Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Martinsville, The during CMS and state inspections, most recent first.
Surveyors identified that food was not stored, prepared, and served in a safe and sanitary manner when staff prepared meal trays without hairnets, expired ranch dressing and milk were left in the walk-in refrigerator, and debris and food particles accumulated on and around the dishwasher area. These conditions occurred despite a facility policy requiring food to be stored and prepared in a clean, safe, and sanitary manner.
Surveyors found that two residents were living in unsanitary conditions, including stained or absent bed linens, strong urine odors, and urine-soiled briefs left in a shared bathroom garbage can. One resident reported discarding her own soiled briefs in the bathroom trash and not recalling when her sheets were last changed, while another resident sharing the bathroom noticed briefs in the trash that she had not placed there. In a separate room, a resident’s bed had no sheets on two consecutive days, and a fleece blanket and mattress were found saturated with urine, with the resident unable to recall when linens or the blanket were last cleaned. A CNA acknowledged that soiled briefs should not remain in the bathroom trash, and the facility could not provide a related policy.
Surveyors observed that food was not prepared or stored in a sanitary manner, with dietary staff lacking proper hair coverage, expired and unlabeled food items in storage, dirty floors and surfaces, improper storage of utensils, and incomplete temperature records. These deficiencies had the potential to affect nearly all residents in the facility.
A resident with anxiety, depression, bipolar disorder, and dementia was prescribed Risperdal for bipolar episodes, and the dose was increased without documented informed consent. The DON confirmed there was no record of consent before the higher dose was given, despite the facility’s psychotropic medication guideline requiring informed consent and documentation of dose changes.
Failure to Protect Residents from Abuse: The facility failed to protect two residents from physical and verbal abuse by another resident. One resident was cognitively intact and had diagnoses including depression, anxiety, and PTSD, while the other had severe cognitive impairment and multiple psychiatric diagnoses. Staff and the ADM confirmed an altercation in which one resident entered the other resident’s room, both shouted at each other, and one resident struck the other in the face while the other hit back, resulting in skin tears.
Failure to Provide Written Transfer/Discharge Notice: The facility failed to ensure written transfer/discharge notifications were provided to two residents and their representatives when one resident with Alzheimer’s disease and delusional disorder was sent to the ER and later returned, and another resident with cerebral infarction and aphasia was discharged to the hospital. The clinical records lacked documentation of the required written notices, and the DON confirmed no written notification had been provided.
MDS assessments were coded incorrectly for two residents. One resident receiving Escitalopram for depression had the antidepressant item and PASRR Level II status marked incorrectly on the admission MDS, and another resident receiving hospice care had hospice-related MDS items coded as not receiving hospice services despite an active order and care plan.
Failure to complete a PASARR Level I when a resident had new depression and anxiety diagnoses. The resident’s record showed dementia, depression, and anxiety, but the existing PASARR indicated no mental health diagnosis was known or suspected and said a new screen was required if new information changed those findings. The clinical record did not contain a new Level I, and the MDS nurse stated the resident needed one because of the new diagnoses.
Failure to Provide Heel Pressure Relief While in Wheelchair: A resident with cerebral infarction, vascular dementia, and a left heel pressure ulcer was repeatedly observed sitting in a wheelchair with the affected foot resting on the floor and no pressure-relieving device in place. The care plan addressed heel offloading in bed, but it lacked documentation for pressure relief while up in the wheelchair. Staff interviews showed heel floating was used in bed, while wheelchair positioning practices were unclear, and the wound record continued to track the left heel ulcer with ongoing treatment changes.
Improper Urinary Catheter Bag Positioning: A resident with Alzheimer's disease, DM2, BPH with lower urinary tract symptoms, dementia, and obstructive/reflexive uropathy had a suprapubic catheter and a care plan intervention to monitor drainage bag position. The resident was observed twice with the catheter bag inside a concealed bag touching the ground below the wheelchair, and the record showed a recent UTI with cloudy, foul-smelling urine and ABX treatment.
Daily Nurse Staffing Post Missing Actual Hours Worked: The facility failed to ensure the daily census report included the actual hours worked by staff for 7 of 7 days reviewed. The posted staffing report lacked actual hours worked, and the ADM confirmed during interview that the report posted did not include that information. The facility policy provided stated that the facility would comply with the CMS requirement for daily staffing posting.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact, was found to have ants both inside and outside her dresser drawer, and reported ongoing ant presence in her room, including in her bed. The facility's pest control policy was reviewed but was undated, indicating a failure to ensure an effective pest control program.
