Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at James River Nursing And Rehabilitation during CMS and state inspections, most recent first.
Three residents who required assistance with bathing did not consistently receive showers according to their care plans and preferences, often going extended periods without bathing. Residents reported feeling dirty and uncomfortable, and staff interviews confirmed that staffing shortages and turnover led to missed showers, with management aware of the ongoing concerns.
The facility failed to ensure cups and glasses were air-dried before storage, leading to potential contamination risks. Observations showed improper storage of 102 cups/glasses, contrary to FDA guidelines. Interviews revealed staff were unaware of proper drying procedures, and the facility lacked a relevant policy.
A facility failed to maintain resident dignity and respect in two incidents. In one, a resident felt intimidated during a group discussion with staff about care prioritization. In another, a CNA handled a cognitively impaired resident roughly and used derogatory language. These actions violated the facility's policies on resident dignity.
The facility failed to provide a clean, safe, and homelike environment for residents, as evidenced by unaddressed maintenance issues. A resident reported trash and stained ceilings, another faced wall damage from a power chair, and a third had a loose electrical outlet affecting device charging. Despite residents notifying staff, these issues persisted, indicating a breakdown in maintenance reporting and follow-up.
The facility failed to secure medication carts, leaving them unlocked and unattended on three occasions. An LPN, a CMT, and the DON were involved in incidents where carts were left unsecured in hallways and near resident areas. Staff interviews confirmed that carts should be locked when unattended, but no formal policy was provided.
Facility staff failed to maintain proper infection control during medication administration and glucometer disinfection. An LPN used a gloved finger to stir medications for a resident with complex medical needs, while a CNA/CMT improperly handled spilled medications for another resident. Additionally, staff did not follow proper disinfection procedures for glucometers used on multiple residents, risking cross-contamination. These actions were acknowledged as breaches of infection control protocols by facility leadership.
The facility failed to provide scheduled showers to two residents, impacting their right to self-determination. One resident, with multiple health conditions, received showers sporadically, leading to feelings of uncleanliness. Another resident, also with significant health issues, experienced long delays between showers, despite needing substantial assistance. Staff interviews revealed inconsistencies in shower provision, with the DON and Administrator acknowledging the issue.
A resident's privacy was compromised when a CNA left the room door open during incontinence care, exposing the resident to the hallway. Despite the resident's discomfort and the facility's policy on maintaining privacy, the door was left open due to the roommate's preference. Staff interviews confirmed that privacy should have been ensured by closing the door or using the privacy curtain.
A resident was admitted to the facility without the required PASARR screening, which is necessary to identify mental disorders or intellectual disabilities. Despite the facility's policy requiring a Level I PASARR before admission, the documentation was missing from both electronic and paper records. The MDS Coordinator and other staff acknowledged the oversight, noting the resident's long-term stay and relevant diagnoses.
A resident in an LTC facility did not receive necessary services for personal hygiene, as staff failed to provide adequate peri-care and change urine-soaked items. The resident, dependent on staff for mobility and hygiene, was observed sitting in a urine-soaked wheelchair pad. Staff did not follow proper procedures for incontinent care, including hand hygiene and changing soiled clothing, leading to a deficiency.
A resident's code status was inconsistently documented across their medical records, with a DNR order on the face sheet and a full code status in the care plan. Staff interviews revealed confusion about who was responsible for ensuring consistency, despite the information being available in multiple locations. The DON and Administrator acknowledged the need for consistent documentation, but discrepancies remained.
A facility failed to document a diagnosis justifying catheter use for a resident, despite policy requiring such documentation. The resident's records, including the MDS and physician's orders, lacked a diagnosis for the catheter, and staff interviews confirmed the expectation for such documentation. The resident had a history of kidney complications and UTIs, but these were not linked to the catheter use in the records.
A facility failed to obtain a physician's order for a resident's CPAP therapy, resulting in inconsistent application of the CPAP machine at bedtime. The resident, who had chronic respiratory failure and was cognitively intact, reported that staff did not always assist with the CPAP. Interviews with staff revealed a lack of awareness and communication regarding the resident's CPAP needs, and there was no documented order for the therapy in the resident's records.
