Emporia Rehabilitation And Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

his room to ensure he had a straw. Per the Grievance Report they discussed their investigative findings on 9/29/25 with the daughter and she expressed her satisfaction.There was no evidence in the clinical record that the facility staff continued to monitor Resident #1 for signs and symptoms of dehydration due to more frequent episodes of low urine output and poor oral intake both solid and fluid intake considering the concern voiced by the Responsible Party, his daughter and there was no evidence of supplement shakes started twice a day.On 10/22/25 at approximately 4:45 PM the Administrator and Director of Nursing provided a copy of a Complaint/Grievance initiated 10/15/25 from Resident #1's Responsible Party, his daughter stating patient passed away at the hospital. Daughter stated he had a UTI (urinary tract infection) and was septic. Doctor at the hospital told the family He hadn't had anything to eat or drink in 4 days She had not been informed about the urinalysis or antibiotic. The facility Administrator provided a copy of the Facility Reported Incident that she had completed and submitted dated 10/22/25.On 10/22/25 a review of Resident #1's meal intakes for the 4 days prior to discharge to the emergency room was completed (fluid intake was not recorded): 10/5/25 0-25% meal intake for breakfast and lunch meals, 51-75% evening meal; 10/6/25 76-100% for breakfast and lunch meals, 0-25% for evening meal; 10/7/25 0-25% for breakfast, lunch and evening; 10/8/25 76-100% for breakfast and lunch meal, 0-25% for evening mealThere was no evidence in the clinical record that the Nurse Practitioner or the Responsible Party, his daughter had been notified of the poor meal and fluid intake and low urine output.On 10/22/25 during the end of day meeting,

the Administrator, Director of Nursing and the Regional Director Clinical Services were made aware of the concerns, no further information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Emporia Rehabilitation and Healthcare Center

200 Weaver Avenue Emporia, VA 23847

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

more frequent episodes of low urine output and poor oral intake both solid and fluid intake considering the concern voiced by the Responsible Party, his daughter and there was no evidence of supplement shakes started twice a day.On 10/22/25 per clinical record review (the Medication Administration Record and progress notes for October did not contain an entry for supplements) and according to interviews with the registered dietician, certified nursing assistants and nurses Resident #1 was given a Health Shake on his lunch tray daily, no evidence of amount consumed or any other supplements.On 10/22/25 at 4:21 PM a telephone interview was conducted with the Medical Director, Employee- E, who stated he had not seen Resident #1 as a patient but was aware of his care. He stated that Resident #1 had a decent amount of urine output, and the urine didn't show any concentration. He said they were monitoring his urine specific gravity on his urinalysis reports which were not indicative of dehydration. He also stated that Resident #1 was not showing clinical symptoms of dehydration. When questioned on his expectations of nurses completing assessments for dehydration, he stated he could not address nursing standards of care. On 10/22/25, a review of the clinical record, lab results for 9/13/25 urine specific gravity revealed, 1.013 (normal 1.010-1.030 and 10/8/25 urine specific gravity revealed, 1.016 (normal 1.010-1.030)On 10/22/25 at approximately 4:45 PM the Administrator and Director of Nursing provided a copy of a Complaint/Grievance initiated 10/15/25 from Resident #1's Responsible Party, his daughter stating patient passed away at the hospital. Daughter stated he had a UTI (urinary tract infection) and was septic. Doctor at the hospital told

