Emporia Rehabilitation And Healthcare Center
EMPORIA REHABILITATION AND HEALTHCARE CENTER in EMPORIA, VA — inspection on October 23, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Emporia Rehabilitation and Healthcare Center
200 Weaver Avenue Emporia, VA 23847
SUMMARY STATEMENT OF DEFICIENCIES
According to the Administrator's investigation, she concluded that the allegation of neglect was unfounded as transfer to the hospital on [DATE] 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Emporia Rehabilitation and Healthcare Center
200 Weaver Avenue Emporia, VA 23847
SUMMARY STATEMENT OF DEFICIENCIES
Ensure that residents are free from significant medication errors.
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] 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.
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