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 Cedars Healthcare Center during CMS and state inspections, most recent first.
The facility staff failed to administer medications timely for three residents, affecting their treatment for conditions like hypertension, Parkinson's, and COPD. A resident reported not receiving morning medications on time, while another experienced delays in COPD treatments, necessitating unscheduled doses. A third resident did not receive a critical inhaler for several days. Staff interviews revealed a practice of administering medications within an hour of the scheduled time, but documented delays exceeded this timeframe.
A resident received an incorrect dosage of propranolol due to a transcription error by the facility and a dispensing error by the pharmacy. The resident was prescribed a low dose with a specific titration schedule for drug-induced tremor, but received a higher dose than ordered. The facility's nurse was unable to provide evidence of proper administration, and the pharmacy confirmed sending full tablets instead of half tablets.
A long-term care facility failed to ensure the availability of medications for several residents, resulting in missed doses and non-compliance with physician orders. Residents experienced issues with medications such as Gabapentin, Propranolol, Bevespi, and Breo Ellipta due to delays in delivery, pharmacy errors, and insurance coverage issues. The facility's policies on medication administration were not effectively followed, contributing to the deficiencies.
The facility staff failed to maintain sanitary conditions in the kitchen, with issues such as wet nesting of dishes, improper use of hair nets, and inadequate dishwashing procedures. Observations showed staff plating food without beard guards and not following proper dishwashing protocols, leading to potential bacterial growth. The facility's policies did not adequately address these issues, and the administrator was informed of the deficiencies.
The facility failed to implement its abuse policy by not conducting timely criminal background checks for 14 employees and not obtaining checks for 9 others, including key staff. Additionally, the facility did not verify the professional licenses of 5 employees before they worked with residents, despite policy requirements. These lapses were identified during a survey and an HR audit.
Several residents in an LTC facility did not receive medications as ordered due to pharmacy delivery delays and communication lapses. Residents with conditions like chronic pain and opioid dependence missed doses of methadone, Suboxone, and other medications. The facility's policy on missed medications was not effectively followed, leading to deficiencies in care.
A long-term care facility failed to ensure the availability of medications for several residents, leading to missed doses and inadequate pain management. Residents experienced delays in receiving prescribed medications such as Percocet, Methadone, Suboxone, and various ointments and eye drops due to pharmacy delivery issues and inadequate medication management systems. Staff interviews revealed ongoing challenges with timely medication deliveries and reordering processes.
The facility failed to store medications properly on the 200-unit and 300-unit. Unopened insulin and eye drops were found at room temperature instead of refrigerated, and lorazepam was not secured in a locked compartment. Staff were unaware of the reasons for these storage issues, and the facility's policy requires medications to be stored according to manufacturer recommendations.
Facility staff failed to maintain sanitary conditions in food handling and dishwashing. Staff were observed without proper hair restraints, and dishwashing procedures did not include rinsing or proper drying, contrary to facility policies. These deficiencies were confirmed by the dietary services district manager.
The facility failed to educate and offer pneumococcal vaccinations to several residents, as required by its infection control policy. Documentation of immunization status and history was missing or outdated for all residents reviewed. The regional infection preventionist confirmed the lack of documentation and acknowledged that records should have been updated with the most recent vaccine information.
The facility failed to report and document abuse allegations for three residents, including a serious rape allegation, a CNA-related incident, and a resident-to-resident abuse case. The facility did not submit follow-up reports or notify required agencies in a timely manner, and there were lapses in documentation and reporting procedures.
A resident with severe psychiatric symptoms alleged rape while at a facility, but the staff failed to provide credible evidence of an investigation. The DON believed the allegation was against a hospital, not the facility, and did not pursue further action. The facility's abuse policy was not followed, and the administrator confirmed no investigation evidence was available.
A facility failed to develop a care plan for a resident with incontinence, despite assessments indicating the need. The resident, diagnosed with incontinence of bowel and bladder, confirmed experiencing episodes, and an LPN acknowledged the oversight. The issue was presented to the administrator.
Facility staff failed to administer oxygen according to physician's orders for three residents. One resident's concentrator was set at 2.5 LPM instead of 5 LPM, causing shortness of breath. Another resident's concentrator was set at 5 LPM instead of the prescribed 2 LPM. A third resident received oxygen at 2 LPM instead of 5 LPM, despite normal oxygen saturation levels. These issues were discussed with the facility's administration.
The facility exceeded the acceptable medication error rate of 5%, reaching 6.67%, due to two incidents where medications were unavailable. A resident did not receive gentamicin eye drops as the RN could not find them, and another resident did not receive Lactulose because the LPN could not locate it and the pharmacy had not sent it. The facility's policy requires medications to be reordered at least three days in advance, but there was no evidence of a reorder for the Lactulose.
The facility failed to provide routine dental services to two residents, leading to deficiencies in their care. One resident required dental extractions and follow-up care but did not receive it, while another resident experienced difficulty eating due to missing upper teeth and was not scheduled for dental services in a timely manner. Both residents expressed their need for dental care, but the facility did not adequately address these needs.
