Below 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 Bayside Of Poquoson Health And Rehab during CMS and state inspections, most recent first.
A resident with advanced dementia and severe cognitive impairment was found to have fall mats in their room that were soiled with stains, debris, and shoe prints. The mats, intended as a safety intervention for fall risk, were not kept clean, and staff were observed standing on them, indicating a failure to maintain sanitary resident equipment.
Facility staff did not create a person-centered care plan for a resident with a PEG tube, despite the resident's severe cognitive impairment and visible site issues such as leakage and irritation. The care plan lacked any mention of the PEG tube, even though physician orders for site care and flushing were present. The resident's family was observed providing care to the site, highlighting the absence of staff intervention.
Facility staff failed to provide consistent hygiene care and assistance with activities of daily living for two dependent residents. One resident received only sporadic showers and was not shaved as scheduled, while another was not offered or provided assistance with shaving unwanted hair, despite both being coded as dependent for these tasks in their care plans and assessments.
A resident with neurogenic uropathy and urinary retention was observed multiple times with an unsecured Foley catheter, as the stat lock device was improperly wrapped around the tubing instead of stabilizing it. Staff and DON confirmed the catheter was not appropriately secured, in violation of the care plan and physician orders.
A resident with a history of stroke and sleep apnea did not consistently receive proper C-PAP therapy as ordered, with reports of the device being misapplied and water entering the mask and tubing. Staff did not ensure the device was correctly in place or investigate when the resident removed it, resulting in inadequate respiratory care.
An LPN was observed leaving a medication cart unlocked and unattended while administering medications to multiple residents, making drugs accessible to unauthorized individuals. The Administrator later secured the cart but did not address the issue with the LPN. The administrative team was informed of the findings and did not provide comments.
A resident who had recently undergone a breast biopsy was not properly assessed or monitored for wound infection by facility staff, despite visible drainage and changes in condition. The lack of communication and documentation regarding the surgical site led to the resident developing sepsis and requiring hospitalization. Staff and the PA were unaware of the biopsy and its aftercare needs, and relevant medical information was not accessible in the primary EHR system.
A resident with a PEG tube and severe cognitive impairment was observed with improper tube positioning, leakage, and skin irritation at the insertion site. The care plan did not address the PEG tube, and there was no specific physician order for the tube itself. Staff did not consistently provide necessary site care, and the resident's family member was seen performing dressing changes. The site was later found to be irritated due to a fungal infection.
Facility staff did not maintain a complete and accessible medical record for a resident who underwent a breast biopsy, resulting in missing progress notes and lack of documentation regarding post-procedure monitoring. Key information was only found in an electronic health record system that staff and surveyors were not aware of or trained to use.
Facility staff did not ensure proper collaboration and documentation with hospice agencies for three residents receiving end-of-life care, resulting in missing or incomplete care plans, lack of hospice participation in care plan meetings, and insufficient integration of hospice documentation into the facility's records.
The facility failed to ensure that five CNAs completed the required twelve hours of in-service training, including dementia management and abuse prevention. Interviews revealed that CNAs could not recall completing the training, and the DON admitted that training had not been a focus. The Administrator and Corporate Consultants did not comment on the findings.
The facility's kitchen and storage areas were found unsanitary, with a rusty drawer, open and dirty food bins, and mouse droppings. A sticky trap was covered with insect carcasses, and mildew was present on a closet door. The Dining Services Manager admitted to a mouse problem and lack of communication with maintenance.
The facility failed to implement an effective pest control program, affecting dining services. During an inspection, open and dirty bins of flour, sugar, and rice were found in the dry storage room, along with food debris and a black sticky substance on the floor. Mouse droppings and a dead mouse were discovered near a trap, and a sticky trap was covered with insect carcasses. The Dining Services Manager admitted to a mouse problem, and despite being informed, no further action was taken by the Regional Manager.
A resident with multiple medical conditions was found in an undignified state, dressed only in an incontinent brief without a top sheet or blanket. The resident, who was cognitively intact, expressed a desire to wear clothes and was unable to get assistance as the call bell was disconnected and placed on the side of the bed affected by his stroke. The bed was elevated to an unsafe height, and the door was closed, which was reportedly the resident's preference. A CNA acknowledged the inappropriate bed height and unplugged call bell, but no satisfactory explanation was provided for the oversight.
