Thalia Gardens Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Virginia Beach, Virginia.
- Location
- 4142 Bonney Road, Virginia Beach, Virginia 23452
- CMS Provider Number
- 495241
- Inspections on file
- 19
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Thalia Gardens Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure monthly drug regimen reviews by a licensed pharmacist were documented or acted upon for multiple residents with complex medical and psychiatric conditions. Records for several residents showed no monthly pharmacy reviews for extended periods and no documentation of staff responses to pharmacist-identified irregularities, even when PRN psychotropic and opioid medications were frequently administered. The DON reported that she did not know the location of the monthly reviews, that the facility could not provide them, and that no process or system was in place to respond to pharmacist-identified irregularities, including those requiring urgent action.
The governing body failed to ensure an effective QAPI program and overall management systems, resulting in multiple unresolved deficiencies in environmental services, sanitation, infection control, and medication storage and administration that affected all residents’ quality of life. Resident Council minutes and grievance logs documented ongoing complaints about inadequate linens and delayed laundering of personal clothing, while surveyors observed large amounts of unfolded clean laundry and other unsatisfactory conditions in the laundry area. Significant turnover in key leadership roles, including a new DON, Social Services Director, HR Director, and Maintenance Director, coincided with persistent maintenance and pest control issues. The facility also failed to notify the State agency when a fire watch was initiated after fire panel trouble alarms, and surveyors found the facility lacked an effective staff training program on required topics such as QAPI, effective communication, and behavioral health.
The facility failed to maintain an effective QAPI program for most of the review period, with no documentation of QAPI meetings, no Performance Improvement Plan, and no active Performance Improvement Projects despite multiple identified system issues. Resident Council minutes and grievance logs showed that administration was aware of ongoing concerns from residents and families that persisted without resolution. The Assistant Administrator reported no available QAPI documentation from prior leadership and confirmed that expected monthly QA and quarterly QAPI meetings were not occurring as required. Surveyors also found the facility lacked an effective staff training program, including required training on QAPI, effective communication, and behavioral health, contributing to substandard quality of care findings and an extended survey.
The facility lacked a functioning QAPI program and active performance improvement projects for most of the four reviewed quarters, affecting all residents. Surveyors conducting an extended survey for substandard quality of care found no documentation of QAPI activities from the prior administrator and no current performance improvement projects. An assistant administrator reported having no QAPI information before early 2026 and stated that, although the facility was expected to hold monthly Quality Assurance and quarterly QAPI meetings, three of four quarters reviewed contained no QAPI information. Facility leadership, including the administrator, assistant administrator, regional nurse consultant, and DON, were informed of these findings during survey debriefings.
Facility staff did not maintain required documentation of staff COVID-19 vaccination education, offers, or vaccination status. When surveyors requested Infection Control information for staff, the IP reported she had not been directed to track staff COVID-19 vaccination status and had no records showing that staff were educated on COVID-19 vaccine benefits and risks, offered the vaccine, or given information on how to obtain it. In a subsequent interview, facility leadership, including the Administrator and DON, did not provide any additional information regarding staff COVID-19 vaccination data.
The facility failed to maintain an effective QAPI training program for all staff, as evidenced by missing QAPI content in orientation materials, use of an outdated annual education calendar without QAPI, and lack of documented QAPI education for sampled RNs, an LPN, and CNAs. The staff development coordinator reported she did not provide QAPI training and believed it was handled by HR, while the HR director confirmed QAPI was not included in new-hire orientation. Limited computer-based QAPI training records showed only some employees from various disciplines had completed QAPI modules, with no clear evidence that all staff were trained or that training was updated after new QAPI goals were set.
Surveyors found that the facility failed to maintain an effective training program that included required behavioral health education for all staff. When training records for several RNs, an LPN, and CNAs were reviewed, there was no documentation of behavioral health training, and interviewed staff could not recall receiving such training, only noting that some education occurred in person or on the computer. The Staff Development Coordinator acknowledged having no evidence that employees had received behavioral health care training, and facility leadership was informed that required behavioral health training was not documented or effectively implemented.
Staff failed to maintain a safe, clean, and homelike environment across all units, with multiple residents reporting large flying roaches in rooms and common areas, difficulty sleeping due to pests, and unclean shower rooms. Surveyors observed live and dead roaches in bathrooms, a wasp nest at a resident window with a gap into the room, leaking toilets with pans catching water, stained and bulging ceiling tiles over beds, damaged doors and thresholds, and filthy floors with food debris and encrusted brown substances in several rooms. On one unit, many semi-private rooms were very small, with one bed abutted against the wall, limiting access for care and cleaning and reducing privacy for residents and visitors; staff and visitors confirmed these concerns. Hallways were cluttered with equipment, furniture, and supplies, and an emergency bathroom pull cord used by an independently ambulating resident did not activate the nurse call system. Shower rooms and the laundry area were cluttered and soiled, with used dressings, soiled items, and large amounts of unfolded and soiled laundry present, and the kitchen had missing floor tiles at the entrance, creating a trip hazard.
Staff failed to ensure that large wall clocks in the rooms of four cognitively impaired residents were functioning and displayed the correct time. Over several days, surveyors repeatedly observed clocks stuck at the same time or showing inconsistent, incorrect times while residents were in their rooms, either in bed or in wheelchairs. Staff entered these rooms multiple times to deliver care, pick up meal trays, and provide ice and water but did not address or report the non-functioning clocks. Some residents verbally indicated that the clocks were wrong or that they did not know the time when looking at the clocks. The unit manager and DON later acknowledged that accurate clocks are important for resident orientation and that staff should have noticed the problem.
Facility staff did not ensure that residents knew they could review the survey results binder or where it was located. In a resident group meeting with the council president and several residents, all attendees reported they were unaware of their ability to access the survey book and could not identify its location, with one suggesting it might be behind the nurse’s station. The Activities Director stated that residents were educated at each resident council meeting about the binder’s location and that this was documented in council minutes, but no approach was described for updating residents going forward. When these findings were presented to the Interim Administrator, DON, ADON, and a corporate nurse consultant, they offered no comments or concerns.
The facility failed to ensure that a resident with dementia and limited English proficiency, and her family, were invited to and able to participate in person-centered care plan meetings, despite a care plan that emphasized communication needs and family involvement. Medical record review confirmed that care plan meetings occurred but did not document resident or family attendance, while the resident’s daughter reported never being invited. In a separate case, the facility did not update another resident’s care plan after her clinical status changed: although an indwelling Foley catheter order had been discontinued months earlier and staff reported the resident was now incontinent without a catheter, the care plan continued to list an active catheter problem with related interventions, and also continued hospice-related goals and interventions after hospice services had been certified as ending because the resident was no longer terminal.
Facility staff did not consistently post required daily nurse staffing information in a prominent, accessible location for residents, staff, and visitors. Over several days of surveyor observation, no nurse staffing postings were seen on the units or at the receptionist’s desk, and multiple alert residents and a regular visitor reported not knowing where to find this information. The Administrator was unsure of the posting location, and the Assistant Administrator directed surveyors to a Human Resources hall bulletin board displaying only an “as worked” schedule for a single shift, while the usual frame at the receptionist’s desk was empty and being replaced. The staffing coordinator reported she typically posted staffing daily and kept prior postings, but available records covered only part of the preceding months and showed numerous missing dates and incomplete entries, including absent census data and blank RN slots, contrary to facility policy requiring daily shift-specific posting of nursing personnel providing direct care.
Surveyors found that staff failed to discard expired Humulin R insulin on two of three medication carts. During separate medication cart audits on two units, an LPN on each unit identified a bottle of Humulin R insulin that had been open longer than the 28-day discard period and acknowledged that the insulin was no longer good and should have been discarded. A subsequent interview with facility leadership did not provide additional information regarding these expired insulin vials.
