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 Blue Ridge Rehabilitation And Nursing during CMS and state inspections, most recent first.
Failure to timely notify the physician of a resident’s change in condition. A resident with CHF, ESRD, COPD, metabolic encephalopathy, and acute cystitis developed nausea and vomiting, and staff interviews and record review showed the symptoms had been present for several days before the NP was informed. The NP ordered Zofran and a UA after learning of the issue, while an RN and an LPN reported the change had been known on the unit but was not documented or communicated promptly.
Failure to document a resident’s change in condition. A resident with CHF, ESRD, COPD, metabolic encephalopathy, and acute cystitis developed nausea and vomiting, and staff verbally reported and monitored the issue across shifts, but the record lacked timely progress notes describing the change. The NP later noted the resident had not felt well over the weekend, had gastric emesis at the bedside, and was treated with Zofran and a UA for possible UTI, while the DON stated progress notes were typically not done unless there was a concern.
A resident with multiple complex diagnoses, including Alzheimer's disease and malnutrition, was admitted without a completed admission assessment or a baseline care plan addressing ADL needs such as bed mobility, dressing, eating, and transfers. Staff interviews confirmed that required documentation and care planning were not completed within the expected timeframe.
Facility staff did not inform a resident's family when the resident was sent to the ER from dialysis. The facility learned of the transfer from a transport company but did not notify the resident's son, who only found out the next day. Documentation confirmed the facility's policy requires prompt notification of such changes.
Facility staff did not follow physician orders for oxygen administration for two residents, with oxygen concentrators set at incorrect flow rates. In both cases, the settings did not match the prescribed liters per minute, and staff had to adjust the equipment after the discrepancies were identified during the survey.
Facility staff did not honor the documented food dislikes of two residents, serving them vegetables listed as dislikes on their meal tickets. Both residents confirmed receiving unwanted foods, and the dietary manager acknowledged that such preferences should have been respected and substitutions provided, as outlined in facility policy.
The facility failed to provide written notice for room changes to several residents, violating their rights. Residents experienced room changes without prior written notification, despite the facility's policy requiring it. The lack of communication led to confusion and dissatisfaction among residents, highlighting a significant oversight in adhering to established protocols.
Several residents in the facility experienced inadequate assistance with activities of daily living (ADL) and delayed responses to call bells. A resident was left waiting for toileting assistance, resulting in an accident, while another resident's request for grooming was not prioritized. Additionally, a resident was left unattended on the toilet, and another had their call bell out of reach, preventing them from calling for help. These incidents reflect a failure to adhere to care plans and facility policies.
Two residents in a LTC facility experienced significant medication errors due to unavailability of prescribed medications. One resident missed several doses of vancomycin for osteomyelitis and c-diff, while another missed multiple insulin doses for diabetes. Staff interviews revealed inadequate processes for handling unavailable medications, and the facility's policy was not followed, leading to a lack of physician notification and alternative measures.
The facility staff failed to maintain accurate clinical records for residents, including incorrect documentation of oxygen and nebulizer tubing changes, missing dermatologist treatment notes, incomplete dialysis communication, and inconsistent wound treatment records. Additionally, there was a discrepancy in documenting a resident's code status, with conflicting information between the nurse practitioner's notes and the care plan.
The facility failed to meet the shower preferences of three residents, leading to a deficiency in personal care. A resident received only one shower in a month, despite being cognitively intact and preferring evening tub baths. Another resident, able to communicate effectively, filed a grievance about not receiving showers twice weekly, as preferred. A third resident, with multiple health conditions, reported going ten days without a shower. Despite adequate staffing, the facility did not uphold the residents' preferences, and the DON acknowledged the ongoing issue.
The facility failed to follow its abuse prevention policies regarding pre-employment screening and background checks for a significant number of employees. Out of twenty-five records reviewed, eighteen lacked reference checks, two had unverified licenses, and six did not include a sworn statement regarding criminal history. The human resource manager acknowledged the disorganization of records, which hindered compliance with the facility's policy.
The facility failed to update care plans for four residents, leading to deficiencies in care. A resident's care plan was outdated, indicating the use of a communication board despite verbal communication abilities. Another resident experienced a fall, but the care plan was not updated to prevent future falls. A third resident had a fall requiring a hospital visit, yet the care plan was not revised. Lastly, a resident experienced significant weight loss, but the care plan was not updated to address this change. Facility policies did not adequately address care plan revisions following significant events.
The facility staff failed to follow physician orders for three residents, leading to deficiencies in care. A resident did not receive a prescribed nutritional supplement due to stock issues, another did not have sutures removed or a dermatology follow-up scheduled, and a third did not receive consistent wound care or the application of a multi-podus boot. Staff interviews revealed issues with ordering processes, documentation, and adherence to care plans.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions for a resident with a feeding tube, and did not follow transmission-based precautions for a resident with scabies. Additionally, the facility did not respond appropriately to a COVID-19 outbreak, failing to conduct contact tracing or broad-based testing. The presence of Legionella bacteria in the water system was not adequately addressed, indicating significant gaps in infection control practices.