The facility staff failed to ensure the survey results book was accessible during the initial entrance. A sign in the main lobby indicated the book's location, but it was not found. The administrator had kept the book in his office since expecting surveyors. These findings were shared with the Administrator, DON, and corporate staff.
The facility failed to provide a clean, comfortable, and homelike environment for residents in three rooms, with issues such as unrepaired drywall gouges and poor-quality linens. Observations included residents with stained or missing bedding. Staff interviews revealed a lack of communication and reporting regarding maintenance and linen quality, with no maintenance logs indicating reported issues.
The facility failed to update care plans for two residents, one with a brain injury and behaviors, lacking specific goals and a behavior modification plan, and another with contractures, not reflecting discontinued fall mats and use of splints. Medication oversight was also inadequate, with no monthly reviews for a resident on psychotropic drugs. These issues were noted by surveyors, and the facility's administration could not provide further documentation.
Two residents in an LTC facility did not receive their prescribed medications due to staff oversight. One resident did not receive prn Senna for constipation due to a failure in the bowel movement tracking system, while another missed three doses of gabapentin for neuropathy because staff did not check the stat box for availability. These deficiencies were identified during a survey and shared with the facility's administration.
A resident with multiple health conditions did not receive scheduled showers due to a preference against late-night bathing, leading to refusals. Facility staff were unclear about documentation codes for refusals, resulting in inconsistencies in care records. The administrator was informed of these findings.
The facility failed to ensure pharmacy recommendations were obtained and acted upon for two residents, leading to a deficiency in the medication regimen review process. A resident with a complex medical history did not have the required monthly Medication Regimen Review (MRR) completed for 2024, and another resident's pharmacy review documents were not scanned into the electronic health record. The Director of Nursing admitted that MRRs were kept in a binder, inaccessible to staff, and not incorporated into the electronic system, highlighting a systemic issue in documentation practices.
A resident received PRN Lorazepam for anxiety without a stop date, exceeding the 14-day limit without proper documentation. The medication was administered multiple times over several months, and the DON acknowledged the lack of required documentation during a meeting.
An inspection revealed that facility staff failed to ensure medications were not expired and were properly labeled. A medication cart audit found insulin pens without open dates and a vial without a resident name. Additionally, expired Lorazepam tablets were found in the Stat box. An LPN and the DON acknowledged the responsibility of nurses to check expiration dates, and the Administrator was informed of these issues.
Failure to Maintain Clean and Sanitary Fall Mats for Resident
Penalty
Summary
Facility staff failed to maintain clean and sanitary resident equipment for one resident with advanced dementia, paranoid schizophrenia, and severe protein-calorie malnutrition. The resident was assessed as having severe cognitive impairment, including long and short-term memory problems and severely impaired decision-making abilities. The resident's care plan identified a risk for falls, with interventions including the use of two fall mats placed on either side of the bed for safety. During multiple observations, the fall mats were found to be soiled with dark stains, bread crumbs, debris, and shoe prints. Staff were also observed standing on the mats, and the mats were not kept clean as required. These findings were confirmed through staff interviews, which acknowledged the condition of the mats and the lack of regular cleaning and disinfection.
Failure to Develop Person-Centered Care Plan for PEG Tube
Penalty
Summary
Facility staff failed to develop a person-centered care plan addressing the needs of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had diagnoses including vascular dementia and chronic gastric outlet obstruction status post PEG tube placement, was assessed as having severely impaired cognitive abilities. During an observation, the resident's daughter was seen managing the PEG tube site, which showed signs of leakage and irritation, and the external bumper was positioned too far from the abdominal skin. The daughter cleaned and dressed the site herself, indicating a lack of staff intervention at that time. A review of the resident's care plan revealed no problem or intervention related to the PEG tube, despite existing physician orders for daily site care and regular flushing of the tube. The absence of a specific care plan for the PEG tube, combined with the observed site condition and family involvement in care, demonstrated that the facility did not fully address the resident's needs related to the PEG tube. Administrative staff were informed of these findings and did not provide comments or express concerns during the exit interview.