Surveyors found that the facility failed to conduct and document required QAPI activities, with no QAPI records for most of the review period and no active Performance Improvement Projects. The Assistant Administrator reported that current leadership could not locate prior QAPI documentation and that expected monthly QA and quarterly QAPI meetings were not evidenced. Review of maintenance, pest control, Resident Council, and grievance records showed that administration was aware of ongoing resident and family concerns that persisted without resolution. The survey also identified an ineffective staff training program on QAPI, communication, and behavioral health, and there was no documentation that the governing body was informed of or acting on the identified issues.
A resident with Alzheimer’s disease, severe cognitive impairment (low BIMS score), and communication difficulties was care planned for supervision with toileting and partial assistance with bathing, yet was observed ambulating independently to a shared bathroom where the emergency pull-cord system was not functioning. Surveyors found that pulling the bathroom emergency cord did not activate lights or an alert at the nurse’s station, and a CNA was unaware whether the cord signaled at the station. This confirmed that a working emergency call system was not available in the bathroom and bathing area used by the resident.
Facility staff did not maintain an effective training program for RNs, LPNs, CNAs, and other employees, with no documented education on behavioral health care or communication, including communication with a Spanish-speaking resident. Staff reported they had not been trained to communicate with this resident and instead relied on the family and a Spanish-speaking ADON to translate. The Staff Development Coordinator confirmed the absence of training records and there were no communication tools or established communication process in the resident’s room. Facility leadership was informed that required staff training, including communication training, was not effectively maintained or documented.
A cognitively intact resident with multiple medical conditions repeatedly reported that personal items such as soaps, lotions, clothing, and perfume were going missing and stated that she and her daughter had informed staff and prior administrators many times without action. CNAs acknowledged awareness of the resident’s allegations but were unsure whether these concerns had been reported, despite the DON’s stated expectation that a grievance be completed whenever items were reported missing, lost, or stolen. Only one grievance was documented, and when the findings were presented to the administrative team, they offered no comments or concerns.
Facility staff failed to complete required pre-employment screening, resulting in multiple employee files lacking sworn statements, state police criminal background checks, or verification of licenses/certifications. An internal audit had already identified missing documents, but no corrective action was taken and the issue was not brought to QA. One employee was hired and allowed to work before the criminal background report was obtained and reviewed; when the report was later received from a sister facility, it showed barrier crimes including assault of a family member, malicious wounding, and indecent exposure. The Regional HR Director reported prior problems with the state police online system and reliance on another facility’s HR staff to obtain background checks, and leadership offered no additional information during interviews.
Staff failed to maintain a safe environment by leaving kitchen floor tiles missing at the kitchen entrance and by not repairing a damaged dining room entry door. The removed tiles were stored on a pellet warmer near the exposed area, and the Director of Maintenance acknowledged that the missing tiles created a potential trip hazard. The dining room entry door was observed splitting apart with the bottom hinge detached, and the door was being kept propped open; the Director of Maintenance stated the door could fall if staff attempted to close it, identifying it as a hazard. Facility leadership reported no additional concerns when interviewed about these conditions.
The facility failed to maintain an effective pest control program, as multiple cognitively intact residents reported large flying roaches in their rooms, bathrooms, and shower areas, and a visitor also reported seeing roaches. Surveyors directly observed roaches on a bathroom floor in one resident’s room, along with standing water and roach bait houses, after the resident had previously complained to housekeeping about room cleanliness and roaches. Two residents in another room reported wasp nests by their window for several weeks, and surveyors confirmed two nests and a gap between the screen and window that allowed insect entry. Leadership was informed of an additional gap at a hallway-to-courtyard threshold that could admit insects, and it was determined that pest control services had lapsed for two months due to unpaid invoices, while pest control logs had been destroyed and left blank, omitting documentation of roach sightings and the wasp nests.
A Spanish‑speaking resident with dementia, severe cognitive impairment (BIMS 5/15), and multiple ADL assistance needs had a care plan identifying a communication problem, a preference for Spanish, and an intervention to provide a translator as necessary. The H&P documented a language barrier and noted that one of two nurses could speak Spanish, and the DON stated an interpretation document was kept at the nurse’s station. However, CNAs caring for the resident reported they were not aware of any interpreter services or interpreter information, demonstrating that interpreter services were not effectively available or communicated to staff to support this resident’s identified communication needs.
Facility staff did not ensure that residents knew where to find the list of contact names, addresses, and phone numbers for the ombudsman, adult protective services, and other State agencies. In a resident group meeting with the Resident Council President and four other residents, all five reported they did not know how to contact these agencies. The Activities Director later stated that residents are educated at each resident council meeting about the ombudsman and the location of the contact information, and that this is documented in council minutes. When these findings were presented to the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, they did not offer comments or concerns.
A resident with intact cognition but extensive ADL dependence and multiple chronic conditions, including chronic respiratory failure and COPD, experienced an acute episode of hypoxemia with O2 saturations in the 70–80% range and chills, prompting an acute provider visit and respiratory treatments. Although facility policy required prompt notification of the resident’s representative and maintenance of current contact information after significant changes in condition, staff did not document any notification or attempted notification of the resident’s POA or secondary emergency contact at the time of the event. Subsequent surveyor calls showed that listed phone numbers were not working or could not receive voicemail, and the secondary contact reported not receiving any call, while the resident later supplied an updated number; the DON confirmed there was no record of contact attempts and that she had not been informed of the change in condition.
A resident with moderately impaired cognition and a history of malignant neoplasm of the colon reported that multiple personal items, including beverages, toiletries, and bifocals, had been missing for several months and that she had informed various staff, including the DON and nurse aides. However, only a single grievance form was found, documenting missing Ensure but not the other items, and the Social Worker stated she was unaware of the missing items until the surveyor’s inquiry. This reflects a failure by staff to properly initiate and document a grievance for all reported missing items and to ensure the resident’s grievance was fully recognized and addressed.
A resident with a history of stroke, aphasia, and anxiety, and with severely impaired cognition per BIMS, had a PRN Lorazepam 0.5 mg G-tube order written without a stop date and used for more than 14 days without documented prescriber re-evaluation. The clinical record lacked evidence that the physician or other prescribing practitioner assessed the ongoing appropriateness of this psychotropic medication, even though the care plan identified anti-anxiety drug use and outlined monitoring for adverse reactions.
Facility staff failed to timely report an allegation of abuse involving a resident with moderately impaired cognition and a diagnosis including malignant neoplasm of the colon. The resident reported being shoved back into bed by staff after nearly falling, and a facility synopsis documented that she was shoved twice by two staff members while being assisted to bed. The incident date and the report date in facility records showed a five-day delay before the allegation was reported to state agencies. Staff interviewed during the survey stated they were not aware of the incident, and leadership provided no additional information about the delay, resulting in a deficiency for failure to promptly report suspected abuse.
Facility staff failed to accurately complete an admission MDS when a resident was incorrectly coded as receiving an anticoagulant with a documented indication, despite no corresponding physician order, care plan entry, or physician progress note confirming anticoagulant use. The same MDS also recorded a BIMS score indicating intact cognition, but the primary deficiency involved the inaccurate documentation of high-risk drug class use.
Staff failed to follow a physician’s order for continuous O2 at 3 L/min via nasal cannula for a cognitively intact resident with chronic respiratory failure, COPD, and multiple comorbidities. Over at least three days, the resident was repeatedly observed in bed with the O2 concentrator set at 5 L/min, and the resident reported earlier breathing difficulty. An RN later verified the physician’s order for 3 L/min and acknowledged that the flow rate had been at 5 L/min for several days before adjusting it back to the ordered rate.
A resident with anxiety and moderately impaired cognition had a one-time order for Ativan 0.5 mg. During a medication pass, the ADON obtained a 1 mg Ativan tablet from the stat box for an RN to administer. The RN opened the single-dose package and, while wearing gloves, broke the 1 mg tablet in half by hand, wasting one half and giving the other half to the resident. Facility leadership later stated that policy requires use of a tablet splitter to ensure dose accuracy and minimize contact with the scored tablet, indicating that proper medication administration technique was not followed.
Facility staff failed to provide required discharge instructions and documentation to two residents who left AMA. One resident with multiple acute and chronic conditions and moderate cognitive impairment left shortly after admission, and nursing notes only recorded that the resident left with family and signed AMA paperwork, with no evidence of discharge instructions or a recapitulation of the stay being provided, consistent with the DON’s statement that discharge summaries are not given for AMA discharges. Another resident with a hip fracture and intact to moderately impaired cognition was discharged by staff after the son arrived unexpectedly, with non‑narcotic medications provided but no documented discharge orders, and the receiving facility reported that it received only a face sheet and PASRR because the discharging facility stated it would not send additional records due to the AMA status, leaving the admitting facility without an H&P, clinical notes, or a medication list.
A resident with a history of stroke, aphasia, anxiety, severely impaired cognition (BIMS 4/15), and total dependence for ADLs was not provided necessary nail care. The resident was observed in bed with fingernails approximately 1.75 inches beyond the fingertips, discolored, and with scratches on the thighs and right arm. A CNA later acknowledged that the resident’s nail care had been overlooked.
Failure to Conduct and Act on Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews (DRRs) for multiple residents and the facility’s failure to respond to pharmacist-identified irregularities according to established policies and procedures. For several residents, surveyors found no documentation in the clinical record of monthly pharmacist reviews or of the facility’s response to any identified irregularities. The Director of Nursing (DON) repeatedly stated that she did not know where the monthly DRRs were located, did not have them, and that the facility was unable to provide this information during the survey period. For one resident with diagnoses including a right femur neck fracture, alcoholic cirrhosis, hypertension, and depression, the quarterly MDS showed moderately impaired cognition. Review of this resident’s clinical record from late April revealed no documentation of the facility responding to irregularities identified by the pharmacist during monthly DRRs. When interviewed, the DON stated she did not know where the monthly DRRs were and could not provide them, and no additional information was produced by the end of the survey. Another resident with type 2 diabetes, chronic kidney disease, muscle weakness, and hypertension, and with severely impaired cognition per the admission MDS, also had no documented facility response to pharmacist-identified irregularities in the progress notes, and the DON again reported that the monthly DRRs could not be located or provided. For two additional residents, one with a stroke and aphasia and another with cataracts and anxiety, surveyors found that no monthly pharmacy reviews were documented in their clinical records over a 12‑month period. In the first of these cases, the resident had severely impaired cognition and active orders for PRN lorazepam via G‑tube and multiple PRN morphine doses for varying levels of pain or distress, which were frequently administered without documented pharmacy reviews or recommendations. The last pharmacy review in this resident’s record was dated more than a year earlier, and the last recommendation several months earlier. For the resident with cataracts and anxiety, no monthly pharmacy reviews were documented for the same 12‑month period, with the last review and recommendation both dated in the prior year. The DON acknowledged that she had only recently started a pharmacy review and recommendation binder and could not provide further information. The facility also failed to implement and follow policies and procedures for responding to pharmacist-identified irregularities, including those requiring urgent action, for two other residents. One resident with severe cognitive impairment and multiple psychiatric and neurologic diagnoses, including non‑Alzheimer’s dementia, seizure disorder, bipolar disorder, schizophrenia, and psychotic disorder, had no documentation in the progress notes of the facility responding to irregularities identified by the pharmacist during monthly DRRs. Another resident with extensive medical conditions, including chronic respiratory failure with hypoxia, diabetes with autonomic polyneuropathy, lymphedema, cirrhosis, NASH, hepatic fibrosis, COPD, morbid obesity, ventral hernia with obstruction, gastroparesis, panic disorder, chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of facility responses to pharmacist-identified irregularities. In both cases, the DON stated she did not have a process for responding to pharmacist-identified irregularities and had not developed a system since beginning employment, and the facility was unable to provide the missing DRRs or additional information before the survey concluded.
Failure of Governing Body to Implement Effective QAPI, Oversight, and Reporting Systems
Penalty
Summary
The governing body failed to ensure an effective QAPI (Quality Assurance Performance Improvement) program and overall management systems, despite being legally responsible for establishing and implementing facility policies and appointing a properly licensed administrator. Surveyors identified multiple deficient practices across environmental services, sanitary and clean building conditions, infection control practices, and medication storage and administration, which affected all residents’ quality of life. The facility had no documentation of a Performance Improvement Plan and had not held QAPI meetings for three of four quarters. Resident Council minutes and grievance logs showed that residents and families had repeatedly raised concerns, including inadequate linens and delays in washing and returning personal clothing, and these issues continued for several months without resolution. During the survey period, the facility was undergoing significant administrative turnover, with a newly hired DON, Social Services Director, Human Resources Director, and Maintenance Director, and several new managers employed for a month or less. Long-term residents complained about facility conditions, and staff interviews confirmed ongoing laundry problems. Observation of the laundry department revealed mounds of clean, dry laundry waiting to be folded and other unsatisfactory conditions. Review of maintenance and pest control logs revealed additional unresolved issues. The facility also failed to notify the State survey and certification agency when a fire watch was initiated after trouble alarms on the fire control panel, even though a fire watch was conducted and later lifted once the system was repaired. Surveyors determined that the facility lacked an effective training program for employees on required topics, including QAPI, effective communication, and behavioral health, and that the governing body should have been made aware of the issues identified during survey debriefings.
Failure to Maintain Effective QAPI Program and Staff Training
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program and QAA activities for three of four quarters reviewed, affecting all residents. Surveyors found no documentation that multiple identified system issues, including those related to maintenance and pest control, were being discussed during QAPI meetings. There was no documentation of a Performance Improvement Plan and no QAPI team meetings for most of the review period. Review of Resident Council minutes and grievance logs showed that administration was aware of ongoing issues and concerns voiced by residents and families, yet these issues continued for several months without resolution. Substandard quality of care was identified, prompting an extended survey. During interviews, the Assistant Administrator reported having no information about QAPI activities prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She indicated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but confirmed there was no current Performance Improvement Project in place. The extended survey also determined that the facility did not have an effective training program, with failures in required staff training on QAPI, effective communication, and behavioral health. These findings demonstrated that the facility did not have an operational, documented, or effective QAPI and staff training system in place during the review period.
Failure to Maintain Comprehensive QAPI Program and Performance Improvement Projects
Penalty
Summary
The facility failed to implement and maintain a comprehensive QAPI (Quality Assurance Performance Improvement) program, including performance improvement projects, for at least three of four reviewed quarters, affecting all residents. During a survey in which substandard quality of care was identified and an extended survey was initiated, surveyors determined that the facility did not have evidence of ongoing QAPI activities or current performance improvement projects. In an interview, the Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any documentation of QAPI activities from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI meetings, but four quarters of records were reviewed and three had no information. The Administrator and other leadership staff were informed of the substandard quality of care findings during end-of-day debriefings on multiple days of the survey. No specific resident medical histories or individual clinical conditions were described in the report; the deficiency was systemic, involving the absence of documented QAPI processes and performance improvement projects intended to monitor and improve care for all residents.
Failure to Document Staff COVID-19 Vaccination Education, Offers, and Status
Penalty
Summary
Facility staff failed to document COVID-19 vaccination information for staff members, including education, offers of vaccination, and vaccination status. During the Infection Control task on 4/23/26 at approximately 1:05 PM, surveyors requested the facility’s Infection Control information for staff. At 3:38 PM, the Infection Preventionist (IP) reported that she had not been directed to maintain staff COVID-19 vaccination status and therefore had no records of staff vaccination information. The IP further stated she had no documentation that any staff had been provided education on the benefits and potential risks of the COVID-19 vaccine, nor that staff had been offered the vaccine or given information on how to obtain it, because she had not been instructed to perform these activities. On 4/28/26 at 3:30 PM, during a final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant, the facility’s leadership team did not provide comments or additional information regarding staff COVID-19 data. No specific residents or their medical histories were mentioned in relation to this deficiency, and the report focuses solely on the lack of staff COVID-19 vaccination documentation and associated education and offering processes.
