Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Deficiencies: 1
Date: Nov 15, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in care and services provided by the nursing facility, specifically reviewing care related to Resident #1.
Findings
The facility staff failed to utilize proper turning and repositioning techniques for Resident #1, resulting in pain to the resident's right shoulder. The facility conducted re-education for clinical staff on proper repositioning techniques following the incident.
Deficiencies (1)
Facility staff failed to utilize proper turning/repositioning technique while providing care to Resident #1.
Report Facts
Residents affected: 1
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Identified as the person providing care to Resident #1 and received additional education |
| Facility Administrator | Interviewed regarding the incident and re-education efforts | |
| Director of Nursing | Interviewed and provided statements on proper repositioning techniques |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 25
Date: Sep 13, 2022
Visit Reason
Complaint investigation triggered by multiple resident and family concerns including allegations of abuse, neglect, misappropriation, inadequate care, and failure to provide necessary services.
Complaint Details
Complaint investigation revealed multiple allegations of abuse, neglect, misappropriation, inadequate care, and failure to provide necessary services. Immediate jeopardy was called on 09/16/2022 related to abuse and neglect concerns. The facility failed to report allegations timely and failed to investigate and protect residents from abuse and neglect. Residents reported fear and retaliation for reporting concerns.
Findings
The facility failed to ensure residents' rights to dignity, privacy, and self-determination; failed to provide adequate care including medication administration, pressure ulcer care, communication, and discharge planning; failed to protect residents from abuse, neglect, and financial exploitation; failed to maintain a safe environment; and failed to provide required staff training and competency evaluations. Immediate jeopardy was called related to abuse and neglect concerns. Multiple residents were affected with harm or potential for harm.
Deficiencies (25)
Failed to honor residents' right to a dignified existence and self-determination, including failure to assist residents after meals and failure to respect resident preferences for caregiver gender.
Failed to protect resident privacy and confidentiality, including unauthorized use of resident's photo and health information in marketing materials and use of unqualified interpreters.
Failed to assess and allow resident self-administration of medications, removing medications without assessment.
Failed to provide residents access to personal funds/trust accounts on weekends and evenings.
Failed to provide quarterly statements of trust accounts to residents.
Failed to limit charges against residents' personal funds to authorized amounts, resulting in overcharges.
Failed to post required notices including names and contact information for state agencies and advocacy groups.
Failed to offer and provide advance directive planning to residents and responsible parties.
Failed to maintain residents' personal privacy during care and failed to protect personal health information.
Failed to maintain a clean, comfortable, and homelike environment including repair of room damages and cleanliness.
Failed to respond promptly to resident grievances and failed to document responses.
Failed to protect residents from abuse and neglect, including failure to investigate and report allegations timely, and failure to protect residents from resident-to-resident abuse.
Failed to implement policies to prevent abuse and neglect, including failure to conduct pre-hire screening and license verification, and failure to provide staff training.
Failed to timely report allegations of abuse, neglect, or misappropriation to appropriate authorities.
Failed to provide timely notification to residents and ombudsman of transfers and discharges.
Failed to provide accurate and complete MDS assessments, including cognitive assessments.
Failed to develop and implement comprehensive person-centered care plans addressing communication, activities of daily living, contractures, discharge planning, and changes in condition.
Failed to provide care and services that meet professional standards including medication administration, diabetes management, pressure ulcer care, and rehabilitative services.
Failed to maintain a safe environment and provide adequate supervision to prevent accidents for a confused fall risk resident.
Failed to provide care and assistance to maintain grooming and personal hygiene for residents.
Failed to provide pharmaceutical services to meet residents' needs including timely medication availability and safekeeping of controlled drug prescriptions.
Failed to perform COVID-19 testing in accordance with CDC guidance for symptomatic and newly admitted residents.
Failed to maintain an accurate system to track staff COVID-19 vaccination and booster status and failed to provide booster education.
Failed to provide a functional bedside table for a resident.
Failed to provide staff education on dementia care, abuse prevention, and reporting for all nursing staff.