Failure to Provide Hygiene Care and Assistance with Activities of Daily Living
Penalty
Summary
Facility staff failed to provide adequate hygiene care and assistance with activities of daily living for two dependent residents. One resident, who had a history of stroke with left hemiplegia and moderate cognitive impairment, reported receiving only one shower since admission, despite being scheduled for two showers per week. Documentation confirmed a lack of showers in January, with only sporadic showers documented in February and March. The resident also reported not being shaved as scheduled, and staff interviews confirmed inconsistencies in providing this care. Another resident, with diagnoses including end stage renal disease, diabetes, hypertension, and muscle weakness, was observed with a significant amount of hair on her neck and chin. The resident expressed a desire to have the hair removed and reported that staff had never asked if she wanted it shaved. Staff interviews confirmed that personal hygiene assistance, including shaving, was not consistently offered or provided, despite the resident being coded as dependent for personal hygiene in the care plan and MDS assessment.
Failure to Secure Indwelling Catheter as Ordered
Penalty
Summary
Facility staff failed to provide required care to prevent complications associated with the use of an indwelling catheter for one resident. The resident, who was admitted following an acute hospital stay and had a diagnosis of neurogenic uropathy with urinary retention, required a Foley catheter as per physician orders and care plan. The care plan specified that the catheter should be positioned below the bladder, tubing should be free of kinks, and the catheter should be secured for safety. During observations on multiple occasions, the resident's catheter tubing was found to be unsecured, with the stat lock device wrapped around the tubing rather than properly stabilizing it. Staff interviews and direct observation confirmed that the catheter was not appropriately secured, which was also acknowledged by the Director of Nursing. The lack of proper catheter stabilization was directly observed and documented, constituting a failure to follow the resident's care plan and physician orders.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide necessary and appropriate respiratory care for a resident with a history of stroke, left hemiplegia, and obstructive sleep apnea. The resident was admitted following an acute hospital stay and had physician orders for C-PAP use at bedtime for acute and chronic respiratory failure with hypercapnia. The care plan specified monitoring to ensure the C-PAP mask was in place during nighttime or sleeping hours. However, the resident reported that the C-PAP was not consistently applied, and when it was, it was sometimes misapplied, resulting in water entering the mask and tubing. The resident stated that due to water splashing into his nose, he had to remove the mask and was unable to drain the tubing or reposition the mask independently. The resident also indicated that staff did not inquire about the reason for mask removal, which prevented him from explaining the improper application and water issue. These observations and resident interviews demonstrated that staff did not ensure the C-PAP was properly applied and functioning as ordered, nor did they adequately monitor or address the resident's respiratory care needs.
Unsecured Medication Cart During Medication Pass
Penalty
Summary
Facility staff failed to secure resident medications as required by professional standards. On the morning of 3/27/25, an LPN was observed passing medications on a resident hall, moving from room to room and leaving the medication cart unlocked and unattended between pulling and administering medications. This made the medications accessible to unauthorized individuals. Later, the Administrator, accompanied by visitors, noticed the unattended, unlocked medication cart in the hallway and closed the locking mechanisms without addressing the issue with the LPN, who was inside a resident's room at the time. When the LPN returned, he used his key to unlock the cart and continued his medication pass. The LPN was not available for interview later that day, and when the findings were shared with the administrative team, they had no comments or concerns.
Failure to Monitor and Assess Surgical Wound Resulting in Sepsis
Penalty
Summary
Facility staff failed to assess and monitor a surgical wound on a resident's right breast following a breast biopsy, which contributed to the resident developing sepsis and requiring hospitalization. The resident had a history of major depressive disorder and was admitted with open areas related to dermatitis on the right buttock and perineum, but there was no documentation or care plan intervention addressing the recent breast biopsy or the need for monitoring the surgical site. Staff interviews revealed that the presence of drainage from the right breast was observed, but the physician assistant (PA) was not informed of the biopsy or the need for wound monitoring, and the wound care consult was only ordered after the resident became acutely ill. Clinical records and family interviews indicated that the resident had undergone a breast biopsy prior to admission, with steri-strips in place and instructions for monitoring for infection. However, the facility's staff did not document or communicate the need for ongoing assessment of the biopsy site. The PA and other staff members were unaware of the procedure and its aftercare requirements, and the relevant discharge information was not accessible in the primary electronic health record system used by the staff. The lack of awareness and monitoring led to the resident exhibiting signs of infection, including fever, hypotension, and decreased oxygen saturation, ultimately resulting in a diagnosis of sepsis attributed to the right breast wound. Interviews with staff and family further confirmed that the resident's condition deteriorated over several days, with increased lethargy, refusal to eat, and visible drainage from the breast. The resident expressed concerns about inadequate care and safety upon hospital admission. The facility administration acknowledged that there were no progress notes or monitoring of the breast wound, and the PA confirmed he was not made aware of the biopsy or the need for wound care until after the resident was transferred to the hospital.
Failure to Provide Proper PEG Tube Care
Penalty
Summary
Facility staff failed to properly care for a percutaneous endoscopic gastrostomy (PEG) tube for one resident with vascular dementia and chronic gastric outlet obstruction. The resident was observed to have a PEG tube with the external bumper positioned too far from the abdominal skin, and the insertion site was noted to be leaking and irritated with redness and raised areas. The resident's daughter was seen cleaning and dressing the site herself, indicating a lack of staff intervention at that time. Review of the resident's care plan did not identify a problem related to the PEG tube, and there was no physician order specifically for the PEG tube, though there were orders for its management, including daily cleansing and dressing and regular flushing for patency. Further observations revealed the PEG site remained wet and the dressing was disheveled. A CNA interviewed stated it was not their responsibility to clean or dress the PEG site, but only to notify a nurse if changes were observed. The hospice nurse later identified the irritation as being due to a fungal infection, for which an antifungal had been ordered. These findings demonstrate that the facility staff did not provide appropriate care and monitoring for the resident's PEG tube as required.
Incomplete and Inaccessible Medical Record for Resident Following Breast Biopsy
Penalty
Summary
Facility staff failed to maintain a complete and accessible medical record for one resident who had a history of major depressive disorder and was admitted and later discharged from the facility. The resident underwent a breast biopsy for a mass, with the procedure and follow-up occurring while under the facility's care. The admission MDS assessment and care plan were documented, but there was a lack of progress notes and documentation regarding the biopsy and subsequent monitoring for signs and symptoms of infection in the resident's medical record accessible to staff and surveyors. During interviews, the facility administrator and DON acknowledged that there were no progress notes available and that the physician assistant (PA) was unaware of the biopsy until after the resident was discharged to another facility. The relevant documentation regarding the biopsy and follow-up was only found in a separate electronic health record system (Point Click Care Connect) that staff and surveyors were not aware of or trained to access. As a result, the facility did not maintain a complete and readily accessible medical record for the resident in accordance with accepted professional standards.
Failure to Coordinate and Document Collaborative Hospice Care
Penalty
Summary
Facility staff failed to establish and provide collaborative hospice care for three residents with advanced illnesses, as evidenced by lack of documented coordination between the facility and the hospice agency. For one resident with advanced dementia, schizophrenia, and severe malnutrition, although hospice services were elected and initiated, there was no evidence of a jointly developed plan of care or hospice participation in interdisciplinary care plan meetings. The hospice nurse confirmed non-participation in facility care plan meetings and maintained separate documentation, with only general visit records and no detailed care information in the resident's clinical record. Another resident with vascular dementia and a PEG tube was admitted for hospice services following a physician's order and hospice assessment. However, the clinical record lacked an order for hospice admission and did not document hospice participation in care plan meetings, except for two instances months apart. The hospice nurse again reported not attending facility care plan meetings and not sharing detailed care documentation, with only basic visit information available in the facility's records. A third resident with end-stage renal disease was also identified as receiving hospice care, but the facility failed to provide a hospice care plan, nurses' notes, or other relevant documentation. The care plan meeting notes did not include hospice participation, and the hospice nurse confirmed non-involvement in these meetings and separate record-keeping. Facility staff acknowledged the absence of documentation supporting hospice agency participation in care plan conferences for these residents.
