Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 3
Jul 16, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident environment safety, advance directives, and overall facility conditions.
Findings
The facility failed to maintain a safe, clean, and comfortable environment due to malfunctioning air conditioning affecting multiple residents and areas. Additionally, the facility failed to ensure a Do Not Resuscitate (DNR) order was properly followed for one resident, resulting in CPR being administered contrary to the resident's wishes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain a clean, comfortable, homelike environment due to non-functioning air conditioning units affecting residents and hallways. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a Do Not Resuscitate resident's wishes were followed, resulting in CPR being administered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a comfortable environment for residents, staff, and the public due to air conditioning system issues. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Ambient temperature: 83.8
Ambient temperature: 84.4
Ambient temperature: 84.6
Ambient temperature: 85.2
Number of rooms with air conditioning issues: 7
Number of portable air conditioning units: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed about air conditioning issues and repair plans | |
| Administrator | Interviewed regarding air conditioning issues and facility response | |
| Director of Nursing | Participated in final interview and acknowledged DNR issue | |
| Interim Administrator | Participated in final interview regarding facility issues | |
| Maintenance Assistant | Recorded ambient temperatures and provided information on air conditioning | |
| Social Worker | Interviewed regarding failure to upload DNR document | |
| Other Staff Member #5 | Reported CPR was performed on Resident #6 and was not informed of code status | |
| Licensed Practical Nurse #3 | Reported Code Blue and CPR initiation on Resident #6 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Mar 7, 2023
Visit Reason
The inspection was conducted due to complaints regarding unsafe smoking practices and failure to maintain accurate care plans and supervision for residents who smoke.
Findings
The facility failed to maintain accurate care plans and provide adequate supervision for residents who smoke, resulting in a resident sustaining burns from smoking while on oxygen. The facility was found to have immediate jeopardy which was later abated after implementation of a removal plan. Additional findings included failure to complete annual performance reviews for a CNA and failure to provide required training on QAPI, compliance and ethics, and behavioral health for some contract employees.
Complaint Details
The complaint investigation was triggered by unsafe smoking practices leading to a resident catching fire while smoking in bed with oxygen, resulting in burns and hospitalization. The facility was found to have immediate jeopardy which was abated after corrective actions.
Severity Breakdown
Level 3: 1
Immediate jeopardy: 1
Level 1: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to review and revise a resident's care plan for safe smoking, resulting in burns from smoking while on oxygen. | Level 3 |
| Failed to prohibit unsafe smoking practices and provide adequate supervision, resulting in immediate jeopardy. | Immediate jeopardy |
| Failed to complete an annual performance review for one CNA. | Level 1 |
| Failed to provide training regarding the facility QAPI program for two contract employees. | Level 1 |
| Failed to provide training regarding the facility compliance and ethics program for two contract employees. | Level 1 |
| Failed to provide behavioral health training for one contract employee. | Level 1 |
Report Facts
Residents in survey sample: 11
Residents affected by deficiencies: 2
Resident #1 BIMS score: 11
Resident #1 burn TBSA: 5
Resident #1 oxygen order: 2
CNA #1 hire date: Jun 11, 2019
CNA #1 last performance review: Jan 19, 2022
IJ removal plan verification date: Mar 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Resident #1's unit manager | Interviewed regarding smoking safety assessments and care plan |
| LPN #8 | Nurse caring for Resident #1 on 2/26/23 | Interviewed about Resident #1's burn incident and emergency response |
| ASM #1 | Executive Director | Interviewed regarding smoking policies and immediate jeopardy removal plan |
| ASM #2 | Director of Clinical Services | Interviewed regarding smoking policies, immediate jeopardy removal plan, and staff training |
| ASM #3 | Vice President of Operations | Interviewed regarding smoking policies and immediate jeopardy removal plan |
| ASM #4 | Regional Clinical Director | Interviewed regarding smoking policies and immediate jeopardy removal plan |
| RN #2 | Staffing Development Coordinator | Interviewed regarding employee training deficiencies |
| OSM #4 | Dietary Cook | Employee record reviewed; lacked required training on QAPI, compliance, ethics, and behavioral health |
| OSM #6 | Speech Therapist | Employee record reviewed; lacked required training on QAPI, compliance, and ethics |
| OSM #9 | Dietary Manager | Interviewed regarding contract employee training |
| OSM #10 | Rehab Director | Interviewed regarding contract employee training |
Inspection Report
Routine
Deficiencies: 18
Nov 11, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication administration, resident care, infection control, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to properly assess residents for self-administration of medications, failure to notify physicians of changes in condition, inadequate housekeeping and maintenance leading to unsanitary conditions, failure to protect residents from abuse, incomplete investigations of resident-to-resident altercations, failure to complete PASRR Level II screening, lack of baseline care plans for new admissions, incomplete care plans for restorative and fall prevention services, inadequate assistance with activities of daily living, improper respiratory equipment maintenance, failure to ensure timely physician visits, incomplete staff performance reviews, failure to post daily staffing census, improper medication labeling and refrigerator monitoring, inadequate infection control practices including PPE use and environmental cleanliness, and ineffective pest control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Level of Harm - Actual harm: 2