A resident with severe protein calorie malnutrition and other conditions did not receive the prescribed therapeutic diet during lunch. The meal ticket indicated a regular advanced dysphagia diet with fortified pudding parfait and pureed meat with gravy, which were missing. A nurse confirmed the discrepancy, and the dietary manager acknowledged the oversight.
A resident with a regular diet and a preference for fresh fruit was not served the fruit salad listed on their meal ticket, despite it being part of their documented food preferences. The dietary manager admitted the oversight, noting that fruit plates were prepared daily but not served as required. The resident's care plan highlighted the need to maintain proper nutrition, yet the failure to provide the preferred fruit was not corrected until identified during the survey.
A resident's clinical record inaccurately included hospice notes for other residents due to a clerical error. The medical records clerk admitted to scanning and uploading the notes incorrectly, leading to the misfiling. The resident had severe cognitive impairments and multiple diagnoses, including diabetes and chronic kidney disease.
An LPN failed to follow infection control practices during a medication pass, handling medications with cross-contaminated gloved hands. The LPN used a computer and touched various surfaces before directly handling medications with her fingers, contrary to the facility's policy requiring standard precautions. The issue was acknowledged by the DON and administrator.
The facility failed to educate and offer COVID-19 vaccines to two residents, as required by its infection control policy. The residents' clinical records lacked documentation of their immunization status and any education or offering of the vaccine since their admission. The regional infection preventionist confirmed that these steps should have been completed upon admission.
A resident with a physician's order for 5 liters per minute of oxygen via tracheostomy mask experienced shortness of breath due to malfunctioning oxygen concentrators. The concentrators were unable to deliver the prescribed oxygen flow, as confirmed by an LPN who observed the incorrect settings and acknowledged the need for properly functioning equipment.
A resident's comprehensive care plan for pressure injuries was not implemented as ordered, with treatments missing on several dates. The care plan included specific treatment orders for pressure ulcers, but the treatment administration record showed blank spaces, indicating missed treatments. Interviews with staff confirmed the expectation for individualized care and documentation, yet the facility failed to adhere to its policy for optimal personalized care.
The facility staff failed to document incontinence care for three residents, as evidenced by missing entries in ADL records. Despite residents being dependent for toileting, documentation gaps were found for several months. Interviews with CNAs confirmed that care was to be documented in PCC, but records were incomplete. The facility's policy required routine care, including incontinence care, to be provided by CNAs under supervision.
The facility staff failed to provide ordered treatments for two residents, leading to deficiencies in care. One resident did not receive prescribed wound care for an arterial heel wound on multiple occasions, as evidenced by blank spaces in the TAR and lack of documentation. Another resident's nephrostomy tube output was not monitored and recorded as ordered, with several shifts missing documentation. The executive director and DON were informed, but no further information was provided.
A resident with stage three and stage four pressure injuries did not receive physician-ordered treatments on multiple occasions. The treatments were not documented in the treatment administration record, and interviews with staff confirmed the lack of adherence to the facility's policy on pressure injury care.
A resident with severe cognitive impairment and identified as an elopement risk was found outside the facility, indicating a failure in monitoring and supervision. The resident's wander guard, intended to prevent elopement, was not consistently checked or documented as required. Staff interviews confirmed the need for daily and shift checks, but documentation gaps contributed to the incident.
A resident with a history of impulsive behaviors and suicidal ideation was able to climb out of a window onto the roof, leading to a fall and ongoing safety concerns. Despite being independent in daily activities, the resident's care plan noted impulsive behaviors, but the facility failed to secure the environment adequately. The resident expressed suicidal intentions and attempted to jump from the roof again, highlighting the facility's failure to maintain a safe environment.
A resident with a history of medical conditions was not allowed to make decisions regarding her treatment, despite being cognitively capable. She requested to go to the hospital due to abdominal pain but was given medication instead, leading her daughter to call 911. Staff interviews confirmed that residents have the right to make their own treatment decisions, but the facility failed to honor this right.
A resident with a history of impulsive behaviors and psychiatric disorders climbed out of a window, resulting in a fall. Despite expressing suicidal ideation and a plan, the facility failed to report the incident to authorities in a timely manner, violating their occurrence reporting policy.
A resident with severe cognitive impairment and an indwelling catheter did not receive consistent catheter care and output documentation as required by the facility's policy. Despite staff claims of performing these tasks, the treatment administration record showed missing entries for catheter care and output on multiple dates and shifts. The facility's leadership was informed of these issues.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility staff failed to adhere to professional standards of practice regarding the timely administration of medications for three residents. Resident #2 reported not receiving her morning medications on time, with multiple instances documented where medications scheduled for 7 a.m., 8 a.m., and 9 a.m. were administered several hours late. This included critical medications such as propranolol for hypertension and carbidopa-levodopa for Parkinson's. The resident expressed that despite informing the nursing staff, the issue persisted. Resident #4 also experienced delays in medication administration, particularly with treatments for COPD. The Medication Admin Audit Report showed that medications scheduled for 7 a.m. were often administered after 10 a.m., and on one occasion, a scheduled 7 a.m. albuterol nebulizer treatment was not given until 6:37 p.m. This delay necessitated an unscheduled prn dose earlier in the day, which was not documented until much later. Resident #5 reported not receiving his Breo Ellipta inhaler for several days, which is crucial for managing his COPD. The medication administration record confirmed that the inhaler was not administered on multiple days, and there was no documentation of physician notification regarding these omissions. Interviews with nursing staff and the medical director revealed a practice of administering medications within an hour of the scheduled time, but the documented delays exceeded this timeframe, indicating a failure to maintain therapeutic levels as intended by the facility's policy and professional standards.