A resident with significant health conditions, including bilateral above-knee amputations, experienced loose bed rails that were not properly maintained or documented by the facility staff. Despite the resident's notification to staff, the issue persisted, highlighting a deficiency in the facility's monitoring and maintenance processes.
A facility experienced a 14% medication error rate due to improper administration practices. An LPN failed to prime an insulin pen before use, and another LPN mixed medications without a physician's order for a resident with a PEG tube. Staff interviews confirmed these actions were against facility protocols.
A resident with type two diabetes received insulin without the pen being primed, as required by the manufacturer's instructions. An LPN administered 4 units of insulin without priming the NovoLog FlexPen, despite the facility's expectation to prime before each use. The resident was cognitively intact and received insulin injections daily.
The facility failed to provide timely written notifications to residents and their representatives regarding hospital transfers. Three residents did not receive written notices in a timely manner, with delays ranging from 30 to 47 days. Staff interviews revealed a lack of awareness and implementation of the process for sending out these notices, and the Business Office Manager admitted to delays due to availability. The Administrator confirmed that the facility did not issue written transfer notices, relying instead on verbal communication and monthly logs sent to the Ombudsman.
The facility failed to protect residents from misappropriation when an LPN was found with multiple pills in their pockets, leading to 17 missing doses of medication affecting twelve residents. The facility's policies on abuse, neglect, exploitation, and misappropriation were not followed, and the investigation process was not thoroughly documented.
The facility failed to ensure complete and accurate medical records for four residents, as staff did not document or verify the administration of prescribed treatments. The ADON assumed treatments were completed by a nurse who left unexpectedly and did not confirm with the residents.
The facility failed to administer a resident's as-needed pain medication despite multiple requests and visible signs of pain. The resident, with severe sepsis and other conditions, reported significant pain, but the medication was not given, and proper documentation was lacking.
Failure to Honor Resident Shower Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring reasonable shower preferences for three residents. Observations, interviews, and record reviews revealed that these residents, all of whom had no cognitive impairment and required partial to moderate assistance with bathing, did not consistently receive showers according to their stated preferences or care plans. Documentation showed significant gaps between showers, with some residents going up to 13 days without a shower, despite care plans indicating a preference for two showers per week on specific days. There was no documentation of resident refusals or additional showers provided. Interviews with the affected residents confirmed that they felt dirty, had oily hair, and experienced discomfort such as itching and skin issues due to infrequent bathing. One resident with cellulitis reported that infrequent showers led to skin cracking under abdominal folds. All three residents expressed a desire for more frequent showers and indicated that their preferences were not being met, often receiving only one shower per week instead of the two specified in their care plans. Staff interviews corroborated these findings, with CNAs and LPNs acknowledging that residents were not receiving the required number of showers due to staffing shortages and turnover among shower aides. Staff reported being pulled to other duties, which resulted in missed showers, and confirmed that residents had voiced concerns about the lack of regular bathing. Management was aware of these concerns, and staff were unsure how many showers residents actually received each week, despite a process for reviewing shower sheets.
Improper Drying and Storage of Cups and Glasses
Penalty
Summary
The facility failed to adhere to professional standards for food safety by not ensuring that cups and glasses were air-dried before storage, potentially leading to contamination or bacterial growth. Observations on two separate occasions revealed that a total of 102 small water and juice cups/glasses were stored upside down in a manner that trapped water, preventing proper air drying. This practice was contrary to the 1999 Food Code issued by the FDA, which mandates that equipment and utensils must be air-dried before being stored to prevent microorganism growth. Interviews with dietary staff and the dietary manager indicated a lack of awareness and understanding of the proper procedures for drying dishes. Dietary aides admitted to not knowing that dishes needed to be completely dry before storage, while the dietary manager was unaware of the improper storage method being used. The facility also lacked a specific policy regarding the air drying of dishes, and the administrator acknowledged the absence of such a policy and the inadequate air gap for drying, which contributed to the deficiency.