Failure to Maintain Effective QAPI Training Program for Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective training program for all staff on its Quality Assurance and Performance Improvement (QAPI) program. During an extended survey triggered by findings of substandard quality of care, surveyors determined that required QAPI training was not consistently provided to staff, including RNs, LPNs, and CNAs. Interviews with staff and review of training records for five sampled nursing staff members showed no documentation of QAPI education, and those staff members reported they could not recall receiving such training. The facility’s orientation materials, which covered topics such as employee benefits, health and safety, resident rights, infection control, and competencies, did not include QAPI. The Staff Development Coordinator stated she did not provide QAPI training and believed it was handled by Human Resources, while the Human Resources Director confirmed that QAPI was not part of new-hire orientation. The annual education calendar used by the Staff Development Coordinator was from 2017 and did not list QAPI as a topic. Later, the Staff Development Coordinator produced limited documentation of computer-based QAPI training, showing that 14 employees from various disciplines received QAPI in-service education in one month and that 117 employees had completed QAPI training assigned on a prior date; however, she was unsure if this list included all employees. There was no evidence of ongoing QAPI training after new QAPI goals were established, and no additional education documents were available for the sampled staff.
Failure to Maintain Effective Behavioral Health Training Program for Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective training program that included required behavioral health care and services education for all staff, as identified during a survey that resulted in a finding of Substandard Quality of Care and an extended survey. During the survey, the survey team requested training schedules and documentation from the Staff Development Coordinator, who reported she had no evidence that behavioral health training had been provided to all staff, stating only that some staff had received training on the computer. A list of employees, including RNs, LPNs, CNAs, and other disciplines, was requested for review. Review of the educational records for five sampled nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of behavioral health training. When these staff members were interviewed, they reported they could not remember receiving behavioral health training and stated that some trainings were done in person and some on the computer, without being able to identify behavioral health content. The Staff Development Coordinator confirmed she did not have documentation of any employees receiving behavioral health care training. During end-of-day debriefings, facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and Director of Nursing, were informed that the facility lacked an effective training program regarding required topics, including behavioral health, and that education/training documents were maintained by the Staff Development Coordinator.
Widespread Environmental, Pest, and Cleanliness Failures Across All Units
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment across all three units, as evidenced by widespread pest infestations, environmental disrepair, and unclean resident care areas. Multiple cognitively intact residents reported large flying roaches in their rooms and throughout the building, including on walls and ceilings, making it difficult to sleep and causing some to question whether they should avoid showering. Residents also reported that pest control had not treated their rooms. Surveyors directly observed roaches in resident bathrooms and rooms, including live and dead roaches on floors, and facility leadership acknowledged that a gap at a courtyard threshold served as an entry point for bugs. A wasp nest with egg sacs and a live wasp was observed between a resident room window and screen, with a gap allowing air and insects into the room; residents stated the nest had been present for about three weeks and that staff were aware. The physical environment on the Fine Unit and other areas was in disrepair and not maintained in a clean or homelike condition. Numerous ceiling tiles in halls and resident rooms were stained, bulging, loose, or missing, including heavily stained tiles over residents’ beds. Walls, doors, and thresholds were damaged, including a wall in disrepair between rooms, a resident room door with frayed and swollen edging, and a courtyard threshold removed in a way that left a gap and uneven flooring. Bathrooms had leaking toilet cisterns with pans catching actively dripping water, heavily stained and loose tiles, and containers under valves collecting standing water that staff acknowledged likely attracted roaches. In several rooms, floors were described and observed as filthy, sticky, and covered with trash, food debris, and accumulated brown or yellowish substances on floors, walls, and cove bases. In at least two rooms, staff and the Housekeeping Director stated that residents frequently spit on the floor, and that encrusted brown substances could not be removed with current cleaning methods. Resident rooms on the Fine Unit were small, with many semi-private rooms having one bed abutted directly against the wall near the door, leaving no space on one side of the bed. Residents were observed lying in beds with body parts resting on the walls, and stains were noted on walls where residents’ heads rested. Staff, including CNAs and housekeeping, reported difficulty providing care and cleaning around beds placed against walls, and a family member reported feeling cramped and lacking privacy when visiting a loved one in such a room. Visitors and residents commented that the Fine Unit rooms were much smaller and older than rooms on other units and that they had seen roaches in the building. The State Life Safety Inspector stated that beds should not be abutted against the wall, that the rooms were small, and that there should be enough room for stretchers to enter to assist either resident in an emergency. Shared and unit shower rooms were observed to be cluttered and unclean. On one unit, the shower room bathroom contained multiple shower chairs, a pair of shoes on the floor, a toilet covered in black plastic with a sign indicating it needed repair or replacement, and used latex gloves on the plastic and floor. A commode bucket with dried brown-looking substance and used items was found on a commode chair, and the shower area had brown substances on walls and floors, wet hair near the drain, and a wet washcloth on a shower bed. On another unit, the shower room was full of clutter, including shower chairs with bags of soiled clothing, and a bathtub filled with incontinence products, towels, shirts, dust, and sheets. The shower floor and tiles appeared soiled and dusty, water was constantly dripping from the shower head, and a used saturated dressing with pink and yellow secretions was observed at the shower drain. The water closet in that shower room was extremely cluttered, and the toilet was sealed with plastic and tape with an “out of order” note. Hallways and common areas were not maintained free of clutter and obstructions. On the Fine Unit, furniture, equipment, and supplies were stored on both sides of a hallway near resident rooms, including a mattress, rollator, multiple cardboard boxes, pallets of boxed items, a large trash can, and a rolling hamper. On another hall, wheelchairs, a shower bed, chairs, oxygen concentrators, mats, positioning devices, a laundry cart, a Hoyer lift, and a wheelchair were stored in the corridor across from resident rooms and near a shower room. A family member reported concern that hallway clutter would make it hard to evacuate a resident in an emergency and that her visually impaired loved one, who ambulates and may wander, could fall or be injured due to the clutter. Emergency call systems were not consistently functional in resident-accessible bathrooms. In a shared bathroom used by several rooms, including one resident who ambulated independently to the bathroom, the emergency alarm pull cord did not light up or send an alert to the nurse’s station when tested on two separate days. A CNA at the nurse’s station stated he was not aware whether the emergency pull-cord alarm sent an alert. This non-operable emergency call system remained in use by a resident who was observed throughout the survey ambulating independently to that restroom. Individual resident rooms showed repeated failures to maintain cleanliness and a homelike environment. One resident’s room was repeatedly observed with a filthy floor, trash debris, and an exposed outlet with sharp edges near the HVAC unit; a reddish substance resembling vomit was seen on the floor until housekeeping was called to clean it. Another resident’s room had a sticky floor, food accumulated around the perimeter, dark yellow/brown substances on the floor, and copious brown drippage behind the headboard down to the floor; the resident stated she had informed housekeeping about the dirt and roaches in her room and bathroom. In another room, a resident was observed with a fall mat between beds that had debris and footprints, a soiled glove on the floor, and a floor that was noticeably dirty and in need of mopping. In yet another room, the wall under the window was dirty and needed painting, and crusty material was present on the floor, wall, and baseboard behind the bed; the resident stated staff never cleaned the room and that she had to look out at the “nasty mess.” Support service areas were also not maintained in a clean, orderly condition. The laundry room contained washed clothing left in washers, dryers full of clothing waiting to be folded, and tables piled halfway to the ceiling with unfolded clothing. Shelves held many plastic bags of clothing identified by the laundry aide as personal belongings to be donated. The laundry room floors were grossly soiled, and a large bin of soiled laundry contained pillows with yellowish-brown substances mixed in with soiled bed linens. In the kitchen, floor tiles were missing at the entrance, and the removed tiles were placed on a pellet warmer next to the missing area. The Director of Maintenance stated the tiles had been removed a couple of months earlier and acknowledged that the missing tiles could be an area where staff could trip and fall. Throughout the survey, residents, family members, visitors, and staff consistently reported concerns about roaches, room size and layout, clutter, and cleanliness. Residents described roaches crawling on ceilings and walls, flying roaches present day and night, and worsening infestations since construction began. Staff interviews confirmed difficulty providing care and cleaning in cramped rooms with beds against walls and acknowledged environmental issues such as gaps at thresholds that allowed insect entry and leaking plumbing that contributed to standing water. Despite these observations and reports, during multiple debriefings and final interviews, the administrative team either made no comments, voiced no concerns, or did not provide additional information regarding the identified environmental and cleanliness deficiencies.
