Deficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to investigate specific concerns related to resident care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely transfer/discharge notifications, inaccurate resident assessments, incomplete care plans addressing resident preferences, failure to meet professional standards of care during resident transfers, inconsistent respiratory care, inadequate food safety practices, incomplete documentation of advance directives, and lack of a written water supply contingency plan.
Deficiencies (14)
Failure to provide written notification of the reason for transfer/discharge to Resident #59 and the resident's representative.
Failure to accurately determine significant change in Resident #59's condition related to weight loss using the RAI process.
Failure to accurately code Resident #59's PRN pain medication and weight loss on the MDS assessment.
Failure to accurately code Resident #70 for Hospice services on admission MDS.
Failure to ensure accurate MDS assessments for Residents #79, #30, #59, and #70.
Failure to develop and implement comprehensive person-centered care plans addressing residents' preferences for no oral suction and no oxygen for Residents #34 and #70.
Failure to ensure placement of Dycem non-slip material in Resident #38's wheelchair seat as indicated in care plan.
Failure to follow care plan intervention for two-person assist with mechanical lift transfers for Resident #46, resulting in a fall.
Failure to use appropriately sized mechanical lift pad and failure to transfer Resident #46 with assistance of two staff members, resulting in a fall.
Failure to complete neuro-checks and vital signs as ordered by medical provider for Resident #76 after a fall.
Failure to consistently wear beard net while preparing food in the kitchen, risking contamination.
Failure to consistently provide and document oxygen usage per physician's order and hospice plan for Resident #65.
Failure to maintain complete and accurate clinical records including documentation of verbal communication, education, and proper completion of advance directives for multiple residents.
Failure to have a written procedure detailing the facility's process to ensure availability of water in response to loss of normal water supply.
Report Facts
Residents sampled: 24
Weight loss percentage: 6.1
MDS BIMS score: 6
MDS BIMS score: 13
MDS BIMS score: 12
MDS BIMS score: 3
MDS BIMS score: 4
MDS BIMS score: 7
MDS BIMS score: 5
Oxygen liters per minute: 8
Oxygen liters per minute: 5
Water storage gallons: 60
Water supply plan gallons: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about MDS assessments and care plan modifications for Resident #59 |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about MDS assessments and care plan modifications for Resident #59 and Resident #70 |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Involved in Resident #46 fall during mechanical lift transfer |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Provided information about lift pad sizes and Resident #46's fall |
| Registered Nurse #3 | Registered Nurse | Resident #46's nurse at time of fall |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed medication pass and oxygen check for Resident #65 |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Discussed oxygen orders and hospice communication for Resident #65 |
| Other Employee #2 | Food Service Aide | Observed preparing food without beard net |
| Administrator | Administrator | Participated in pre-exit meetings and discussions of deficiencies |
| Director of Nursing | Director of Nursing | Participated in pre-exit meetings and discussions of deficiencies |
| Regional Nurse Consultant | Regional Nurse Consultant | Participated in pre-exit meetings and discussions of deficiencies |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 24, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including care plan implementation, medication administration, infection control, food safety, vaccination policies, and quality assurance processes.
Findings
The facility was found deficient in multiple areas including failure to provide baseline care plan summaries to residents, incomplete care plan reviews, failure to provide adequate ADL care, medication administration errors, inadequate infection control practices, improper food storage and sanitation, lack of documented vaccination status and refusals, incomplete COVID-19 testing and vaccination tracking for staff, and absence of a functional quality assurance and performance improvement program.
Deficiencies (12)
Failed to provide residents #54 and #71 with a written summary of their baseline care plan within 48 hours of admission.
Failed to review and revise the care plan to reflect resident #180's current status and failed to invite resident #54 to care plan meetings.
Failed to provide ADL care for dependent resident #36.
Failed to follow physician's orders for medication administration for residents #9, #71, and #180.
Failed to ensure a physician ordered supplement was kept under direct observation until consumed for resident #54.
Failed to store and prepare food in a sanitary manner and maintain a clean food service area.
Failed to provide a quality assurance and performance improvement (QAPI) plan and evidence of corrective actions.
Failed to provide evidence of quarterly quality assessment and assurance (QAA) committee meetings.
Failed to perform hand hygiene during medication administration on Wing 2.
Failed to determine flu and pneumonia vaccination status and obtain consent or refusal documentation for residents #8, #40, and #55.
Failed to properly implement COVID-19 testing procedures including inadequate specimen collection and missing required testing for staff member #1.
Failed to implement policies and procedures for additional infection control precautions for unvaccinated staff and failed to track vaccination status accurately for staff member #4.