The facility failed to provide education and offer flu and pneumonia immunizations to three residents, as revealed during a review of immunization protocols. Clinical records lacked documentation of education, offers, or consent for the vaccines. The infection preventionist confirmed these deficiencies, noting that floor nurses are responsible for offering immunizations upon admission. Despite the facility's policies requiring documentation of education and consent, these were not followed, and no additional information was provided by the facility's leadership.
The facility failed to educate and offer the COVID-19 vaccine to four residents and one staff member. Clinical records showed no evidence of education or offering of the 2023-2024 spike vaccine. The infection preventionist confirmed the lack of documentation, and the human resources manager could not find immunization information for a staff member. The facility's policy on vaccination planning was not followed.
A resident's personal property was moved to another room without prior notice or consent while the resident was at a medical appointment. The move was due to conflicts with a roommate, but staff failed to communicate or involve the resident in the process. The resident, who was cognitively intact, expressed dissatisfaction with the lack of communication and handling of personal items.
The facility failed to maintain adequate funds on-site, denying two residents timely access to their personal funds, potentially affecting 41 residents with trust accounts. One resident reported multiple instances of being unable to withdraw money for shopping, while another experienced delays in accessing funds for outings. The Business Office Manager cited a recent bank change and insufficient petty cash as reasons for the issue, with only $5 available at the time of the survey. The facility's policy did not address residents' access to funds, and there was no visible posting of banking hours.
A resident was found with Bengay cream, antifungal powder, and Tums at her bedside without an assessment for self-administration ability or physician orders. Facility staff, including an LPN and the unit manager, confirmed that medications should be stored in the medication cart unless an order allows self-administration. The unit manager removed the items, and a review of the resident's records showed no assessment for self-administration ability, contrary to facility policy.
A facility failed to develop a complete care plan for a resident with end-stage renal disease receiving dialysis. The resident's care plan lacked blood pressure parameters despite recent increases in blood pressure readings. An LPN noticed the changes but was unsure if they had been reported to the physician. The DON confirmed the absence of these parameters in the care plan.
A resident at high risk for falls experienced a fall after becoming agitated about a room change. The facility staff failed to conduct a post-fall assessment or update the resident's care plan, as required by the facility's Fall Prevention Program policy. Interviews revealed a lack of documentation and follow-up, highlighting a deficiency in the facility's response to the incident.
The facility failed to provide proper catheter care for two residents. One resident's catheter tube was not anchored, risking dislodgement, despite a physician's order to check the placement every shift. Another resident's catheter bag was found on the floor, contrary to the facility's policy and care plan, which required it to be suspended above the floor to prevent infection. Both issues were confirmed by nursing staff.
A facility failed to adhere to infection control measures and professional standards for oxygen therapy. A resident's nebulizer mask and tubing were not changed weekly as required, and the oxygen tubing was not labeled with a date. Staff interviews confirmed the equipment should be changed weekly, but the treatment administration record inaccurately reflected this. The unit manager confirmed the deficiency, and the findings were shared with the facility administrator and DON.
A facility failed to provide meals or snacks for a resident with ESRD and diabetes during offsite dialysis treatments, resulting in the resident missing meals on dialysis days. Staff interviews confirmed no food was sent with the resident, and the dietary manager cited concerns about meals going missing. Additionally, the facility did not maintain effective communication with the dialysis center, as the dialysis communication book was found to be incomplete, contrary to the facility's policy and contract requirements.
A Novolog insulin pen on a medication cart was improperly labeled with a handwritten name instead of a pharmacy label, violating pharmacy standards. The pen was taken from a back-up supply kit, and the facility's policy requiring a usage slip was not followed. The issue was discussed with the facility's administration.
A resident with hand tremors did not receive a two-handled sippy cup as recommended by therapy and documented in her care plan. Despite the resident's cognitive awareness and multiple health conditions, staff were unaware of the requirement, and the dietary department was not notified, leading to the absence of the cup on meal trays.
The facility staff failed to follow food safety standards, with unlabeled and expired food products found in the kitchen, and improper food distribution practices observed on a unit. A CNA mixed clean and soiled trays, raising infection control concerns. The dietary manager and facility leadership were informed of these issues.
Failure to Timely Notify Physician of Change in Condition
Penalty
Summary
The facility failed to inform the physician timely of a change in condition for one resident who developed nausea and vomiting. The resident had diagnoses including congestive heart failure, end stage renal disease, chronic obstructive pulmonary disease, metabolic encephalopathy, and acute cystitis without hematuria, and was assessed as moderately cognitively impaired on the most current MDS. Review of the clinical record showed a nurse practitioner note indicating the resident was seen for nausea and vomiting, with Zofran ordered and a urinalysis ordered because of a history of possible UTI. A nursing assessment the next day documented that the resident said they had complained of nausea for the past several days. Staff interviews showed the change in condition had been known on the unit before the nurse practitioner visit, but it was not documented or communicated to the physician in a timely manner. An RN stated that after returning from a four-day break, the resident was not at baseline and had been reporting nausea and vomiting for several days. The nurse practitioner stated the staff should have contacted the outside service or an on-call person about the change in condition, but was unaware of any concerns until speaking with the resident. An LPN stated that during shift report it was reported the resident had been nauseated and had vomited, and that there was no documentation of the change in condition on prior shifts.