Inappropriate Staff Behavior and Lack of Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by two separate incidents involving inappropriate staff behavior. In the first incident, a resident with multiple sclerosis and other health conditions was involved in a disagreement with CNAs regarding the prioritization of care. The situation escalated when the resident was taken to the library for a discussion with multiple staff members, including an LPN and an ADON. The resident felt intimidated by the presence of multiple staff members and the loud, demanding tone used by the LPN, which was audible and visible to others in the facility. In the second incident, a resident with severe cognitive impairment and multiple health issues was subjected to rough handling and verbal abuse by a CNA. The CNA was reported to have transferred the resident roughly and used derogatory language, referring to the resident as a "fucking goat" in the presence of other staff and the resident. This behavior was corroborated by multiple staff members who witnessed the incident, and it was noted that the CNA had a history of being rude and using inappropriate language with residents. These incidents highlight a failure to adhere to the facility's policies on treating residents with dignity and respect. The staff's actions, including the use of inappropriate language and rough handling, were not in line with the facility's guidelines for maintaining a respectful and dignified environment for residents. The facility's policies emphasize the importance of treating residents with kindness and respect, which was not upheld in these cases.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident #70 reported trash and debris under the bed and recliner, as well as stained ceilings, which were confirmed upon observation. The maintenance request log showed a previous report of a leak by the smoke detector, but no entry regarding the ceiling damage above the bed was documented. This indicates a lack of follow-up on maintenance issues, contributing to the resident's discomfort and perception of an unclean environment. Resident #30 experienced wall damage in their room, reportedly caused by staff driving a power chair into the wall, which left the metal drywall corner bracket exposed. The resident also noted peeling wallpaper above their bed, which they attempted to cover with a plant. Despite the resident's awareness of the maintenance staff's efforts to address repairs, there were no documented maintenance requests for the wall damage, highlighting a gap in communication and documentation of maintenance needs. Resident #49 faced issues with a loose electrical outlet that could not securely hold plugs, affecting their ability to charge devices like a cell phone. The resident had informed staff multiple times, but the issue persisted, as observed with the CPAP machine's plug hanging loosely from the outlet. Interviews with staff, including the Maintenance Director, revealed a lack of awareness of the specific issues in the residents' rooms, suggesting a breakdown in the reporting and addressing of maintenance concerns. The facility also lacked a policy for monitoring electrical outlets, further contributing to the oversight of this deficiency.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During observations, three separate incidents were noted where medication carts were left unlocked and unattended. On one occasion, an LPN left a medication cart unlocked in the hallway while administering medications to a resident in their room. The Assistant Director of Nursing later locked the cart. In another instance, a medication cart was left unlocked near a resident lounge area, unattended by staff, until the Director of Nursing secured it. A third observation noted a medication cart left unlocked in a hallway, with several residents and staff passing by, until a Certified Medication Technician locked it. Interviews with various staff members, including a CNA/CMT, an Admissions Nurse, and the Director of Nursing, confirmed that the facility's practice is to lock medication carts when not attended by staff. However, the facility did not provide a policy regarding the storage of medications, indicating a lack of formal guidance on this critical safety procedure. The facility census at the time was 101, highlighting the potential risk posed by the unsecured medication carts in a busy environment.