Non-Compliance with CNA Training Requirements
Penalty
Summary
The facility staff failed to ensure that five sampled Certified Nurse Aides (CNAs) completed the mandatory twelve hours of in-service education and training within twelve months. This training was to include dementia management and resident abuse prevention. A review of the training transcripts and education records for CNAs #7, 6, 3, 8, and 9 revealed non-compliance with this requirement. During interviews, CNA #7 and CNA #3 could not recall if they had completed the necessary training. The Director of Nursing (DON) acknowledged that training and education had not been a focus, although there was an ongoing plan to address compliance. In a final interview, the Administrator, DON, and two Corporate Consultants did not provide comments or express concerns regarding these findings.
Unsanitary Conditions in Kitchen and Storage Areas
Penalty
Summary
The facility staff failed to maintain a clean and sanitary food preparation area, as observed during an inspection of the kitchen and storage areas. A metal drawer under a food preparation counter was found to be rusty, off its track, and littered with food debris adhered by a sticky greasy substance. In the dry storage room, large rolling bins of flour, sugar, and rice were left open and dirty, with a dried film and white food debris in the crevices of the sliding tops. The floor of the storage room was covered with food debris and a black sticky substance around the baseboards and corners. Mouse droppings were found on the floor near a mouse trap with a dead mouse, and a sticky trap behind the main door was covered with insect and spider carcasses, indicating it had been in place for a long time. A black mildew substance was observed on the backside of a closet door in the dry storage room, along with empty cardboard boxes, a broken shelf, and more food debris on the floor. The Dining Services Manager acknowledged the issues, admitting to a problem with mice and a lack of communication with the maintenance director.
Ineffective Pest Control in Dining Services
Penalty
Summary
The facility staff failed to implement an effective pest control program, which affected dining services and the facility as a whole. During an inspection of the kitchen area, several deficiencies were observed. In the dry storage room, which contained various food items, three large rolling bins of flour, sugar, and rice were found open and dirty, with a dried film and white food debris in the crevices of the sliding tops. The floor was littered with food debris and a black sticky substance around the baseboards and corners. Mouse droppings were found on the floor near a mouse trap containing a dead mouse. Additionally, a sticky trap behind the main door was covered with insect and spider carcasses, some of which were dried, indicating the trap had been in place for a long time. A black mildew substance was also found on the backside of a closet door in the dry storage room, along with empty cardboard boxes, a broken shelf, and more food debris on the floor. The Dining Services Manager admitted to the presence of a mouse problem and acknowledged that the maintenance director was unaware of the situation. Despite being informed of the issues, the Regional Manager and Dining Services Manager had no further information to provide. Upon a follow-up inspection, the same sticky trap full of insects remained unchanged, and either the same mouse trap or an identical one was still in the same location. The report indicates a lack of effective pest control measures and inadequate maintenance of cleanliness in the kitchen and storage areas, contributing to the pest problem.
Resident's Dignity and Self-Determination Not Respected
Penalty
Summary
The facility staff failed to uphold a resident's right to a dignified existence and self-determination, as evidenced by the treatment of a resident with multiple medical conditions, including dysphagia after stroke, diabetes, and end-stage renal disease. The resident, who was cognitively intact with a BIMS score of 15/15, was found in an undignified state, dressed only in an incontinent brief without a top sheet or blanket. The resident expressed a desire to wear clothes and was unable to get assistance, as the call bell was disconnected and placed on the side of the bed affected by his stroke, making it inaccessible. The resident's bed was elevated to an unsafe height, and the door was closed, which was reportedly the resident's preference. However, the resident was heard yelling for help, indicating a lack of response to his needs. A CNA acknowledged that the bed height was inappropriate for safety and that the call bell should not be unplugged. Despite the resident's request for clothing and a blanket, the CNA did not provide a satisfactory explanation for the oversight. The facility administrator was informed of these issues during an end-of-day meeting, but no further information was provided.
