Rosedale Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Virginia.
- Location
- 1719 Bellevue Avenue, Richmond, Virginia 23227
- CMS Provider Number
- 495283
- Inspections on file
- 27
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rosedale Health & Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not follow infection control practices by storing unwrapped linen on an open shelf next to an environmental services cart and mops, with administrative staff confirming this was an infection control issue. No relevant policy was provided during the survey.
Staff failed to follow professional standards by not adhering to physician orders for insulin administration, repeatedly administering scheduled medications several hours late for two residents, and not clarifying or timely administering medications for another resident. These actions resulted in medication errors and noncompliance with facility policy requiring medications to be given within one hour of scheduled times.
Staff did not provide required ADL care, including turning and repositioning, for a dependent resident with severe cognitive impairment and a history of CVA and diabetes. Documentation reviews and staff interviews confirmed that on multiple occasions, the necessary care was not performed as required by the resident's care plan.
Staff failed to administer ordered medications and treatments in a timely manner, including delayed IV antibiotics, missed blood glucose checks, and omitted doses of insulin, gabapentin, and trazodone, despite medication availability. Bowel prep for a colonoscopy was not given, resulting in a canceled procedure, and required PICC/midline care was undocumented. Additionally, a GI appointment was not scheduled as ordered, with no evidence of follow-through in the medical record.
Staff did not consistently provide or document Foley catheter care for a resident with neuromuscular bladder dysfunction, despite physician orders and facility policy requiring care every shift. Review of treatment records showed multiple missed entries, and an LPN confirmed that care should be performed and documented each shift.
Facility staff failed to provide and document prescribed oxygen therapy for two residents with chronic respiratory conditions. On multiple occasions, oxygen was not administered or not documented as given according to physician orders, as shown by missing entries on the treatment administration records. Nursing staff confirmed that proper documentation was required and that missing entries meant there was no evidence of care provided.
Facility staff did not document a physician's response to pharmacist recommendations for a resident with multiple chronic conditions, including suggestions regarding prolonged antibiotic use and a dose reduction for Protonix. Despite facility policy requiring documentation of actions taken or explanations for disagreement, no such documentation was found for two separate MRRs.
Two residents were not provided with meals that honored their documented allergies and dietary preferences. One resident, with multiple medical conditions and a need for a gluten-free diet and adherence to Jewish dietary guidelines, was served food containing gluten and not provided with appropriate alternatives. Another resident, who disliked eggs, was served eggs for breakfast. Staff interviews confirmed that the residents' preferences were not met, despite facility policy requiring accommodation of such needs.
Two residents with moderate cognitive impairment and multiple medical conditions did not receive snacks during the day or at bedtime, as required. Observations and staff interviews confirmed that snacks such as milk, applesauce, crackers, and yogurt were not available on the units, with only minimal items found on one occasion. Staff reported that only limited sandwiches were sent for diabetic residents, and the Director of Dietary Services acknowledged there were no set par levels for nourishment items and was unaware of the issue.
Staff failed to consistently provide essential supplies such as urinals, gloves, and cup tops for two residents with incontinence and chronic medical conditions. Multiple staff interviews and supply closet observations confirmed recurring shortages, with staff sometimes needing to retrieve supplies from other rooms or provide bottled water due to missing cup lids. The central supply process did not prevent these shortages, and no supply management policy was provided.
Facility staff failed to treat two residents with dignity and respect, as evidenced by grievances, resident council minutes, and staff interviews describing rude and dismissive behavior by agency RNs and CNAs. One resident, with multiple chronic conditions, reported verbal aggression and profanity from a CNA, while staff confirmed that some agency personnel used curt tones and did not address residents respectfully, contrary to facility policy.
A resident who was cognitively intact and their own responsible party was moved from a private to a semi-private room without receiving written notice or consenting to the new roommate assignment. Despite the resident's resistance and involvement of the ombudsman, staff proceeded with the move, and documentation did not show that the facility's policy for advance notice and consent was followed.
A resident who was cognitively intact and his own responsible party was moved from a private to a semi-private room despite repeatedly refusing the change. Staff proceeded with the move based on payer status and the need for the private room, but there was no documented clinical need or isolation requirement for another resident. The facility's actions did not align with its own policy, which allows residents to refuse certain room changes.
Facility staff did not promptly notify the physician, nurse practitioner, or resident representatives about significant changes in condition for two residents, including delayed antibiotic administration due to pharmacy alerts, unreported high blood glucose requiring additional insulin, and unreported aggressive behavior with refusal of care. Staff interviews and facility policy confirmed that such notifications were required but not completed.
Facility staff did not maintain a clean and homelike environment, as evidenced by rooms with peeling wallpaper and exposed spackled drywall, and failed to provide adequate linens for several residents. Multiple residents and staff reported frequent shortages of towels, washcloths, and bed linens, which hindered the ability to provide basic care such as bathing and incontinence care.
Facility staff did not include PICC/midline care in the comprehensive care plan for a resident with multiple complex diagnoses, despite documentation and staff acknowledgment of the need. The care plan addressed other risks but omitted interventions for the PICC/midline, and no relevant policy was provided.
A resident with hypertension did not receive prescribed doses of Verapamil and Prazosin because staff failed to obtain the medications when they were unavailable in the Omnicell. The MAR showed missed administrations, and staff did not follow procedures to secure the medications or notify the provider, resulting in non-compliance with facility policy requiring administration of medications as ordered.
A resident with severe cognitive impairment and multiple medical conditions did not receive a chest x-ray as promptly as ordered by the physician. Staff were unable to schedule the x-ray after hours and deferred the task to the next shift, resulting in a delay beyond the facility's typical 24-hour timeframe for such services.
Facility staff did not document a resident's blood sugar value after a physician-ordered recheck, despite the recheck being performed and signed off by an LPN. The clinical record lacked the numerical blood sugar reading, and the responsible nurse acknowledged the documentation requirement but could not recall the incident. The facility also lacked a policy on maintaining a complete and accurate clinical record.
Facility staff did not consistently implement or document incontinence care interventions for three residents with significant physical impairments and incontinence needs, despite comprehensive care plans specifying frequent assistance and hygiene. ADL records showed multiple missing entries for bowel and bladder care, and an LPN confirmed that lack of documentation meant the care plan was not implemented. Leadership was informed of these deficiencies.