Failure to Document Change in Condition
Penalty
Summary
The facility failed to document assessments related to a change in condition for one resident with congestive heart failure, end stage renal disease, chronic obstructive pulmonary disease, metabolic encephalopathy, and acute cystitis without hematuria. The resident’s most current MDS was an admission assessment, and the resident was assessed as moderately cognitively impaired. Review of the clinical record showed a nurse practitioner note indicating the resident was seen for nausea and vomiting, and the nurse practitioner ordered Zofran and a urinalysis for possible UTI. Prior to that note, there were no progress notes documenting nausea or vomiting, and the last note before the event did not identify any concerns. Interviews showed that staff were aware of the resident’s nausea and vomiting but did not document the change in condition in the record. An RN stated that after returning from a four-day break, she noticed the resident was not at baseline and had been reporting nausea and vomiting for several days. The nurse practitioner stated the resident had reported not feeling well over the weekend and had a basin at the bedside with a small amount of gastric emesis, but staff should have contacted the outside company or an on-call person about the change in condition. An LPN stated that report from the prior shift included nausea and vomiting, that the resident was assessed and monitored overnight, and that there was no documentation from the previous shifts even though the concern had been verbally passed along and monitored. The facility policy required accurate, complete, and timely documentation of assessments, observations, and services, including documentation no later than the shift in which the assessment or observation occurred.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan for one resident within 48 hours of admission, as required. The clinical record review revealed that the resident, who had diagnoses including Alzheimer's disease, HIV, anxiety disorder, dementia, and malnutrition, did not have an admission assessment completed. The most recent MDS was a discharge assessment, and the comprehensive care plan lacked interventions for activities of daily living (ADL) such as bed mobility, dressing, eating, and transfers. During staff interviews, the MDS coordinator confirmed that the admission assessment and baseline care plan for ADL care were missing for this resident. This information was presented to the director of nursing and the administrator, with no further information provided before the exit conference. The deficiency was identified through clinical record review and staff interviews, which confirmed the absence of required documentation and care planning for the resident's immediate needs following admission.
Failure to Notify Family of Resident's Emergency Room Transfer
Penalty
Summary
Facility staff failed to notify the family of a resident's change in condition when the resident was sent to the emergency room from dialysis. According to staff interviews, the unit manager (an LPN) stated that the facility became aware of the resident's transfer to the ER only after the transport company informed them. Despite this knowledge, no one from the facility notified the resident's son about the ER transfer. The son only learned of the situation when he arrived at the facility the following day to take the resident to an appointment. A review of the resident's clinical record showed a progress note indicating the resident had been admitted to the hospital, and facility documentation confirmed a policy requiring prompt notification of the resident's representative in such situations. The deficiency was identified for one resident out of a sample of eleven, and the issue was discussed with the facility's administrator and director of nursing during the survey.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Facility staff failed to administer oxygen therapy according to physician orders for two residents. In the first instance, a resident's oxygen concentrator was observed to be set at 3 liters per minute (LPM), while the physician's order specified continuous oxygen at 2 LPM via nasal cannula. The treatment administration record indicated that a registered nurse had documented the resident was receiving oxygen at the correct rate, but direct observation revealed otherwise. Upon being notified, the nurse acknowledged the discrepancy and adjusted the setting to the ordered amount. In the second case, another resident's oxygen concentrator was found set at 2.5 LPM. The physician's order required supplemental oxygen at 2 LPM, with an allowance to increase to 3 LPM only if oxygen saturation dropped below 92%. The nurse confirmed the setting was incorrect and adjusted it to 2 LPM. Facility documentation reviewed stated that oxygen is to be administered under physician orders. These findings were discussed with facility leadership during the survey.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
Facility staff failed to honor the documented food preferences of two residents during meal service. In one instance, a resident was served carrots, broccoli, and cauliflower, all of which were listed as food dislikes on her meal ticket. The resident confirmed during an interview that she often receives food she does not like and simply leaves it uneaten. The dietary manager acknowledged that the purpose of listing food dislikes on the meal ticket is to inform staff of resident preferences and that these items should have been substituted with another vegetable. In a separate instance, another resident was served carrots, which were also listed as a food dislike on her meal ticket. This resident expressed resignation, stating that nothing would be done about the issue. The dietary manager reiterated that food dislikes should be honored and substitutions made as necessary. Facility documentation, including the Food Preparation Guidelines policy, supports the expectation that resident preferences are to be honored regarding food and drinks.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility staff failed to provide written notice prior to room changes for five residents, violating their right to be informed in advance. Resident #53 experienced room changes on two occasions without receiving any written or verbal notice. The facility's social worker confirmed that the room changes were due to roommate conflicts, but no written notices were provided. The facility's policy requires written notification in a language and manner the resident understands, but this was not adhered to. Resident #200 also experienced multiple room changes without written notification. The social worker admitted to verbally informing the resident about one of the changes but acknowledged the absence of written notices for all room changes. The facility's administrator confirmed that residents should be notified ahead of time to allow for planning, yet this protocol was not followed. Other residents, including #57, #12, and #13, also did not receive written notifications for their room changes. Resident #57 was moved for isolation purposes without prior written notice. Resident #12 was moved under the pretext of renovations, which did not occur, and expressed a desire to reunite with a previous roommate. Resident #13 was separated from a preferred roommate without written notice, and the facility failed to address her preference adequately. The facility's policy mandates written notice for room changes, but this was consistently overlooked.
