to the ER. She stated that the facility never gave her paperwork related to the transfer or bed hold notice, and the DON could not find documentation for the transfer notice, bed hold, or hospital notification. Resident 51, also cognitively intact with a BIMS score of 15 out of 15, was sent to the hospital after becoming hypotensive during dialysis and reporting nausea and lightheadedness; the resident later stated he did not know whether any paperwork was given. Resident 99, who had a BIMS score of 14 out of 15, was sent to the hospital after staff observed him slumped over in the day room with food falling from his mouth and he was difficult to arouse. The DON stated there was no documented evidence that Resident 99 or his representative received a written transfer notice or bed hold notice for the emergency transfer.
Dignified Dining Experience Not Maintained
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents observed during meal service. One resident, who could feed herself, had her meal tray delivered to the dining room at 12:40 PM but was still waiting for tray set-up 23 minutes later, with the lids still on the food when observed at 1:03 PM. A CNA confirmed that the resident only needed tray set-up and that it should have been done when the tray was delivered. Another resident reported that the resident seated with her was served and then staff left to serve the hallway, causing the dining room residents to finish at different times and leaving her tray cold. A CNA stated that the meal service process was not right and described staff serving part of the dining room, then the hallway, and then returning to the dining room. The DM and RD both confirmed that residents in the dining room should be served at the same time and that tray set-up should occur when the meal is delivered.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of a resident-to-resident abuse incident involving one resident out of nine residents reviewed for abuse. The resident involved had diagnoses including bipolar disorder, generalized anxiety disorder, delusional disorders, and convulsions. An EMR health status note documented the resident threatening another resident, throwing water on the resident, cursing at the resident, and using racial slurs, with staff present and intervening. Review of the Facility Reported Incident showed no evidence that other residents were asked whether they were afraid of any residents or had concerns about any residents in the facility. During interview, the Administrator, DOO, and SSD confirmed that residents were not asked if they felt safe or fearful of any resident. The facility policy titled Abuse, Neglect, and Exploitation was reviewed.
Inaccurate PASARR Screening for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASARR Level I screening was completed accurately before admission for two residents reviewed for PASARR. One resident was admitted with a diagnosis of bipolar disorder, and the PASARR Level I screening dated 10/22/25 indicated the resident did not have a current serious mental illness and did not need a Level II referral. However, the resident's EMR, MDS, care plan, and order summary showed a diagnosis of bipolar disorder, psychotropic medication use, and orders for Zyprexa and Lamictal related to bipolar disorder. During interview, the SSD confirmed the PASARR Level I was not completed correctly because the bipolar diagnosis was not identified on the screen. A second resident was admitted with a diagnosis of schizophrenia, and the PASARR dated 07/25/22 indicated the resident met nursing facility criteria and could have a safe and appropriate plan of care developed, but also stated the resident did not have a current serious mental illness and did not meet the applicable criteria for serious MI, IDD, or related condition. The DON stated she could not locate a more updated PASARR screening form and acknowledged the document completed by the previous social worker was inaccurate. When asked whether it should have been corrected by submitting a new form, the DON stated it absolutely should have been redone.
Incomplete Assessment and Transfer Documentation
Penalty
Summary
The facility failed to conduct and document a thorough assessment for one resident with dementia with behavioral disturbance, coronary artery disease, heart failure, and diabetes. The resident’s admission MDS coded a BIMS score of 3 out of 15, indicating severely impaired cognitive abilities for daily decision making. The record showed the resident required extensive assistance with bed mobility, dressing, personal hygiene, and toileting, and was totally dependent for bathing. The last documented skin review noted no skin impairment, but a nurse practitioner progress note later documented warm, dry skin with a boggy left heel and a deep tissue injury, along with bilateral upper extremity strength of 5/5 and left foot drop. After the resident was found on the floor unresponsive and transferred to the emergency room, the transfer information under Section B - Key Clinical Information did not include an assessment of the resident’s condition, a rationale for the transfer, vital signs, or other pertinent information. It also stated the resident was not alert but did not define the resident’s baseline. The facility did not have a written protocol outlining a nurse’s interventions before transfer to another level of care. During interview, the DON stated the documentation did not meet facility expectations and was unacceptable, and that the change should have been documented first with a comprehensive assessment including blood pressure, heart rate, respirations, oxygen saturation, and blood sugar if diabetic, along with provider and family notification.
Failure to Provide Foot Care
Penalty
Summary
The facility failed to ensure one resident received foot care. Resident 77 was admitted with diagnoses including candidiasis of the skin and nail, hemiplegia, and hemiparesis. The care plan identified potential impairment to skin integrity related to fragile skin and directed weekly skin observations. The MDS showed the resident had a BIMS score of 15 out of 15 and was dependent on staff for personal hygiene. During observation, Resident 77 was found in bed with both feet dry and covered with flaking skin. The resident stated his feet were dry and felt scratchy against the sheets and said, "I don't know why they don't lotion them." A weekly skin review dated 02/12/26 documented the skin as intact and not dry. Later observations again showed dry, flaking skin on both feet, and an LPN confirmed the condition and stated she would have the CNA wash the resident's feet and apply an emollient. A CNA also confirmed the resident had dry, flaking skin on his feet. The facility policy stated residents are to receive proper foot care to maintain mobility and good foot health, and that nursing assistants are to inspect skin during bathing and report concerns to the nurse immediately.