Facility staff did not provide or document required incontinence care for three dependent residents with complex medical needs. Despite care plans specifying frequent checks and assistance, ADL records showed multiple instances of missing documentation for bowel and bladder elimination across various shifts. CNA interviews indicated uncertainty about care time frames, and administrative staff were informed of the deficiencies.
The facility failed to implement comprehensive care plans for several residents, including those with C-diff, dialysis AV fistulas, colostomies, and incontinence needs. Staff did not adhere to infection control measures, failed to document necessary assessments, and did not provide required care as outlined in the care plans.
Facility staff failed to adhere to transmission-based precautions for residents with C-diff and COVID-19. A resident with C-diff was visited by staff without proper PPE, and hand hygiene was not performed correctly. Another resident with C-diff had staff enter without PPE and use ineffective hand sanitizer. A COVID-19 positive resident was visited by staff without the required N95 mask, gown, gloves, or eye protection. These actions violated facility policies and CDC guidelines.
The facility failed to provide incontinence care for three residents who were dependent on staff for toileting hygiene. Despite care plans and facility policies requiring regular checks and peri-care, documentation revealed lapses in care provision. Staff interviews confirmed expectations for care and documentation, but these were not consistently met, resulting in deficiencies.
A resident did not receive documented colostomy care on multiple occasions, as required by their care plan. Facility staff interviews revealed that CNAs were responsible for emptying and burping colostomy bags, while nurses were to change the bags and document the care. However, the eTARs lacked evidence of care being provided on several dates, indicating a failure to adhere to the facility's policy for licensed nurse-provided colostomy care.
A resident, identified as severely cognitively impaired and requiring moderate assistance for eating, did not receive feeding assistance on a specific date, as per the facility's records. Despite having a care plan and physician's order for a mechanically soft diet, the resident did not eat on that day. Interviews with staff revealed communication gaps regarding feeding assistance needs, and the resident's family had expressed concerns about inadequate food intake. The administrative staff was made aware of the issue.
A resident with end-stage renal disease did not receive complete dialysis care as the facility staff failed to monitor the dialysis AV fistula for function on several occasions. The physician's orders required daily assessment for thrill and bruit, and signs of infection every shift, but the records lacked evidence of these assessments. The facility's policy emphasized preventing infection and maintaining catheter patency, yet the necessary documentation was missing, leading to a deficiency finding.
Failure to Follow Infection Control Practices for Linen Storage
Penalty
Summary
Facility staff failed to implement proper infection control practices regarding linen storage. During a review of the unit linen closets, it was observed that packs of blankets wrapped in plastic were stored on shelves next to an unwrapped blanket and sheet, which were placed on an open shelf adjacent to an environmental services cart and mops. When questioned, an administrative staff member acknowledged that unwrapped linen should not be stored next to the environmental services cart and confirmed this was an infection control issue. Additionally, the facility was unable to provide a policy related to linen storage or infection control practices during the survey. No further information or documentation was provided by the facility prior to the survey exit.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice for three residents, resulting in multiple deficiencies related to medication administration and adherence to physician orders. For one resident, staff did not follow the physician's order to contact the physician before administering insulin when the resident's blood sugar exceeded 400. Instead, insulin was administered first, and the physician was contacted only after the medication failed to reduce the blood sugar. This was confirmed through clinical record review and staff interviews, where it was acknowledged that the order required immediate physician notification prior to insulin administration. Another resident experienced repeated delays in the administration of multiple scheduled medications, including gabapentin, furosemide, Novolog, tiotropium bromide, sennosides-docusate sodium, MiraLAX, and clopidogrel bisulfate. These medications, scheduled for administration at 9:00 a.m., were consistently given several hours late over multiple days. Staff interviews confirmed that medications should be administered within one hour before or after the scheduled time, and that late administration is considered a medication error. Facility policy also required medications to be administered within 60 minutes of the scheduled time. A third resident was affected by unclear and unclarified medication orders, as well as late administration of medications. The resident had orders for modafinil at two different times, but the order was not clarified, leading to confusion among staff and issues with pharmacy supply. Additionally, other medications for this resident, such as acarbose and metoprolol, were administered outside the prescribed time frames. Staff interviews and policy reviews confirmed that medications were not administered as ordered and that orders requiring clarification were not addressed in a timely manner.
Failure to Provide Required ADL Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically turning and repositioning, for a dependent resident with a history of diabetes mellitus, cerebrovascular accident (CVA) with hemiplegia and hemiparesis, and vascular dementia. The resident was assessed as severely cognitively impaired and totally dependent on staff for all ADL needs, including bed mobility. The care plan required two staff members to assist with repositioning and turning in bed as necessary. A review of the ADL documentation for November and December revealed multiple dates and shifts with missing entries for turning and positioning. Interviews with CNAs confirmed that if the care was not documented, it was not performed. This was corroborated by staff statements indicating that blanks in the documentation meant the required care was not provided. The deficiency was brought to the attention of administrative and nursing leadership, with no further information provided prior to the survey exit.
Failure to Administer Medications and Coordinate Care as Ordered
Penalty
Summary
Facility staff failed to administer physician-ordered medications and treatments in a timely and accurate manner for multiple residents. In one instance, a resident with a urinary tract infection did not receive an ordered intravenous antibiotic until four days after the order was written, despite the medication being available in the facility's Omnicell system. Documentation showed that pharmacy alerts regarding allergies and drug interactions delayed administration, but staff did not follow up promptly with the provider or pharmacy to resolve the issue. Additionally, the same resident did not have a blood glucose recheck performed at the time specified by the provider, with the check occurring nearly two hours late. Another resident did not receive multiple scheduled medications, including insulin, gabapentin, and trazodone, on specific dates, even though these medications were available in the facility's Omnicell. Staff interviews confirmed that nurses should have checked the Omnicell and administered the medications as ordered. In a separate case, a resident scheduled for a colonoscopy did not receive the required bowel preparation medications, which were available in house stock, resulting in the procedure being canceled and delayed. Documentation and staff interviews indicated that the medication was not located or administered as required, and the provider was not notified in a timely manner. Additional deficiencies included failure to provide required PICC/midline dressing changes for a resident, with no documentation to support that the care was provided as ordered. Another resident did not have a gastrointestinal appointment scheduled as ordered by the physician, and there was no evidence in the medical record or from the physician's office that the appointment was made. These failures were identified through clinical record review, staff interviews, and review of facility policies, with no further information or corrective actions provided prior to the survey exit.