Survey Results Book Not Accessible
Penalty
Summary
The facility staff failed to ensure that the survey results book was readily accessible during the initial entrance of the facility. On August 26, 2024, at approximately 7:05 PM, a sign was observed on a table in the main lobby indicating that the Survey Book was kept there, but no Survey Book was found. An interview conducted at approximately 7:09 PM with the administrator revealed that the Survey Book was in his office. The administrator stated that he had kept the Survey Book since Friday, August 23, 2024, because he was expecting the surveyors to arrive at any time to survey the facility. These findings were shared with the Administrator, the Director of Nursing (DON), and corporate staff on August 28, 2024, during the final interview.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for residents in three rooms on Hall 100. Observations revealed deep gouges in the drywall by the head of the bed in multiple rooms, which had not been repaired. Additionally, residents were provided with linens that were in poor condition, including sheets and blankets with holes and stains. One resident was observed asleep with a stained blanket, while another was lying in bed with no top sheet or blanket, wearing only a brief. Interviews with facility staff highlighted a lack of communication and reporting regarding maintenance issues and linen quality. A CNA was unaware of why a resident did not have proper bedding, and an LPN indicated that maintenance repairs are only completed if reported, but she did not know if the gouges had been reported. The LPN also stated that CNAs should not use stained or torn linens and should inform the laundry department to remove them. A review of maintenance logs showed no reports of the damaged drywall, indicating a breakdown in the reporting process.
Deficiencies in Care Plan Review and Medication Oversight
Penalty
Summary
The facility failed to adequately review and revise the care plan for two residents, leading to deficiencies in their care. For one resident with a history of traumatic brain injury and behaviors, the facility did not document specific measurable goals or implement a behavioral modification care plan. Despite the resident's history of altercations and psychiatric evaluations, the care plan lacked defined interventions and did not address the resident's specific triggers or fears. Additionally, there was no evidence of a monthly Medication Regimen Review by a Registered Pharmacist, which is required for residents on psychotropic medications. Another resident, who was at risk for falls and had contractures, did not have their care plan updated to reflect the discontinuation of fall mats and the use of an elbow splint and palm guard. Staff interviews revealed that the resident was not considered a high fall risk, and the use of floor mats had been discontinued without updating the care plan. The Director of Nursing acknowledged that the care plan should be updated quarterly and with any changes in resident care, including the addition or removal of interventions. The deficiencies were brought to the attention of the facility's Administrator and Director of Nursing, who were unable to provide further documentation or evidence of corrective actions. The lack of updated care plans and oversight of medication management for residents with complex needs highlights significant gaps in the facility's care planning and review processes.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to follow a physician's order for two residents, leading to deficiencies in medication administration. Resident #38, who was admitted after an acute care hospital stay and diagnosed with essential hypertension, did not receive the prescribed prn Senna for constipation. Despite having a bowel movement tracking system that alerts staff if a resident hasn't had a bowel movement in three days, the system failed to notify the staff, and the resident went six days without a bowel movement. Interviews with the LPN and CNA revealed that they were unaware of the resident's condition due to the lack of alerts, and the physician was not notified for further action. For Resident #21, the facility staff failed to administer the ordered gabapentin for neuropathy. The medication was not given for three consecutive days due to it being marked as unavailable in the EMAR, despite being present in the stat box. The ADON confirmed that the nurses did not check the stat box for availability, leading to the resident missing three doses. These findings were shared with the facility's administration, but no further information was provided.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility staff failed to provide necessary services to maintain good grooming and personal hygiene for a resident who was unable to perform self-care. The resident, who had multiple diagnoses including dysphagia after stroke, diabetes, and end-stage renal disease, was observed with a strong body odor and reported not receiving showers at a preferred time. The resident expressed a preference against late-night showers, which led to refusals when offered at such times. Despite being scheduled for two showers per week, the resident's records indicated inconsistencies in receiving these showers, with some instances marked as 'NA' and others as bed baths instead of showers. Interviews with facility staff revealed a lack of clarity and consistency in the documentation and response to shower refusals. An LPN stated that residents are scheduled for two showers a week and can request more, but there was uncertainty about the documentation codes used for refusals. The staff member was unsure of the meaning of 'NA' in the records and indicated that 'RR' is used for resident refusals. The facility administrator was informed of these findings, but no further information was provided at the time of the report.