A resident with a history of falls and high fall risk experienced multiple falls, including one resulting in fractures and another leading to paralysis, without appropriate care plan updates or new interventions. Another resident with dementia and high elopement risk exited the facility through a malfunctioning door lock, which had been previously reported as faulty, and the incident was not documented in nursing notes. Staff interviews revealed lapses in communication, documentation, and adherence to facility policies regarding incident response and supervision.
A resident with multiple chronic conditions fell while attempting to get out of bed, resulting in left arm pain and an x-ray order. An LPN placed the abnormal x-ray results in the physician binder but did not directly notify the physician, contrary to facility policy requiring direct notification of abnormal results.
A resident with a history of fractures, osteoporosis, and high fall risk was admitted with fall precautions, but the facility failed to document the fall risk or history of falls in the baseline care plan. Despite fall risk reviews indicating high risk, the care plan lacked appropriate interventions, and the required documentation and resident signature were missing.
A resident with atherosclerotic heart disease and dementia developed a pressure ulcer, but the facility failed to notify the resident's representative in a timely manner. Despite a nursing note indicating an attempt to contact the family, no further attempts were documented, and the representative was only informed during a visit. The facility's policy required notification within 24 hours, which was not followed.
The facility did not resolve grievances related to meal service for five residents, who were observed not receiving fruit cocktail with their meals despite raising the issue in a Resident Council Meeting. The Dietary Manager confirmed the fruit was available but not served, and the DON provided meeting minutes documenting the unresolved complaints.
The facility failed to provide house shakes to nine residents with orders for them due to running out of stock over the weekend. The Dietary Manager confirmed the shortage, and the Director of Nursing presented an Order Listing Report detailing the residents' needs for the shakes, which were prescribed for purposes such as wound healing and weight loss. The Administrator acknowledged the shortage, which left residents without their supplements until Monday lunch, highlighting a lapse in meeting dietary needs.
The facility failed to follow approved dietary menus, impacting multiple residents who did not receive the correct meals, including desserts and fruits. Observations and interviews confirmed discrepancies between the served meals and the approved menus, which were not aligned with the facility's substitution policy.
A resident with bipolar disorder repeatedly refused medication and exhibited increased disruptive behaviors, but the facility failed to notify the physician as required by policy. The resident's condition included agitation and verbal aggression, leading to psychiatric hospitalization. The DON was unaware of the policy for notifying physicians after medication refusals.
A facility failed to implement treatment orders for a resident with a stage 3 pressure ulcer. Despite recommendations to cleanse the wound and apply dressings, orders were not entered into the MAR/TAR until weeks later. Interviews revealed that the orders were improperly entered and not activated, leading to a delay in care.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the worsening of existing ulcers and the development of new ones. A resident with dementia developed an unstageable ulcer on the left heel and a new ulcer on the left buttock, with inadequate pressure relief interventions. Another resident developed a Stage III ulcer on the upper back, with delayed treatment and poor communication among staff.
The facility failed to maintain a safe and sanitary environment, with issues including a dark substance on a vent cover, unsecured biohazard room, loose electrical outlet, and unsanitary resident bathrooms. The biohazard room contained unsecured cleaners and biological specimens, while several bathrooms had strong odors and dark substances around toilets.
The facility failed to provide written transfer and discharge notices to two residents and their representatives. One resident with chronic obstructive pulmonary disease and another with multiple diagnoses, including schizophrenia, were transferred to the hospital without the necessary documentation. The facility's policy did not include sending written notices, and the Interim DON confirmed this practice.
The facility failed to provide written notification of its bed-hold policy to two residents transferred to the hospital. One resident had chronic obstructive pulmonary disease, and another had schizophrenia, dysphagia, and other conditions. The Interim DON acknowledged that the facility did not provide the notification forms in writing prior to transfer, contrary to the facility's policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident's assessment incorrectly marked PASARR Level II status, and another resident's assessment inaccurately indicated IV feeding. These errors were acknowledged by the MDS Coordinator during interviews.
A resident with chronic respiratory issues was observed multiple times with unlabeled nasal cannula oxygen tubing, despite physician's orders and facility policy requiring labeling. An LPN indicated that the facility lacked a respiratory therapy department, leaving the responsibility to nursing staff, who were unaware of when the tubing was last changed.