Level of Harm - Potential for minimal harm: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to assess residents for self-administration of medications and improper medication administration practices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify physician of change in resident's condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a safe, clean, comfortable, and homelike environment including housekeeping and maintenance deficiencies. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from abuse resulting in harm. | Level of Harm - Actual harm |
| Failure to complete thorough investigation of resident-to-resident altercation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete PASRR Level II screening for a resident with serious mental illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop baseline care plans within 48 hours of admission for new residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise comprehensive care plans related to restorative services and falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate assistance with activities of daily living, specifically nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care to maintain or improve range of motion and mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure timely physician visits as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide annual performance reviews and required training for Certified Nursing Assistants. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post daily nurse staffing information including census. | Level of Harm - Potential for minimal harm |
| Failure to properly label multi-dose medications and monitor medication refrigerator temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain infection prevention and control program including PPE use, environmental cleanliness, and quarantine procedures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep essential equipment in safe working order including laundry equipment and plumbing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide working call system in resident bathrooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a pest control program and follow pest control recommendations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 3
Residents affected: 2
Residents affected: 195
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN9 | Licensed Practical Nurse | Named in medication administration deficiency and interview about medication administration |
| RN20 | Registered Nurse, Staff Development Nurse | Named in medication administration deficiency and interview about medication administration education |
| LPN14 | Licensed Practical Nurse | Named in interview about resident capability to self-administer eye drops |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies including medication administration, change in condition notification, abuse investigation, infection control, and care plan development |
| Consulting Pharmacist | Named in interview about medication regimen review | |
| CNA8 | Certified Nursing Assistant | Named in abuse incident witness statement and interview about call light issues |
| LPN17 | Licensed Practical Nurse | Named in abuse incident witness statement and interview about abuse incident |
| Administrator | Named in interviews about environmental concerns, abuse investigation, infection control, and housekeeping | |
| SW4 | Social Worker | Named in abuse incident interview |
| ADON | Assistant Director of Nursing | Named in interviews about restorative care, infection control, and care plan development |
| PTA | Physical Therapy Aide | Named in interview about resident therapy services |
| RA30 | Restorative Aide | Named in interview about restorative care services |
| RA18 | Restorative Aide | Named in interview about restorative care services and infection control |
| LPN1 | Licensed Practical Nurse | Named in interview about ADL assistance |
| LPN40 | Licensed Practical Nurse | Named in interview about resident alcohol use and respiratory tubing |
| DOR | Director of Rehabilitation | Named in interview about therapy and restorative services |
| LPN31 | Licensed Practical Nurse | Named in observation and interview about resident contracture |
| LPN32 | Licensed Practical Nurse, Unit Manager | Named in interview about medication labeling and refrigerator monitoring |
| IP | Infection Preventionist | Named in interview about respiratory tubing labeling |
| PCA22 | Patient Care Assistant | Named in observation and interview about PPE use with quarantined resident |
| CNA27 | Certified Nursing Assistant | Named in observation and interview about mask use |
| Laundry Aide 37 | Laundry Aide | Named in observation and interview about laundry room cleanliness and equipment |
| LPN10 | Licensed Practical Nurse | Named in interview about call light issues and maintenance notification |
| LPN35 | Licensed Practical Nurse | Named in interview about call light system outage |
| Human Resource Director | Named in interview about staff performance reviews |
Inspection Report
Routine
Deficiencies: 16
Feb 19, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, safety, infection control, medication management, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during wound care, inadequate cleanliness and maintenance of the environment, failure to provide care plan information during hospital transfers, failure to notify the Long-Term Care Ombudsman of resident discharge, failure to provide scheduled showers, inadequate pressure ulcer care, unsafe use of scissors during dressing changes, failure to provide appropriate pain management, improper medication storage, failure to obtain dental services, inadequate hospice coordination, poor infection control practices, failure to implement antibiotic use protocols, and failure to maintain a pest control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to provide privacy during wound dressing change for Resident #183. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a clean, comfortable, homelike environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care plan information to receiving provider at hospital transfer for Resident #94. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify Long-Term Care Ombudsman of Resident #94's discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written information on bed-hold policy to Resident #94 upon hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled twice-weekly showers to Resident #183. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and implement pressure relieving devices for Resident #183. | Level of Harm - Minimal harm or potential for actual harm |