Failure to Maintain Accurate Resident Room Clocks for Orientation Needs
Penalty
Summary
Facility staff failed to reasonably accommodate the needs of four residents by not ensuring that the large wall clocks in their shared bedrooms were working and displayed the correct time. For one resident with anemia, hypertension, anxiety, and depression, the clock in the room consistently displayed 5:51 over multiple days and times, with the second hand not moving. This resident was observed in the room on several occasions, either in bed or in a wheelchair, while the clock remained incorrect. Staff members entered the room repeatedly to pick up food trays, deliver ice and water, and provide care, but no staff member addressed or corrected the non-functioning clock. A second resident with severe cognitive impairment had a wall clock that continuously displayed 4:20 over several days and at various observation times, with the hands not moving. This resident was observed lying in bed or sitting in a wheelchair while the clock remained inaccurate. As with the first resident, staff were seen entering the room for routine tasks such as tray pickup, ice and water delivery, and care provision, yet no one intervened to fix or report the incorrect clock. The unit manager later stated that clocks in residents’ rooms should be accurate for resident orientation and that staff should have noticed the problem. A third resident with severe cognitive impairment had a wall clock that showed varying, incorrect times across multiple observations, including 10:50, 1:38, 4:20, 11:34, and 2:02, without corresponding to the actual time. This resident was observed in the room in a wheelchair or in bed while the clock times changed inconsistently. During one interaction, when asked what time lunch was being served, the resident looked at the clock and stated she did not know. Staff were again observed performing routine tasks in the room without addressing the inaccurate clock. A fourth resident, with diagnoses including diabetes, cerebral infarction, hemiplegia, and aphasia and a BIMS score indicating severe cognitive impairment, had a wall clock that remained fixed at 2:47 over several days and times, with the hands not moving. This resident, observed both in bed and in a wheelchair, stated that the clock was wrong and did not work, yet staff entering the room for care and services did not correct or report the issue. Facility leadership and the DON acknowledged during interviews that clocks in residents’ rooms should be accurate and that staff should have observed that the clocks were not working.
Residents Unaware of Access to Survey Results Binder
Penalty
Summary
Facility staff failed to ensure that residents knew where the survey results binder was located or that they had access to it. During a resident group meeting held with the Resident Council President and four other residents who regularly attend, all five residents reported they were unaware they could review the survey book or had access to it, and none could identify its location; the council president speculated it might be behind the nurse’s station. A subsequent interview with the Director of Activities revealed that the facility’s position was that residents were educated at every resident council meeting on where to locate the survey results binder, and this education was documented in the resident council minutes, but no suggestions were offered on how residents would be updated going forward. In a final interview with the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns.
Failure to Involve Resident/Family in Care Planning and to Update Care Plans After Status Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively impaired resident and her family were invited to and able to participate in person-centered care plan meetings. The resident, who had Type 2 diabetes and Alzheimer’s disease, was assessed on a quarterly MDS with a BIMS score of 5/15, indicating severely impaired decision-making. Her care plan, revised on 1/28/26, documented dementia, a primary language of Spanish, and detailed communication interventions, including use of a translator as necessary and discussion of concerns with the resident and family. Despite this, her daughter reported never receiving an invitation to or attending a care plan meeting, and review of the medical record showed two care plan meetings with no documentation that the resident or family were present. A second deficiency concerns the facility’s failure to review and revise another resident’s person-centered care plan when her status changed. This resident had a history of stroke with aphasia and anxiety, and a Significant Change MDS with a BIMS score of 4/15, indicating severely impaired decision-making, and was coded as dependent for all ADLs. Observation on 4/21/26 found the resident in bed without a bedside drainage bag, and a CNA stated that the resident had not had an indwelling catheter for at least two months and was incontinent of urine, confirming this by examining the peri area. Medication and treatment orders showed an indwelling Foley catheter order from 8/03/25 that was discontinued on 10/23/25, with no rationale documented for the discontinuation. Despite the discontinuation of the catheter order months earlier, the resident’s care plan still contained an active problem dated 6/12/25 stating that she currently had a 16 French indwelling catheter with a 10 ml balloon for end-of-life care, with related goals and interventions for catheter management. Additionally, the care plan included a hospice problem dated 9/08/25 with goals and interventions related to hospice services, while a hospice certification note dated 2/18/26 documented that hospice services would end on 2/21/26 because the resident was no longer considered terminal and would be discharged from hospice. These discrepancies show that the care plan was not reviewed and revised to reflect the resident’s current status regarding catheter use and hospice enrollment.
Failure to Post Daily Nurse Staffing Information in Accessible Locations
Penalty
Summary
Facility staff failed to ensure that daily nurse staffing information was posted in a prominent and readily accessible location for residents, staff, and visitors. During multiple days of survey observations, surveyors did not see any daily nurse staffing postings on the nursing units or at the receptionist’s desk. Group and individual interviews with alert and oriented residents revealed that they did not know where to find information about daily nurse staffing or how to determine how many staff members were working. A visitor who reported visiting regularly also stated she did not know where the nurse staffing information was located and had not seen it posted. When interviewed, the Administrator was unsure where the nurse staffing information was posted and referred the surveyor to the Assistant Administrator. The Assistant Administrator indicated that staffing information was posted on a bulletin board in the Human Resources hall and showed an “as worked” schedule for a single shift and date, and then acknowledged that the posting at the receptionist’s desk should include the facility name, shift, nursing positions, and census. The receptionist produced an empty picture frame from under the desk, stating they were replacing the frame where the posting was usually kept. The Assistant Administrator did not know if postings were retained for 18 months. The staffing coordinator stated she usually posted the nurse staffing daily and that prior postings were available, but was unsure if they covered the past 18 months. Records provided showed postings only from late August to early March, with numerous missing dates and incomplete information, including missing census data and blank RN time slots on certain shifts, despite facility policy requiring daily posting for each shift of the number of nursing personnel providing direct care.
Expired Humulin R Insulin Found on Medication Carts
Penalty
Summary
Facility staff failed to provide appropriate pharmaceutical services when two bottles of Humulin R insulin remained in use on medication carts beyond the 28-day discard period after opening. During a medication cart audit on the [NAME] unit Front Hall cart at approximately 2:05 p.m., surveyors and an LPN identified a bottle of Humulin R, 100 units of insulin, with an open date indicating it should have been discarded after 28 days; the LPN acknowledged it should have been discarded. In a separate audit on the Fine Unit Cart #2 at approximately 2:27 p.m., surveyors and another LPN found a bottle of Humulin R insulin with an open date showing it was also past the 28-day discard timeframe, and the LPN stated that it was no longer good and needed to be discarded. A final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant did not yield any additional information about these findings. No specific residents, their medical histories, or conditions at the time of the deficiency were identified in the report, and the deficiency centers on the presence of expired insulin on two of three medication carts as observed and confirmed by facility nursing staff.