A resident with multiple diagnoses, including schizophrenia and dementia, was mistakenly given another resident's medications, leading to hospitalization. The error occurred when an agency nurse administered the wrong medications, despite facility policies requiring proper identification and adherence to the MAR.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The deficiency involves failure to ensure food was stored, prepared, and served in a safe and sanitary manner during two kitchen observations. During a kitchen tour, the Activity Director and Social Service Director were observed preparing meal trays in the kitchen without wearing hairnets. In the walk-in refrigerator, surveyors observed a one-gallon jug of ranch dressing that had an expiration date of 12/12/25 but was opened on 12/29/25, indicating it was opened after its expiration date and remained stored there. Surveyors also observed a buildup of debris and food particles on top of the dishwasher and along the floor underneath the metal dishwasher tables, indicating the dishwashing area and floors were not thoroughly cleaned. On a subsequent observation in the walk-in refrigerator, surveyors found two full one-gallon jugs of 2% milk with an expiration date of 1/29/26 that remained in storage past that date. Facility staff, including the Dietary Manager and Regional Dietary Director, acknowledged that the expired ranch dressing and milk should have been removed from the refrigerator and that the dishwashing area should have been thoroughly cleaned. The facility’s Food Storage policy, dated 11/29/19, stated that food should be stored and prepared in a clean, safe, and sanitary manner, which was not followed in these instances.
Failure to Maintain Clean Linens and Sanitary, Odor-Free Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary and safe environment in resident rooms and shared bathrooms. In one shared bathroom between two rooms, surveyors observed a large orange/brown stain on the fitted sheet of one bed and a urine-soiled brief left in the bathroom garbage can, along with a strong urine odor. One resident using that bathroom stated she could not remember when her sheets were last changed and reported that when she changed her own briefs, she threw the soiled briefs into the bathroom garbage can. Another resident who shared the same bathroom reported that she also placed her own soiled briefs in the garbage can and had noticed soiled briefs in the garbage that she had not put there. A CNA confirmed that soiled briefs should not have been left in the bathroom garbage can and that staff should have checked and removed garbage bags and soiled briefs. In another room, surveyors noted a strong urine odor and found a resident lying on a bed without any sheets, covered only with a small fleece blanket. The resident was unsure of the source of the urine odor and could not remember when she last had sheets on her mattress. On the following day, the same bed still had no linens, and the fleece blanket thrown on top of the bed was saturated with urine, with the mattress also wet. The resident reported that staff had not put linens on her mattress on either day and could not recall when the blanket was last cleaned. When requested, the facility was unable to provide a policy related to these issues.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure food was prepared and stored in a sanitary manner, as observed during a kitchen inspection. Dietary staff were seen with hair not fully covered by hair nets, with hair hanging out and down the back and shoulders. Multiple food items in the refrigerators were either past their use-by dates, unlabeled, or undated, including milk, gelatin, bacon grease, ham, and ground beef. The walk-in refrigerator had a visibly dirty floor with food debris and a leaking juice container, while the walk-in freezer had visible mold-like substances on the door. Additionally, a scoop was stored inside a flour bin in the dry goods area, and dirty linens were found inappropriately stored in a trash bag on the floor. Food safety records for temperature checks were incomplete for the morning shift. Interviews with the Dietary Manager and Administrator confirmed that these practices were not in accordance with facility policy, which requires proper hair restraints, labeling and dating of food, clean storage areas, and regular temperature checks. The observed deficiencies had the potential to affect nearly all residents in the facility, as the unsanitary conditions and improper food handling could compromise food safety for 52 of 53 residents.
Failure to Document Informed Consent for Increased Antipsychotic Dose
Penalty
Summary
The facility failed to ensure that a resident was informed of and participated in the treatment plan for mood and behavior management. Resident 36 had diagnoses including anxiety disorder, depression, bipolar disorder, and dementia. The resident was prescribed Risperdal 0.5 mg twice daily from 7/31/25 to 8/12/25 for bipolar episodes, and on 8/13/25 the order was increased to 1 mg twice daily. The clinical record did not contain informed consent for the increased antipsychotic dose. The DON stated during interview that there was no documentation showing informed consent was provided before the resident received the increased Risperdal dose. The facility’s psychotropic medication guideline, provided by the Administrator, stated that informed consent should be obtained from the resident and/or resident representative as appropriate and that education should include side effects, risks versus benefits, and dose changes, with documentation in nurses’ notes.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident for 1 of 2 residents reviewed for abuse, involving Resident 4 and Resident 18. Resident 4’s record showed diagnoses of depression, anxiety, and post-traumatic stress disorder, and an annual MDS assessment indicated the resident was cognitively intact. Staff interviews confirmed that Resident 4 was often aggressive with staff and other residents, and that Resident 4 hit Resident 18 on the head. The Administrator stated that Resident 4 struck Resident 18 in the face after an altercation, during which Resident 18 shouted at another resident, Resident 4 entered Resident 18’s room, the two residents shouted at each other, and Resident 18 hit Resident 4 on the head, causing skin tears. Resident 18’s record showed diagnoses including bipolar disorder, depression with psychotic features, cognitive communication deficit, adjustment disorder with depressed mood, and anxiety, and an MDS assessment indicated severely impaired cognition. A CNA stated Resident 18 was not cognitively intact. The facility’s Abuse Prevention Program policy stated that resident abuse and mistreatment would not be tolerated, including abuse by other residents.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to ensure that written transfer/discharge notification was provided to the resident and the resident representative for 2 of 4 residents reviewed for hospitalization and discharge. One resident had diagnoses including Alzheimer's disease and delusional disorder and was transferred to the emergency room before returning to the facility; the clinical record did not contain documentation that a written notice was provided to the resident or the resident representative. The DON stated during interview that there was no documentation showing the resident and resident representative received a written notice of transfer/discharge. A second resident had diagnoses including cerebral infarction and aphasia and was admitted to the facility before being discharged to the hospital. The clinical record also showed no written transfer/discharge notification was provided to the resident or the resident's representative. During interview, the DON stated that no transfer/discharge notification had been provided in writing. The Administrator provided the facility's Bed Hold, Transfer and Discharge Policy and Procedure, which stated that the resident, family member, and/or legal representative, if applicable, were to receive a written form prior to transfer to a hospital and that the original State Transfer/Discharge/Bed Hold notice was to be sent with the resident and/or representative.
MDS Assessments Were Coded Incorrectly for Antidepressant, PASRR Level II, and Hospice Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to code MDS items correctly for 2 of 15 residents reviewed. For one resident with diagnoses including anxiety disorder, insomnia, and depression, the admission MDS dated 9/8/25 did not indicate use of an antidepressant and did not indicate a PASRR Level II determination. The clinical record showed the resident was receiving Escitalopram 20 mg daily for depression, and a PASRR Level II Outcome notice dated 9/4/25 documented Long Term Approval without Specialized Services. During interview, the MDS Coordinator stated the antidepressant item should have been marked yes and the PASRR Level II item should have been marked yes, and she stated the facility did not have an MDS policy and used the RAI manual for coding. For another resident with diagnoses including CHF and COPD, the record showed an active physician order for hospice care and a care plan reflecting hospice services. However, the quarterly MDS dated 8/21/25 indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months and did not receive hospice care. During interview, the MDS Coordinator stated the resident was receiving hospice care and that the assessment was incorrectly coded.
Failure to Complete PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a PASARR was completed when a new mental health diagnosis was added for one resident. The resident’s clinical record included diagnoses of dementia, depression, and anxiety, and the PASARR Level I dated 2/10/25 indicated that no Level II was required because no severe mental illness was identified and that no mental health diagnosis was known or suspected. The Level I also stated that if new changes occurred or new information refuted those findings, a new screen must be submitted. The resident was admitted with diagnoses of depression and anxiety, but the clinical record did not contain a new Level I screen reflecting those diagnoses. During interviews, the MDS nurse stated that a new Level I would be done when a new diagnosis or new psychotropic medication was prescribed, and later stated that the resident required a new Level I because of the new diagnoses of anxiety and depression. The facility’s policy on PASRR, dated 5/17/23, stated that people confirmed to have ID, DD, or MI are evaluated to determine the need for specialized services and appropriate placement options.
Failure to Provide Documented Heel Offloading While Resident Was in Wheelchair
Penalty
Summary
The facility failed to ensure Resident 53 received the necessary intervention to promote healing of a facility-acquired pressure ulcer on the left heel. Resident 53 had diagnoses including cerebral infarction, vascular dementia, and an unstageable pressure ulcer of the left heel. The quarterly MDS indicated severe cognitive impairment and risk for pressure ulcers, and the care plan identified the left heel wound with interventions for offloading boots while in bed, but it lacked documentation of interventions to relieve pressure from the left heel while the resident was in a wheelchair. During multiple observations, Resident 53 was seen sitting in a wheelchair in the dining room or hallway with the left foot resting on the floor and wearing only a yellow sock. No pressure relieving devices were observed on the feet or beside the wheelchair. Staff interviews indicated that while in bed the resident’s heels were floated, and while in the chair the resident was supposed to keep her feet off the floor or use wheelchair pedals to float the heels, but one staff member was unsure whether heel floating was required in the wheelchair. The clinical record lacked documentation of how pressure relief was to be maintained for the left heel while the resident was up in the wheelchair. The wound record showed ongoing treatment and reassessment of the left heel wound, including changes in wound care orders and a later update from unstageable to stage 4 after debridement revealed deeper tissue involvement. The NP documented the wound as stable on several assessments, with measurements changing over time, and the weekly wound evaluations listed wheelchair cushion, nutritional supplements, and heel boots as preventative interventions. Despite these entries, the observations and record review did not show documented pressure-relieving measures in place for the left heel while Resident 53 was seated in the wheelchair.
