Summit Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynchburg, Virginia.
- Location
- 1300 Enterprise Drive, Lynchburg, Virginia 24502
- CMS Provider Number
- 495381
- Inspections on file
- 16
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Summit Health And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, which was documented by nursing staff but not reported to a physician or provider for several days. No treatment orders or dressing changes were initiated until the wound NP assessed the wound, despite facility policy requiring prompt notification and intervention. Interviews with LPNs and the DON confirmed that the expected notifications and care orders were not completed in a timely manner.
A resident with multiple comorbidities was admitted with an unstageable pressure ulcer, but staff did not perform a comprehensive wound assessment or initiate treatment orders until several days later. Despite facility policy requiring prompt evaluation and intervention, nursing staff failed to document wound details or contact providers for care, resulting in a lack of timely wound management until a wound NP intervened.
A registered nurse delegated medication administration and blood glucose checks to a CNA, who is not licensed to perform these tasks, resulting in unlicensed staff administering medications and performing clinical procedures. In a separate incident, an LPN failed to verify the resident's name on a medication supply card and prepared medication from the wrong resident's supply. These actions led to a failure to meet professional standards of nursing care.
Staff failed to consistently implement enhanced barrier and contact precautions for residents with indwelling devices or multidrug-resistant infections, including not using required PPE and not posting appropriate signage. Additionally, staff did not perform proper hand hygiene during incontinent care and meal tray delivery, increasing the risk of cross-contamination among residents.
Facility staff did not honor a resident's stated preference for twice-weekly showers, as documented in the admission MDS and scheduled by staff. Despite the resident's medical conditions and moderate cognitive impairment, records showed only one shower was provided, with bed baths given on other scheduled days. The unit manager was unable to provide evidence that the resident received showers as planned.
Staff failed to promptly notify the physician and responsible party of significant changes in condition for two residents, including the onset of a urinary tract infection with new wounds and the dislodgement of a feeding tube. In both cases, documentation and interviews confirmed that required notifications were not made in a timely manner, despite facility policy mandating prompt communication.
A resident with severe cognitive impairment was found with unexplained facial and neck bruising and a skin tear. Facility staff did not immediately report the injury of unknown origin to the state agency or APS as required by policy, and there was no evidence of timely notification to the appropriate authorities.
A resident with severe cognitive impairment and multiple health issues was found with unexplained facial and neck bruising and a skin tear. Facility staff did not immediately report the injury to the state agency or APS as required, and documentation showed delays and inconsistencies in notification. The incident was not reported in accordance with facility policy, and there was no evidence of timely communication with the appropriate authorities.
A resident with multiple complex medical conditions and severely impaired cognition was admitted, and although a baseline care plan was created, there was no documentation that the plan was reviewed with or provided to the resident's representative. Staff confirmed that the baseline care plan should have been shared, but the required documentation and provision of the summary did not occur.
A resident with multiple chronic conditions expressed a preference for female caregivers, which was honored in practice but not documented in the care plan. Staff interviews confirmed that this preference should have been included in the care plan following assessment and review, but it was omitted.
Two residents with severe cognitive impairment and total incontinence did not receive timely incontinence care, with staff failing to check for urine and bowel incontinence at the required intervals. Staff relied on smell rather than visual inspection to detect bowel incontinence, resulting in both residents remaining in soiled briefs for over three hours, contrary to care plan and facility policy expectations.
The facility did not have a certified Activity Director overseeing the activities program for all residents. The Activity Director was not informed of the certification requirement when hired and had not completed the process, although she was enrolled in a certification class and had received course materials. The Administrator confirmed the lack of certification and provided documentation of the director's enrollment.
A resident with a chronic leg ulcer and peripheral vascular disease was found without a required wound dressing, as the dressing had come off during morning care and staff did not promptly replace it or notify the nurse. The wound was left uncovered with drainage, contrary to physician orders for daily wound care and dressing.
A resident with severe cognitive impairment and multiple risk factors for pressure ulcers was not repositioned by staff for several hours, despite care plan interventions and facility policy requiring frequent turning and repositioning. Staff interviews confirmed the lack of repositioning, and leadership acknowledged the expectation for two-hourly repositioning for residents unable to move themselves.
