Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blue Ridge Therapy Connection during CMS and state inspections, most recent first.
Incomplete Care Plans for Code Status and Advance Directives The facility failed to include current code status on several residents’ CCPs and did not develop care plan focuses, goals, or interventions for trauma-informed care related to PTSD or for end-of-life decisions/advance directives. Residents included individuals with DNR orders, a Full Code order, and diagnoses such as cognitive impairment, PTSD, depression, anxiety, COPD, heart failure, and other chronic conditions; surveyors reviewed the records and found the required care plan elements missing.
Failure to Treat a Resident with Dignity During Breakfast: An Activity Assistant tried to bring a resident with dementia and total ADL dependence to the dining room for breakfast, but a CNA yelled that she was a "feeder" and should not be brought in yet. The exchange was heard by other residents and staff, and the CNA later acknowledged the comment may not have been appropriate. The facility policy stated staff must speak respectfully, avoid labeling residents by diagnosis or care needs, and keep staff-to-staff communication out of residents' hearing.
A resident with PTSD, anxiety, schizoaffective disorder-bipolar type, Parkinson's disease, depression, mild cognitive impairment, weakness, and DM2 did not have a completed Level II PASARR after short-term approval expired. The resident's most recent MDS showed a BIMS score of 15/15, indicating intact cognition. Surveyors found that the facility had not completed the required review, and the administrator confirmed the omission and provided a fax cover sheet showing a new request had only recently been initiated.
Failure to Provide Baseline Care Plan Copy: A resident with dementia, COPD, CHF, AFib, cirrhosis, anxiety, depression, and panic disorder was cognitively impaired with severe decision-making deficits, yet the facility could not show that the baseline care plan was reviewed with the resident or representative or that a copy of the baseline care plan and meds was provided. The admission assessment only showed the baseline care plan was completed, and the DON could not locate a progress note documenting that it had been shared.
Failure to provide fingernail care for a dependent resident. A resident with dementia, depression, anxiety, HF, HTN, and generalized weakness was dependent on staff for all ADLs and had impaired memory and decision-making. Staff observed the resident with excessively long, jagged fingernails and dark material under the nails on multiple occasions, despite the resident being generally cooperative with personal care and the facility policy calling for routine nail care and regular trimming.
A resident’s chart was inaccurate because Tylenol remained listed as an allergy even though the resident had active Tylenol orders and was receiving scheduled doses for lower back pain. The resident had a BIMS score of 11 and diagnoses including toxic encephalopathy, gait abnormalities, and muscle weakness. Surveyors found the mismatch between the allergy list, MAR, and medication orders during record review, and the resident later stated Tylenol helped with pain and had not caused any issues.
A resident with CKD and dementia, and severe cognitive impairment, had a nebulizer order for congestion, but surveyors repeatedly observed the nebulizer mask lying uncovered on the bedside table. The facility policy required the mask or mouthpiece to be stored in a plastic ziplock bag when not in use, and the IP stated it should be rinsed, dried, and kept in a clean bag between uses.
The facility staff failed to provide ADL care for a resident with diabetes and muscle weakness, who was observed multiple times with long and dirty fingernails despite being dependent on staff for personal hygiene.
The facility staff failed to administer the pneumococcal vaccine to a resident despite having obtained consent in 2019. The resident, with severe cognitive impairment and multiple diagnoses, did not receive the vaccine until 2024 after a verbal consent was obtained via phone. The issue was confirmed by the Infection Preventionist and discussed with the facility's administration.
Incomplete Care Plans for Code Status, PTSD, and Advance Directives
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for multiple residents, including care plan elements related to code status, trauma-informed care, and advance directives. For one resident with toxic encephalopathy, gait and mobility abnormalities, and muscle weakness, the clinical record included a DNR order, but the surveyor could not find the resident’s current code status on the comprehensive care plan. The resident’s quarterly MDS showed a BIMS score of 11, indicating moderately impaired cognitive skills for daily decision making. A second resident with cognitive communication deficit, dysphagia, history of falling, and diabetes also had a DNR order in the record, but the surveyor could not find the resident’s current code status on the comprehensive care plan. A third resident with hemiplegia and hemiparesis following cerebral infarction, GERD, and chronic respiratory failure likewise had a DNR order, but the care plan did not include the resident’s current code status. In each of these cases, the surveyor reviewed the record and found the code status missing from the comprehensive care plan before being provided updated care plans later in the survey process. The facility also failed to include required care plan content for other residents’ end-of-life decisions and psychosocial needs. One cognitively intact resident with PTSD, depression, anxiety, and multiple other diagnoses reported military service and ongoing therapy for PTSD, but the care plan did not show a focus, goal, or interventions for trauma-informed care. The same resident had a DNR order and durable DNR document, yet the care plan did not show a focus, goal, or interventions addressing end-of-life care decisions or the advance directive. Another cognitively intact resident with PTSD, anxiety, schizoaffective disorder, Parkinson’s disease, depression, and other diagnoses had a DNR order and durable DNR document, but the care plan did not include a focus, goal, or interventions for end-of-life care decisions. A third cognitively intact resident with bipolar disorder, anxiety, panic disorder, heart failure, COPD, depression, schizoaffective disorder, epilepsy, and other diagnoses had a Full Code order and a preferred intensity of care document indicating CPR, but the care plan did not include a focus, goal, or interventions addressing the resident’s end-of-life care decisions or advance directive for CPR.