the family He hadn't had anything to eat or drink in 4 days She said she had not been informed about the urinalysis or antibiotic. The facility Administrator provided a copy of the Facility Reported Incident that she had completed and submitted dated 10/15/25 regarding daughter's allegation of neglect where he was transferred to the hospital on [DATE REDACTED] and had passed away due to a urinary tract infection. According to the Administrator's investigation, she concluded that the allegation of neglect was unfounded as transfer to the hospital on [DATE REDACTED] was a result of Resident #1's sudden clinical decline.On 10/22/25 a review of Resident #1's meal intakes for the 4 days prior to discharge to the emergency room was completed (fluid intake was not recorded):10/5/25 0-25% meal intake for breakfast and lunch meals, 51-75% meal intake for evening meal, 10/6/25 76-100% for breakfast and lunch meals, 0-25% for evening meal, 10/7/25 0-25% for breakfast, lunch and evening meal,10/8/25 76-100% for breakfast and lunch meal, 0-25% for evening mealPer the facility's policy on Ureterostomy Care, General Guidelines1. Determine if the resident is on intake or output before discarding urine.2. Check urine for unusual appearance and record findings.3.

Maintain a daily record of residents' daily fluid output, as indicated. On 10/21/25 a review of Resident #1's clinical record (Treatment Administration Record) Monitor and Document urostomy output revealed holes/blanks for output on 9/28/25 on the day shift, 9/9/25 and 9/16/25 evening shift, and on 9/16/25 and 9/17/25 night shift.According to Lippincott's standards of practice for assessing dehydration in older adults, clinical assessments should include but not limited to: Oral mucosa and tongue: Look for dryness and stickiness. This is a more reliable sign in older adults than skin turgor.Mental status: Look for changes in mental status, such as dizziness, confusion, or delirium, which can be symptoms of dehydration in older adults.Urine color and output: Assess urine color (dark yellow may indicate dehydration) and monitor for decreased urine output. Note: While often used, urine color and output are considered unreliable markers when used alone in older adults. Laboratory assessments: Urine specific gravity: Elevated urine specific gravity (e.g., >1.020) can indicate dehydration but is unreliable when used alone in older adults.On 10/22/25 during the end of day meeting, the Administrator, Director of Nursing and the Regional Director Clinical Services were made aware of the concerns, and no further information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Emporia Rehabilitation and Healthcare Center

200 Weaver Avenue Emporia, VA 23847

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents are free from significant medication error for 1 resident (#2) in a survey sample of 6 residents.For Resident #2 the facility staff failed to follow the physician orders for parameters on administering the drug Midodrine (an alpha-Adrenergic Agonist used to raise blood pressure).Resident #2 was admitted to the facility on [DATE REDACTED] with diagnoses that included but were not limited to Interstitial pulmonary disease, generalized anxiety disorder, major depressive disorder, unspecified dementia, dysphagia, Barretts esophagus, and generalized weakness. Resident #2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/9/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 8 out of possible 15 indicating moderate cognitive impairment.On 10/21/25 a review of the clinical record revealed that Resident #2 had orders that included the medication Midodrine for hypotension (low blood pressure). A review of the MAR (Medication Administration Record) for September and October 2025 revealed the following orders: Midodrine HCL Tablet 5 mg. Give 5 mgt by mouth three times per day for low bp HOLD FOR SYSTOLIC GREATER THAN 130. Order date 10/7/25The MAR revealed the following regarding the administration of Midodrine:10/10/25 - bp was 139/73 medication marked as administered at 2 pm.10/12/25 - bp was 132/76 medication marked as administered at 9 pm.10/19/25 - bp was 145/71 medication marked as administered at 9 pm. On 10/20/25 the order was changed to read: Midodrine HCL Tablet 5 mg. Give 5 mgt by mouth three times per day for low bp HOLD FOR SYSTOLIC GREATER THAN 120. Order date 10/7/25A review of the MAR revealed the following:10/20/25 - bp was 131/75 and medication marked as administered at 9 pm. On 10/22/25 an interview was conducted with LPN # who stated that the importance of paying attention to the parameters on a medication is that in this case you can either cause a blood pressure to be too high if you give it when you should hold it, but also cause someone to bottom out if you hold it when you should have given it, either way it could cause negative outcomes for the resident. On 10/22/25 at approximately 3:30 p.m the DON was asked about the expectation of the nurses following physician orders, and she stated nurses are expected to follow physician orders exactly as they are prescribed. On 10/22/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet