Charlottesville Health & Rehabilitation Center

confusion, agitation, and anxiety over the weekend.

The nurse practitioner documented her intent to

altered level of consciousness.

The resident's son reported that R5 was experiencing confusion, and

requested that three medications, Amitriptyline, Trazodone and Seroquel to be discontinued due to concerns that they cause delirium.

The medications were held for three days, and then restarted after the three-day hold, and lab work was obtained.

Labs that were obtained were within normal limits and no concerns.On 9-3-25, a facility documentation review was conducted.

The policy titled, General Guidelines for Medication Administration, read in part, medications are to be administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications, and that medications must be administered in accordance with written orders of the prescriber.On 9-4-25 at 10:00 a.m., an interview was conducted with the Therapy Director. He stated that R5 participated well in therapy and received all three disciplines-speech therapy, occupational therapy, and physical therapy. He explained that the resident ambulated several times a day, used NuStep, and completed exercises.

The Therapy Director stated that although the resident became fatigued, he participated well and completed his therapy sessions.On 9/4/24 at 11:00 AM, the Administrator, Regional Director of Clinical Services, and Director of Nursing were informed of the concerns described above.

They were advised that discharge orders had not been followed, resulting in two antipsychotic medications being added to the admission paperwork that were not on the discharge medication list.

They were also informed that the resident's son had requested on 8/9, 8/11, and 8/12 that the three antipsychotic medications (Amitriptyline, Trazodone and Seroquel) be discontinued due to causing delirium.

Additionally, they were informed of two progress notes written by the nurse practitioner indicating that while there was intent to discontinue these medications as requested, the medications were not actually discontinued. A request for a policy for antipsychotic medication use was requested.

The regional director of clinical services stated there was no policy related to psychotropic medications. On 9/4/25, a review of facility documentation was conducted.

The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission.

The patient's admission information is to be reviewed, and orders approved by the attending physician.

The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.No additional information was provided.

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Charlottesville Health & Rehabilitation Center 505 West Rio Road Charlottesville, VA 22901

evidence that R6 started receiving home health care on 3/27/25 after being seen by R6's primary care

Instruction policy read in part Discharge planning will be initiated and coordinated by the social

equipment, Home Health Services, etc. (the social service department and/or therapy will take responsibility for completion of arrangements).No other information was provided prior to the exit conference on 9/4/25.

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Charlottesville Health & Rehabilitation Center 505 West Rio Road Charlottesville, VA 22901

information is to be reviewed, and orders approved by the attending physician.

The physician, nurse

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Charlottesville Health & Rehabilitation Center 505 West Rio Road Charlottesville, VA 22901

orders, at each required visit.

failed to ensure medication review was performed by physician services on admission for one

clinical record review of Resident #5 was conducted.

The review showed the residents did not have a diagnosis of depression or delirium on the diagnosis list; however, amitriptyline was documented for depression without a corresponding diagnosis. A nurse practitioner's progress notes dated 8/11/25 and 8/13/25 documented the son's request for the antipsychotic medications (amitriptyline, trazodone and Seroquel) to be discontinued.

The nurse practitioner stated it was her intent to discontinue the medications, but she did not complete the discontinuation.

The medications were ordered on admission, 8/4/25 and continued until R5 was discharged on 8/15/25.On 9/4/25 at 9:00 a.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, LPN#1 (LPN1).

LPN1 stated she reviewed Resident #5's diagnoses and was unable to find depression, or delirium.

She stated the facility's nurse practitioner had assigned the diagnosis of depression, although there was no history of depression in the resident's hospital record. LPN1 further stated that delirium was noted in the nurse practitioner's progress notes, but the hospital discharge summary showed it had resolved; therefore, it was not placed on the diagnosis list.

The MDS Regional Director, who participated by phone, stated the medication Amitriptyline was listed on the hospital record, but no diagnosis was documented with it.On 9/5/25 at 9:40 a.m., an interview was conducted with the nurse practitioner.

The nurse practitioner stated the diagnosis of depression came from the hospital.

She reported that when reviewing the history and physical and the hospital paperwork, she was unable to find the diagnosis of depression, but believed that was how she obtained it.

When asked about the diagnosis of depression being linked to the antidepressant medication, she stated the nursing staff entered that diagnosis with the medication on admission, and she did not catch that the resident had no history of depression when she signed off on the paperwork.On 9/4/25, a review of facility documentation was conducted.

The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission.

The patient's admission information is to be reviewed, and orders approved by the attending physician.

The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.On 9/4/25 at 11:00 a.m., the administrator, director of nursing and the regional clinical care coordinator was made aware of the above concerns.No additional information was provided.

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Charlottesville Health & Rehabilitation Center 505 West Rio Road Charlottesville, VA 22901

Review of the as worked weekend scheduled for March 2025 revealed on March 8th and 9th (Saturday and Sunday), there were two certified nursing assistants scheduled on unit one for 7 a.m. through 7 p.m.

Review of the resident census log for these dates documented a census of 59 residents on unit one. On 9/2/25 at 2:30 the director of nursing (DON) was interviewed regarding scheduling adequate nursing staff.

The DON verbalized not having a staff coordinator at the present time and was currently taking on that role, but typically there are four to five certified nurse assistants (CNA's) on unit one on both day/evening shift and evening/night shift (7:00 a.m. to 7:00 p.m. and 7:00p.m. to 7:00 a.m.).

Review of current as worked schedules indicated no staffing concerns. On 9/3/25 at 4:20 p.m. CNA #1 (an aide that worked the weekend in question) was interviewed. CNA #1 verbalized that unit one should have four CNA's each shift. CNA #1 said during that weekend the aides had thirty residents each and showers were not completed. CNA #1 said the other aide and herself helped each other and were able to provide hygiene and a shortened bed bath to residents, was able to feed residents with the help of other nursing staff and keep all the residents safe. CNA #1 said when this occurred, the staff prioritized what needed to be done and showers are not considered. CNA #1 verbalized there were no incidents (such as falls or needs not being met) during this time period. CNA #1 verbalized this was an isolated incident and has been better since agency has been allowed to come into the facility.

The above finding was presented to the DON and administrator on 9/3/25.

The administrator verbalized that the facility has had a lot of turnovers in employment and call outs especially on weekends.

The administrator said that recently the facility has started using agency staff to fill in vacancies when needed and is working towards hiring more staff.On 9/4/25 at 9:00 a.m. license practical nurse (LPN #4-unit manager) was interviewed. LPN #4 the goal is to staff four CNAs on each twelve-hour shift, which does not always occur. LPN #4 verbalized when the unit is that short on help, the CNAs will do what is important for the residents. On 9/4/25 the administrator presented the facility assessment and verbalized.

Based on our census, acuity, and budget, the facility should be between four and five nursing assistants per shift.Review of incident logs, grievance logs, and resident council minutes did not evidence concerns regarding needs of residents or incident/accident concerns related to low staffing.

The survey team conducted interviews regarding getting showers as scheduled with four residents in the survey sample, identified as R1, R2, R3, and R4.

There were no concerns expressed except for R1(resident council president) who wanted to change shower schedule to be done early in the morning prior to breakfast, because of handing out daily menus to residents just after breakfast.

This information was presented to LPN #4, LPN #4 verbalized being aware of the preference and had just gone into effect. No other information was presented prior to the exit conference.

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Charlottesville Health & Rehabilitation Center 505 West Rio Road Charlottesville, VA 22901

in place and a wound care company began to monitor and treat the wound.

Further review of the daily skilled assessment progress notes dated 1/31/25 through 2/3/25 and weekly skin assessments dated 2/7/25 and 2/14/25 had inconsistent documentation of R6 having a pressure ulcer either by documenting No on the progress notes or no documentation regarding a stage three pressure ulcer on skin assessments.

On 9/3/25 at 8:30 a.m. the director of nursing (DON) and nurse consultant (administrative staff, AS #3) were interviewed. AS #3 reviewed R6's clinical record and agreed there were discrepancies in the skin assessments and progress notes.

A facility policy titled Wounds/Skin Impairments read in part, The Skin and Observation Tool will be completed by a licensed nurse [.], detailing any wounds/skin impairments.

No other information was provided prior to the exit conference on 9/4/25.