Failure to Provide and Document Foley Catheter Care
Penalty
Summary
Facility staff failed to provide Foley catheter care as ordered for a resident diagnosed with neuromuscular dysfunction of the bladder. The physician's order required catheter care every shift and as needed, which was documented in the resident's treatment administration records (TARs) from September through November. However, review of the TARs revealed multiple instances where catheter care was not documented as provided, with blank spaces noted on specific dates and shifts. An interview with an LPN confirmed that catheter care should be performed at least once per shift and documented on the TAR. The facility's policy also required routine hygiene and documentation of catheter care, including the date and time care was given. Despite these requirements, the records did not show evidence that catheter care was consistently provided or documented for the resident during the identified periods.
Failure to Provide and Document Prescribed Oxygen Therapy
Penalty
Summary
Facility staff failed to provide prescribed respiratory care and services for two residents with chronic respiratory conditions. For one resident with chronic obstructive pulmonary disease, staff did not administer continuous oxygen as ordered by the physician on multiple shifts, as evidenced by blank documentation on the treatment administration record (TAR) for several dates. Interviews with nursing staff confirmed that oxygen administration should be documented on the TAR, and the facility's policy requires recording the date and time of oxygen setup or adjustment in the medical record. For another resident with chronic respiratory failure and hypoxia, staff did not document the administration of oxygen therapy as ordered on several shifts throughout the month. The resident's care plan and physician orders specified continuous oxygen, but the TAR showed missing documentation for multiple day, evening, and night shifts. Nursing staff confirmed that if documentation is missing, there is no evidence that oxygen was administered. Facility policy also requires documentation of the rate, route, and rationale for oxygen administration.
Failure to Document Physician Response to Pharmacist Recommendations
Penalty
Summary
Facility staff failed to document a physician's response to pharmacist recommendations made during the monthly Medication Regimen Review (MRR) for one resident. Specifically, recommendations from the pharmacist regarding the prolonged use of antibiotics (Fluconazole and Ketoconazole) and a suggested dose reduction for Protonix were not addressed or documented by the physician. The facility's policy requires that recommendations from the pharmacist be acted upon and documented by staff or the prescriber, with either acceptance and action or a documented explanation for disagreement. The resident involved had multiple diagnoses, including diabetes mellitus, congestive heart failure, seizures, and chronic respiratory failure with hypoxia, and was not cognitively impaired according to the most recent assessment. Despite the facility's established process for reviewing and responding to MRR recommendations, there was no evidence in the clinical record or facility documentation that the physician responded to the pharmacist's recommendations for this resident on two separate occasions.
Failure to Honor Resident Dietary Allergies and Preferences
Penalty
Summary
Facility staff failed to honor dietary allergies and preferences for two residents, resulting in the provision of inappropriate food items. One resident, who was cognitively intact and had multiple diagnoses including diabetes, heart failure, and morbid obesity, reported allergies to several foods and a need for a gluten-free diet, as well as adherence to Jewish dietary guidelines. Despite these documented needs and preferences, the resident was served chicken noodle soup containing gluten, and her meal ticket did not reflect her gluten intolerance or religious dietary requirements. The resident stated that staff did not understand her needs and required her to provide proof of her gluten intolerance, and staff interviews confirmed that her preferences were not being met. Another resident, who was moderately cognitively impaired and had chronic medical conditions, had a documented dislike of eggs. Despite this, the resident was served eggs for breakfast, as observed by surveyors. The resident expressed dissatisfaction with the food provided, and the dietary director acknowledged that serving eggs did not honor the resident's stated preferences. The resident's care plan and dietary orders did not indicate any allergies but did specify food preferences that were not followed. Interviews with dietary staff revealed that the process for identifying and accommodating food allergies and preferences involved resident interviews and electronic documentation, with meal tickets intended to reflect these needs. However, in both cases, the system failed to ensure that residents' dietary restrictions and preferences were honored, resulting in the provision of inappropriate meals. The facility's policy recognizes residents' rights to make personal dietary choices and to receive reasonable accommodations for individual, religious, cultural, and ethnic preferences, but these were not upheld in the observed incidents.
Failure to Provide Snacks Between Meals and at Bedtime
Penalty
Summary
Facility staff failed to provide snacks during the day and at bedtime for two residents, both of whom were moderately cognitively impaired and had significant medical conditions, including Parkinson's Disease, convulsions, chronic kidney disease, hereditary and idiopathic neuropathy, and arthritis. Observations conducted on multiple units at various times revealed that snacks such as milk, applesauce, ice cream, crackers, yogurt, and peanut butter were not available, with only a minimal amount of milk and yogurt found on one occasion. The facility census at the time was 120 residents. Interviews with the affected residents confirmed that they did not receive snacks during the day or at bedtime, and that nothing was provided between meals. Multiple CNAs corroborated this, stating that there were no snacks available for residents on day, evening, or night shifts, except for some peanut butter and jelly or cheese sandwiches sent for diabetic residents. One CNA demonstrated the lack of available snacks by showing an almost empty jar of peanut butter and noting the absence of crackers. The Director of Dietary Services stated that snacks such as PBJ and grilled cheese sandwiches were offered at any time, but also acknowledged that there were no established par levels for nourishment items like milk, applesauce, or crackers, and was unaware of any issue prior to the survey. The facility's policy on between meal and bedtime snacks indicated the purpose was to provide adequate nutrition, but no further information was provided prior to the survey exit.