Medication Dosage Error Due to Transcription and Pharmacy Dispensing Mistakes
Penalty
Summary
The facility staff failed to accurately transcribe a physician's order for a resident, leading to the administration of an incorrect medication dosage. The resident, who had a neurologist's assessment indicating drug-induced tremor and parkinsonism, was prescribed propranolol at a low dose with a specific titration schedule. However, the facility transcribed the order incorrectly, resulting in the resident receiving a higher dose than prescribed. The medication administration record showed that the resident received three doses daily, but the supply was depleted earlier than expected, indicating that the resident likely received the full 10 mg tablet instead of the prescribed half tablet. Further investigation revealed that the pharmacy had also contributed to the error by sending full tablets instead of half tablets as ordered. The nurse on duty was unable to provide evidence of the medication being administered as documented, and the pharmacist confirmed the error in dispensing the medication. The facility's director of nursing acknowledged the transcription error and the discrepancy with the pharmacy's supply, which led to the resident receiving an incorrect dosage of propranolol.
Medication Availability Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to ensure the availability of medications for several residents, leading to missed doses and non-compliance with physician orders. Resident #1 did not receive Gabapentin for neuropathy for three consecutive days due to a hold order placed when the medication was unavailable. The attending physician noted frequent issues with medication availability, particularly with narcotics, and attributed some of the problems to the use of agency staff unfamiliar with the residents. The medication was eventually found in the facility, but not before several doses were missed. Resident #2 experienced similar issues with the blood pressure medication Propranolol. The resident missed multiple doses over several days, with documentation indicating the medication was out of stock or awaiting delivery. An error by the pharmacy resulted in the resident receiving the incorrect dosage, as full tablets were dispensed instead of the prescribed half tablets. This error contributed to the depletion of the medication supply, leaving the resident without the necessary medication. Residents #4 and #5 also faced medication availability issues with their respiratory medications, Bevespi and Breo Ellipta, respectively. Both residents missed several doses due to delays in delivery and issues with insurance coverage. The facility's contracted pharmacy confirmed delays in dispensing the medications, and the facility staff were unable to provide the medications as ordered. The facility's policies on medication administration and handling missed medications were not effectively followed, contributing to the deficiencies observed.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility staff failed to maintain sanitary conditions in the main kitchen, affecting food storage, preparation, and service. Observations revealed that dishes were not allowed to air dry and were being stacked while wet, which can lead to bacterial growth. During meal service, a dietary aide was seen plating food without a beard guard, despite having visible facial hair. Additionally, a cook was observed preparing food without a hair net, and another dietary aide's hair net did not adequately cover her hair. The facility's food services district manager acknowledged these issues and stated that larger hair nets would be provided. Further observations indicated that the facility staff did not properly wash dishes, as a dietary aide was seen using only two of the three sinks in the manual washing process, skipping the rinse step. The facility's policy on manual warewashing did not address the need for rinsing dishes. The dietary services district manager confirmed these observations and attempted to correct the process. The facility administrator was informed of these deficiencies during end-of-day meetings, but no additional information or corrective actions were provided in the report.
Failure to Implement Employee Pre-Screening and License Verification
Penalty
Summary
The facility staff failed to implement their abuse policy regarding the pre-screening of employees, as evidenced by the review of 26 employee records. For fourteen employees, the facility obtained criminal background checks from the Virginia State Police beyond 30 days from hire, with some employees being hired as much as 1 year and 8 months prior to the background check being obtained. The Human Resource Manager (HRM) conducted an audit and re-ran criminal background checks for these employees, but the initial failure to comply with the policy was noted. Additionally, the facility staff failed to obtain criminal background checks for nine employees, including key personnel such as the human resources manager and the director of nursing. Despite the HRM's audit identifying seven of these employees as lacking a background check, no checks were on file at the time of the survey. Two employees hired after the audit also did not have background checks on file, indicating ongoing non-compliance with the facility's policy. Furthermore, the facility staff did not verify the professional licenses of five employees before allowing them to work with residents. This included failing to verify the licenses of a certified nursing assistant, a licensed practical nurse, and the facility administrator. The HRM stated that license look-ups are conducted during interviews, but there was no evidence that the facility reviewed additional public information or disciplinary actions against licenses, as required by their policy. These deficiencies highlight significant lapses in the facility's adherence to its abuse prevention policies.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to administer medications as ordered by physicians for several residents, leading to deficiencies in care. Resident #20 did not receive methadone for pain management on multiple occasions due to delays in pharmacy delivery, despite the medication being reordered. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) acknowledged ongoing issues with timely pharmacy deliveries, but no immediate solutions were provided. Resident #20, however, did not report any pain concerns from the missed doses. Resident #40 did not receive Calmoseptine ointment as ordered for folliculitis because it was not ordered from the pharmacy, despite being an in-house stocked item. The LPN was unsure why the ointment was unavailable, and the supply clerk confirmed that no request for the ointment had been made. This oversight resulted in the resident not receiving the prescribed treatment for several days. Other residents, including Resident #93, Resident #80, Resident #70, Resident #77, and Resident #323, also experienced missed doses of various medications due to similar issues with pharmacy deliveries and communication lapses. These residents had conditions such as chronic pain, opioid dependence, and allergic conjunctivitis, which required timely medication administration. The facility's policy on missed medications was not effectively followed, as evidenced by the lack of timely reordering and communication with the pharmacy and physicians.