Failure to Conduct and Document Required QAPI Activities and Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program met regulatory requirements, including conducting QAPI meetings at least quarterly and maintaining documentation of QAPI activities. Surveyors reviewing four quarters of records found no QAPI documentation for three of the four quarters in 2025, with only one quarter in 2026 having documentation. The Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but there was no current Performance Improvement Project in place. During the survey, which was extended after substandard quality of care was identified, surveyors reviewed maintenance logs, pest control logs, Resident Council minutes, and grievance logs. These records showed that administration was aware of ongoing issues and concerns voiced by residents and families that continued for several months without resolution. The survey also determined that the facility did not have an effective training program, including required training on QAPI, effective communication, and behavioral health. Despite the identification of substandard quality of care and other issues by the survey team, there was no documentation that the governing body was aware of or acting on these findings.
Non-Functional Bathroom Emergency Call System for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functional emergency call system in a resident bathroom and bathing area used by a cognitively impaired resident. Resident #16, who has Type 2 diabetes without complications and Alzheimer’s disease, was assessed on a recent quarterly MDS as having severely impaired cognitive abilities, with a BIMS score of 5/15. The resident’s care plan identified communication problems related to dementia, a primary language of Spanish, and the need for various communication supports and monitoring of her ability to express needs and discomfort. Functionally, the resident required supervision or touching assistance for toileting hygiene and partial-to-moderate assistance with showering/bathing, but was observed during the survey to ambulate independently to the shared bathroom. On an initial bathroom tour on 4/21/26, surveyors observed that the emergency pull alarm in the bathroom shared by specified rooms on Unit 1 appeared non-functional, as it would not light up or be heard at the nurse’s station. This same bathroom was used by Resident #16, who was repeatedly observed ambulating independently to this restroom despite the non-operable emergency call system. On 4/24/26, the emergency pull cord was tested again and, when pulled, did not send an alert to the call enunciator at the nurse’s station. When asked, CNA #3 stated he was not aware whether the emergency pull-cord alarm sent an alert while at the nurse’s station. These observations and staff interviews confirmed that a working emergency call system was not available in the bathroom and bathing area used by Resident #16.
Failure to Maintain Effective Staff Training on Behavioral Health and Communication
Penalty
Summary
Facility staff failed to develop, implement, and maintain an effective training program for all staff, specifically lacking required education on behavioral health care and communication. During an extended survey conducted after substandard quality of care was identified, surveyors interviewed the Staff Development Coordinator, who stated she had no evidence that behavioral health training had been provided to all staff and acknowledged that some staff only received computer-based training. Review of educational records for five nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of training on behavioral health care. Staff interviews further revealed that these employees had not received training on communication with a Spanish-speaking resident. Staff reported that they relied on the resident’s family to translate and on the Assistant DON, who spoke Spanish, rather than on any formal training or structured communication process. The Staff Development Coordinator confirmed there was no documentation of any employees receiving training on communication with a Spanish-speaking resident, and surveyors observed that there were no communication tools in the Spanish-speaking resident’s room and no developed or implemented process for communicating with that resident. Facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and DON, were informed that required training, including communication training, was not being effectively maintained or documented.
Failure to Address Resident’s Repeated Reports of Missing Personal Belongings
Penalty
Summary
Facility staff failed to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions by not appropriately addressing repeated reports of missing personal items. The resident, who had diagnoses including cancer, hypertension, and hyperlipidemia, was cognitively intact for daily decision-making as evidenced by a BIMS score of 12/15 on a recent MDS assessment. During an interview, the resident reported that personal belongings such as soaps, lotions, clothes, and a bottle of perfume (reported as broken) were being stolen on a weekly basis. The resident stated that both she and her daughter had reported these issues many times to staff, prior administrators, and nursing, but nothing had been done. The resident and her daughter again reported the missing items during a care plan meeting. Staff interviews showed that CNAs were aware of the resident’s allegations of missing items but did not consistently report them according to facility expectations. CNA #7 stated that if a resident reported missing items, they would look for the items and/or report it to the charge nurse or DON, but CNA #7 was not aware whether this resident’s missing items had actually been reported. CNA #3 recalled that the resident had previously alleged missing items but was unsure whether this had been reported to anyone. The DON stated that the expectation was that a grievance be completed whenever a resident reported missing, lost, or stolen items; however, only one grievance, dated 4/22/26, was provided, despite the resident’s reports that the problem had occurred many times. When the findings were presented to the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, they made no comments and voiced no concerns.
Failure to Complete Pre-Employment Background Checks and Credential Verification
Penalty
Summary
Facility staff failed to thoroughly investigate prospective employees' histories before hiring, resulting in incomplete personnel files and delayed identification of disqualifying criminal backgrounds. A review of 25 employee records hired over the last 2 years on 4/22/26 showed that 11 files were missing at least one required document: a sworn statement, a state police criminal background search, or verification of a certificate or license. The Human Resources (HR) Director reported that an in-house audit had already identified missing documents in employee records, but no action had been taken to correct the problem or to refer the issue to the Quality Assurance committee. The HR Director further stated that an employee hired on 4/7/26 began employment before the facility received and reviewed the state police criminal background report. The background check was requested on 4/8/26, and the report was not received until the evening of 4/21/26 from a sister facility, at which time it was discovered that the employee had barrier crimes, including assault of a family member, malicious wounding, and indecent exposure. The employee was terminated on 4/22/26 before clocking in that day. The Regional HR Director explained that the facility’s process was to obtain background checks and ensure all required documents were completed, and stated that it was their policy not to hire employees with past criminal prosecutions. She also reported that the in-house HR Director had experienced issues with the state police online system and had relied on a sister facility’s HR Director to obtain the documents. During subsequent interviews with the Administrator, Assistant Administrator, Regional President of Operations, DON, Regional Nurse Consultant, and Regional MDS Consultant, no additional information was provided and staff voiced no comments.
Environmental Hazards from Damaged Flooring and Dining Room Door
Penalty
Summary
Facility staff failed to maintain an environment free from accident hazards in the kitchen by not replacing missing floor tiles at the kitchen entrance. During an observation, surveyors noted that several floor tiles were missing at the point of entry into the kitchen, and the removed tiles were placed on a pellet warmer next to the area where the tiles were missing. In an interview, the Director of Maintenance stated that the tiles had been removed a couple of months earlier and acknowledged that the area with missing tiles could cause staff to trip and fall, identifying it as a hazard. The facility also failed to address a damaged dining room entry door that presented an accident hazard. During an observation of the dining room, the entry door was seen splitting apart, and the bottom door hinge was not attached to the door. In a subsequent interview, the Director of Maintenance reported that the door was being replaced and explained that it was currently propped open because the bottom hinge was broken. The Director of Maintenance further stated that if staff attempted to close the door, it could fall, and acknowledged this condition as a hazard. In a final interview, the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant had no further comments or concerns regarding these findings.