Report Facts
Residents affected: 60
Employees missing criminal background checks: 13
Licensed employees missing license verification: 13
Employees missing abuse/neglect training: 3
Residents affected by abuse/neglect: 10
Residents affected by medication errors: 2
Residents affected by pressure ulcers: 2
Residents affected by communication failures: 3
Residents affected by financial exploitation: 3
Residents affected by unsafe discharge: 1
Residents affected by falls: 1
Residents affected by inadequate infection control: 1
Staff members with incomplete training: 6
CNA missing annual evaluations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Named in abuse and neglect findings; terminated 9/16/22 after abuse investigation |
| CNA N | Certified Nursing Assistant | Named in resident dignity and care findings |
| Employee D | Regional Nurse Consultant | Interviewed regarding resident privacy and abuse investigations |
| Employee J | Regional Director of Revenue Cycle | Interviewed regarding resident trust fund misappropriation and medication billing |
| Employee G | Receptionist | Interviewed regarding resident grievances and trust fund access |
| Employee E | Social Worker | Interviewed regarding abuse investigations, resident grievances, and mental health services |
| Employee Q | Laundry Aide | Interpreted for resident with language barrier |
| Employee R | Housekeeper | Interpreted for resident with language barrier |
| Employee S | Mental Health Nurse Practitioner | Provided behavioral health services and interviewed |
| Employee T | Physician | Primary care provider for Resident #217; interviewed about medical history and communication |
| Employee X | Director of Human Resources | Interviewed regarding staff training and competency records |
| LPN H | Licensed Practical Nurse | Interviewed regarding medication administration and communication with Resident #78 |
| CNA H | Certified Nursing Assistant | Interviewed regarding communication with Resident #78 |
| RN D | Registered Nurse | Interviewed regarding communication with Resident #318 |
| CNA W | Certified Nursing Assistant | Interviewed regarding communication with Resident #318 |
| Employee F | Maintenance Director | Interviewed regarding maintenance requests and bedside table repair |
| LPN B | Licensed Practical Nurse | Interviewed regarding shaving residents |
| CNA E | Certified Nursing Assistant | Interviewed regarding shaving residents and catheter bag placement |
| RN C | Unit Manager/Registered Nurse | Interviewed regarding medication prescription handling |
| LPN G | Licensed Practical Nurse | Interviewed regarding medication reorder process |
| Employee DD | Admissions Director | Interviewed regarding resident trust account access |
| Employee EE | Activity Leader | Interviewed regarding resident trust account access |
| Employee CC | Assistant Regional Director of Finance | Interviewed regarding resident trust account access |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Nov 8, 2019
Visit Reason
The inspection was conducted following complaints alleging mistreatment and failure to follow proper care procedures for residents, including dignity violations, medication errors, care planning deficiencies, and infection control issues.
Complaint Details
The complaint investigation was substantiated with findings of dignity violations, medication errors, care planning deficiencies, failure to provide timely Medicare non-coverage notices, failure to administer medications as ordered, inaccurate clinical documentation, and infection control lapses.
Findings
The facility failed to maintain resident dignity during admission assessments, failed to assess residents for safe medication self-administration, failed to provide timely notification of Medicare non-coverage, failed to develop and revise comprehensive care plans, failed to administer medications and treatments as ordered, failed to maintain accurate clinical records, and failed to maintain sanitary conditions in the shower room.
Deficiencies (10)
Facility staff failed to maintain respect and dignity for one resident during an admission skin assessment performed between 1:00 am and 1:30 am, causing distress to the resident.
Facility staff failed to assess a resident to determine if they were safe to self-administer medications before leaving medications at the bedside.
Facility staff failed to provide timely notification of Medicare non-coverage and complete an Advanced Beneficiary Notice for sampled residents.
Facility staff failed to develop and implement comprehensive care plans for residents, omitting important treatments such as nebulizer therapy and wound care.
Facility staff failed to review and revise the care plan after the development of unstageable pressure ulcers on a resident's left ankle and heel.
Facility staff failed to follow nursing standards by leaving medication at the bedside without observing administration and failed to administer insulin and IV antibiotics as ordered for a resident.
Facility staff failed to administer cardiac medication as scheduled, with doses given late beyond the facility's one-hour window.