Failure to Treat a Resident with Dignity During Breakfast
Penalty
Summary
The facility failed to treat a resident with respect and dignity when an Activity Assistant attempted to bring the resident, who was sitting in a wheelchair by the door of the room, toward the dining room for breakfast. The resident had diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, anxiety disorder, heart failure, hypertension, and generalized weakness. The MDS dated 7/22/2025 indicated impaired short- and long-term memory, impaired decision-making, and dependence on staff for all ADL care. On 9/24/2025 at approximately 8:30 AM, a surveyor observed CNA #4 yell to the Activity Assistant, "She's a feeder and you can't bring her in here right now!" When the Activity Assistant asked for clarification, CNA #4 repeated, "She's a feeder, don't bring her in here!" The Activity Assistant then parked the resident in the hall. The interaction was witnessed by approximately 20 residents in the dining room and 5 staff members not including CNA #4. During interview, CNA #4 stated they were telling the Activity Assistant not to bring the resident in because she was a feeder and they were not ready for the feeders yet, and acknowledged that this may not have been the right thing to say. The facility policy on dignity stated that residents are to be cared for in a manner that promotes well-being and self-worth, that staff speak respectfully to residents at all times and do not label or refer to residents by diagnosis or care needs, and that verbal staff-to-staff communication is conducted outside the hearing range of residents and the public.
Failure to Complete Level II PASARR Review
Penalty
Summary
Facility staff failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for one of 33 sampled residents. Resident #12 had diagnoses including PTSD, Anxiety Disorder, Schizoaffective Disorder-Bipolar Type, Parkinson's Disease, Depression, Mild Cognitive Impairment, Weakness, and Diabetes Mellitus Type 2. The most recent MDS, with an ARD of 6/18/25, assigned a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The clinical record showed that Resident #12 had short-term approval for a Level II PASARR through 7/20/25, but the facility did not complete a new Level II PASARR after that approval expired. During the end-of-day meeting on 9/24/25, the concern was discussed with the administrator, DON, ADON, regional nurse consultant, infection preventionist, and QA nurse. On 9/25/25, the administrator stated that a Level II PASARR had not been completed and provided a fax cover sheet showing that a request for a new Level II PASARR was initiated on 9/24/25. The facility policy reviewed stated that the state designated authority will review residents who have had a Level II evaluation at least once a year.
Failure to Provide Baseline Care Plan Copy
Penalty
Summary
The facility failed to provide the resident or the resident’s representative with a copy of the baseline care plan for one resident in the survey sample. The resident had diagnoses including cirrhosis of the liver, dementia, COPD, chronic atrial fibrillation, chronic diastolic heart failure, anxiety, depression, and panic disorder. The MDS assessment dated 9/7/25 stated the resident was cognitively impaired with both short- and long-term memory impairment and severely impaired decision-making ability. The demographic sheet listed multiple family members with contact information, and the resident was listed as their own responsible party. During record review, surveyors could not locate evidence that the baseline care plan had been provided to the resident, the resident’s authorized representative, or any family members. The admission assessment section for baseline care plan initiation showed only that the baseline care plan had been completed; the boxes indicating that it had been reviewed with the resident/responsible party and that a copy of the baseline care plan and medications had been given were not checked. The DON stated the information should be on the admission assessment or in a progress note, but surveyors were unable to find a progress note documenting that the baseline care plan had been reviewed or printed for the resident or family. The facility policy stated a baseline plan of care to meet the resident’s immediate needs shall be developed within 48 hours of admission and that the resident and representative will be provided a summary of the baseline care plan.
Failure to Provide Fingernail Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for all activities of daily living received necessary assistance with fingernail care. The resident had diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, anxiety disorder, heart failure, hypertension, and generalized weakness. The MDS assessment dated 7/22/2025 indicated the resident had impaired short- and long-term memory, impaired decision-making, and required staff assistance for all ADLs. During the initial tour on 9/23/2025, the resident was observed in the room with fingernails that were excessively long, jagged, and had dark brown material under all fingernails of both hands, and the resident was unable to answer questions. The resident’s care plan identified a need for assistance with ADLs related to advanced age, cognitive impairment, and dementia, with a goal that all ADL needs would be met. On 9/24/2025, the resident was again observed with long, jagged fingernails and dark brown material underneath each nail. CNA #4 stated the resident was cooperative with care, and CNA #1 stated the resident was typically cooperative with bathing and personal hygiene and that staff or hospice provided daily care depending on the day. The facility’s fingernail/toenail policy stated routine nail care may be performed by nursing staff or qualified activity team members and included daily cleaning and regular trimming, but no documentation was provided showing the resident had received nail care before the concern was discussed with the Administrator, DON, ADON, QA nurse, and regional consultants.