Infection Control Deficiencies in Medication Administration and Glucometer Disinfection
Penalty
Summary
The facility staff failed to maintain proper infection control practices during medication administration and glucometer disinfection, leading to deficiencies in care. For Resident #254, a Licensed Practical Nurse (LPN) was observed using a gloved finger to stir crushed medications in a cup before administering them via a peg-tube. This action was acknowledged by multiple staff members, including the Director of Nursing (DON) and Administrator, as unacceptable and a breach of infection control protocols. Resident #254 had a complex medical history, including chronic obstructive pulmonary disease, respiratory failure, and dysphagia, requiring careful medication management. In another incident, a Certified Nursing Assistant/Medication Technician (CNA/CMT) was observed handling medications for Resident #8 inappropriately. After spilling pills from a medication cup onto a tapestry runner, the CMT used a plastic spoon to scoop them back into the cup and administered them to the resident. This action was contrary to infection control guidelines, which require discarding dropped medications. Resident #8 had severe cognitive impairment and multiple health conditions, including congestive heart failure and chronic renal failure, necessitating precise medication administration. The facility also failed to properly disinfect glucometers used for blood glucose testing for Residents #74, #22, and #14. Observations revealed that staff did not follow the manufacturer's disinfection procedures, such as thoroughly wiping the glucometer with a disinfectant wipe and allowing it to air dry. Instead, staff wrapped the glucometer in a sani-wipe without proper cleaning, potentially leading to cross-contamination. These lapses in infection control were acknowledged by the Admissions Coordinator and DON, who emphasized the importance of adhering to infection control guidelines.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to uphold the residents' right to self-determination by not providing showers or baths as requested and care planned for two residents. Resident #46, who has a history of cerebral infarction, COPD, SLE, cognitive communication deficit, and CHF, was scheduled to receive showers twice a week. However, records show that the resident only received showers sporadically, with gaps ranging from seven to fourteen days between showers. The resident expressed dissatisfaction with the infrequency of showers, stating that once a week was insufficient and left them feeling dirty and tired. Resident #49, with diagnoses including metabolic encephalopathy, type 2 diabetes, bilateral leg amputation, CKD, CHF, and chronic respiratory failure, also experienced a lack of regular bathing. Despite being cognitively intact and requiring substantial assistance, the resident received showers or bed baths with significant delays, sometimes up to a month apart. The resident expressed feeling unclean and uncomfortable due to the infrequent bathing schedule and mentioned a previous agreement for more frequent showers, which was not being honored. Interviews with facility staff, including CNAs and the DON, revealed inconsistencies in the provision of showers, with some staff unaware of the residents' needs or the facility's policies. The DON and Administrator acknowledged that residents should be offered showers twice a week, regardless of hospice status, and that the current practice of extended delays between showers was not acceptable.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during the provision of personal care. An observation revealed that the door to the resident's room was left open while a Certified Nursing Assistant (CNA) was performing incontinence care, exposing the resident's unclothed back to anyone passing by in the hallway. The resident, who has moderate cognitive impairment and is dependent on staff for personal care, expressed discomfort with being exposed, although noted that their roommate preferred the door open due to claustrophobia. Interviews with various staff members, including a CNA/Certified Medication Technician, a Licensed Practical Nurse (LPN), the Admissions Coordinator, and the Director of Nursing (DON), confirmed that it is against facility policy to leave a resident exposed in such a manner. The staff acknowledged that privacy should be maintained by closing the door or at least pulling the privacy curtain during personal care. The facility's policy on dignity emphasizes the importance of respecting residents' privacy and ensuring their well-being, which was not adhered to in this instance.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident prior to or upon admission. The facility's policy mandates that all new admissions and readmissions undergo a Level I PASARR screening to identify any mental disorders, intellectual disabilities, or related disorders. If the Level I screening indicates potential issues, a Level II evaluation is required. However, for one resident, no Level I or Level II PASARR was found in the records, despite the resident having diagnoses that include intellectual disabilities and dementia. The MDS Coordinator, responsible for PASARRs, stated that Level I screenings are typically completed at the hospital before admission, or by the facility if the resident comes from home. The Coordinator believed the resident should have had a PASARR completed due to their long-term stay at the facility. However, upon review, neither the electronic medical record nor the paper records contained the necessary PASARR documentation. The Director of Nursing and Administrator confirmed that a Level I PASARR should have been completed prior to admission, but it was not found in the records.