Failure to Maintain Effective Pest Control and Document Pest Activity
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to prevent and address roaches and other pests, resulting in multiple resident complaints and direct observations of pests by surveyors. During a Resident Council meeting with the President and four other regular attendees, all participants agreed the facility was not a safe, clean, comfortable, and homelike environment. Several cognitively intact residents, as evidenced by Brief Interview for Mental Status (BIMS) scores of 14–15, reported seeing large flying roaches throughout the facility, including in their rooms and shower areas, and described the shower room as unclean. One resident stated roaches crawled on ceilings and walls and made it difficult to sleep and reported not seeing pest control treat their room. Another resident, who had a BIMS score of 0 but was described by staff and through interviews as alert and oriented times four, reported that flying roaches were present during the day and night and that the problem had worsened since construction began. A visitor in the dining room also reported seeing roaches in the building and expressed concern that the older section of the facility needed attention. In one resident’s room and bathroom, surveyors directly observed four roaches on the bathroom floor (two dead and two alive on their backs), and the Maintenance Director did not remove them during the observation. The same room contained two roach bait houses and a plastic container under the toilet’s on/off valve that had collected standing water, which the Maintenance Director acknowledged was related to a flooding bathroom and likely attracted roaches. The resident reported having told housekeeping about how dirty the room was and that roaches crawled and flew around the room and bathroom; when the surveyor and housekeeper re-entered the bathroom later, roaches were again observed and then removed by the housekeeper. Additional pest-related issues were identified on another unit, where two residents in a shared room reported the presence of wasp nests by the window and stated the nests had been there for about three weeks and that staff were aware. Visual inspection revealed two wasp nests between the screen and glass, one with multiple round, greyish-white egg-like sacs and a live wasp on an empty cell, and a second smaller nest, along with a quarter-inch gap between the outside screen and the window that allowed outside air to be felt and contained what appeared to be a dead wasp. During the end-of-day debriefing, facility leadership was informed that a gap at the threshold from the hallway door to the courtyard could be a point of entry for insects and roaches. It was also noted that contracted pest control services were not completed for two months due to a lapse in vendor payment processing, and that the Maintenance Director had destroyed pest control logs across all units, leaving them blank and failing to document the roach sightings and the wasp nests reported by residents and observed by surveyors.
Failure to Ensure Access to Interpreter Services for Spanish-Speaking Resident
Penalty
Summary
Facility staff failed to ensure language interpreter services were available to allow effective communication for a Spanish‑speaking resident. The resident had Type 2 diabetes without complications and Alzheimer's disease, and a recent MDS assessment showed a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision‑making. The MDS also documented that the resident required varying levels of assistance with oral hygiene, dressing, eating, toileting hygiene, footwear, personal hygiene, and showering/bathing. The person‑centered care plan identified a communication problem related to dementia, noted that Spanish was the resident’s primary language, and stated that the resident preferred to communicate in Spanish, although she understood and spoke some English. The care plan included multiple communication interventions, including providing a translator as necessary to communicate with the resident. The resident’s History and Physical documented a language barrier and indicated that assistance was available from one of two nurses, with one able to speak Spanish. The DON reported that an interpretation document was kept at the nurse’s station on the resident’s unit. However, during interviews, CNAs assigned to care for the resident stated they were not aware of any interpreter services or interpreter services information at the facility. These staff interviews, combined with the clinical record review and the resident’s identified communication needs, showed that interpreter services were not effectively made available or known to direct care staff, resulting in a failure to implement the care‑planned intervention to provide a translator as necessary for this Spanish‑speaking resident.
Residents Unaware of How to Access Ombudsman and State Agency Contact Information
Penalty
Summary
Facility staff failed to ensure that residents knew the location of the list of contact names, addresses, and phone numbers for State agencies, the ombudsman, and adult protective services, resulting in 5 of 5 residents attending a resident group meeting being unaware of how to contact these entities. During a resident group meeting held with the Resident Council President and four regularly attending residents, all participants reported they did not know how to contact the ombudsman, adult protective services, or other state offices. A subsequent interview with the Activities Director revealed that she stated residents are educated at every resident council meeting about the ombudsman and where to find the contact information, and that this education is documented in the resident council minutes. In a final interview with the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns. No additional medical history or clinical conditions of the residents were provided in the report, and the deficiency centers on residents’ lack of awareness of how to access posted or available contact information for external advocacy and protective agencies.
Failure to Notify Resident Representative and Maintain Updated Contact Information After Change in Condition
Penalty
Summary
Facility staff failed to notify a resident’s representative of a significant change in condition and did not maintain updated contact information, contrary to facility policy. The resident, who was cognitively intact per an annual MDS (BIMS score 15/15) but functionally dependent in most ADLs, had a care plan noting ADL self-care deficits related to impaired balance, weakness, and shortness of breath with exertion. The facility’s policy, revised 12/01/22, required staff to promptly inform the resident, consult the physician, and notify the resident’s representative when there is a significant change in physical, mental, or psychosocial condition, including life‑threatening conditions or clinical complications, and to record and periodically update contact information for the resident’s legal representative or family. On 4/21/26, a physician progress note documented that the resident was seen for an acute visit due to hypoxemia, with oxygen saturation dropping into the 70–80% range and associated chills. The note described a significant medical history including morbid obesity, hypoventilatory syndrome, functional quadriparesis, bedbound status, chronic respiratory failure with oxygen dependence, COPD, hypertension, CAD, chronic pain syndrome, GERD, asthma, anemia, and neuropathy. The physician coordinated DuoNeb treatments with nursing staff, after which the resident’s oxygen saturation improved to 89%, chills subsided after increasing room temperature, and vital signs remained stable; the resident denied respiratory and other systemic symptoms at that time. Diagnostic tests (CBC, CMP, CXR) were ordered to further evaluate the hypoxemia and chills. Earlier that day, during the initial tour, the resident was observed in bed under covers in a very warm room and reported not feeling well. The resident’s face sheet listed one family member as Emergency Contact #1 and POA, and another family member as Emergency Contact #2. Surveyor calls to these contacts on 4/21/26 and 4/22/26 revealed that one phone number did not allow a voicemail, another was not working, and the second contact reported not having received any call about the change in condition. The resident later provided an updated phone number for Emergency Contact #2. A review of the medical record showed no documentation that either emergency contact was notified or that attempts to notify them were made on 4/21/26 regarding the change in condition. In interviews, the DON stated she was not informed of the change in condition, believed the resident to be her own responsible party, and acknowledged there was no note in the record indicating the son was contacted on 4/21/26 during the change in condition.
Failure to Properly File and Address Resident Grievance on Missing Personal Items
Penalty
Summary
Facility staff failed to honor a resident’s right to voice grievances and have them promptly addressed when they did not ensure a grievance was filed regarding multiple missing personal items. Resident #12, who had a diagnosis including malignant neoplasm of the colon and was assessed on the MDS with a BIMS score of 12 indicating moderately impaired cognitive abilities for daily decision making, reported during the initial tour on 04/22/2026 that she had been missing two cases of cranberry juice, one case of Ensure Clear, body wash, perfume, baby powder, and her bifocals for approximately four months. She stated she had reported these missing items to multiple staff members, including the DON and nurse aides. Despite these reports, the Social Worker later stated she was not aware of the missing items until 04/28/2026. Review of the facility’s grievance/complaint documentation showed only a single Grievance/Complaint form dated 04/21/2026, which recorded the resident’s report of only two boxes of Ensure being missing and indicated reimbursement for those two boxes, with no documentation of the other missing items the resident had reported over the preceding months. This sequence of events demonstrates that the facility did not consistently initiate or document a grievance for all of the resident’s reported missing items, and key staff, such as the Social Worker, were unaware of the full scope of the resident’s concerns despite her statements that she had reported them to various staff members over an extended period.
Failure to Re-Evaluate Prolonged PRN Lorazepam Order
Penalty
Summary
The deficiency involves the facility’s failure to prevent the prolonged use of an as-needed psychotropic medication without appropriate time limits or documented re-evaluation. One resident with diagnoses including stroke with aphasia and anxiety had a Significant Change MDS assessment showing a BIMS score of 4/15, indicating severely impaired cognitive abilities for daily decision-making. A physician order dated 4/06/2026 directed Lorazepam 0.5 mg via G-tube every 4 hours as needed for anxiety, but the order did not include a stop date. Review of the clinical record showed no documentation by the physician or prescribing practitioner that the resident had been evaluated regarding the appropriateness of continued PRN Lorazepam use. As of 4/28/2026, the resident had been continuously prescribed this PRN Lorazepam for 22 days without a documented reassessment of its ongoing necessity. The resident’s care plan, dated 01/19/2026, identified the use of anti-anxiety medications and listed goals and interventions focused on monitoring and reporting adverse reactions and side effects such as drowsiness, confusion, impaired thinking, and unexpected behavioral changes. However, despite this care plan, there was no evidence in the record that the prescriber had reviewed or justified the continued PRN psychotropic therapy beyond 14 days, and facility leadership acknowledged that the medication should have been re-evaluated or the ongoing need documented.