The facility did not maintain safe water temperatures for a resident, failed to follow required transfer protocols for two residents with significant physical and cognitive impairments, and applied a wander guard device to a resident without completing the necessary assessment or obtaining a physician's order.
Failure to Notify Physician and Initiate Treatment Orders for Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the physician or provider regarding an unstageable pressure ulcer identified on a resident upon admission. The resident, who had multiple diagnoses including congestive heart failure, diabetes, and a history of pressure ulcers, was assessed with an unstageable pressure ulcer on the right hip during the admission nursing assessment. Despite documentation of the wound in daily skilled notes and skin assessments, there was no evidence of any treatment orders or dressing changes for the wound until several days later. Clinical record review showed that the pressure ulcer was present and documented, but no notification was made to the physician or provider, and no treatment orders were initiated until the wound nurse practitioner assessed the wound days after admission. Interviews with LPNs and the wound NP confirmed that standard practice required contacting the in-house or on-call provider for treatment orders when a pressure ulcer was identified, but this was not done. The director of nursing also confirmed that there were no documented treatments or dressing changes for the pressure ulcer until the wound NP's assessment. Facility policies required prompt notification of the physician or practitioner for changes in a resident's condition, including new or existing pressure ulcers, and for staff to report changes in skin integrity. Despite these policies, the required notifications and treatment orders were not obtained in a timely manner, resulting in a delay in care for the resident's pressure ulcer.
Failure to Timely Assess and Treat Pressure Ulcer on Admission
Penalty
Summary
Facility staff failed to thoroughly assess and implement timely interventions for the care of a pressure ulcer for one resident. Upon admission, the resident was noted to have an unstageable pressure ulcer on the right hip, but the initial assessment lacked a detailed description of the wound, including its size, appearance, condition of surrounding skin, and presence of drainage, odor, or pain. Daily skilled notes acknowledged the presence of the pressure ulcer but did not document any treatments or dressing changes. No comprehensive assessment or treatment orders were initiated for the pressure ulcer until five days after admission, when a wound nurse practitioner performed a thorough assessment and began appropriate wound care. The resident had multiple comorbidities, including congestive heart failure, atrial fibrillation, diabetes, obesity, and cognitive communication deficit, and was assessed as cognitively intact. Despite the presence of a pressure ulcer on admission and the absence of hospital-provided wound care orders, nursing staff did not contact the in-house provider, on-call provider, or wound nurse practitioner to obtain necessary treatment orders. Interviews with LPNs and the DON confirmed that no comprehensive wound assessment or treatment orders were documented prior to the wound nurse practitioner's intervention, and staff could not explain why appropriate actions were not taken when the wound was first identified. Facility policy required prompt reporting and documentation of changes in skin integrity, comprehensive wound assessments, and timely notification of providers for evaluation and treatment. These procedures were not followed, as evidenced by the lack of detailed wound assessment, absence of treatment orders, and failure to implement dressing changes for the pressure ulcer during the initial days after admission. The deficiency was confirmed through staff interviews, clinical record review, and facility policy review.
Failure to Ensure Nursing Services Met Professional Standards of Quality
Penalty
Summary
Nursing services failed to meet professional standards of quality when a registered nurse (RN) delegated the administration of oral medications and the performance of fingerstick blood glucose checks to a certified nurse aide (CNA), who is not licensed to perform these tasks. The RN pulled medications and allowed the CNA to administer them to multiple residents, and also permitted the CNA to perform blood glucose monitoring. The CNA confirmed administering medications to at least two residents and performing a blood glucose check on another, while the RN acknowledged asking the CNA to perform these tasks. This delegation of duties was outside the CNA's scope of practice and not permitted by facility policy or state regulations. Additionally, during a medication pass observation, a licensed practical nurse (LPN) failed to verify the resident's name on a pharmacy supply card before preparing medication for administration. The LPN obtained torsemide tablets from a supply card labeled for a different resident and prepared to administer them to another resident. The LPN admitted to checking only the medication and dose, not the resident's name, and stated that the supply card had been misplaced in the medication cart. The unit manager confirmed that the LPN did not follow the expected procedure of verifying the correct medication, dose, and resident name. The residents involved had various medical diagnoses, including diabetes mellitus, hypertension, Parkinson's disease, major depressive disorder, atrial fibrillation, chronic pain, and vascular dementia. The facility's own documentation and staff interviews substantiated that unlicensed staff performed tasks restricted to licensed personnel, and that medication administration procedures were not properly followed, resulting in a failure to ensure nursing services met professional standards of quality.