Facility staff failed to prevent the development of pressure wounds and failed to identify wounds prior to becoming unstageable or advanced stage.
Facility staff failed to maintain accurate clinical records, documenting medication administration that was not actually given.
Facility staff failed to maintain shower equipment and the shower room in a sanitary manner, including clogged drains and heavily discolored shower benches.
Report Facts
Residents in survey sample: 43
Missed insulin doses: 6
Missed IV antibiotic doses: 28
Pressure ulcer size: 4
Pressure ulcer size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Unit Manager | Interviewed regarding missed insulin and IV antibiotic doses for Resident #107 |
| LPN C | Licensed Practical Nurse | Interviewed regarding insulin administration for Resident #107 |
| Employee A | Administrator | Interviewed regarding care plan revision expectations and medication administration standards |
| Employee B | Director of Nursing | Interviewed regarding medication administration standards and pressure ulcer identification |
| Employee N | Housekeeping Supervisor | Interviewed regarding shower room sanitation and cleaning procedures |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: May 24, 2018
Visit Reason
The inspection was conducted based on complaint investigation regarding failure to properly complete and refer Pre-admission Screening and Resident Review (PASARR) for residents with mental illness, failure to develop and implement complete care plans, failure to provide appropriate treatment and care, failure to maintain complete medical records, failure to implement infection prevention and control program, and failure to hold hot foods at safe temperatures.
Complaint Details
The complaint investigation revealed multiple deficiencies related to PASARR screening, care planning, treatment and care, medical record maintenance, infection control, and food safety.
Findings
The facility failed to ensure accurate and timely PASARR screenings for residents with mental illness, failed to develop comprehensive care plans addressing residents' needs including targeted behaviors and non-pharmacological interventions, failed to initiate timely antibiotic treatment for MRSA infection, failed to maintain complete medical records, failed to implement effective infection control practices including proper wound care and ice machine plumbing, and failed to hold hot foods at safe temperatures.
Deficiencies (11)
Facility staff failed to refer a resident with diagnosed mental illness for a level II PASARR screening and failed to ensure PASARR accuracy for another resident.
Facility staff failed to ensure PASARR was completed prior to admission for a resident.
Facility failed to include targeted behaviors and non-pharmacological interventions for use of Ativan for Resident #54.
Facility failed to develop and implement a complete care plan addressing dementia, anxious behaviors, and other needs for multiple residents.
Facility failed to revise care plan to include MRSA diagnosis and correct wound location for Resident #193.
Facility failed to ensure timely initiation of antibiotic treatment for MRSA infection for Resident #193 until 6 days after hospital discharge.
Facility failed to ensure bowel protocol was in place to manage constipation for Resident #54.
Facility failed to ensure physician reviewed medications and treatments at each visit for Resident #193.
Facility failed to hold prepared hot foods at safe temperatures; pureed toast at 114°F and oatmeal at 124°F.
Facility failed to maintain complete medical records; February 2018 bowel movement record for Resident #54 was unavailable.
Facility failed to implement effective infection control program including failure to start timely antibiotic for MRSA infection, improper wound care contact with bed surface, improper handling of unused wound care items, and ice machine drain lacking air gap.
Report Facts
Sample size: 35
Medication administration dates: 9
Temperature: 114
Temperature: 124
Vancomycin dose: 500
Vancomycin start delay: 6
BIMS score: 3
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee G | Director of Social Services | Interviewed regarding PASARR screening for Resident #75 |
| Employee F | Observed taking food temperatures in kitchen | |
| Employee D | Head of Maintenance | Interviewed regarding ice machine air gap |
| RN A | Registered Nurse | Interviewed regarding care plan for Resident #76 |
| MDS Coordinator Employee B | Interviewed regarding care plan for Resident #76 | |
| MDS Coordinator other A | Interviewed regarding care plans for Residents #62 and #76 | |
| DON | Director of Nursing | Interviewed and notified of multiple findings including delayed antibiotic initiation and missing bowel records |
| ADON | Assistant Director of Nursing | Observed wound care for Resident #193 and handling of wound care items for Resident #54 |
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