Improper Urinary Catheter Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate care to prevent urinary tract infections for one resident reviewed for UTIs. Resident 9 had diagnoses including Alzheimer's disease, type 2 diabetes mellitus, benign prostatic hyperplasia with lower urinary tract symptoms, dementia, and obstructive and reflexive uropathy. The resident had a suprapubic catheter placed on 6/20/25, and the care plan included an intervention to monitor the position of the drainage bag. On 9/26/25, Resident 9 was observed twice in the activity room with the urinary catheter bag inside a concealed bag that was touching the ground below the reclining wheelchair. The resident's record also showed a UTI note dated 9/11/25 indicating the resident was diagnosed with a UTI, was prescribed an antibiotic through 10/11/25, and had cloudy, foul-smelling urine. During interview, the clinical nurse consultant stated there was not an infection control issue with the concealment bag being on the ground, but said it did not look pretty and she would reposition the bag so it was not on the ground.
Daily Nurse Staffing Post Missing Actual Hours Worked
Penalty
Summary
The facility failed to ensure that the daily census report included the actual hours worked by staff for 7 of 7 days of daily posted nurse staffing reviewed. On 9/23/25 at 11:30 a.m., the daily census report dated 9/23/25 showed no actual hours worked. On 9/29/25 at 12:23 p.m., the Administrator presented the daily census report for 9/23/25 through 9/29/25, and it still lacked documentation of actual hours worked. During an interview on 9/29/25 at 12:58 p.m., the Administrator stated that the daily census report posted lacked documentation of the actual hours worked. On 9/29/25 at 1:32 p.m., the Administrator provided the facility policy, Staffing Posting Requirement, and indicated it was the policy currently being used by the facility; the policy stated that the facility, in cooperation with CMS, would comply with the requirement of daily posting staff in the facility.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of ants in a resident's room. During an observation, several ants were seen crawling both inside and outside a dresser drawer that was partially open in the resident's room. The resident reported that ants were present in her room consistently and had previously been found in her bed. Review of the resident's clinical record showed diagnoses including chronic obstructive pulmonary disorder, personality disorder, and major depressive disorder, and the resident was noted to be cognitively intact. The facility's current pest control policy, which aims to ensure a pest-free environment, was provided but was undated.
Failure to Prevent Falls and Elopement Due to Inadequate Supervision and Hazard Control
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent repeated falls for a resident assessed as high risk for falls. The resident, who had diagnoses including diabetes, osteoporosis, osteoarthritis, and a history of traumatic fracture, experienced multiple falls during her stay. Despite being identified as high fall risk on assessments and having a history of falls, the baseline care plan did not document the resident's fall risk or specific interventions to prevent falls. After a witnessed fall and subsequent unwitnessed fall resulting in fractures of the wrist and hand, there was no documentation of new orders or interventions following the x-ray results. Additionally, after another fall where the resident was unable to stand and later became paralyzed, there was no interdisciplinary team (IDT) note or root cause analysis completed, contrary to facility policy. The facility also failed to ensure adequate supervision and safety measures for a resident assessed as high risk for elopement due to wandering behaviors. The resident, diagnosed with Lewy Bodies dementia, was able to exit the facility through an unlocked door without staff knowledge. The care plan for this resident included interventions for wandering but did not address the malfunctioning door lock, which had been reported as faulty by staff prior to the incident. The resident was found outside by a physical therapist, and there was no documentation of the elopement event in the nursing progress notes, despite an incident report being completed. Interviews with staff revealed lapses in communication and documentation regarding both residents' incidents. For the resident with repeated falls, staff did not consistently notify providers of critical results or update care plans with new interventions. For the resident who eloped, staff had previously reported the faulty door lock, and the incident was not properly documented in the clinical record. Facility policies required immediate reporting, investigation, and care plan updates for incidents and accidents, but these procedures were not followed in these cases.