Failure to Provide Adequate Supplies for Resident Care
Penalty
Summary
Facility staff failed to provide necessary supplies, including urinals, gloves, and cup tops, for two residents with significant medical needs. One resident, admitted with Parkinson's Disease, convulsions, and chronic kidney disease, was assessed as moderately cognitively impaired and required substantial assistance with toileting due to frequent incontinence. Observations of supply closets revealed inconsistent availability of urinals and gloves, with periods where these items were missing or in short supply. Staff interviews confirmed recurring shortages of essential supplies such as urinals, gloves, adult briefs, towels, washcloths, and sheets, with staff sometimes needing to retrieve gloves from other resident rooms or carry them in their pockets due to lack of availability. Another resident, also moderately cognitively impaired and diagnosed with hereditary and idiopathic neuropathy, arthritis, and chronic kidney disease, required peri-area cleaning with each incontinence episode. This resident reported that their size of briefs was not always available. Staff interviews across multiple shifts consistently indicated shortages of gloves, urinals, and other personal care items, with some staff noting that these shortages persisted over weekends and during night shifts. Additionally, staff reported having to provide residents with bottled water due to the absence of lids for water cups. The central supply supervisor, who had recently assumed the role, described the supply ordering and stocking process, noting that orders are typically placed weekly and that rush orders can be made if items run out. However, the process did not prevent periods of supply shortages, especially when the supervisor was not present. No facility policy regarding supply management was provided, and administrative staff were made aware of the findings during the survey.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
Facility staff failed to provide dignity and respect to two residents, as evidenced by multiple documented incidents and staff interviews. For one resident, a grievance was filed by the resident's sister, stating that an agency RN was rude and abrasive after the family waited for hours for assistance. The RN reportedly responded dismissively, saying, 'I am busy too.' Resident council meeting minutes over several months also documented ongoing concerns about staff attitudes and customer service issues. Staff interviews confirmed that agency staff, including CNAs, have been observed responding rudely to residents, such as refusing requests or speaking in a curt manner. The facility's own policy requires residents to be treated with dignity and respect at all times, but these standards were not met. Another resident, who was cognitively intact and had multiple medical conditions including diabetes, CHF, and chronic respiratory failure, reported that a CNA used profanity and was verbally aggressive when asked about her behavior. The resident stated she did not feel treated with dignity or respect. Additional staff interviews corroborated that some staff, particularly agency staff, have been short or used a hard tone of voice with residents. One CNA stated that residents were not being treated with dignity. The facility's policy emphasizes respectful communication and addressing residents by their preferred names, but these practices were not consistently followed.
Failure to Provide Written Notice and Obtain Consent for Room Change
Penalty
Summary
Facility staff failed to provide a written notice of a room change and did not ensure resident consent to a new roommate assignment prior to moving a resident from a private room to a semi-private room. The resident, who was documented as cognitively intact and their own responsible party, was resistant to the move and had previously notified the ombudsman to mediate the situation. Despite the resident's refusal and ongoing discussions, staff proceeded with the room change, packing the resident's belongings and moving them to the new room without documented written notice or evidence of consent to the new roommate. Progress notes and staff interviews confirmed that the resident was not agreeable to the move, expressed distress during the process, and that staff could not confirm the resident had met the new roommate prior to the move. The facility's policy required advance notice and explanation for room changes unless medically necessary, but the clinical record did not show that these requirements were met. The deficiency was identified through review of clinical records, staff interviews, and facility policy documentation.
Failure to Honor Resident's Right to Refuse Room Change
Penalty
Summary
Facility staff failed to honor a resident's right to refuse a room change, resulting in the involuntary relocation of a cognitively intact resident from a private to a semi-private room. The resident, who was his own responsible party and had no documented behaviors or clinical need for a private room, was actively involved in discharge planning to return to the community. Despite the resident's clear and repeated refusals to move, as documented in progress notes and staff interviews, the facility proceeded with the room change. On the day of the move, multiple staff members, including the social worker, director of admissions, and a CNA, entered the resident's room to assist with packing and moving. The resident became visibly upset, yelling at staff and demanding they leave his belongings alone. Despite his protests and physical resistance, staff continued to pack and relocate him to the new room. Staff interviews confirmed that the resident had not agreed to the move and that the facility's rationale was based on payer status and the need to use the private room for another resident, although documentation did not support an immediate clinical need for the private room. Facility policy states that residents have the right to refuse room changes if the move is solely for staff convenience or involves relocation between skilled and non-skilled units. In this case, the move was not supported by a documented clinical need or isolation requirement for another resident, and available room options were not fully explored or offered to the resident. The facility's actions were inconsistent with their own policy and the resident's rights, as evidenced by the lack of documentation supporting the necessity of the move and the resident's clear refusal.
Failure to Notify Physician and Responsible Parties of Significant Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify the physician, nurse practitioner, and/or resident representative in a timely manner regarding significant changes in condition or care for multiple residents. In one instance, a resident with a urinary tract infection had an order for Ertapenem, but due to pharmacy alerts about a possible allergy and drug interaction, the medication was not available for four days. During this period, nurses documented waiting for the pharmacy and did not promptly notify the physician or nurse practitioner about the delay, despite facility policy and staff statements indicating that such notifications should occur immediately when medication is unavailable or when alerts are received. In another case, the same resident experienced a critically high blood glucose reading, requiring multiple administrations of insulin as ordered by the nurse practitioner. However, there was no documentation that the resident's representative was notified of the high blood sugar or the additional insulin orders, contrary to facility policy and staff expectations that representatives should be informed of such significant changes. A separate incident involved a resident with severe cognitive impairment who exhibited combative and aggressive behavior, including refusal of care, spitting, kicking, and biting staff. Despite these significant behavioral changes and refusal of care, there was no evidence that the physician or responsible party was notified, nor was there an investigation into the incident. Staff interviews confirmed that such notifications should have occurred, and the facility's policy requires prompt notification of significant changes in a resident's condition or behavior.
Failure to Maintain Clean, Homelike Environment and Provide Adequate Linens
Penalty
Summary
Facility staff failed to provide a safe, clean, and homelike environment for three residents, as evidenced by multiple observations and interviews. In one case, a resident's room had peeling wallpaper and visible spackled drywall behind the bed, which the resident and maintenance director acknowledged was due to ongoing renovations. The maintenance director confirmed that the current state of the room did not meet clean and homelike standards, and the facility's policy requires such an environment. Another resident's room also had peeling wallpaper on three walls, and the resident reported that it had been in that condition for some time. Additionally, there was a consistent lack of clean linens, towels, and washcloths available for residents. Staff interviews confirmed that there were frequent shortages of linens, making it difficult to provide basic care such as bathing and incontinence care. Residents reported having to wait until late morning for linens, and staff stated that they often ran out of supplies. A third resident reported that for several days there had been no linen available in the morning, forcing them to use a pillowcase for personal hygiene. Observations confirmed the lack of necessary linens and supplies on multiple units. Staff interviews further corroborated the ongoing issue with linen shortages, which directly impacted the ability to provide care. The facility's own policy emphasizes the importance of providing clean bed and bath linens in good condition as part of a homelike environment.