Medication Availability Issues in LTC Facility
Penalty
Summary
The facility failed to ensure the availability of medications for several residents, leading to missed doses and inadequate pain management. Resident #69, who had a broken foot, did not receive her prescribed pain medication, Percocet, on a specific date due to a delay in delivery from the pharmacy. Similarly, Resident #80, who was managing cancer-related pain with Methadone, experienced multiple instances where the medication was not administered as ordered, with nursing notes indicating delays in pharmacy delivery. Resident #70, who was prescribed Suboxone for opioid dependence, also faced issues with medication availability. The facility's system for accounting for controlled drugs was inadequate, as evidenced by discrepancies in the recorded quantity of Suboxone. Additionally, Resident #20 did not receive Methadone for several days due to pharmacy delivery issues, despite the medication being reordered in advance. The Director of Nursing acknowledged ongoing issues with timely medication deliveries from the pharmacy. Other residents, including Resident #40, Resident #93, and Resident #274, also experienced missed doses of various medications due to unavailability. These included Calmoseptine ointment, eye drops, and Lactulose, with nursing staff citing delays in pharmacy deliveries and issues with reordering processes. Interviews with staff and residents highlighted a pattern of medication management failures, with the facility's policies on medication administration and reordering not being effectively implemented.
Improper Storage of Medications on Two Units
Penalty
Summary
The facility failed to properly store medications on two of its units, the 200-unit and the 300-unit, as observed during a survey. On the 300-unit, an unopened vial of Humalog insulin was found stored at room temperature on a medication cart, despite the label indicating it should be refrigerated until opened. Additionally, a 30 ml bottle of liquid lorazepam, a controlled medication, was stored in the medication refrigerator without being secured in a separately locked, permanently affixed compartment. The licensed practical nurse (LPN) on the 300-unit was unaware of why the insulin was improperly stored and confirmed the absence of a lock box for controlled medications in the refrigerator. On the 200-unit, two unopened bottles of Xalatan eye drops and three Promethegan suppositories were also found stored at room temperature on a medication cart, contrary to their labels which instructed refrigeration. The registered nurse (RN) on the 200-unit verified that the medications had not been opened and was unsure why they were not stored in the refrigerator. The director of nursing (DON) acknowledged that medications were supposed to be refrigerated as labeled and suggested that someone might have mistakenly placed them on the cart instead of in the refrigerator. The facility's policy on medication storage, revised in August 2024, mandates that medications be stored according to manufacturer recommendations and that controlled substances requiring refrigeration be kept in a locked box within the refrigerator.
Sanitation Deficiencies in Food Handling and Dishwashing
Penalty
Summary
The facility staff failed to adhere to sanitary practices in food storage, preparation, and service, as observed in the main kitchen and dining room. During meal service, staff members were seen without proper hair restraints, such as hair nets and beard guards, which are necessary to prevent food contamination. Specifically, a dietary aide was observed plating food without a beard guard, and a cook was seen preparing food without a hair net. Another dietary aide's hair net was insufficient to cover her hair, and the facility's social services director was also seen in the kitchen without a hair net. The facility's policy requires all staff to have their hair off the shoulders and properly restrained, which was not followed. Additionally, the facility staff did not wash dishes in a manner that prevents contamination. A dietary aide was observed using only two of the three sinks for manual dishwashing, skipping the rinse step before sanitizing. The facility's policy did not address the need for rinsing dishes. Furthermore, after dishwashing, dishes were stacked wet, which could lead to bacterial growth. The facility's policy states that all dishware should be air-dried and properly stored, which was not adhered to. These observations were confirmed by the dietary services district manager and brought to the attention of the facility administrator.
Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility staff failed to educate and offer pneumococcal immunizations according to the facility's infection control policy for several residents. Specifically, three out of five residents reviewed did not have documentation of education or an offer of the pneumococcal vaccine, and their records lacked any status or history of pneumococcal immunizations. Additionally, the immunization status was not up to date in the clinical records for all five residents reviewed. The regional infection preventionist confirmed the absence of documentation regarding the pneumococcal immunization status and education for these residents. The facility's policy mandates that residents be offered education and the pneumococcal vaccine unless contraindicated or already immunized. However, the clinical records for two residents were not updated with the most recent vaccine status, despite evidence of additional vaccinations. The regional infection preventionist acknowledged that immunization history should be obtained upon admission and that the records should have been updated accordingly. These findings were discussed with the administrator and regional consultants, but no further information was provided before the survey concluded.