Failure to Notify Physician of Abnormal X-ray Results After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of abnormal x-ray results for a resident who experienced a fall. The resident, who had multiple diagnoses including diabetes mellitus, a history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis, attempted to get out of bed and fell, resulting in left arm pain. The nurse practitioner was notified and ordered an x-ray, with instructions to notify the clinician of any change in condition. When the x-ray results became available later that day, the LPN placed the results in the physician binder but did not directly notify the physician, and there was no documentation of how or when the physician was informed. The facility's policy required direct physician notification for abnormal x-ray results, but this was not followed in this instance.
Failure to Implement Baseline Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to implement a baseline care plan addressing fall risk for a resident with multiple diagnoses, including diabetes mellitus, a history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. Upon admission, the resident's hospital records indicated osteoporosis and compression fractures, and the resident was placed on fall precautions. Despite this, the baseline care plan created did not document the resident's history of falls, nor did it include the resident's signature. Additionally, the care plan did not address the resident's high risk for falls, as identified in fall risk reviews conducted on two separate occasions. During interviews and record reviews, it was confirmed that the Director of Nursing presented all care plans for the resident, but none included a plan for high fall risk. The facility's policy required the admitting nurse to initiate a baseline care plan assessment upon admission to identify potential problems and implement appropriate interventions, with further review and revision by the interdisciplinary team within 72 hours. However, this process was not followed for the resident in question, resulting in the omission of necessary fall risk interventions in the baseline care plan.
Failure to Notify Resident's Representative of Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's physical status. Resident B, who had diagnoses including atherosclerotic heart disease and dementia, developed a pressure ulcer on the coccyx, which was discovered on 9/5/24. A nursing progress note indicated that a call was made to inform the resident's family representative, but contact was not made, and no further attempts were documented. A wound assessment report later confirmed the presence of an unstageable pressure ulcer. The resident's representative was not informed of the wound until a visit on 9/14/24, when a staff member mentioned it. The Director of Nursing stated that family members were contacted via phone, and if not reached, a message was left without further follow-up unless the resident was transferred to a hospital. The facility's policy required notification within 24 hours of a significant change, but this was not adhered to in this case.
Failure to Address Resident Grievances Regarding Meal Service
Penalty
Summary
The facility failed to address and resolve grievances related to food concerns for five residents, as observed during a survey. On December 27, 2024, multiple residents, including Residents B, C, D, E, and F, were observed not receiving fruit cocktail with their meals, despite having previously raised this issue during a Resident Council Meeting on November 20, 2024. Resident D specifically mentioned not receiving desserts or any fruit, and this was corroborated by the absence of fruit cocktail on the meal trays of the residents observed in the dining room. The Dietary Manager confirmed that the fruit cocktail was available in the refrigerator but was not distributed with the lunch trays. The Director of Nursing provided the Resident Council Meeting Minutes, which documented the residents' complaints about not receiving fruit or desserts with meals. Despite these grievances being documented, the facility did not take prompt action to resolve the issue, as evidenced by the continued absence of fruit cocktail during meals on the day of the survey.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide house shakes to nine residents who had orders for them, resulting in a deficiency. The Dietary Manager (DM) confirmed during interviews that the facility ran out of house shakes over the weekend, affecting residents who required these nutritional supplements. The Director of Nursing (DON) presented an Order Listing Report, which detailed the specific orders for each resident, including the frequency and purpose of the shakes, such as wound healing and weight loss. The residents affected included those with orders dating back several months, indicating a prolonged need for these supplements. The Administrator (ADM) acknowledged that the facility ran out of health shakes on Saturday evening, leaving residents without their prescribed supplements until lunch on Monday. The facility's policy on fortified foods and supplements was reviewed, which indicated that the Dining Services Department was responsible for preparing and delivering these items to nursing for distribution. This deficiency was related to specific complaints and highlighted a lapse in the facility's ability to meet the dietary needs of its residents as per their care plans.
Failure to Follow Approved Dietary Menus
Penalty
Summary
The facility failed to adhere to the approved dietary menus for two observed meals, impacting multiple residents. During a kitchen tour, the Dietary Manager indicated that the lunch menu included fried chicken, mashed potatoes, baked beans, and fruit cocktail. However, observations revealed that several residents, including Residents D, B, C, E, and F, did not receive the fruit cocktail as part of their meal. Interviews with these residents confirmed that they were not offered the fruit cocktail, and the Dietary Manager admitted that the fruit cocktail was not served with the lunch tray. This issue was previously raised in a Resident Council Meeting, where residents complained about not receiving desserts or fruit with their meals. Further discrepancies were noted on another day when the posted menu indicated lunch items such as nachos, rice, and Dutch apple pie, but residents received different items, including baked beans and a dish with marshmallows instead of the apple pie. The cook provided a handwritten menu that did not match the approved dietician menu, which listed different meals for the observed dates. The facility's policy on menu substitutions was reviewed, indicating that staff could choose any food within the same list to substitute for unavailable items, but this policy was not followed as the approved menus were not adhered to.