Incomplete Allergy Documentation for a Resident Receiving Tylenol
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for one resident because the allergy list was not updated to reflect current medication use. The resident’s record listed Tylenol as an allergy, yet the clinical record also contained three active Tylenol (acetaminophen) orders: one as needed for pain, one as needed for temperature of 99.5 or greater, and one scheduled twice daily for lower back pain. The resident’s diagnoses included toxic encephalopathy, unspecified abnormalities of gait and mobility, and muscle weakness, and the quarterly MDS assessment showed a BIMS score of 11, indicating moderately impaired cognitive skills for daily decision making. A review of the current MAR showed the resident was receiving Tylenol twice daily at 9:00 a.m. and 5:00 p.m., and there was no documentation that the resident had received Tylenol under the as-needed orders for pain or fever. The issue was identified during the survey when the DON and QA Nurse were informed that the resident was receiving Tylenol despite the allergy listing. The administrative staff later provided evidence that the FNP had spoken with the resident about Tylenol and pain control, and an LPN documented that the resident and the resident’s daughter wished for Tylenol to continue. During interview, the resident stated they took Tylenol, had not had any issues, and that it helped with pain.
Nebulizer Mask Left Uncovered
Penalty
Summary
The facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment and help prevent the development and transmission of communicable diseases and infections for Resident #110. Resident #110 had diagnoses including chronic kidney disease and dementia, and the most recent MDS assigned a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident also had a provider order dated 9/08/25 for Ipratropium-Albuterol Solution 0.5-2.5mg/3ml to be inhaled via nebulizer every six hours for congestion. Surveyors observed Resident #110's nebulizer mask lying uncovered and directly on the bedside table on 9/23/25 at 2:10 PM, 9/24/25 at 11:18 AM, and 9/25/25 at 8:10 AM. The facility policy titled Medicated Nebulizer Treatment, revised 4/22/14, stated to place the nebulizer mask or mouthpiece in a plastic ziplock bag when not in use. The Infection Preventionist stated that after nebulizer use, the mask should be rinsed, dried, placed back in a clean plastic bag, and changed weekly. The survey team discussed the concern with the administrative team on 9/25/25, and no further information was provided before exit.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility staff failed to provide activities of daily living (ADL) care for one dependent care resident, identified as Resident #45. Resident #45, who has diagnoses including diabetes and muscle weakness, was observed to have long fingernails with debris under them. The resident's annual minimum data set assessment indicated a significant cognitive impairment and dependency in personal hygiene. The comprehensive care plan for Resident #45 included interventions for nail care by a nurse or podiatrist as needed. Despite these interventions, the resident was observed multiple times with long and dirty fingernails, indicating a failure to provide the necessary ADL care. This issue was noted during an initial tour and subsequent observations, and it was discussed with facility leadership during an end-of-day meeting.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility staff failed to provide a resident with the pneumococcal vaccine despite having obtained consent from the resident's Responsible Party (RP) in 2019. The resident, who had diagnoses including diabetes, vascular dementia, and depressive disorder, was severely impaired in cognitive skills for daily decision-making. The resident's clinical record inaccurately indicated that the vaccine had been offered and declined. Upon review, it was found that the vaccine had not been administered until 2024, following a verbal consent obtained via phone from the RP. The Infection Preventionist (IP) confirmed that the vaccine should have been administered in 2019 when the original consent was obtained. The facility's policy required consent for the administration of the pneumococcal vaccine, which had been properly obtained but not acted upon. The issue was discussed with the facility's administration, including the Administrator, Director of Nursing, Quality Assurance Nurse, and Nurse Consultant, but no further information was provided to the survey team 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 49 citations issued within 25 miles in the last 12 months — 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 Stuart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Hall - Laurel Meadows | 13.2 mi | ★★★★★ | 0 | 0 |
| Stokes County Nursing Home | 15.3 mi | ★★★★★ | 7 | 0 |
| Stanleytown Health And Rehabilitation Center | 18.1 mi | ★★★★★ | 0 | 0 |
| Skyline Nursing & Rehabilitation | 19.4 mi | ★★★★★ | 11 | 0 |
| Surry Community Health Center By Harborview | 21.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Blue Ridge Therapy Connection.
100% money-back within 48 hours.
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.