Inadequate Incontinent Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, the staff did not provide adequate peri-care and failed to change urine-soaked items for a resident who was incontinent of bladder. The resident, who was cognitively intact but dependent on staff for mobility and personal hygiene, was observed sitting in a urine-soaked wheelchair pad while waiting for care. During the observed incident, multiple staff members, including CNAs and the ADON, were involved in transferring the resident using a Hoyer lift. Despite the presence of urine on the resident's wheelchair pad and floor, the staff did not change the wet Hoyer sling or the resident's urine-soaked pants. The CNAs also failed to perform proper peri-care, using the same wipe for multiple areas and not changing gloves between dirty and clean tasks. Interviews with various staff members, including a CNA/CMT, LPN, Admissions Coordinator, and the DON, revealed that the facility's expected procedures for incontinent care were not followed. These procedures included performing hand hygiene, using one wipe per swipe, and ensuring all clothing and linens were clean before being put back on the resident. The staff's actions during the incident did not align with these expectations, leading to the deficiency.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was consistent throughout their medical record. The resident, who had a history of cerebral infarction, altered mental status, COPD, chronic respiratory failure with hypoxia, and systemic lupus erythematosus, was documented as having a do not resuscitate (DNR) order on their face sheet. However, the care plan indicated the resident was full code, meaning they wished to receive CPR if their heart or breathing stopped. Interviews with various staff members, including CNAs, CMTs, LPNs, RNs, and the Social Service Director, revealed that the code status information was available in multiple locations, such as the electronic medical record (EMR), the resident's closet care plan, and the face sheet. Despite this, there was a lack of consistency in ensuring that the code status matched across all these records. Staff members believed that the information should match and that audits were conducted to ensure accuracy, but there was confusion about who was responsible for these audits. The Director of Nursing and the Administrator both acknowledged that the code status should be consistent throughout the resident's chart. They explained that the admission nurse was responsible for entering the code status information, and a match back audit was supposed to be conducted 24 hours after orders were entered. However, discrepancies were noted, and it was unclear who was responsible for ensuring the accuracy of the code status across all records, leading to the deficiency identified by the surveyors.
Lack of Documentation for Catheter Use in Resident
Penalty
Summary
The facility failed to ensure proper documentation and justification for the use of a catheter in a resident's medical record. Specifically, Resident #47's medical record did not contain a diagnosis to justify the use of a catheter, despite the resident arriving at the facility with a catheter already in place. The facility's policy on catheter care, revised in August 2022, requires staff to review and document the clinical indications for catheter use prior to insertion, which was not adhered to in this case. The resident's face sheet, progress notes, Minimum Data Set (MDS), physician's orders, care plan, and Treatment Administration Record (TAR) all lacked documentation of a diagnosis that warranted the catheter use. Interviews with facility staff, including the Infection Control Nurse, Admissions Coordinator, Director of Nursing (DON), and Administrator, revealed that there was an expectation for a diagnosis to be documented for catheter use. The staff acknowledged that physician orders should be based on diagnoses, and the absence of such documentation was a lapse in following standard practice. The facility census at the time was 101, and the resident had a history of kidney complications and urinary tract infections (UTIs), but these were not explicitly linked to the need for a catheter in the documentation.
Failure to Obtain Physician's Order for CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea by not obtaining a physician's order for the use of a CPAP machine at bedtime. The resident, who was cognitively intact and had a history of chronic respiratory failure with hypoxia, had a CPAP machine at their bedside but reported that staff did not always apply the mask or turn on the machine at night. The resident expressed a willingness to use the CPAP if assisted by staff, but there was no documented order for CPAP therapy in the resident's Treatment Administration Record (TAR) or Medication Administration Record (MAR). Interviews with facility staff, including LPNs and the Director of Nursing, revealed a lack of awareness and communication regarding the resident's CPAP therapy needs. The staff believed that CPAP treatment would be documented in the nursing TAR, but there was no confirmation of its presence. The Director of Nursing and the Administrator acknowledged that there should have been an order for CPAP use, including pressure settings, and that nurses were responsible for ensuring the CPAP was applied. The deficiency was identified through observation, interviews, and record reviews, highlighting a failure to adhere to the facility's policy on CPAP support.
Failure to Ensure Proper Installation and Maintenance of Bed Rails
Penalty
Summary
The staff at the facility failed to ensure the correct installation and maintenance of bed rails for a resident, identified as Resident #49. The resident's bed rails were observed to be loose, allowing movement back and forth several inches, which the resident had reported to the staff. The resident, who was cognitively intact, relied on the bed rails for mobility and positioning due to bilateral above-knee amputations and other significant health conditions, including metabolic encephalopathy, type 2 diabetes, and chronic kidney disease. Despite the resident's notification to the staff about the loose rail, the issue persisted, indicating a lapse in maintenance and monitoring. The facility did not have a policy regarding the use, installation, and monitoring of side rails, which contributed to the deficiency. The Maintenance Director stated that he installed the enabler bars after therapy evaluations and checked them monthly, but did not maintain a log of these checks. The Director of Nursing mentioned that side rail assessments should be reviewed by management and monitored quarterly or when there are changes in the resident's condition. However, there was no formal documentation or consistent process to ensure the safety and security of the bed rails, leading to the deficiency observed during the survey.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14% error rate during an observed medication pass. This deficiency was identified through two specific incidents involving medication administration errors. In the first incident, a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident with type two diabetes, despite the manufacturer's instructions requiring priming before each use. The resident's blood sugar level was 206 mg/dL, necessitating 4 units of insulin, which was administered without priming the pen. In the second incident, the facility did not adhere to its policy for administering medications through an enteral tube. An LPN crushed and mixed three medications—diltiazem, gabapentin, and oxycodone—before administering them via a percutaneous endoscopic gastrostomy (PEG) tube to a resident. The facility's policy requires each medication to be administered separately with flushing between medications, and there was no physician's order to crush or mix these medications. The resident involved had a diagnosis of chronic obstructive pulmonary disease, respiratory failure, encephalopathy, and dysphagia, and was on a nothing by mouth (NPO) status. Interviews with facility staff, including the Director of Nursing (DON) and the Medical Director, confirmed that the facility's expectations were not met in these instances. The staff acknowledged that insulin pens should be primed before each use and that medications administered through a PEG tube should be given separately with appropriate flushing. The lack of adherence to these protocols contributed to the medication errors observed during the survey.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility staff failed to ensure that all residents were free from significant medication errors when a Licensed Practical Nurse (LPN) did not prime an insulin pen before administering insulin to a resident. The resident, who was cognitively intact and had diagnoses including type two diabetes, obesity, dependency on renal dialysis, high blood pressure, and heart failure, was observed receiving insulin injections seven days a week. During an observation, the LPN performed a blood sugar test on the resident, which resulted in a reading of 206 mg/dL, indicating the need for 4 units of sliding scale Novolog insulin. However, the LPN administered the insulin without priming the pen, contrary to the manufacturer's instructions. The manufacturer's instructions for the NovoLog FlexPen, revised in March 2008, specify that the pen should be primed before each injection to ensure proper dosing. The LPN admitted to only priming the insulin pens for their initial use and not for subsequent administrations. Interviews with the Admissions Coordinator and the Director of Nursing (DON) confirmed that the facility's expectation was for staff to prime insulin pens prior to each administration. This oversight in following the correct procedure for insulin administration led to a significant medication error for the resident.