Failure to Implement Infection Control Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as evidenced by multiple observed deficiencies in the use of enhanced barrier precautions (EBP), contact precautions, and standard hand hygiene protocols. For two residents with indwelling medical devices, staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. In one case, a resident with a suprapubic catheter had EBP signage inside the room but lacked PPE availability in the room or bathroom, and there was no external indicator of EBP status. Staff admitted to forgetting to wear gowns and were unclear about the location and use of EBP indicators. Another resident with a feeding tube also did not have appropriate PPE available, and staff were unaware of the resident's EBP status despite signage being present in the room. For a resident being treated for a multidrug-resistant urinary tract infection, the facility did not follow contact precautions protocols. There was no signage on the door to indicate the type of precautions required, and PPE such as gloves, gowns, or masks was not readily available near the room entrance. Staff acknowledged the absence of proper signage and PPE setup, and there was confusion regarding the placement of EBP and contact precaution signage. Additionally, staff failed to perform required hand hygiene during incontinent care and meal tray delivery. During incontinent care, a CNA did not perform hand hygiene after removing gloves and before handling clean linen, only washing hands after disposing of soiled linens. During meal service, the same CNA did not perform hand hygiene between delivering trays to multiple residents, even after touching items in residents' rooms and assisting with feeding. Interviews with staff and review of facility policy confirmed that these actions were not in accordance with expected infection control practices.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
Facility staff failed to honor a resident's expressed preference for twice-weekly showers. The resident, who had diagnoses including a left femur fracture, osteoarthritis, malnutrition, and anxiety, was assessed as moderately cognitively impaired and indicated on the admission MDS that choosing how to bathe was very important. Review of shower records showed the resident only received a shower on one occasion, with subsequent bathing logs indicating bed baths rather than showers on the scheduled days. The unit manager confirmed the resident was scheduled for showers twice weekly but could not provide evidence that these showers were consistently provided as scheduled. This deficiency was presented to facility leadership, and no additional information was provided prior to the exit conference.
Failure to Timely Notify Physician and Representative of Changes in Condition
Penalty
Summary
Facility staff failed to timely notify the physician and the resident or their representative of significant changes in condition for two residents. For one resident with diagnoses including urinary tract infection, urine retention, pressure ulcers, and renal insufficiency, there were multiple documented changes in condition and treatment, such as the onset of a urinary tract infection requiring intravenous antibiotics, the insertion of a PICC line, and the development of unstageable pressure ulcers. Despite these events, there was no documentation that the resident or their responsible party was informed of these changes until several days later, and the responsible party expressed concern about the lack of timely notification. In another case, a resident with severe cognitive impairment and dependent on a feeding tube experienced a dislodgement of the enteral feeding tube. The incident was discovered when the resident was sent out for a neurology appointment, and the family member present at the appointment noticed the absence of the tube and bleeding at the stoma site. Documentation did not show that the family or physician was notified of the dislodgement prior to the resident being sent out for medical attention. Interviews with staff and administration confirmed that the expected notifications did not occur as required. Facility policy requires prompt notification of the resident, physician, and representative of changes in condition, but in both cases, there was a lack of timely communication and documentation regarding significant changes in the residents' medical status. No additional information or evidence of timely notification was provided prior to the survey exit.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to follow abuse prevention policies regarding the immediate reporting of an injury of unknown origin for one resident. The resident, who had multiple diagnoses including dementia with severe cognitive impairment, was found with moderate bruising on both sides of the face and neck, as well as a skin tear on the right cheek. The resident was unable to explain the cause of the injuries due to baseline confusion, and there was no documentation of a recent fall or incident that could account for the injuries. The facility's nursing note indicated that the DON and the resident's emergency contact were notified, but there was no evidence of immediate reporting to the state agency or adult protective services (APS) as required by facility policy. Facility documentation included an initial synopsis form describing the injury, but there was no confirmation that this report was sent to the state agency, APS, or the department of health professions (DHP). The state agency had no record of receiving the initial report, and there were conflicting report dates regarding notification to APS. The administrator and DON confirmed during interviews that there was no evidence of immediate notification to the required authorities, and only the final investigation findings were confirmed as submitted several days after the incident. The facility's policy required immediate reporting of such incidents, but this was not followed in this case.