Failure to Timely Report Allegation of Resident Abuse to State Agencies
Penalty
Summary
Facility staff failed to timely report an allegation of abuse to the appropriate state agencies for one resident. The resident, who had a diagnosis including malignant neoplasm of the colon and a BIMS score of 12 indicating moderately impaired cognitive abilities for daily decision making, reported that she had almost fallen out of bed and was shoved back into bed by staff. During the survey’s initial tour, the resident stated she had informed Veterans Administration staff about this incident, that she had not experienced such treatment since, and that she felt safe. A Facility-related Synopsis documented that the resident had an incident in which she was shoved twice by two staff members while being assisted back to bed, with the employees’ names unknown. The Facility-related Synopsis showed an incident date of 08/28/25 and a report date of 09/03/25, indicating the allegation was reported five days after the alleged incident. The report was sent to various state agencies and concluded that the resident could not provide specific dates or times of the alleged incident and that the allegation of abuse was unfounded, while also noting that the resident felt safe in the facility. Current staff interviewed during the survey stated they were not aware of the incident. During a final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant, no further information was provided regarding the delay or circumstances of the reporting, confirming that the allegation of abuse was not reported to the appropriate state agencies within the required timeframe.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for Resident #39. The resident was admitted with diagnoses including liver cirrhosis, diabetes, and status post right foot trans metatarsal amputation. The admission MDS with an assessment reference date of 4/6/2026 documented that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15/15, indicating intact cognitive abilities for daily decision-making. In section N0415 (High-Risk Drug Classes: Use and Indication), the MDS coded that the resident was receiving an anticoagulant and that an indication for its use was documented. However, review of the Physician’s Order Summary, the resident’s care plan, and a physician progress note dated 4/7/2026 did not show any order, documentation, or care plan entry indicating that the resident was actually receiving an anticoagulant. During an interview, the MDS Coordinator acknowledged that the 4/6/2026 admission MDS was not coded accurately because the resident had not been taking an anticoagulant.
Failure to Follow Physician’s Oxygen Flow Rate Order
Penalty
Summary
Facility staff failed to follow a physician’s order for oxygen flow rate for one resident with multiple chronic conditions, including chronic respiratory failure with oxygen dependence, COPD, morbid obesity, hypoventilatory syndrome, functional quadriparesis, and other comorbidities. The resident was cognitively intact per a recent MDS (BIMS score 15/15) and was care planned for ADL self-care deficits related to impaired balance, weakness, and shortness of breath with exertion. The March 2025 Physician Order Summary specified that the resident was to receive continuous oxygen at 3 L/min via nasal cannula for COPD. Despite this order, during the initial tour on 4/21/26 around 12:30 p.m., the resident was observed in bed with the oxygen concentrator set at 5 L/min via nasal cannula, and the resident reported having had trouble breathing earlier that morning. On 4/22/26 at approximately 4:45 p.m., the resident was again observed in bed receiving oxygen at 5 L/min via nasal cannula. On 4/23/26 at about 5:10 p.m., an RN stated she would need to verify the physician’s orders regarding the oxygen flow rate. After reviewing the orders, the RN confirmed the resident should be receiving 3 L/min of oxygen and was informed that the oxygen flow rate had been set at 5 L/min for three days. The RN then checked the concentrator in the resident’s room and stated she changed the flow rate back to 3 L/min. These observations and interviews showed that the resident had been receiving oxygen at a higher flow rate than ordered for at least three days, constituting a failure by staff to follow the physician’s order for oxygen administration.
Improper Technique Used to Split Ativan Tablet for One-Time Dose
Penalty
Summary
Facility staff failed to follow proper medication administration technique when preparing and administering a one-time dose of Ativan for Resident #23. The resident, who had diagnoses including cataracts and anxiety and a BIMS score of 9/15 indicating moderately impaired cognitive abilities for daily decision-making, had a physician’s order dated 4/23/2026 for Ativan 1 mg, to give 0.5 tablet by mouth one time only for anxiety. During the morning medication pass on 4/23/2026, the ADON obtained a single-dose package of Ativan 1 mg from the stat box for administration by RN #4. RN #4 opened the package and, while wearing gloves, broke the 1 mg tablet in half by hand, wasted one half, and administered the remaining 0.5 mg to the resident. A nurse’s note documented that a one-time authorization had been obtained from the pharmacy to remove one Ativan 1 mg tablet from the stat box to fulfill the 0.5 mg one-time order. In a subsequent interview, the DON stated that the 1 mg Ativan tablet should not have been broken by hand, as facility policy requires the use of a tablet splitter to ensure dose accuracy and minimize contact with the scored tablet. The failure to use a tablet splitter and instead manually break the tablet constituted improper technique in achieving the ordered dose of medication for the resident.
Failure to Provide Discharge Instructions and Transfer Documentation for Residents Leaving AMA
Penalty
Summary
Facility staff failed to provide required discharge information and documentation for two residents who left the facility against medical advice (AMA). One resident was admitted with multiple acute and chronic conditions, including sepsis, hypertension, diabetes, pneumonia, and COPD, and had a BIMS score of 12/15 indicating moderate cognitive impairment. The resident left AMA within three days of admission. The facility’s transfer and discharge policy, including AMA, required that residents and families be informed of the risks and benefits of staying, alternatives, and that these discussions be documented, as well as completion of a discharge summary and post‑discharge plan of care for anticipated transfers or discharges. Nursing documentation on the day of discharge only noted that the resident left with his daughter, signed AMA paperwork, and was stable, with no signs of distress, and there was no documentation that any discharge instructions, recapitulation of the stay, or other written information were provided. Interviews with facility staff confirmed that discharge summaries and related information were only provided for planned or anticipated discharges and not for residents leaving AMA. The discharge planner stated that nursing staff would provide discharge summaries at the time of discharge, while the DON stated that discharge summaries were provided only for planned discharges and that no information was given to residents who left AMA. The DON further stated that no recapitulation of the stay would be given to residents at the time of discharge if they signed out AMA, and that the facility’s practice was to limit discharge summaries to anticipated transfers or discharges. Surveyors informed facility leadership that no effort had been made to assist this resident to adjust to the new living arrangement because the resident signed out AMA. For the second resident, who had a displaced intertrochanteric fracture of the left femur and intact to moderately impaired cognition based on MDS BIMS scores, the facility failed to ensure that the admitting facility received necessary admission documents when the resident left AMA. Progress notes showed that the resident’s son arrived to take the resident home, staff noted there were no discharge orders in the chart, and an on‑call supervisor authorized discharge and instructed staff to give non‑narcotic medications to the son. The discharge summary documented discharge to an assisted living setting with improvement in condition, but it lacked signatures from the resident or family. Interviews revealed that facility staff considered the departure AMA, notified the VA caseworker of the AMA status, and did not send clinical documentation beyond a face sheet and PASRR. The admitting facility’s AD reported receiving only those two documents, stated that the discharging facility said they would not send paperwork because the resident left AMA, and reported not receiving an H&P, clinical notes, or a medication list, which delayed the resident’s admission to the new facility.
Failure to Provide Necessary ADL Assistance and Nail Care
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for one resident who was completely dependent on staff for all ADL care. The resident had a history of stroke with aphasia and anxiety, and a Significant Change MDS with an ARD of 2/24/2026 documented a BIMS score of 4/15, indicating severely impaired cognitive abilities for daily decision-making, and coded the resident as dependent in section GG0130 for all functional abilities. On 4/21/26 at approximately 2:40 PM, the resident was observed asleep in bed with fingernails extending about 1.75 inches beyond the fingertips and appearing discolored, and with scratches noted on the thighs and right arm. In a subsequent interview, a CNA acknowledged that the resident’s nail care had been overlooked.
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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