Failure to Develop Comprehensive Care Plan for PICC/Midline
Penalty
Summary
Facility staff failed to develop a comprehensive care plan addressing the care and management of a peripherally inserted central catheter (PICC) or midline for one resident. The resident was admitted with multiple diagnoses, including diabetes mellitus, congestive heart failure, seizures, and chronic respiratory failure with hypoxia. Despite these complex medical needs, the resident's care plan, dated 1/18/25, did not include any interventions or focus related to the presence or care of a PICC or midline catheter. The care plan only addressed risks related to weight loss, malnutrition, and hydration, with no mention of the PICC/midline. Clinical documentation confirmed that the resident had a PICC line, which was removed on 3/10/25, and the resident was aware of the procedure. Interviews with the resident and staff confirmed the presence and subsequent removal of the PICC line, and staff acknowledged that special needs such as a midline should be included in the care plan. No facility policy regarding care planning was provided, and the deficiency was acknowledged by administrative and clinical leadership.
Failure to Provide Prescribed Medications Due to Pharmacy Service Lapse
Penalty
Summary
Facility staff failed to provide necessary pharmacy services for one resident by not obtaining and administering prescribed medications. The resident had physician's orders for Verapamil and Prazosin to be given at bedtime for hypertension, as documented in both the clinical record and the medication administration record (MAR). However, review of the MAR showed that these medications were not administered on a specific date, with blank spaces indicating missed doses. Staff interviews revealed that when medications are unavailable, nurses are expected to check the Omnicell, contact the pharmacy, and notify the provider for alternative orders or to place the medication on hold. In this case, the medications were not available in the Omnicell, and there was no evidence that further steps were taken to obtain or administer the medications as ordered. The facility's policy requires medications to be administered according to prescriber orders, but this was not followed for the resident in question.
Delay in Providing Ordered Radiology Services
Penalty
Summary
Facility staff failed to provide timely radiology services as ordered for one resident with multiple complex medical conditions, including diabetes mellitus, cerebrovascular accident with hemiplegia, and vascular dementia. The resident was severely cognitively impaired and fully dependent on staff for activities of daily living, including bed mobility. A physician's order was placed for a one-time chest x-ray due to a productive cough. Documentation shows that staff attempted to schedule the x-ray after hours but were unable to do so and deferred the task to the next shift. The x-ray order was subsequently placed the following day, and the imaging was completed and resulted the day after the initial order. Staff interviews indicated that the expected timeframe for obtaining and receiving x-ray results is typically within 24 hours. The facility's policy states that radiological and diagnostic services are to be provided to meet residents' needs, either on-site or through contracted providers. No additional information or documentation was provided by facility administration regarding the delay or actions taken to ensure timely completion of the ordered radiology service.
Failure to Document Blood Sugar Reading in Clinical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident by not documenting the numerical blood sugar reading after a physician-ordered recheck. The physician's order required a blood glucose recheck at 2:00 a.m., and the medication administration record indicated the recheck was performed at 3:59 a.m. However, a review of the clinical record, including the medication administration record, nurses' notes, and blood sugar summary, did not reveal the actual blood sugar value obtained during the recheck. The nurse responsible for the recheck confirmed that the blood sugar number should have been documented but could not recall the specific resident or event. Additionally, the facility did not have a policy regarding the maintenance of a complete and accurate clinical record. Administrative staff, including the administrator and director of nursing, were informed of the concern, and no further information was provided prior to the survey exit.
Failure to Implement and Document Incontinence Care Plans
Penalty
Summary
Facility staff failed to implement comprehensive care plans for incontinence care for three residents. Each resident had a documented care plan specifying the need for substantial or maximal assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene as needed for incontinent episodes. Despite these documented interventions, reviews of the activities of daily living (ADL) records revealed multiple instances of missing documentation for 'bowel and bladder elimination' across various dates and shifts for all three residents. The residents involved had significant medical histories, including end stage renal disease, HIV, cancer, malnutrition, colitis, diabetes mellitus, hemiplegia, hemiparesis, rhabdomyolysis, and spondylosis. All were assessed as not cognitively impaired and required maximal or dependent assistance for mobility, transfers, bathing, dressing, and toileting. The care plans were tailored to their physical limitations and incontinence needs, yet the required interventions were not consistently documented as provided. During interviews, an LPN confirmed that if interventions listed on the care plan are not evidenced, the care plan was not implemented. The administrator, DON, and regional director of clinical operations were made aware of these concerns, but no further information was provided prior to the survey exit.
Failure to Provide and Document Incontinence Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically incontinence care, for three dependent residents. Each resident had significant medical conditions, including end stage renal disease, HIV, cancer, malnutrition, colitis, diabetes mellitus, hemiplegia, hemiparesis, rhabdomyolysis, and spondylosis. Their most recent MDS assessments indicated that they required maximal or total assistance for mobility, transfers, bathing, dressing, and toileting, with care plans specifying the need for frequent checking and changing of briefs and provision of toileting hygiene as needed for incontinent episodes. Review of the ADL records for these residents revealed multiple instances of missing documentation for 'bowel and bladder elimination' across various dates and shifts. The documentation gaps spanned several months and included both day, evening, and night shifts. The care plans for each resident clearly outlined the need for substantial or maximal assistance with toileting and incontinence care, yet the records did not consistently reflect that this care was provided or documented as required. Interviews with CNAs revealed a lack of awareness regarding specific time frames for providing incontinence care, and both CNAs stated that care was documented on the ADL forms. However, the missing documentation suggests that either the care was not provided or not properly recorded. Facility administrative staff, including the administrator, DON, and regional director of clinical operations, were made aware of these concerns during the survey process. No additional information was provided prior to the survey exit.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for several residents, leading to deficiencies in care. For one resident with a diagnosis of C-diff, staff did not adhere to contact precautions as outlined in the care plan. Observations revealed that staff entered the resident's room without the required personal protective equipment (PPE) such as gowns and gloves, and did not follow proper hand hygiene protocols. Interviews with staff confirmed a lack of compliance with the care plan's requirements for infection control measures. Another resident with end-stage renal disease and a dialysis AV fistula did not receive the necessary monitoring as per the care plan. The facility's records showed that assessments of the dialysis fistula for function were not documented on multiple occasions. This lack of documentation indicates that the required checks for thrill and bruit, as well as signs of infection, were not consistently performed, which is a critical component of the resident's care plan. Additional deficiencies were noted in the care of residents with colostomies and those requiring incontinence care. For a resident with a colostomy, the care plan specified that colostomy care should be provided every shift, yet records showed multiple instances where this care was not documented. Similarly, residents dependent on staff for toileting hygiene did not receive the necessary incontinence care as outlined in their care plans. These failures to implement the care plans highlight significant lapses in the facility's adherence to established protocols for resident care.