Failure to Immediately Report Injury of Unknown Origin Suspicious for Abuse
Penalty
Summary
Facility staff failed to immediately report an injury of unknown origin, suspicious for abuse, involving a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, and depression. The resident was found with moderate bruising on the face and neck, as well as a skin tear, with no documented cause or recent incident to explain the injuries. The nursing note indicated that the resident was unable to communicate what had happened due to baseline confusion, and the Director of Nursing and emergency contact were notified. However, there was no evidence that the injury was immediately reported to the state agency or adult protective services (APS) as required. Facility documentation showed inconsistencies and delays in reporting, with the initial incident form completed but lacking confirmation of submission to the appropriate authorities. The state agency had no record of receiving the initial report, and APS was not notified until several days after the incident. Interviews with the current administrator and DON confirmed the absence of fax or email confirmations and an inability to explain the conflicting report dates. The facility's policy required immediate reporting of such incidents, but this was not followed in this case.
Failure to Provide Baseline Care Plan Summary to Resident's Representative
Penalty
Summary
Facility staff failed to provide a baseline care plan summary to the resident's representative within 48 hours of admission for one resident. The resident was admitted with multiple complex diagnoses, including Parkinson's disease, sepsis, urinary tract infection, pressure ulcer, respiratory failure, and a history of hip fracture, and was assessed as having severely impaired cognitive skills. The admission assessment included a baseline care plan addressing key care areas such as catheter care, constipation prevention, hospice services, diet, pressure ulcer care, fall prevention, and assistance with activities of daily living. Despite the creation of the baseline care plan, there was no documentation in the clinical record that the plan was reviewed with the resident's representative or that a summary or copy of the plan was provided. The relevant sections of the admission assessment regarding completion and review of the baseline care plan, as well as provision of the plan summary and medications, were not completed. Staff interviews confirmed that the baseline care plan should have been reviewed and provided to the family, and that this could be done through the electronic health record, but there was no evidence this occurred.
Failure to Update Care Plan with Resident's Caregiver Preference
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for one resident following the identification of a specific care preference. The resident, who was admitted with multiple diagnoses including spinal stenosis, cardiomyopathy, chronic respiratory failure, diabetes, and depression, was assessed as cognitively intact. During an interview, the resident expressed a preference for female caregivers to provide personal care, a preference that had been honored in practice by the facility. However, a review of the resident's care plan, last revised on 3/28/25, showed that while assistance with activities of daily living was documented, there was no mention of the resident's preference for female caregivers. Interviews with facility staff, including the LPN unit manager and the RN MDS coordinator, confirmed that this preference should have been included in the care plan but was not. The omission was acknowledged by staff during the survey, and no additional information was provided by facility leadership before the survey concluded.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for activities of daily living, specifically incontinence care. Both residents had severe cognitive impairment and were always incontinent of bladder and bowel, as documented in their care plans and Minimum Data Set (MDS) assessments. The care plans for both residents specified that they were not candidates for a toileting program and required staff to provide toileting hygiene as needed for incontinent episodes, with the goal of keeping them clean and dry. Observations revealed that both residents remained in their Broda chairs in the dining room for extended periods without being checked for incontinence. For one resident, there was a gap of three hours between incontinence checks, during which the resident was found to have had a thick and sticky bowel movement. The assigned CNA reported relying on smell to detect bowel incontinence and only visually checked the front of the brief for urine incontinence, without fully inspecting for fecal incontinence. The other resident was also not checked for incontinence for over three hours, with the CNA confirming that she did not open the brief to check for urine or bowel incontinence, again relying on smell for detection of fecal incontinence. Interviews with the CNA, the unit manager RN, and the DON confirmed that the expectation was for residents to be checked for incontinence at least every two hours and that a visual check for both urinary and bowel incontinence was required. The facility's policy also required staff to provide incontinence care as needed. Despite these expectations and policies, staff did not perform timely or thorough incontinence checks for the two residents, resulting in a failure to meet their care needs as outlined in their care plans.