Inadequate ADL Assistance and Delayed Response to Call Bells
Penalty
Summary
The facility staff failed to provide adequate assistance with activities of daily living (ADL) for several residents, leading to multiple deficiencies. Resident #12, who required extensive assistance for toileting, experienced significant delays in staff response to her call bell, resulting in her urinating on the floor. On multiple occasions, the call bell was observed to be engaged for extended periods before staff responded, despite the presence of numerous staff members in the vicinity. The resident, who was cognitively intact, reported frequent delays in receiving assistance, which was corroborated by observations during the survey. Resident #22, who required assistance with personal hygiene, was observed with significant facial hair that she expressed a desire to have removed. Despite her request, the staff failed to provide the necessary grooming assistance in a timely manner. The resident's care plan indicated a need for extensive assistance with grooming, yet the staff did not prioritize her request, citing time constraints and other activities as reasons for the delay. Other residents, such as Resident #57, were left unattended in vulnerable situations, such as being left on the toilet for an extended period without assistance. The facility staff also failed to ensure that Resident #40's toenails were trimmed as required by her care plan, and Resident #49's call bell was repeatedly found out of reach, preventing her from calling for assistance. These incidents highlight a pattern of inadequate response to residents' needs and a failure to adhere to care plans and facility policies regarding timely assistance and call light accessibility.
Medication Errors and Omissions in LTC Facility
Penalty
Summary
The facility staff failed to ensure that two residents were free from significant medication errors. For Resident #32, the staff did not administer the prescribed antibiotic, vancomycin, as ordered by the physician. The resident, who was being treated for osteomyelitis and c-diff, missed several doses of vancomycin due to unavailability. The medication administration record (MAR) indicated missed doses on specific dates, and there was no documentation of the physician being notified about these omissions or any alternative orders being sought. Resident #249, an insulin-dependent diabetic, also experienced medication errors. The facility staff failed to administer multiple doses of insulin, specifically Basaglar and Humalog, as prescribed. The MAR showed missed doses on several occasions, and nursing notes indicated that the medications were not available. However, there was no evidence that the physician was informed about the unavailability of insulin or that any alternative measures were taken to address the situation. Interviews with facility staff, including LPN #6 and RN #1, revealed inconsistencies in the process of handling unavailable medications. The emergency supply of medications was found to be inadequately stocked, lacking essential medications like insulin. The facility's policy on unavailable medications was not followed, as there was no proper documentation or notification to the physician regarding the missed doses. The facility administrator and director of nursing were informed of these findings during a mid-day meeting.
Deficiencies in Clinical Record Maintenance and Documentation
Penalty
Summary
The facility staff failed to maintain accurate clinical records for several residents, leading to deficiencies in care. For one resident, the staff did not properly document the changing of oxygen and nebulizer tubing. The nebulizer mask and tubing were observed to be dated incorrectly, and the treatment administration record (TAR) was signed off inaccurately, indicating changes that did not occur on the documented dates. This discrepancy was confirmed by the unit manager, who acknowledged the incorrect documentation. Another resident, who was being treated for scabies by a dermatologist, had incomplete clinical records as the facility failed to include treatment notes from the dermatologist. Despite multiple entries in the nursing notes referencing the scabies diagnosis and treatment, the dermatologist's information was missing from the resident's chart. The unit manager confirmed the absence of these notes and had to contact the dermatologist to obtain the necessary documentation. Additionally, the facility did not maintain a complete clinical record for a resident undergoing dialysis. The communication book intended for documenting dialysis sessions was found with blank pages, and no information was recorded in the resident's clinical record regarding dialysis treatments, medications, or weights. Furthermore, the facility failed to accurately document another resident's wound treatments, as the bandages were not changed as ordered by the physician, leading to drainage through the bandage. Lastly, there was a discrepancy in documenting a resident's code status, with conflicting information between the nurse practitioner's notes and the care plan, which indicated a DNR status.
Failure to Meet Residents' Shower Preferences
Penalty
Summary
The facility failed to accommodate the shower preferences of three residents, leading to a deficiency in meeting their personal care needs. Resident #71, who was cognitively intact, expressed dissatisfaction with not receiving showers twice a week as scheduled, receiving only one shower between late July and late August. The resident preferred evening tub baths for relaxation, but the facility's records showed a significant gap in providing these services. Interviews with staff, including an LPN and the DON, revealed awareness of the issue, with attempts to address it by assigning a dedicated shower aide, yet the problem persisted. Resident #57 also experienced a failure in receiving showers twice weekly, as preferred. Despite being assessed as able to communicate effectively, the resident's MDS did not document preferences for routine activities. The resident filed a grievance in July about the lack of showers, and the facility's grievance log showed similar complaints from other residents. The facility's shower schedule indicated assigned days, but the resident received only five showers in a month. Staff interviews and observations during the survey did not clarify the reason for the unmet preferences, despite adequate staffing levels. Resident #53, with a history of coronary artery disease, hypertension, diabetes, and depression, did not receive showers twice per week as preferred. The resident, who required moderate assistance, reported going ten days without a shower. The facility's records confirmed only four showers in a month, with no documentation of refusals. Interviews with CNAs and the LPN unit manager did not provide reasons for the missed showers, and the DON acknowledged the issue, noting that audits had been conducted but the problem remained unresolved.
Failure to Conduct Pre-Employment Screening and Background Checks
Penalty
Summary
The facility staff failed to adhere to their abuse prevention policies concerning pre-employment screening and background checks for a significant number of employees. Out of twenty-five employee records reviewed, eighteen lacked reference checks, two had unverified licenses prior to employment, and six did not include a sworn statement regarding any criminal history. This deficiency was identified during a review of employee records, which revealed missing documentation that is required by the facility's policy to ensure the safety and well-being of residents. The human resource manager acknowledged the absence of the necessary information and attributed it to disorganized employee records, making it difficult to locate the required documentation. The facility's policy mandates job reference checks, drug screenings, licensure verifications, and criminal conviction record checks for all new employees. The policy also prohibits the employment of individuals with a history of abuse, neglect, exploitation, or any related disciplinary actions. Despite these requirements, the facility failed to comply, as evidenced by the missing documentation in the employee records reviewed.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plans for four residents, leading to deficiencies in their care. Resident #80's care plan was outdated, indicating the use of a communication board despite the resident's ability to communicate verbally. This oversight persisted for approximately four months, as confirmed by the LPN unit manager, who acknowledged the resident's verbal communication abilities. Resident #57 experienced a fall, but the care plan was not updated to reflect this incident or to implement new interventions to prevent future falls. The resident was identified as high risk for falls, yet the most recent intervention was dated several months prior to the fall. Similarly, Resident #39 had a fall that required a hospital visit, but the care plan was not revised to address the incident or to include new preventive measures, despite recommendations for care plan revision in the post-fall review. Resident #32 experienced a significant weight loss of 22.6 pounds in one month, yet the care plan was not updated to reflect this change or to implement interventions addressing the weight loss. The facility's policies on comprehensive care plans and fall prevention did not adequately address the need for care plan revisions following significant events such as falls or weight changes. Interviews with facility staff, including the DON, confirmed the expectation for care plans to be updated with each change or event, highlighting the deficiencies in the facility's care planning process.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility staff failed to administer the nutritional supplement Pro-stat to Resident #77 as ordered by the physician for over two months. The resident, who was admitted with multiple diagnoses including protein-calorie malnutrition, did not receive the supplement due to it being out of stock and unavailable for administration. The medication administration record documented that the Pro-stat was not administered on several occasions, and staff interviews revealed issues with vendor changes and ordering processes that delayed the supplement's availability. Resident #57 did not have sutures removed or a follow-up dermatology appointment scheduled as ordered by the doctor. The resident, who had a history of scabies, was found with red lesions and dried blood on his body. The clinical record review showed a lack of documentation from the dermatologist, and the unit manager confirmed the absence of this information in the resident's chart. The director of nursing later identified a suture that needed removal and confirmed that the dermatology follow-up had not been scheduled. Resident #32 did not receive wound care and the application of a multi-podus boot as ordered by the physician. The resident reported that bandage changes for a foot ulcer were frequently missed, and the treatment administration record confirmed that the wound care was not consistently performed. During an observation, the resident's wound was found to have drained through the bandage, and the multi-podus boot was not in place. The unit manager acknowledged the ongoing issue of staff not performing the wound care as ordered and noted that the order for the multi-podus boot had not been correctly updated in the clinical record.