Failure to Provide Timely Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as required by regulations. This deficiency was identified for three residents out of a sample of ten. The facility did not have a policy in place for issuing written transfer notices, which contributed to the oversight. In the case of Resident #30, the transfer notice was not effectively communicated, as the resident and their spouse did not recall receiving any written notification. The notice was initiated on the electronic record system on the day of transfer but was not printed and mailed until 47 days later. Resident #65 experienced a similar issue, with the effective date of the transfer notice being 30 days after the initial transfer and 35 days after a subsequent transfer. The resident's family was informed by phone, but there was no evidence of a written notice being sent in a timely manner. Resident #70 also did not receive a timely written notice, with the effective date being 37 days after the transfer. Interviews with staff revealed a lack of understanding and implementation of the process for sending out written transfer notices. The facility's staff, including LPNs, RNs, and the ADON, were unaware of the requirement to send written notices to families. The Business Office Manager was responsible for sending out the notices but admitted to delays due to their availability. The Administrator confirmed that the facility did not issue written transfer notices, relying instead on verbal communication and monthly logs sent to the Ombudsman. This systemic failure to provide timely written notifications constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Account for Missing Medications and Protect Residents from Misappropriation
Penalty
Summary
The facility failed to keep all residents free from misappropriation when staff could not account for 17 doses of medication, affecting twelve residents. The incident involved a Licensed Practical Nurse (LPN) who was found with multiple pills in their pockets, which were identified as controlled substances such as oxycodone, Lortab, Xanax, and Norco. The police were called, and the LPN was arrested. The facility's Assistant Director of Nursing (ADON) and other staff members conducted a medication count and found discrepancies in the narcotic log, indicating that 17 pills were missing from the count. The missing medications were not documented as administered in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and the narcotic records showed slash marks indicating doses given but not properly accounted for. The facility's policies on abuse, neglect, exploitation, and misappropriation were not followed, as the medications were not signed out correctly, and the investigation process was not thoroughly documented. The Director of Nursing (DON) and other staff members were unaware of the exact number of missing pills and relied on sticky notes and handwritten lists to track the discrepancies. Interviews with staff members revealed that it was not appropriate to put resident medications in staff's pockets or to pop multiple residents' medications at the same time. The facility's failure to account for the missing medications and to follow proper procedures for documenting and investigating the incident resulted in a deficiency in protecting residents from misappropriation of their belongings or money.
Failure to Document and Verify Resident Treatments
Penalty
Summary
The facility failed to ensure all residents' medical records were complete and accurate, as staff did not document whether treatments were completed for four residents and did not follow up on potentially missed treatments. Resident #2, who had multiple diagnoses including cellulitis, multiple sclerosis, and severe sepsis, had orders for various creams to be applied to different parts of the body. On a specific date, the evening doses of these treatments were not documented as administered, and the Assistant Director of Nursing (ADON) noted this without confirming with the residents if the treatments were actually given. Resident #4, who had diagnoses including rhabdomyolysis and chronic pain syndrome, also had orders for skin treatments and blood sugar checks. On the same date, the evening treatments and blood sugar checks were not documented as completed, and the ADON again noted this without verifying with the resident. Similarly, Resident #9, who had type two diabetes and other conditions, had an order for a vaginal cream that was not documented as administered on the same date. Resident #10, diagnosed with COVID-19 and pneumonia among other conditions, had an order for a compression stocking that was not documented as addressed on the same evening. The ADON assumed the treatments were completed by a nurse who had to leave unexpectedly and did not verify with the residents. The Director of Nursing (DON) deferred questions about the missed treatments to the ADON, emphasizing that treatments should be administered as ordered by the physician.
Failure to Administer Pain Medication as Requested
Penalty
Summary
The facility failed to ensure effective pain management for a resident who required such services. Specifically, the staff did not administer the resident's as-needed pain medication when requested, despite the resident showing physical signs of pain. The resident, who had severe sepsis with septic shock, type 2 diabetes mellitus with diabetic chronic kidney disease, and bacteremia, reported experiencing significant pain on the night in question. The resident requested pain medication multiple times from the CNA, who reported the requests to the nurse three times, but the medication was never administered. The resident described the pain as a 10 on a scale of one to 10 and was visibly uncomfortable. The facility's policy on administering oral medications was not followed, as evidenced by the lack of documentation on the MAR/TAR and narcotic records. The ADON, who arrived to cover for a nurse, was unaware of any residents being in pain due to not receiving their medication. The DON confirmed that medications should be administered as ordered by the physician. The failure to administer the pain medication as requested and the lack of proper documentation led to the deficiency noted in the report.
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Illustrative
What surveyors actually found near you
We read the 148 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glendale Gardens Nursing & Rehab | 1.2 mi | ★★★★★ | 15 | 0 |
| Spring Valley Health & Rehabilitation Center | 2.7 mi | ★★★★★ | 33 | 0 |
| Cox Medical Centers Meyer Orthopedic And Surgical | 3.1 mi | ★★★★★ | 1 | 0 |
| Springfield Villa | 3.2 mi | ★★★★★ | 10 | 1 |
| Birch Pointe Health And Rehabilitation | 3.8 mi | ★★★★★ | 0 | 0 |
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