| Use of sharp tip scissors instead of bandage scissors to cut Resident #183's dressing, posing injury risk. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate pain management for Resident #80, resulting in unnecessary pain. | Level of Harm - Actual harm |
| Failure to store medications securely on Unit 1-A; medications left unsecured on medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain dental services for Resident #146 as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure hospice agency provided coordinated plan of care for Resident #175. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain good infection control practices including contamination of clean dressing and lack of soap in resident bathroom. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement antibiotic use protocol; Resident #68 received antibiotic to which bacteria was resistant. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe, comfortable environment; multiple doors had chipped sharp edges. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program; roaches and mice observed in multiple areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in survey sample: 62
Shower refusals or missed showers: 15
Ciprofloxacin doses administered: 18
Medication bottles left unsecured: 6
BIMS score: 15
BIMS score: 9
BIMS score: 10
BIMS score: 14
BIMS score: 14
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Failed to close door during wound care and used sharp scissors to cut dressing |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including privacy, hospital transfer procedures, wound care, and pain management |
| RN #3 | Wound Nurse | Evaluated pressure ulcer on Resident #183 |
| CNA #13 | Certified Nursing Assistant | Reported Resident #183 refused shower on one occasion |
| Assistant Administrator | Assistant Administrator | Interviewed regarding environmental and pest control deficiencies |
| LPN #4 | Licensed Practical Nurse | Interviewed about dental care for Resident #146 |
| LPN #5 | Licensed Practical Nurse | Interviewed about dental care for Resident #146 |
| LPN #6 | Licensed Practical Nurse | Interviewed about dental care for Resident #146 |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed about Resident #175's behavioral issues and medication |
| CNA #5 | Certified Nursing Assistant | Observed handling laundry without hand hygiene |
| Other #2 | Housekeeping Supervisor | Interviewed about soap refilling and pest control |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jun 8, 2017
Visit Reason
The inspection was conducted to investigate complaints regarding residents' rights to vote, care planning participation, maintenance issues, catheter care, medication management, and housekeeping.
Findings
The facility failed to ensure residents' voting rights were fully supported, including assistance with registration and absentee ballots. One resident's representative information was not updated, affecting care plan participation. Maintenance issues were found in resident rooms and bathrooms. A resident's indwelling catheter was not properly secured, risking trauma. Expired and unlabeled insulin products were found in the medication cart. One garbage container door was left open, posing sanitation risks.
Complaint Details
The complaint investigation revealed failures in residents' voting rights, care plan participation, maintenance, catheter care, medication management, and housekeeping.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Potential for minimal harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure protocols were in place to enable 12 of 34 residents to exercise their right to vote. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update Resident Representative information for 1 of 27 residents, resulting in missed care plan meeting invitations. | Level of Harm - Minimal harm or potential for actual harm |
| Maintenance services were not provided to ensure a functioning interior in resident rooms and bathrooms on 4 of 4 units. | Level of Harm - Potential for minimal harm |
| Failed to ensure resident's indwelling catheter was secured to prevent trauma and potential dislodgment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to discard expired biological medication and failed to label when a multidose vial of insulin was opened. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure 1 of 3 garbage container doors were closed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents unable to exercise voting rights: 12
Residents wanting to vote in 2017 gubernatorial election: 28
Residents wanting absentee ballots for primary: 22
Residents who would have voted in 2016 presidential election if asked: 18
Residents with guardianship unable to vote: 39
Residents affected by failure to update representative info: 1
Units with maintenance issues: 4
Residents affected by catheter care deficiency: 1
Residents affected by medication labeling and expiration issues: 2
Garbage containers with open doors: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Interim Activities Director | Directed by Administrator to ensure residents had opportunity to vote; interviewed regarding voting procedures and deficiencies. | |
| Administrator | Interviewed about residents' voting rights and facility policies; acknowledged policy inadequacies. | |
| Social Worker | Interviewed about residents without ID cards and voting rights. | |
| MDS Coordinator | Provided care plan invitations and interviewed about Resident #4's care plan participation. | |
| Director of Maintenance | Interviewed regarding maintenance issues and repair responsibilities. | |
| Director of Housekeeping | Interviewed during maintenance observation tour. | |
| Wound Care Nurse | Observed catheter care and discussed catheter stabilization device. | |
| Director of Nursing | Interviewed regarding medication refrigerator checks and catheter stabilization. | |
| Dietary Manager | Interviewed about garbage container door being open. | |
| LPN #5 | Licensed Practical Nurse | Identified expired Lantus FlexPen in medication cart. |
| Unit Manager | Identified unlabeled vial of insulin in medication refrigerator. |
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