Failure to Report and Document Abuse Allegations
Penalty
Summary
The facility staff failed to report allegations of abuse for three residents, including a serious allegation of rape by a resident who was no longer at the facility. The initial report was made to the state survey agency, but the facility did not submit a follow-up report with the investigation findings. The Director of Nursing (DON) believed a follow-up was unnecessary as the allegation was against a hospital, not the facility. However, the facility administrator, who was the abuse coordinator, admitted there was no evidence of a completed investigation or reported results. In another incident, the facility staff did not notify all required agencies about an abuse allegation involving a resident and a certified nursing assistant (CNA). The facility attempted to fax the report to the Virginia Department of Health Professions (DHP) but failed to confirm successful transmission. Additionally, the CNA's employee file lacked a sworn statement or criminal background check, indicating a lapse in proper documentation and reporting procedures. The facility also delayed reporting an allegation of resident-to-resident abuse for another resident. The incident was reported two days late, contrary to the administrator's acknowledgment of the requirement to report within two hours. The administrator could not explain the delay, highlighting a failure in adhering to the mandated reporting timelines. These deficiencies indicate a pattern of inadequate reporting and documentation of abuse allegations within the facility.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility staff failed to provide credible evidence of an investigation following an allegation of sexual abuse made by a resident. The resident, who had a history of severe psychiatric symptoms and was under an emergency custody order, alleged that she was raped while she was a resident at the facility. The facility documentation and electronic health records indicated that the resident was discharged from the facility and later made the allegation while at a hospital. The facility provided a one-page document stating that an investigation had started, but no evidence of an investigation or resident assessments was available. The Director of Nursing (DON) stated that the allegation was against the hospital, not the nursing facility, and therefore did not pursue further action. The facility administrator, who was the abuse coordinator, confirmed that no investigation evidence was available and acknowledged that the process was not properly commandeered due to being in training. The facility's abuse policy requires the Executive Director to determine when an investigation is needed and to direct it, but this procedure was not followed in this case.
Failure to Develop Care Plan for Incontinence
Penalty
Summary
The facility failed to develop a complete care plan for a resident, identified as Resident #5, who was diagnosed with incontinence of bowel and bladder, chronic congestive heart failure, and chronic atrial fibrillation. The resident's most recent Minimum Data Set (MDS) assessment indicated that they were always incontinent of bowel and bladder and had a cognitive score of 14 out of 15, suggesting they were cognitively intact. Despite these assessments, the resident's care plan did not include a plan for managing incontinence. During an interview, the resident confirmed experiencing incontinent episodes and acknowledged the staff's efforts to keep them clean and dry. An LPN, serving as the MDS coordinator, acknowledged that a care plan for incontinence should have been created upon the resident's admission and updated accordingly. This deficiency was presented to the facility administrator during a staff meeting.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to provide appropriate respiratory care to three residents by not administering oxygen according to the physician's orders. For one resident, the oxygen concentrator was set at 2.5 liters per minute instead of the prescribed 5 liters per minute via tracheostomy mask for hypercarbia. Despite attempts to adjust the setting, the concentrator was not functioning properly, and the resident reported experiencing shortness of breath at night. Another resident's oxygen concentrator was set at 5 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula. The discrepancy was identified and corrected by a licensed practical nurse, who was unsure why the setting was incorrect. A third resident, diagnosed with chronic congestive heart failure and chronic atrial fibrillation, was observed receiving oxygen at 2 liters per minute, despite a physician's order for 5 liters per minute continuous via nasal cannula. The resident's oxygen saturation level was within normal range, but the oxygen setting was not in accordance with the physician's order. The licensed practical nurse assigned to this resident acknowledged the incorrect setting after reviewing the order. These deficiencies were discussed with the facility's administrator and corporate staff, but no additional information was provided before the exit conference.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5 percent, resulting in a rate of 6.67 percent. During a medication pass observation, a registered nurse (RN) did not administer gentamicin eye drops to a resident as ordered by the physician. The RN was unable to locate the drops in the medication cart and stated that they were not available, indicating that the pharmacy would be contacted. The resident's clinical record showed a physician's order for the eye drops to be administered twice daily, but the morning dose was missed. This issue was discussed with the administrator and regional consultants, but no further information was provided before the survey concluded. Additionally, another resident did not receive Lactulose, a medication for constipation, during a medication pass. A licensed practical nurse (LPN) could not find the Lactulose in the medication cart or the medication room and noted that the pharmacy had not sent it. The LPN mentioned that the resident sometimes refused the medication and did not offer it during the pass. The LPN had attempted to reorder the medication two days prior, but there was no evidence of the reorder in the computer system. The facility's policy requires medications to be reordered at least three days in advance to ensure availability. This finding was presented to the administrator and corporate staff, with no additional information provided before the exit conference.