Report Facts
Residents in survey sample: 20
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: Many
Residents affected: Many
Residents affected: 1
Residents affected: 3
Staff members affected: 5
Staff members affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS nurse #1 | Interviewed regarding baseline care plan provision and care plan meetings | |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding baseline care plan provision |
| Administrator | Notified of multiple deficiencies and participated in meetings | |
| Director of Nursing | DON | Notified of deficiencies, participated in meetings, and provided statements |
| Resident #54 | Interviewed regarding care plan and supplement consumption | |
| Resident #71 | Interviewed regarding care plan and medication administration | |
| Resident #36 | Interviewed and observed regarding ADL care | |
| Resident #9 | Clinical record reviewed for medication administration | |
| Resident #180 | Clinical record reviewed for care plan and medication administration | |
| Resident #8 | Vaccination status reviewed | |
| Resident #40 | Vaccination status reviewed and interviewed | |
| Resident #55 | Vaccination status reviewed and interviewed | |
| SM #1 | Staff Member | COVID-19 testing and vaccination status reviewed |
| SM #2 | Staff Member | Interviewed regarding vaccination exemption and precautions |
| SM #3 | Staff Member | Observed and interviewed regarding mask use |
| SM #4 | Staff Member | Vaccination status documentation discrepancy |
| SM #21 | Staff Member | Observed performing COVID-19 specimen collection |
| SM #22 | Staff Member | Observed during COVID-19 specimen collection |
| HRS #1 | Human Resource Staff | Interviewed regarding staff work location and duties |
Inspection Report
Routine
Deficiencies: 13
Date: Jul 9, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, notification of changes, transfer and discharge procedures, medication administration, respiratory care, pharmaceutical services, infection control, and facility policies including smoking.
Findings
The facility was found deficient in multiple areas including improper handling and documentation of Durable Do Not Resuscitate (DDNR) orders, failure to notify physicians and hospice providers of resident falls, inadequate documentation and notification during resident transfers, medication administration errors, failure to provide appropriate respiratory care, medication shortages, improper storage of controlled substances, unsanitary food preparation and storage practices, failure to monitor and document psychotropic medication use, incomplete clinical records, and failure to follow infection control protocols.
Deficiencies (13)
Facility staff failed to ensure provider/physician involvement in the implementation of DDNR forms, including use of pre-signed forms without patient information.
Facility staff failed to provide notification of changes for Resident #30, including failure to notify hospice physician of falls.
Facility staff failed to provide appropriate information and documentation during resident transfers for Residents #34 and #37.
Facility staff failed to provide timely notification to residents and representatives regarding transfer and discharge, including appeal rights and bed-hold policies for Residents #34 and #37.
Facility staff failed to follow physician orders for Resident #49 by administering eye ointment to both eyes instead of the left eye only.
Facility staff failed to ensure Resident #30 received oxygen at the physician ordered rate of 3 liters per minute.
Facility staff failed to ensure medication (refresh tears) was available for Resident #49, resulting in a missed dose.
Facility staff failed to ensure narcotic medication lorazepam was stored in a locked permanently affixed box on wing 2.
Facility staff failed to follow infection control program by not using SBAR tools for suspected infections other than UTIs and failed to follow infection control procedures during medication administration for Resident #18.
Facility staff failed to prepare, store, and serve foods in a sanitary manner, including unsecured and unlabeled perishable foods, unclean kitchen environment, and failure to wear beard guard.
Facility staff failed to implement gradual dose reductions and non-pharmacological interventions for Residents #13 and #14, including failure to monitor behaviors and document justification for medication dosage increase.
Facility staff failed to ensure complete and accurate clinical records for Residents #22 and #30, including incomplete CNA flow sheets and missing advanced directive.
Facility staff failed to follow policy regarding smoking supplies for Resident #38, who kept cigarettes and lighter at all times despite policy restrictions.
Report Facts
DDNR forms pre-signed by medical director: 30
Residents in survey sample: 24
Behavior monitoring dates missed: 12
Oxygen liters ordered: 3
Oxygen liters delivered: 2
Medication doses missed: 1
Lorazepam vials: 2
Behavioral episodes documented: 1
BIMS score Resident #13: 6
BIMS score Resident #14: 6
BIMS score Resident #22: 4
BIMS score Resident #30: 7
BIMS score Resident #38: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered eye ointment to both eyes instead of left eye only for Resident #49. |
| LPN #1 | Licensed Practical Nurse | Picked up medication capsules with bare hands and administered to Resident #18. |
| Dietary cook #1 | Dietary Cook | Observed kitchen sanitation issues and agreed personal items should not be in kitchen. |
| Dietary staff #2 | Dietary Staff | Observed not wearing beard guard, then applied it after being asked. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including DDNR forms, transfer documentation, medication monitoring, and bed-hold policies. |
| Social Worker | Social Worker | Left message requesting advanced directive for Resident #30. |
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