Deficiency in Medication Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were obtained and acted upon for two residents, leading to a deficiency in the medication regimen review process. For Resident #2, the required monthly Medication Regimen Review (MRR) by a licensed pharmacist was not completed for the entire year of 2024. This resident, who has a complex medical history including hypertension, seizure disorder, dementia, depression, and traumatic brain injury, was receiving psychotropic medications without documented pharmacist review or recommendations for dose reductions or laboratory tests. The Director of Nursing (DON) admitted that the MRRs were not available in the resident's electronic health record and were instead kept in a binder in her office, which was not accessible to staff in her absence. Resident #2's care plan and clinical records revealed a history of behavioral issues and altercations with other residents, yet there was no behavior management program in place. The care plan interventions were not specific or measurable, and there was no evaluation of the resident's behaviors concerning his specific triggers and fears. Despite the resident's known depression and brain injury, there was no documentation of a psychiatric evaluation being obtained or incorporated into the care plan. The facility's policy required MRRs to be completed monthly and made available to the care team, but this was not adhered to, resulting in a lack of oversight and potential risk to the resident's well-being. For Resident #49, the facility also failed to maintain proper documentation of pharmacy reviews in the electronic health record. Although the DON was able to produce a book containing the pharmacy review and recommendations for 2024, these documents were not scanned into the electronic system. The DON confirmed that a pharmacy recommendation for Resident #49 had been signed off by the physician and the order changed in the Electronic Medication Administration Record (EMAR), but the documentation was not readily accessible to the care team. This oversight highlights a systemic issue in the facility's management of medication regimen reviews and documentation practices.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the PRN anti-anxiety drug Lorazepam. The resident, who was admitted with multiple diagnoses including dementia, anxiety, and Alzheimer's disease, received an order for Lorazepam to be taken as needed for anxiety without a specified stop date. The medication was administered on three occasions over a period of more than 14 days, yet the order remained current without proper documentation justifying the extended use. During a meeting, the Director of Nursing acknowledged the regulation limiting PRN psychotropic drugs to 14 days unless supported by specific documentation, which was not provided in this case.
Medication Expiration and Labeling Deficiencies
Penalty
Summary
During an inspection of a medication cart and the facility's Stat box, it was found that the facility staff failed to ensure medications for resident administration were not expired. Specifically, a medication cart audit revealed an opened Humalog insulin pen and an opened Lantus insulin pen, both without open dates, and an opened vial of mixed Humalog insulin without a resident name or identification. The Licensed Practical Nurse (LPN) acknowledged that the dates should be written on the insulin pens as they expire in 28 days, and a name should be on the vial. These findings were shared with the Administrator, Director of Nursing (DON), and corporate staff, who confirmed that drugs and biologicals should be labeled with a date and resident name. Additionally, the facility staff failed to ensure that all medications available for use in the Stat box were not expired. A review of the Stat box contents revealed five tablets of Lorazepam 0.5 mg that expired four months prior. An LPN stated that while the pharmacy changes the Stat box regularly, it is the nurses' responsibility to check for expired medications. The DON confirmed that all nurses who pass medications are responsible for checking expiration dates and reporting any medications needing replacement to the pharmacy. The Administrator was informed of these findings, but no further information was provided.
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Illustrative
What surveyors actually found near you
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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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Nursing homes near Poquoson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Chesapeake | 3.6 mi | ★★★★★ | 14 | 0 |
| Regency Health And Rehabilitation Center | 3.8 mi | ★★★★★ | 2 | 0 |
| Hampton Health & Rehab Center, Llc | 5.5 mi | ★★★★★ | 0 | 0 |
| Marcella Post Acute | 5.5 mi | ★★★★★ | 15 | 0 |
| Newport News Nursing & Rehab | 5.8 mi | ★★★★★ | 2 | 0 |
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