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility staff failed to provide routine dental services to two residents, leading to deficiencies in their care. For Resident #80, the staff did not arrange for necessary dental extractions and follow-up care after a recommendation was made. Despite the resident's inability to eat solid food due to dental issues and cancer, and a recommendation for extractions to facilitate denture fabrication, there was no evidence of any consultations with an oral surgeon or attempts to arrange further dental services. The resident was unable to be seen at a dental clinic due to expired identification, and the facility social workers were unaware of this issue. The facility did not provide evidence of any follow-up until a progress note indicated an appointment was made for a future date. For Resident #4, the facility failed to arrange for dental services despite the resident's reported difficulty eating due to the absence of upper teeth. The resident had previously had teeth extracted at another facility with a promise of replacement, which was not fulfilled. Upon admission to the current facility, the resident expressed the need to see a dentist, but was not placed on the list for dental services until much later. The social worker assistant acknowledged the oversight, and the resident had not been seen by the facility's dentist since admission. The resident continued to express the need for dental care, including cleaning of the remaining teeth and obtaining upper dentures.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility staff failed to provide a therapeutic diet as prescribed for a resident diagnosed with severe protein calorie malnutrition, dementia, and iron deficiency anemia. The resident, who had a cognitive score indicating intact cognition, was observed during lunch not receiving the complete meal as indicated on their meal ticket. Specifically, the meal ticket prescribed a regular advanced dysphagia diet with an added half cup of fortified pudding parfait and a bowl of pureed meat with gravy, which were missing from the tray. A registered nurse assigned to the resident confirmed the discrepancy and indicated she would inform the kitchen. The dietary manager later acknowledged that the food items were available but had not been added to the meal tray. The resident's clinical record included a dietary progress note indicating a history of weight loss and a recommendation for fortified pudding parfait with two meals, which was ordered on a previous date. This deficiency was presented to the facility's administrator and director of nursing during a staff meeting.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility staff failed to honor the food preferences of Resident #93, who was part of the survey sample. Resident #93, who was cognitively intact and had a regular diet prescribed, expressed a preference for fresh fruit, which was documented in their food preference assessment. Despite this, the resident reported not receiving the fruit salad listed on their meal ticket during lunch. This was confirmed through observation on November 20, 2024, when the resident was served all items on the meal ticket except the fresh fruit plate. The dietary manager acknowledged the oversight, stating that fruit plates were prepared daily and should have been served according to the meal ticket. The resident's care plan, revised in June 2024, indicated a risk of nutrition problems and included interventions to maintain proper nutrition, such as providing the diet as ordered and identifying food preferences. However, the failure to serve the fresh fruit as per the resident's preference and meal ticket was not addressed until it was brought up during the survey.
Inaccurate Clinical Record Due to Misfiled Hospice Notes
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for one of the residents in the survey sample. Specifically, the clinical record of a resident included hospice notes that were intended for three other residents. This error was discovered during a review of the resident's clinical record, which revealed that hospice documentation for other residents was mistakenly included. The resident in question was admitted with multiple diagnoses, including diabetes, adult failure-to-thrive, protein-calorie malnutrition, chronic kidney disease, anxiety, and depression, and was assessed with severe cognitive impairments. The medical records clerk admitted to the error during an interview, explaining that hospice notes were sent to the facility on paper and were scanned and uploaded to the clinical record. The clerk acknowledged that the notes were scanned together and incorrectly uploaded to the wrong resident's record. This issue was discussed with the facility's administrator and regional consultants, but no additional information was provided before the survey concluded.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility staff failed to adhere to proper infection control practices during a medication pass on one of the units. An LPN was observed handling medications with cross-contaminated gloved hands. During the medication pass for Resident #15, the LPN sanitized her hands, applied gloves, and then used the computer before reaching into the medication cart to retrieve medications. The LPN was seen popping medications into her hand and reaching into bulk bottled medications with her fingers before placing them into a medication cup for distribution to the resident. The same LPN repeated this process for another resident, Resident #42, by sanitizing her hands, applying gloves, using the computer, and then handling medications with her fingers. The LPN acknowledged the difficulty in retrieving medications from bottles when they are nearly empty. The facility's policy on medication administration requires the use of standard precautions, which were not followed in this instance. The findings were presented to the Director of Nursing and the administrator, who confirmed that the observed practices were not in line with the facility's policy.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility staff failed to educate and offer COVID-19 immunizations to two residents, as required by the facility's infection control policy. During an infection control survey, it was found that there was no documentation of COVID-19 immunization status for these residents. The clinical records lacked evidence of any education about or offering of the COVID-19 vaccine since their admission to the facility. The regional infection preventionist confirmed that the immunization status should have been obtained upon admission, and vaccines should have been offered if not already received. The facility's policy mandates that residents be educated about the risks and benefits of the COVID-19 vaccine, screened for prior immunization, and have their vaccination documented in their medical records. However, these steps were not followed for the two residents in question.
Oxygen Concentrator Malfunction
Penalty
Summary
The facility staff failed to ensure that an oxygen concentrator was functioning properly for a resident, leading to a deficiency in care. The resident, who had a physician's order for oxygen therapy at 5 liters per minute via tracheostomy mask for hypercarbia, reported experiencing shortness of breath at night due to malfunctioning equipment. During an interview, it was observed that the oxygen concentrator was set at 2.5 liters per minute, contrary to the prescribed 5 liters. A Licensed Practical Nurse (LPN) confirmed the incorrect setting and acknowledged the need for a concentrator capable of delivering the required oxygen flow. A subsequent observation revealed a new concentrator in the resident's room, but it was also unable to reach the necessary 5 liters per minute, indicating ongoing equipment issues.