Uncertified Activity Director Led Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a certified Activity Director for all 114 residents. During interviews, the Activity Director confirmed she was not certified and stated she was unaware of the certification requirement when she accepted the position two years prior. She reported that previous administrators had not discussed the need for certification, but the current administrator had informed her of the requirement and encouraged her to obtain certification. The Activity Director indicated she had enrolled in the necessary class, received the course materials, and completed the required essay, but had not yet submitted it. The Administrator confirmed that the Activity Director was not certified but had been enrolled in the certification class. Documentation of the enrollment was provided. A review of the job description for the Activities Director indicated that appropriate training and/or certification was highly advantageous, but did not specify it as a strict requirement. No further information was provided prior to the survey exit.
Failure to Maintain Wound Dressing as Ordered
Penalty
Summary
Facility staff failed to ensure that a wound dressing was intact for a resident with a non-pressure chronic ulcer on the left calf, adult failure to thrive, and peripheral vascular disease. The resident, who was cognitively intact, was observed without a wound dressing in place and with scant drainage present. The resident reported that the dressing came off during morning assistance with dressing by aides. The registered nurse confirmed the wound was open to air and not covered, and stated that she had not been informed about the missing dressing, despite physician orders requiring the wound to be cleaned and covered with boarded gauze every day shift.
Failure to Reposition High-Risk Resident to Prevent Pressure Ulcers
Penalty
Summary
Staff failed to implement required interventions to prevent pressure ulcers for one resident who was at high risk due to multiple medical conditions, including vascular dementia, failure to thrive, impaired healing from peripheral vascular disease, and protein calorie malnutrition. The resident was severely cognitively impaired, dependent on staff for transfers and repositioning, and had a care plan specifying frequent turning, repositioning, and keeping the skin clean and dry. Despite these documented interventions, the resident was observed sitting in a Broda chair for extended periods without being repositioned by staff. Observations showed that the resident remained in the same position in the Broda chair for several hours, with no staff assistance in repositioning during that time. Interviews with the assigned CNA confirmed that the resident was not repositioned throughout the observed period. The unit manager and DON both stated that the expectation was for staff to reposition residents who are unable to do so themselves at least every two hours. The failure to follow these interventions placed the resident at increased risk for developing pressure ulcers.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for three residents. In one instance, a resident's bathroom sink water temperature was measured at 121.3°F, exceeding the facility's stated safe range of 110°F to less than 120°F. The resident, who was cognitively intact and had multiple medical diagnoses, reported that the water felt very hot but had not experienced any injury. The maintenance director confirmed the temperature was above the required limit and acknowledged the need for seasonal adjustments to maintain safe water temperatures. Documentation showed that previous checks in the same room had recorded temperatures within the acceptable range. In another case, staff failed to follow the required transfer protocol for a resident with severe cognitive impairment and significant physical limitations. The resident's care plan and Kardex specified that all transfers should be performed using a Hoyer lift with two staff members. However, observations revealed that staff transferred the resident manually, without the lift, and at one point, a single staff member completed the transfer alone after another was unable to assist. Both CNAs involved stated they had never used the Hoyer lift for this resident, despite the care plan instructions. The DON confirmed that the care plan and Kardex should accurately reflect the required transfer method and that not following it could result in injury. Additionally, the facility failed to complete a required assessment and obtain a physician's order before applying a wander guard device to a resident at risk for elopement. The resident, who had severe cognitive impairment and a history of wandering, was observed wearing a wander guard without a current elopement risk assessment or a physician's order documented in the medical record. The DON acknowledged that both an assessment and a physician's order were required for the use of such a device, and facility policy supported this requirement.
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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