Failure to Maintain Transmission-Based Precautions
Penalty
Summary
The facility staff failed to maintain proper transmission-based precautions for three residents diagnosed with infectious diseases. For Resident #5, who was diagnosed with Clostridium difficile (C-diff), a staff member entered the resident's room without wearing the required personal protective equipment (PPE) such as a gown and gloves. The staff member also failed to wash their hands with soap and water after exiting the room, which is crucial for preventing the spread of C-diff. The facility's policy and the signage on the resident's door clearly outlined the necessary precautions, but these were not followed. Similarly, for Resident #8, who was also diagnosed with C-diff, a staff member entered the room without the appropriate PPE and used alcohol-based hand sanitizer instead of washing hands with soap and water, which is ineffective against C-diff spores. Additionally, another staff member was observed wearing the same gown and gloves outside the resident's room, which could lead to cross-contamination. The facility's policies and the physician's orders required strict adherence to contact precautions, but these were not consistently implemented. For Resident #10, who was diagnosed with COVID-19, a staff member entered the room wearing only a surgical mask, without donning a gown, gloves, or eye protection as required by droplet precautions. The facility's policy and CDC guidelines specified the use of an N95 mask, gown, gloves, and eye protection for residents with confirmed COVID-19. The lack of adherence to these precautions was observed despite clear signage and available PPE, indicating a failure to follow established infection control protocols.
Failure to Provide Incontinence Care
Penalty
Summary
The facility staff failed to provide incontinence care for three residents, identified as Residents #2, #5, and #6, who were part of a survey sample. Resident #2 was severely cognitively impaired and dependent on staff for toileting hygiene. The clinical records indicated that there were shifts where no incontinence care was provided, despite the care plan specifying the need for peri-care after each incontinent episode and encouraging toileting during the night. Interviews with staff revealed that CNAs were expected to check on residents every two hours and provide care as needed, but this was not consistently documented or performed. Resident #5, who was cognitively intact but dependent on staff for toileting hygiene, also did not receive incontinence care during certain shifts as documented in the facility's records. The facility's policy required staff to provide timely peri-care and apply barrier creams to maintain skin integrity, but these actions were not consistently carried out. Staff interviews confirmed the expectation to document incontinence care and educate residents if they refused care, yet gaps in care provision were noted. Similarly, Resident #6, who was dependent on staff for toileting hygiene, experienced lapses in incontinence care. The care plan for this resident included encouraging toileting after meals and providing peri-care after each incontinent episode. However, documentation showed that care was not provided during some shifts. The facility's policy emphasized the importance of managing incontinence to prevent infections and maintain skin health, but the staff did not adhere to these guidelines consistently, leading to the identified deficiencies.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility staff failed to provide necessary colostomy care for a resident, identified as Resident #4, on multiple occasions. The clinical record review and electronic treatment administration records (eTARs) revealed that colostomy care was not documented as provided during several shifts in March, April, and May 2024. The resident's comprehensive care plan required colostomy care every shift and as needed, but the records did not show evidence of this care being administered on the specified dates. Interviews with facility staff, including a CNA and an LPN, indicated that while CNAs were responsible for emptying and burping colostomy bags, nurses were supposed to change the bags and document the care in the medical record. The facility's policy stated that colostomy and ileostomy care should be provided by a licensed nurse as ordered by the physician. Despite this policy, the lack of documentation in the eTARs suggests that the required care was not consistently provided or recorded. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, assistant director of nursing, and regional director of clinical services, but no further information was provided before the survey exit.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility staff failed to provide feeding assistance to Resident #2 on March 23, 2024. Resident #2 was identified as severely cognitively impaired and required partial/moderate assistance for eating, as indicated in the most recent Minimum Data Set (MDS) assessment. The clinical record review revealed that on the specified date, Resident #2 did not receive feeding assistance and did not eat, despite having a physician's order for a mechanically soft diet with thin liquids. The care plan highlighted the resident's risk for nutritional problems due to poor oral intake and the need to maintain stable weight. Interviews with facility staff, including a CNA and an LPN, provided insights into the situation. The CNA mentioned that feeding assistance requirements are communicated during shift reports, and any refusal to eat is reported to the nurse. The LPN stated that Resident #2 did not have eating issues during her care but acknowledged the family's concerns about the resident's food intake. She also noted that Resident #2 was a slow eater and required ample time for meals, which she communicated to the staff. The administrative staff, including the administrator and the regional director of clinical services, were informed of these concerns, but no further information was provided before the survey exit.
Failure to Monitor Dialysis AV Fistula
Penalty
Summary
The facility staff failed to provide complete dialysis care and services for a resident with end-stage renal disease who required monitoring of their dialysis AV fistula. The physician's orders specified that the dialysis fistula should be assessed daily for thrill and bruit, as well as for signs and symptoms of infection, every shift. However, the electronic treatment administration records did not show evidence of these assessments being conducted on several specified dates. This lack of documentation indicates that the required monitoring was not performed as per the physician's orders. The facility's policy on Hemodialysis Access Care outlines the necessity of preventing infection and maintaining the patency of the catheter by checking for signs of infection and ensuring the patency of the site at regular intervals. Despite this policy, the staff did not document the presence of bruit and thrill, signs of infection, or the condition of the dressing for the resident's AV fistula on the specified dates. Interviews with facility staff confirmed that the monitoring should have been documented in the clinical record, but it was not, leading to the deficiency finding.
Latest citations in Virginia
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
A resident received an incorrect higher dose of Divalproex DR after the pharmacy dispensed 500 mg tablets labeled to be given multiple times daily, which did not match the physician’s order for 250 mg tablets. Nursing staff did not detect the discrepancy between the MAR and the medication card despite facility policy and expectations to verify the right dose and ensure orders matched dispensed medications. Over time, the resident developed weakness and altered mental status, was sent to the hospital at the family’s request, and was found to have an elevated valproic acid level, with hospital documentation indicating motor weakness was possibly medication-induced.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
A resident with chronic pain from degenerative disc disease and avascular necrosis experienced repeated episodes of uncontrolled pain, with scores up to 10/10, despite ongoing adjustments to analgesic medications. The care plan focused on pharmacologic interventions and monitoring but did not include any non-pharmacological pain management strategies, even as pain remained only partially controlled. Staff interviews revealed that some staff avoided the resident due to perceived rude behavior, the resident frequently refused care and appointments because of pain, and the resident requested increased narcotics and medical marijuana. The MDS coordinator stated that ineffective interventions should be revised, yet the care plan was not updated to add alternative or non-pharmacologic approaches, contrary to the facility’s own pain management policy requiring care consistent with professional standards and resident goals and preferences.
The facility failed to implement its abuse policy when a resident made multiple abuse allegations against two CNAs. Although the administrator, acting as Abuse Coordinator, stated that policy required immediate reporting, investigation, and removal of alleged perpetrators from duty, facility records showed both CNAs continued to work their scheduled shifts during the investigation periods. Additionally, an allegation of verbal abuse by the same resident was not investigated. Review of the abuse policy confirmed the requirement for reporting, investigation, and oversight to ensure policies are followed, but these measures were not carried out, compromising resident protection during the investigation of abuse allegations.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
A cognitively intact resident with extensive neurologic and musculoskeletal conditions, including post-stroke hemiparesis, neuropathic pain, hip avascular necrosis, and chronic back pain, was highly dependent on staff for ADLs and refused ADL care almost daily, frequently citing pain as the reason. The ADL care plan contained only a single generic intervention for assistance as needed and was not revised to add individualized, measurable interventions despite persistent refusals. A behavior care plan documented refusals of medications, showers, turning/repositioning, meals, and other care, but interventions were limited to medication administration, monitoring, behavior discussion, and psych evaluation, without specific strategies to address care refusals related to pain. A physician order for additional pain medication prior to showers was present in the record but was never incorporated into the comprehensive care plan, contrary to facility policy requiring person-centered care plans that reflect identified needs, new orders, and alternative interventions when residents refuse treatment.
Facility staff did not ensure timely completion and implementation of pharmacy medication regimen review recommendations for a resident. The DON reported that the pharmacy coordinator notifies her when reviews are ready, she forwards them to the physician for signature, and then to unit managers for implementation, with copies kept in a binder and originals scanned into the chart. Review of one resident’s record showed repeated delays of several weeks between pharmacist recommendations for gradual dose reductions of quetiapine, duloxetine, and pantoprazole, as well as completion of an AIMS assessment, and the physician’s review and signature, contrary to the facility’s medication regimen review policy.
A resident with a left calf hematoma and a right pinky finger fracture did not consistently receive care according to provider orders and documented hospital recommendations. Daily ordered wound care to the left calf was not documented as completed on several days, including when the resident was out for appointments and on one day with no documentation at all. Although hospital and provider notes referenced a splinted right pinky finger fracture and the need for follow-up, there were no specific provider orders, TAR entries, or care plan interventions in the facility record addressing treatment, care, or follow-up for the fracture.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Significant Medication Error From Incorrect Divalproex Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incorrect dosing of Divalproex DR. Clinical record review showed that the resident was being seen repeatedly by advanced practice providers in June for muscle weakness and weakness. A nurse practitioner documented on 6/23/25 that the resident’s weakness was found to be due to an incorrect medication dose being dispensed, noting a 500 mg dose instead of the ordered 250 mg. The physician’s order specified Divalproex DR 250 mg tablets, but the medication dispensed and administered was Divalproex DR 500 mg. Pharmacy records and interviews confirmed that on 5/18/25, the pharmacy dispensed 150 tablets of Divalproex DR 500 mg with a label instructing staff to give two tablets in the morning and three at bedtime, which did not match the physician’s order for 250 mg tablets. Nursing staff interviews indicated that nurses were expected to follow the facility’s medication administration policy, including verifying the right resident, right medication, right dose, and ensuring the medication card matched the MAR. The DON and multiple LPNs stated that if the pharmacy sent the wrong medication or if the milligrams did not match the MAR, nurses were expected to identify and correct the discrepancy, but this did not occur in this case. On 6/20/25, the resident was assessed by an LPN who initially stated she did not observe changes in condition, but her documentation reflected that the resident had altered mental status, and the resident’s mother requested hospital transfer. At the hospital, the discharge summary indicated that the resident’s motor weakness was possibly medication-induced, and lab results showed a valproic acid level of 115, above the normal range of 50–100. A physician assistant interviewed later confirmed that increased doses of Divalproex DR can cause drowsiness, muscle weakness, skin reactions, somnolence, nausea, and vomiting. These findings collectively demonstrate that the resident received an incorrect, higher dose of Divalproex DR over time, constituting a significant medication error that resulted in harm.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Provide Effective, Multimodal Pain Management
Penalty
Summary
Facility staff failed to ensure effective pain management for a resident with chronic pain syndrome related to degenerative disc disease of the lumbar spine and avascular necrosis of the left hip. The resident’s care plan identified bilateral hip pain and neuropathic pain, with goals for the resident to verbalize relief of pain, cope with and complete activities with pain relief, and remain free from interruption in normal activities due to pain. Interventions in the care plan focused on administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly to complaints of pain, and evaluating the effectiveness of pain interventions, including reviewing compliance, symptom alleviation, dosing schedules, resident satisfaction, and impact on function and cognition. However, the care plan, initiated in April 2024 and last revised in December 2025, did not include any non-pharmacological interventions to assist with alleviating the resident’s pain. Clinical record review showed multiple episodes of uncontrolled pain despite ongoing pharmacologic management. A nursing note documented that staff were called to the resident’s room for increased, uncontrolled pain with a reported pain score of 10/10, and the physician assistant provided a one-time order for hydrocodone/acetaminophen 10-325 mg. Subsequent progress notes indicated chronic pain syndrome with ongoing symptom review and pain described as only partially controlled, with continued reports of uncontrolled pain and pain ratings up to 10/10. Although analgesic dosages were adjusted over time, there was no evidence in the record that non-pharmacological or alternative pain management approaches were implemented or documented to help alleviate the resident’s pain. Staff interviews further illustrated issues with the resident’s pain management and staff response. An LPN reported that the resident was sometimes rude and disrespectful, and stated that staff ignored and avoided the resident’s room because of how he spoke to people. The assistant DON reported that the resident refused care daily due to pain, screamed out when his left leg was moved, and declined care, assistance, and appointments because of pain, while also requesting increased pain medication dosages and medical marijuana. The MDS coordinator explained that care plans should be updated with changes in condition or ineffective interventions, and that interventions should be changed if not effective, but there was no indication that non-pharmacological interventions were added to the care plan despite ongoing uncontrolled pain. The facility’s own pain management policy required pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, but documentation and interviews showed that non-pharmacological pain interventions were not developed or implemented for this resident.
Failure to Implement Abuse Policy and Protect Residents During Abuse Investigations
Penalty
Summary
The deficiency involves the facility administrator, who also served as the Abuse Coordinator, failing to effectively implement the facility’s abuse policy when allegations of abuse and neglect were made by Resident #1 on two separate occasions involving two different CNAs. Facility documentation and staff interviews showed that, despite the administrator’s statement that the policy required immediate reporting to state agencies, initiation of an investigation, and removal and suspension of the alleged perpetrator from the facility during the investigation, the alleged perpetrators were not removed from duty. In the first incident, involving CNA1, timecard records showed that CNA1 completed the shift on the day of the incident and continued to work subsequent shifts during the investigation period. In the second incident, involving CNA2, timecard records showed that CNA2 completed the scheduled shift on the day of the incident and continued to work multiple scheduled shifts afterward while the allegation was under investigation. The report further notes that Resident #1 also made an allegation of verbal abuse that was not investigated by the facility. Review of the facility’s “Abuse, Neglect, and Exploitation” policy indicated that the facility would designate an Abuse Coordinator responsible for reporting suspected abuse, neglect, or exploitation to the state survey agency and other officials, and that the facility would provide ongoing oversight and supervision of staff to ensure policies were implemented as written. The failure of the Abuse Coordinator to remove the alleged perpetrators from the facility during the investigations and to investigate the verbal abuse allegation did not ensure the safety and protection of Resident #1 and other residents from potential abuse, as stated in the findings.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Update Comprehensive, Person-Centered Care Plan for Ongoing ADL Refusals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain a complete, person-centered comprehensive care plan with measurable interventions for a resident who was cognitively intact but highly dependent on staff for ADLs. The resident had multiple significant diagnoses, including history of stroke with residual left-sided hemiparesis, neuropathic pain, left hip avascular necrosis, degenerative disc disease with chronic lower back pain, adult failure to thrive, and lower extremity weakness. An ADL care plan initiated on 4/10/2024, with a revision date of 9/29/2025, contained only a single generic intervention stating that the resident would receive ADL assistance as needed, with no additional or revised interventions added despite ongoing issues. Clinical record review showed that the resident refused ADL care almost daily and frequently cited pain as the reason for refusal, yet the ADL care plan was not updated to reflect these refusals or to include individualized strategies to address them. The resident also had a behavior care plan initiated on 3/22/2024 and revised on 1/20/2026, which identified refusal of medications, weights, showers, turning and repositioning, appointments, meals, bed linen changes, and getting up in a chair, as well as use of foul and abusive language toward staff. Interventions on this behavior care plan were limited to administering medications as ordered and monitoring for side effects and effectiveness, discussing behaviors with the resident when reasonable, and evaluation by a psych provider. The care plan did not include personalized interventions specifically addressing the resident’s refusal of care or the underlying pain contributing to those refusals. A physician’s order dated 12/5/2025 directed staff to administer additional pain medication one hour prior to showering on shower days, but this order was not incorporated into the comprehensive care plan. Interviews with the ADON and MDS coordinator confirmed that the resident refused care daily and that care plans were expected to be updated with new orders and changes, yet the comprehensive care plan was not revised to include these person-centered, measurable interventions as required by facility policy.
Delayed Implementation of Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews by the consultant pharmacist were completed and implemented in a timely manner for one resident in the survey sample. The DON described the facility’s process, stating that the pharmacy coordinator notifies her when reviews are ready, she then reviews them and forwards them to the physician for review and signature, and once signed, she gives them to unit managers to ensure recommendations are implemented. The DON also stated she keeps copies of all reviews in a binder in her office and sends the originals to medical records to be scanned into the resident’s chart. The facility’s policy, titled “Medication Regimen Review,” states that each resident’s drug regimen is reviewed at least monthly by a licensed pharmacist and includes a review of the resident’s medical chart. Record review for one resident showed multiple delays between the pharmacist’s recommendations and physician review/signature. A pharmacy review dated 2/18/25 recommended a gradual dose reduction of the antipsychotic quetiapine from 100 mg to 75 mg, but this was not reviewed and signed by the physician until 3/25/25. On 2/18/25, a recommendation for a current AIMS assessment was made and was not signed and completed until 3/27/25. On 7/29/25, a recommendation for a gradual dose reduction of the antidepressant duloxetine 60 mg twice daily was not addressed by the physician until 9/5/25. On 11/26/25, a recommendation to reduce pantoprazole from 40 mg daily to 20 mg was not reviewed and signed by the physician until 12/24/25. These findings demonstrate that pharmacy regimen review recommendations for this resident were not acted upon in a timely manner, contrary to facility policy.
Failure to Follow Wound Care Orders and Obtain Treatment Orders for Finger Fracture
Penalty
Summary
Facility staff failed to follow provider orders for wound care to a resident’s left calf hematoma and did not ensure the ordered daily dressing changes were completed. The resident had a history of a fall prior to admission and diagnoses including contusion of the lower leg, Parkinson’s disease, and muscle weakness. The comprehensive care plan identified impaired skin integrity of the left lower leg related to a hematoma with an intervention to provide treatment as ordered. Provider orders directed staff to cleanse the outer left calf with dermal wound cleanser and apply Xeroform, ABD pad, and Kerlix daily. Review of the treatment administration record showed that on multiple days staff either documented the resident as out of the facility for appointments or left the administration block blank, with no documentation that the treatment was completed before or after the appointments and no documentation at all for one of the ordered treatment days. Facility staff also failed to obtain and implement provider orders for care and treatment of the same resident’s right pinky finger fracture. The resident’s diagnoses included a finger fracture, and the MDS coded an active diagnosis of “other fracture.” Hospital documentation noted a right finger fracture treated with a splint and recommended orthopedic follow-up after discharge. A provider progress note at the facility referenced the fracture and stated to continue supportive care, and a skilled nursing note documented that a splint to the right pinky finger was in place. However, there were no corresponding provider orders in the facility record for treatment, care, or follow-up of the fractured finger, and the treatment administration record contained no entries for fracture care. Further review of the comprehensive care plan revealed no focus area, goals, or interventions addressing the resident’s right pinky finger fracture. Interviews with the medical provider, wound care nurse, interim DON, and unit manager confirmed that there was no clear treatment plan or documented orders for the fracture, and staff described that their usual protocol would be to notify the provider and obtain specific orders or clarify orthopedic recommendations. Several nurses who had provided care to the resident were no longer employed and unavailable for interview, and no additional documentation or policies beyond general requirements to provide treatments as ordered and obtain admission physician’s orders were produced to show that appropriate fracture care orders had been obtained or implemented.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