Failure to Implement Comprehensive Care Plan for Pressure Injuries
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for a resident, identified as Resident #4, specifically regarding pressure injury treatments. The resident's care plan, dated September 6, 2023, indicated the presence of a pressure ulcer on the right heel and a wound on the left Achilles, with specific treatment orders documented in the clinical record. These orders included cleansing the wounds and applying specific dressings daily. However, a review of the treatment administration record (TAR) for May 2024 revealed that treatments were not administered on several dates, as evidenced by blank spaces on the TAR and the absence of corresponding documentation in the nurses' notes. Interviews with facility staff, including an LPN and administrative staff members, confirmed the expectation that care plans should be individualized and that treatments should be documented on the TAR. Despite this, the treatments for the resident's pressure injuries were not consistently documented or administered as ordered. The facility's policy on the Plan of Care emphasizes the importance of providing resident-focused and optimal personalized care, which was not adhered to in this instance. The executive director and director of nursing were made aware of the concern, but no further information was provided before the survey exit.
Incontinence Care Documentation Deficiency
Penalty
Summary
The facility staff failed to provide incontinence care for three residents, as evidenced by missing documentation in the ADL records. Resident #3, who was not cognitively impaired and dependent for toileting, had multiple instances of missing documentation in December 2023 and January 2024. Interviews with CNAs revealed that incontinence care was supposed to be documented in PCC, but the records were incomplete. The facility's policy required routine daily care, including incontinence care, to be provided by CNAs under the supervision of a licensed nurse. Resident #6, also not cognitively impaired and dependent for toileting, had missing documentation in the ADL records for June and July 2024. Despite the resident stating that care was usually provided, there were gaps in the documentation. Interviews with CNAs confirmed that incontinence care was to be documented in PCC, but the records did not reflect consistent care. The facility's policy emphasized the importance of maintaining skin integrity and providing care with dignity. Resident #7, who was moderately cognitively impaired and dependent for toileting, had missing documentation in the ADL records for June, July, and August 2024. Although the resident reported that care was provided when called, the documentation was incomplete. The CNAs reiterated the process of documenting incontinence care in PCC, but the records were not comprehensive. The facility's policy outlined the need for routine care, including incontinence care, to be provided by trained CNAs.
Failure to Administer Wound Care and Monitor Nephrostomy Output
Penalty
Summary
The facility staff failed to provide physician-ordered treatments for two residents, leading to deficiencies in care. For one resident, the staff did not administer the prescribed wound care treatments for an arterial wound on the left lateral heel on multiple occasions in May 2024. The treatment administration record (TAR) showed blank spaces for the dates when the treatment was missed, and there was no documentation in the nurses' notes to indicate that the treatments were completed. The facility's policy on wound care required that residents with skin integrity issues receive treatment based on the wound's characteristics, but this was not adhered to in this case. For another resident, the facility staff failed to measure and record the output from a nephrostomy tube as ordered by the physician. The TARs for July and August 2024 showed that the output was not monitored and recorded on several shifts, and there was no documentation in the nurses' notes for those dates. The purpose of monitoring the nephrostomy tube output is to assess urine output, but the facility did not have a specific policy for this procedure. The executive director and director of nursing were informed of these concerns, but no further information was provided before the survey exit.
Failure to Administer Physician-Ordered Pressure Injury Treatments
Penalty
Summary
The facility staff failed to provide physician-ordered treatments for a resident's pressure injuries on multiple occasions in May 2024. The resident had a stage three pressure injury on the right heel and a stage four pressure injury on the left Achilles. Physician orders required daily cleansing and application of silvasorb gel and wound dressings for both injuries. However, the treatment administration record (TAR) for May 2024 showed that these treatments were not administered on several dates, as indicated by blank spaces on the TAR. Additionally, there were no nurses' notes documenting that the treatments were performed on those dates. Interviews with facility staff revealed that pressure injury treatments are recorded on the TAR, and nurses are expected to sign off on the TAR to confirm that treatments have been administered. Despite this procedure, the treatments were not documented as completed on the specified dates. The facility's policy on slough treatment requires the implementation of treatment as ordered, which was not adhered to in this case. The executive director and director of nursing were informed of the issue, but no further information was provided before the survey exit.
Failure to Monitor Wander Guard Leads to Resident Elopement
Penalty
Summary
The facility staff failed to provide a safe environment for Resident #9, who was identified as an elopement risk due to severe cognitive impairment and other medical conditions such as dementia, hypertension, and macular degeneration. The resident was admitted with a wander guard device intended to prevent elopement by triggering an alarm if the resident approached exit doors. However, documentation revealed multiple instances where the wander guard's placement and functionality were not checked or recorded as required by the facility's policy. Specifically, there were numerous dates across May, June, July, and August where the treatment administration record (TAR) lacked documentation of the wander guard's functioning and placement checks. On June 30, 2024, Resident #9 was found outside the building in the parking lot by a social worker, indicating a failure in monitoring and supervision. The resident was assisted back inside, and it was noted that the wander guard was functioning properly at that time. Interviews with facility staff, including an LPN and a CNA, confirmed that the wander guard should be checked for function daily and for placement every shift, with documentation on the TAR. Despite these protocols, the lack of consistent documentation and monitoring contributed to the resident's elopement, highlighting a deficiency in ensuring a safe environment for residents at risk of wandering.