Failure to Notify Physician of Resident's Medication Refusal and Behavioral Changes
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition, specifically regarding the refusal of medication and increased behavioral issues. Resident C, diagnosed with schizoaffective disorder, paranoid personality disorder, bipolar disorder, and insomnia, was prescribed divalproex sodium for bipolar disorder. Despite multiple refusals to take the medication and exhibiting increased agitation and disruptive behaviors, the physician was not informed as per the facility's policy. The resident's clinical records indicated several instances of medication refusal and behavioral disturbances. From August to October 2024, the resident frequently refused the prescribed divalproex sodium, receiving only a fraction of the doses. The resident's behavior included agitation, verbal aggression, and threats towards staff, as well as disruptive actions that affected other residents. Despite these significant changes in behavior and medication adherence, the facility staff did not notify the physician in a timely manner. The Director of Nursing (DON) was unaware of the specific policy regarding medication refusal, which required notifying the physician after two consecutive refusals or three refusals within a week. This lack of adherence to policy resulted in a failure to address the resident's changing condition appropriately, as evidenced by the resident's eventual need for psychiatric hospitalization.
Failure to Implement Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a pressure ulcer. The resident, diagnosed with Alzheimer's Disease and depression, developed a stage 3 pressure wound on the coccyx, discovered during their stay. Initial treatment recommendations included cleansing the wound with normal saline, applying collagen particles, and covering with bordered gauze. Subsequent recommendations adjusted the dressing to a transparent film, to be applied three times a week and as needed. However, these treatment orders were not entered into the Medication Administration Record and Treatment Administration Record (MAR/TAR) for the initial assessments on 9/11/24 and 9/18/24. A physician's order was eventually entered on 9/26/24, but no treatment was documented until 10/1/24, indicating a significant delay in care. Interviews with the Director of Nursing and the Administrator revealed that the treatment orders may not have been properly entered by staff and were electronically placed in a queue without activation. This oversight resulted in a lack of documented treatment for the pressure wound from its discovery until nearly three weeks later.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, leading to significant deficiencies in care. Resident 34, who had diagnoses including dementia and diabetes mellitus, was identified as being at mild risk for pressure ulcers. Despite this, the resident developed a stage two pressure ulcer on the left heel, which deteriorated into an unstageable ulcer. The facility did not implement timely interventions for pressure relief, such as heel boots or a low air loss mattress, even after recommendations from the Nurse Practitioner. Observations showed that the resident often did not have pressure-relieving devices in place, and the care plan was not updated promptly to address the worsening condition. Additionally, Resident 34 developed a new pressure ulcer on the left buttock, which was also not addressed with adequate pressure relief interventions. The care plan for this injury was delayed, and the necessary pressure-relieving devices were not consistently used. Observations and interviews revealed that the resident spent significant time in bed without appropriate pressure relief, contributing to the deterioration of the pressure ulcers. Resident 5 developed a facility-acquired Stage III pressure ulcer on the left upper back, reportedly caused by tight bra straps. The facility failed to initiate the prescribed wound treatment promptly, and there was a lack of documentation and communication regarding the wound's care. Interviews with staff indicated confusion about the presence and treatment of the wound, and there was no evidence of an interdisciplinary team meeting or root cause analysis to address the development of the pressure ulcer.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility was found to have multiple deficiencies related to maintaining a safe and sanitary environment over a six-day survey period. Observations revealed that the air conditioning vent cover in the nursing supply room was covered with a dark, moist, powder-like substance. Additionally, the biohazard room near the south nursing station was repeatedly found unsecured and unattended, containing multiple containers of liquid cleaners, an unlocked refrigerator with resident biological specimens, and a biohazard bin with full sharps containers. The Director of Nursing acknowledged the need for repair to secure the biohazard room door. Further deficiencies were noted in resident rooms and bathrooms. An electrical outlet in a resident's room was observed to be loose and pulling away from the wall. Several resident bathrooms were reported to have a strong odor of urine and feces, with a dark substance around the base of the toilets. These observations were consistent across multiple dates and times, affecting numerous residents. The facility administrator confirmed the presence of these issues, indicating the need for cleaning and repair of the toilet caulking and the electrical outlet.