Failure to Escort Resident to Appointment
Penalty
Summary
The facility failed to monitor a resident for safety during a physician's appointment. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, acute and chronic respiratory failure, and had a quarterly MDS showing a BIMS score of 15 out of 15, indicating cognitive intactness. The MDS also showed the resident used a wheelchair and had upper and lower extremity impairment. Daily nursing charting documented the resident as alert and oriented, with intact cognition, weak hand grasps, and limited range of motion on both sides. A progress note stated the resident went out to a GI appointment via wheelchair and returned later the same day via wheelchair. Family reported the resident was sent to the appointment without anyone to accompany him, and that a friend later found him sitting outside the office and not dressed appropriately for the cold weather. The ADON confirmed the resident went to the appointment alone and returned unharmed. Staff interviews revealed the facility expected family to be notified of appointments and asked to accompany the resident or arrange an escort if needed, but the facility did not have a policy on transportation to appointments, arranging escorts, appointments, or escorts.
Failure to Attempt Alternatives, Educate, and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure alternative measures were attempted before using bilateral side rails for one resident, failed to review the risks and benefits of side rail use with the resident or representative, and failed to obtain informed consent before the side rails were used. The resident, who was readmitted to the facility and had diagnoses including cerebral infarction, vascular dementia without behavioral disturbance, and acquired absence of the right leg above knee, had a BIMS score of 14 out of 15 on the quarterly MDS, indicating cognitive intactness. The care plan stated the resident used assist bars to maximize independence with turning and repositioning in bed, and the admission/re-admission screening documented bilateral half side rails for safety, but did not mention alternatives or any discussion of risks and benefits.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. During medication administration, 3 medication errors were identified for 3 residents out of 27 opportunities, resulting in an 11.11 percent medication error rate. The errors involved a resident with quadriplegia, dysphasia, and muscle contractures who had a G-tube and orders for hydralazine, metoclopramide, G-tube residual checks every shift, and G-tube placement checks every shift; a resident with congestive heart failure and hypertensive heart disease who had an order for carvedilol with instructions to hold if systolic blood pressure was less than 120; and a resident with type 2 DM who had an order for Humalog Kwikpen sliding scale insulin. For the resident with the G-tube, an RN administered medications through the tube after placing a syringe and water into the port, but did not check residual or tube placement before giving the medications. The RN stated she had checked the physician's order and said there were no orders for residual or placement checks, while the DON, UM, and ADON stated the nurses were expected to follow the physician's orders and check residual and placement before administering medications through the G-tube. For the resident receiving carvedilol, an LPN gave the medication without taking the resident's blood pressure first, despite the order to hold the medication if systolic blood pressure was less than 120. For the resident receiving insulin, an RN administered Humalog Kwikpen insulin without priming the pen after attaching the needle. The RN confirmed she did not prime the pen, and the DON and ADON stated the pen should have been primed to ensure the needle worked before administration.
Meal Substitution and Pureed Diet Not Followed
Penalty
Summary
The facility failed to ensure that Resident 23 received the meal posted on the menu and failed to ensure the resident’s meal was pureed as ordered. During lunch observation, the posted menu listed items including rosemary pork chop, shepherd’s pie, hot dog on bun, cheeseburger on bun, chicken tenders, grilled cheese sandwich, and sides such as baked sweet potato, French fries, peas and carrots, mixed vegetables, onion rings, and dinner roll. At the time of the meal, Resident 23’s tray card indicated a pureed diet with rosemary pork chop, mashed sweet potatoes, creamed spinach, dinner roll, and chocolate chip cookie cake, but the meal observed on the tray was a red sauce main entree, mashed potatoes with gravy, an unidentifiable tan vegetable, and pudding. During interview, the CNA assisting Resident 23 stated she thought the resident was served spaghetti with meat sauce, mashed potatoes, and gravy, and was unsure of the vegetable and dessert. The Dietary Manager confirmed the resident was actually served pureed spaghetti and meat sauce, fortified mashed potatoes with gravy, a chocolate muffin, and mixed vegetables, and stated she followed the substitutions list. She also stated she did not puree pasta because it becomes sticky and gummy once pureed. The Registered Dietician stated she was unaware the Dietary Manager was not pureeing the pasta and confirmed Resident 23 should have been served what was on the menu. Facility policy stated menus are to be prepared in advance, followed as posted, substitutions must have comparable nutritive value, and the dietician must review menus for nutritional adequacy.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure foods were served at palatable temperatures for three residents who received meals from the kitchen. Resident 8 reported that her meal tray was the first on the third cart but was always the last served and that it was always cold; she also stated that her pork chop was so tough the head nurse could not cut it with a fork and that everything was always overcooked. Resident 51 stated that the facility food tasted bad, that hot food was not hot and cold items such as milk were warm. Resident 77 reported that he did not eat much of the facility food because it did not smell good, that a grilled cheese sandwich he received was cold, and that he frequently ordered food from DoorDash because the facility food was cold and did not smell good. The registered dietician confirmed that hot food should be served hot, cold foods should be served cold, and food should not be overcooked and tough. During observation and interview, the dietary manager obtained temperatures on a meal test tray delivered last from the food cart and found cold pasta at 62 degrees Fahrenheit and juice at 62 degrees Fahrenheit.
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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