Failure to Maintain Safe Environment for Resident
Penalty
Summary
The facility staff failed to maintain a safe environment for a resident who was admitted with diagnoses including tracheostomy, hypertension, and psychoactive substance abuse. The resident, who had intact cognition and was independent in daily activities, exhibited impulsive behaviors related to loss of independence, such as attempting to exit through unauthorized doors and climbing out of a facility window. Despite these behaviors being noted in the resident's care plan, the facility did not adequately secure the environment to prevent such incidents. On one occasion, the resident climbed out of a window onto the roof, which was not adequately secured, leading to a fall and a small abrasion above the left eyebrow. The incident was reported, and the window was fixed immediately. However, the resident continued to express suicidal ideation and attempted to jump from the roof again, indicating ongoing safety concerns. The facility's response included initiating one-to-one staffing and conducting a psychiatric evaluation, but the resident refused to go to the emergency department, and EMS determined he was in his right mind. Interviews with staff revealed that the maintenance director was aware of the damaged window and had repaired it after the incident. The facility's policy on elopement prevention and management was reviewed, highlighting the need for secure exits and windows. Despite these measures, the resident's behavior and the facility's response indicated a failure to ensure a safe environment, as the resident was able to access hazardous areas and expressed intentions to harm himself.
Failure to Respect Resident's Treatment Decisions
Penalty
Summary
The facility failed to allow a resident to make decisions regarding her treatment, which was identified during a review of documentation and staff interviews. The resident, who was not cognitively impaired, had a history of medical conditions including encephalopathy, COPD, CHF, and diabetes mellitus. Despite being fully capable of making her own decisions, the resident's requests to go to the hospital due to abdominal pain were not immediately honored. On one occasion, the resident requested to go to the hospital due to stomach cramping but was instead given medication and monitored, leading her daughter to call 911 for assistance. Interviews with facility staff, including an LPN and an RN, revealed that the resident had a history of calling EMS or her daughter if her medical needs were not met to her satisfaction. The staff acknowledged that residents have the right to make their own treatment decisions, including the right to go to the ER if they wish. The facility's Resident Rights policy supports this, stating that residents have a choice and a voice in their treatment. However, the facility's actions did not align with this policy, resulting in a deficiency in respecting the resident's right to make decisions about her care.
Failure to Report Resident's Self-Harm Incident
Penalty
Summary
The facility staff failed to report an allegation of a resident being on the roof with potential for self-harm. The resident, who was cognitively intact and independent in daily activities, had a history of impulsive behaviors and was noted to have attempted to exit through unauthorized doors and windows. On a specific date, the resident climbed out of a window, resulting in a fall and a minor injury. Despite the incident, the resident was assessed and found to be within normal limits, and the necessary notifications were made to the medical provider and director of nursing. Further investigation revealed that the resident had expressed suicidal ideation with a plan, as documented by a psychiatric nurse practitioner. The resident had a history of attention-deficit hyperactive disorder and major depressive disorder, and staff reported that the resident had previously jumped off the roof. The resident expressed a willingness to go to the hospital for further psychiatric evaluation, acknowledging the unsafe nature of his behavior. Despite these serious incidents and the resident's expressed suicidal ideation, the facility failed to report the situation to the appropriate authorities in a timely manner. The facility's occurrence reporting policy mandates the administrator to oversee timely reporting to federal, state, and local authorities, which was not adhered to in this case. This oversight in reporting the resident's behavior and potential for self-harm constituted a deficiency in the facility's compliance with regulatory requirements.
Failure to Document Catheter Care and Output
Penalty
Summary
The facility staff failed to provide appropriate treatment and services for a resident's indwelling catheter. The resident, who was admitted with diagnoses including toxic encephalopathy, obstructive/reflux uropathy, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for daily activities. The comprehensive care plan required monitoring and documenting intake and output as per facility policy, and providing Foley catheter care as needed and daily. However, the treatment administration record (TAR) showed missing documentation for Foley care on specific dates and shifts, as well as missing output documentation on several shifts. Interviews with facility staff revealed inconsistencies in the documentation process. An LPN stated that catheter care and output documentation were recorded on the TAR, but the records did not reflect this consistently. The facility's catheter care policy required catheter care to be performed twice daily, but the documentation did not support adherence to this policy. The executive director, director of nursing, and interim executive director were informed of these concerns, but no further information was provided prior to the exit.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 75 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 Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonnades Health Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Monroe Health & Rehab Center | 1 mi | ★★★★★ | 20 | 0 |
| The Laurels Of Charlottesville | 1.5 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Peace Inc | 1.9 mi | ★★★★★ | 15 | 0 |
| Charlottesville Health & Rehabilitation Center | 2.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.