Failure to Provide Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide the required written notification for transfer and discharge to two residents and their representatives. Resident 1, diagnosed with chronic obstructive pulmonary disease, was sent to the hospital, but the clinical record lacked documentation of the written Notice of Transfer and Discharge forms being provided. Similarly, Resident 31, who had diagnoses including schizophrenia, dysphagia, cognitive communication deficit, and unspecified psychosis, was transferred to the hospital without the necessary written notification being documented in the clinical record. The facility's policy, as provided by the Interim Director of Nursing, did not include sending the Transfer and Discharge form in writing to the resident and the resident representative. Instead, the forms were sent with the resident when they were transferred to another facility. This practice was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the facility did not provide the written notices as required.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents who were transferred to the hospital, as required. This deficiency was identified for two residents during a review of their clinical records. Resident 1, who had a diagnosis including chronic obstructive pulmonary disease, was sent to the hospital, but the clinical record lacked documentation of the facility's bed-hold policy being provided in writing. Similarly, Resident 31, with diagnoses including schizophrenia, dysphagia, cognitive communication deficit, and unspecified psychosis, was transferred to the hospital without documented written notification of the bed-hold policy. During an interview, the Interim Director of Nursing admitted that the facility did not provide the bed-hold notification forms in writing to the residents prior to their transfer. Instead, the forms were sent with the residents when they were transferred to another facility. The facility's policy, which was undated but currently in use, stated that the bed-hold notification should be provided in written form and/or by telephone conversation prior to hospital transfer. This discrepancy between policy and practice led to the deficiency noted by the surveyors.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during their MDS evaluations. For Resident 31, the clinical record review revealed a discrepancy in the Annual MDS assessment dated 2/8/24. The assessment incorrectly marked section A1500 as 'NO' for PASARR Level II, despite a prior determination on 10/20/23 indicating a Level II outcome for long-term approval without specialized services. Additionally, section A1510 was left incomplete, which should have been filled out due to the resident's PASARR Level II status. The MDS Coordinator acknowledged the error during an interview, confirming that the sections were incorrectly marked and incomplete. For Resident 3, the Quarterly MDS assessment dated 7/3/24 inaccurately indicated that the resident received parenteral/IV feeding in section K0520. However, the MDS Coordinator confirmed that the resident had not received IV nutrition since being admitted to the facility. This error was identified during a review of the resident's clinical record and was acknowledged by the MDS Coordinator during an interview.
Failure to Label Oxygen Tubing for Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, diagnosed with chronic respiratory failure with hypoxia, COPD, cognitive communication deficit, and dementia, was observed multiple times with unlabeled nasal cannula oxygen tubing. The physician's orders specified that the resident was to receive oxygen at a rate of 2 liters per minute and that the oxygen tubing should be changed weekly on Sunday nights. However, during several observations over a period of days, the tubing was consistently found to be unlabeled, contrary to the facility's policy. An interview with an LPN revealed that the facility did not have a dedicated respiratory therapy department, suggesting that the responsibility for labeling the tubing fell to the nursing staff. The LPN admitted to not knowing when the tubing was last changed. The facility's policy on oxygen administration, provided by the Regional Nurse Consultant, clearly stated that tubing should be labeled with the date, time, and initials of the staff member completing the service. This lack of adherence to the policy resulted in a deficiency in the standard of care provided to the resident.
Significant Medication Error Involving Resident
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered another resident's medications. The resident, who had diagnoses including schizophrenia, dysphagia, cognitive communication deficit, unspecified dementia, and unspecified psychosis, was mistakenly given a combination of medications not prescribed to them. These medications included Lyrica, Hydralazine, Oxycontin, Cymbalta, Coreg, Calcium, Senna, and Eliquis. This error was identified during a hospital stay, where it was noted that the resident had been given these incorrect medications. Interviews with the Executive Director and the Director of Nursing confirmed that the medication error occurred when an agency nurse administered the wrong medications to the resident. The facility's policy and procedure for medication administration, as well as the guidelines from UnitedRx Long Term Care Pharmacy, were reviewed and indicated that licensed professional nurses are responsible for administering medications according to the Medication Administration Record (MAR) and must identify the resident before administering medication. Despite these guidelines, the error occurred, leading to the resident's hospitalization and subsequent readmission to the facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Martinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Valley Health & Rehab | 3.3 mi | ★★★★★ | 0 | 0 |
| Morgantown Woods Of Journey | 11 mi | ★★★★★ | 10 | 0 |
| Miller's Merry Manor | 14.6 mi | ★★★★★ | 1 | 0 |
| Richland Bean Blossom Health Care Center | 14.8 mi | ★★★★★ | 11 | 0 |
| Springs Of Mooresville, The | 14.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.