Inadequate Infection Control and Response to Outbreaks
Penalty
Summary
The facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. In one instance, staff did not adhere to enhanced barrier precautions for a resident with a feeding tube, as required by the facility's policy. Observations revealed that personal protective equipment (PPE) was not available outside the resident's room, and staff members entered the room without wearing the necessary PPE. Interviews with staff indicated a lack of understanding and communication regarding the enhanced barrier precautions, contributing to the failure to implement appropriate infection control measures. In another case, the facility staff did not follow transmission-based precautions for a resident diagnosed with scabies. Despite the resident's care plan indicating the need for contact isolation, staff members were observed entering the resident's room and providing care without wearing PPE. The facility's infection preventionist was unaware of the need for a line listing and failed to track other symptomatic residents, indicating a lack of proper infection surveillance and monitoring. Additionally, the facility did not respond appropriately to a COVID-19 outbreak. The infection preventionist was unable to provide evidence of contact tracing or broad-based testing, as recommended by the CDC. The facility also failed to maintain a line listing of COVID-19 cases and did not conduct necessary testing for residents and staff. Furthermore, the facility did not adequately address the presence of Legionella bacteria in the water system, as recommended cleaning and follow-up testing were not performed. These deficiencies highlight significant gaps in the facility's infection control practices and response to infectious disease outbreaks.
Failure to Provide Immunization Education and Offers
Penalty
Summary
The facility staff failed to provide education and offer flu and pneumonia immunizations to three residents, as identified during a review of immunization protocols. The clinical records for two residents showed no evidence of education or offers for the flu and pneumonia vaccines since their admission, and there was no documentation of consent or refusal. Another resident's record indicated that while she received the Prevnar 13 vaccine, there was no documentation of being offered the flu vaccine or the pneumococcal 23 vaccine. All three residents had been in the facility for at least eight months and were present during the flu season. During an interview, the facility's infection preventionist confirmed the lack of documentation regarding the immunizations, education, and consents for the three residents. The infection preventionist explained that floor nurses are responsible for offering immunizations upon admission and contacting the responsible party for consent. The facility's policies on influenza and pneumococcal vaccinations require documentation of education and consent, which was not adhered to in these cases. The facility's administrator, director of nursing, and corporate nurse consultant were informed of these findings, but no additional information was provided to address the deficiency.
Failure to Educate and Offer COVID-19 Vaccine
Penalty
Summary
The facility staff failed to provide education and offer the COVID-19 immunization to four out of five residents sampled, as well as to one staff member. During clinical record reviews, it was found that there was no evidence of education or offering of the COVID-19 2023-2024 spike vaccine to the residents. Specifically, Resident #80 had no immunization information noted except for a PPD tuberculin skin test, and Residents #42, #60, and #70 had no information regarding COVID immunization listed. Additionally, there was no documentation indicating that the vaccine was offered, education was provided, or that it was declined or refused. An interview with the facility's infection preventionist confirmed the lack of documentation regarding COVID immunizations for the residents. The infection preventionist stated that floor nurses are responsible for offering immunizations upon admission and contacting the responsible party to determine if they want the immunization. The importance of immunizations was acknowledged to prevent outbreaks. However, the facility's process was not followed, as evidenced by the absence of documentation and education. Furthermore, the facility's human resources manager and administrator were unable to find any COVID immunization information for Other Employee #8 in the employee's file. The employee had to provide a photo of her COVID immunization card, which showed she had received the primary series and one booster dose in October 2022. There was no evidence of the employee being educated on the COVID immunization or being offered subsequent boosters. The facility's policy on Coronavirus Prevention and Response outlines the requirements for vaccination planning, including education and documentation, which were not adhered to in these cases.
Resident's Personal Property Moved Without Notice
Penalty
Summary
The facility staff failed to honor a resident's right to be treated with respect and dignity by moving personal property without prior notice or consent. The incident involved a resident who was cognitively intact and had multiple diagnoses, including congestive heart failure, hip fracture, neurogenic bladder, diabetes, anxiety, and depression. The resident's personal items were moved to another room while the resident was out of the facility for a medical appointment. There was no documentation of verbal or written notice provided to the resident before the room change, and the resident was not given the opportunity to assist or accompany staff during the transfer of personal items. Interviews with facility staff, including the social worker, LPN, CNA, DON, and the administrator, revealed that the room change was made due to conflicts and complaints about the resident's roommate. However, the staff did not recall why the move was conducted on that specific day or why it was done without the resident's supervision. The resident expressed dissatisfaction with the lack of communication and the handling of personal items, particularly the discarding of pretzels. The administrator acknowledged that it was not the facility's expectation for staff to move personal items without the resident's permission or oversight.
Facility Fails to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to maintain adequate funds on-site, denying two residents access to their personal funds, which could potentially affect 41 residents with trust accounts. Resident #226 (R226) reported multiple instances where he was unable to withdraw money from his trust account for shopping. The Business Office Manager (BOM) explained that residents are allowed to withdraw $40 per day, but due to a lack of funds, R226 was unable to access his money. The BOM mentioned that the facility had recently changed banks and was waiting for funds to be replenished, leaving only $5 available at the time. The activity assistant corroborated R226's claims, stating that he often missed out on shopping trips due to insufficient funds. Resident #53 (R53) also experienced delays in accessing her personal funds. Despite having available funds, R53 reported that it sometimes took several days to receive money from her account, especially if she had an outing planned. The BOM, who started working at the facility on August 1, 2024, acknowledged the issue and attributed it to the recent bank switch and insufficient petty cash reserves. At the time of the survey, only $5 was available for residents, highlighting the facility's failure to ensure timely access to personal funds. The facility's policy on resident trust accounts did not address residents' access to funds, focusing only on business office procedures. During the survey, it was noted that there was no visible posting of banking hours for residents, and the BOM confirmed that money was only available Monday through Friday. The administrator attempted to address this by posting a sign indicating banking hours, but the BOM clarified that the receptionist did not have access to the money box, further complicating residents' access to their funds.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility staff failed to ensure that it was clinically appropriate for a resident to self-administer medications. This deficiency was identified for a resident who had Bengay cream, antifungal powder, and Tums at her bedside. The facility staff did not assess the resident's ability to self-administer medications, did not obtain physician orders for these medications, and failed to remove them from the resident's room. During an initial tour, the surveyor observed these medications on the resident's over-bed table and in a bedside drawer. The resident reported using Bengay cream for arthritis pain several times a day. Interviews with facility staff, including an LPN and the unit manager, revealed that medications, including over-the-counter ones, should be stored in the medication cart or room unless there is an order allowing self-administration. The unit manager confirmed that no residents were authorized to self-administer medications and removed the items from the resident's room. A review of the resident's clinical records showed no assessment for self-administration ability, and the facility's policy required such an assessment by the interdisciplinary team. The facility administrator and director of nursing were informed of these findings during an end-of-day meeting.
Incomplete Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to develop a complete care plan for a resident with end-stage renal disease who was receiving dialysis. The resident, who was cognitively intact, had a history of congestive heart failure, pulmonary embolism, and hypertension. A review of the resident's blood pressure readings from late July to late August showed an average systolic pressure in the 140s and diastolic pressure in the 70s, with recent increases to 183/83 and 179/83. Despite these changes, the care plan did not include blood pressure parameters for dialysis, nor were they found in any other focus area of the care plan. An LPN noticed the increase in blood pressure and suggested it could indicate kidney failure but was unsure if it had been reported to the physician. The DON confirmed the absence of blood pressure parameters in the care plan.
Failure to Implement Post-Fall Interventions for Resident
Penalty
Summary
The facility staff failed to implement necessary interventions following a fall incident involving a resident, identified as R57, who was at high risk for falls due to impaired mobility and cognition. On 8/13/24, R57 experienced a fall after becoming anxious and agitated about a room change. Despite the fall being documented in a nursing note, there was no evidence of a post-fall assessment or any interventions to prevent future falls. The resident's care plan, which had not been updated since 3/27/24, did not reflect any new strategies to address the fall risk following the incident. Interviews with the unit manager revealed that the expected protocol, which includes a post-fall review and updating the care plan, was not followed. The unit manager acknowledged the absence of documentation and the importance of these steps in ensuring resident safety. The facility's Fall Prevention Program policy outlines specific actions to be taken after a fall, including assessment, documentation, and care plan review, none of which were completed for R57. The Director of Nursing was aware of the fall but could not provide additional documentation or witness statements to support the incident's circumstances.
Improper Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure proper catheter care for two residents, leading to potential health risks. Resident 41, who has benign prostatic hyperplasia and obstructive uropathy requiring a catheter, did not have the catheter tube anchored to prevent dislodging. Despite having a physician's order to check the placement of the catheter strap every shift, the tubing was observed unanchored during an interview and observation with a registered nurse. The resident did not report any pain or skin concerns, but the lack of anchoring was acknowledged by the nurse. Resident 77, who has multiple diagnoses including congestive heart failure and obstructive uropathy, was found with a catheter bag positioned on the floor, which is unsanitary and poses a risk for infection. The catheter bag was supposed to be suspended below bladder level and above the floor, as per the facility's policy and the resident's care plan. However, observations showed the bag resting on the floor, and both a CNA and an LPN confirmed that this was not the correct positioning. The facility's policy and the resident's care plan both emphasized the importance of maintaining proper catheter positioning to prevent complications.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide oxygen therapy consistent with infection control measures and professional standards of practice for a resident. During an initial tour, it was observed that the resident had a nebulizer mask sitting open to air on the bedside table, and the mask and tubing were dated over a month prior, indicating they had not been changed weekly as required. Additionally, the oxygen tubing was not labeled with a date, and the nasal cannula was found on the floor, which posed a potential infection risk. Interviews with staff revealed that the oxygen and nebulizer tubing should be changed weekly and stored properly to prevent contamination. However, the treatment administration record (TAR) inaccurately indicated that the equipment had been changed on specific dates, despite evidence to the contrary. The facility's policy required weekly changes of nebulizer tubing, but this was not adhered to, as confirmed by the unit manager and the discarded nebulizer mask dated 7/16/24. The findings were shared with the facility administrator and director of nursing, but no additional information was provided to address the deficiency.
Failure to Provide Meals and Ensure Communication for Dialysis Resident
Penalty
Summary
The facility failed to provide meals or snacks for a resident who required dialysis treatment at an offsite location, leading to the resident missing meals on dialysis days. The resident, who had end-stage renal disease, type 2 diabetes, and was dependent on renal dialysis, reported leaving the facility around 10 a.m. and returning around 3 p.m. on dialysis days without receiving any food or drink. Despite being an insulin-dependent diabetic, the resident had to wait until the evening meal to eat, as no food items were sent with him, nor was anything provided upon his return. Interviews with facility staff, including a CNA and the dietary manager, confirmed that no meals or snacks were sent with the resident to the dialysis center. The dietary manager stated that meals were not sent because they often went missing, and there was no established practice of sending packed lunches or snacks. The unit manager was unaware of the need to send meals, assuming the resident would eat at the dialysis center, despite the resident's nutritional issues and dietary needs. Additionally, the facility failed to maintain effective communication with the dialysis center to ensure continuity of care. The resident reported that a folder was sometimes sent with him, but it was not consistently filled out. The dialysis communication book, intended to document the resident's care and treatment at the dialysis center, was found to be full of blank pages. The unit manager acknowledged the lack of follow-up and documentation, which was contrary to the facility's dialysis policy and the contract with the dialysis center, both of which emphasized the importance of communication and coordination between the facility and the dialysis provider.
Improper Labeling of Insulin Pen from Back-up Supply
Penalty
Summary
The facility staff failed to label a Novolog prefilled insulin pen according to pharmacy standards on the B wing unit. During an inspection of the B wing medication cart, it was observed that the insulin pen lacked a pharmacy label indicating the drug name, resident's name, prescribed dose, strength, or administration instructions. Instead, the resident's name and the date opened were handwritten on the pen. A Licensed Practical Nurse (LPN) was unaware of why the pen was labeled in this manner and did not know what happened to the pharmacy-provided bag or label. The Director of Nursing (DON) explained that the insulin pen was taken from a back-up supply kit, and a different LPN had written the resident's name on it. The consultant pharmacist confirmed that nurses are not authorized to label prescription medications and that a form should have been completed and sent to the pharmacy when medications are removed from a back-up supply. The facility's policy required a usage slip to be completed and placed in the drug kit when drugs are removed. This deficiency was discussed with the facility's administration, but no further information was provided before the survey concluded.
Failure to Provide Recommended Eating Equipment
Penalty
Summary
The facility staff failed to provide a two-handled sippy cup for a resident, as recommended by therapy and documented in the resident's plan of care. The resident, who was cognitively intact, had been admitted with multiple diagnoses including atrial fibrillation, hypertension, arthritis, anxiety, depression, hypothyroidism, and a urinary tract infection. The resident was observed eating breakfast without the sippy cup, despite having hand tremors that made it difficult to manage regular cups. The resident confirmed that she had not received the sippy cup for several weeks, although it was initially provided after the recommendation. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's need for the handled cup. The LPN unit manager was unaware of the requirement, and the CNA stated that therapeutic cups were usually listed on meal tickets, but did not recall seeing it on the resident's ticket. The dietary manager confirmed that no notification was sent to the kitchen about the need for the therapeutic cup, resulting in its absence on meal trays. The deficiency was discussed with the facility's administration and clinical services directors, but no additional information was provided before the survey concluded.
Food Safety and Distribution Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards for food safety in the main kitchen and on one of the units, leading to deficiencies in food storage, preparation, and distribution. During an initial kitchen tour, it was observed that multiple open food products, such as syrup, bread, and croissants, were not labeled with an open date. Additionally, expired meat products, sugar, and flour were accessible for distribution. The dietary staff member acknowledged that all opened food products should have an open date, and expired items should have been discarded. The dietary manager was informed of these concerns, and the facility's policy on date marking for food safety was reviewed, which mandates that food be clearly marked with a date for consumption or disposal. On another occasion, the facility staff failed to distribute food in a manner that prevents contamination. During breakfast tray distribution on a unit, a CNA was observed taking a resident's tray back to the cart with other clean trays after the resident had removed some food items. This action mixed clean and soiled trays, which the CNA acknowledged could be an infection control concern. The facility administrator and director of nursing were informed of these findings, but no additional information was provided before the exit conference.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harrisonburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyside Presbyterian Retirement Community | 0.8 mi | ★★★★★ | 2 | 0 |
| Harrisonburg Hlth & Rehab Cntr | 1.7 mi | ★★★★★ | 7 | 0 |
| Vmrc, Complete Living Care | 3.4 mi | ★★★★★ | 0 | 0 |
| Bridgewater Home , Inc. | 5.9 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of New Market | 19.3 mi | ★★★★★ | 0 | 0 |
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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 July 2026) and official state health department websites.