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 Colonial Health & Rehab Center, Llc during CMS and state inspections, most recent first.
A resident was readmitted without proper verification of insulin orders, leading to diabetic ketoacidosis and hospitalization. Another resident experienced a delay in receiving medications for over 12 hours, despite availability in the Omnicell system. A third resident missed several doses of prescribed medications due to delays in pharmacy delivery and failure to use the emergency backup system. These incidents highlight significant lapses in communication and medication management.
The facility failed to implement an effective pain management program for two residents. One resident, readmitted with broken femurs, did not receive necessary pain medication due to unverified physician orders, leading to severe pain and hospital transfer. Another resident did not receive prescribed pain medication upon admission, resulting in unmanaged pain. Communication failures and procedural lapses contributed to these deficiencies.
A resident experienced harm due to the facility's failure to verify medication orders upon readmission. The on-call nurse practitioner did not confirm the orders, resulting in inadequate pain control and high blood sugar, leading to diabetic ketoacidosis. The resident was transferred to the hospital for treatment. Communication failures and procedural lapses among the staff contributed to the incident.
The facility failed to maintain a complete infection control program, with missing surveillance documentation for December 2023 and February 2024, and incomplete tracking for March, April, and May 2024. The director of nursing acknowledged the inaccuracies in the documentation, which did not meet the facility's Infection Prevention and Control Program Policy requirements.
The facility failed to provide adequate documentation during hospital transfers for three residents, lacking evidence of necessary documents and physician notes. Staff interviews revealed inconsistencies in the documentation process, and the facility's policy did not address the required documentation for transfers.
The facility failed to provide written notification of hospital transfers to resident representatives and the Ombudsman for three residents. The Director of Social Services and Admissions admitted to running incorrect reports and not sending notifications, while an LPN stated that nurses do not handle these notifications. The facility's policy requires that discharge/transfer letters be sent to the resident or guardian and copies to the Department of Health and Ombudsman Office, but this was not adhered to.
The facility failed to implement comprehensive care plans for multiple residents, resulting in deficiencies such as not getting a resident out of bed as preferred, not administering tube feeding, missing lab tests, and not providing prescribed medications and oxygen levels. These lapses in care highlight significant issues in following established care plans.
The facility staff failed to provide appropriate oxygen-related care for two residents and did not store a nebulizer mask properly for another. One resident lacked a physician's order for oxygen, while another received oxygen at a lower rate than prescribed. Additionally, a nebulizer mask was left uncovered, contrary to infection control policies. An LPN acknowledged these issues, citing challenges with agency staff.
The facility failed to provide timely and adequate pharmaceutical services, resulting in missed doses of critical medications for several residents. Issues included unavailability of medications, lack of access to the Omnicell system, and poor communication with the pharmacy and physicians. Residents experienced missed doses of Morphine, insulin, Amoxicillin, Revlimid, and Meropenem, highlighting systemic issues in medication management.
A resident's drug regimen was not properly monitored, as staff failed to weigh the resident daily to determine the need for an additional dose of furosemide, as per the physician's order. The oversight was confirmed by a nurse, and the interim administrator and DON were informed.
The facility failed to serve food at a palatable temperature for several residents, as observed through resident interviews and test tray assessments. Despite using equipment to maintain food temperatures, residents reported receiving cold meals, and the issue had been raised in resident council meetings. The facility's policy requires hot food to be palatable at delivery, but ongoing concerns persisted.
A resident was instructed to urinate in her pants instead of being provided with appropriate toileting assistance, leading to feelings of embarrassment and a lack of dignity. Despite being alert and aware of her needs, the resident was not offered a bedpan and was told she could not get out of bed until therapy screened her. Interviews with staff revealed inconsistencies in the understanding of toileting assistance protocols for new admissions.
A resident reported being threatened by another resident, but the facility failed to report the allegation within the required two-hour timeframe. The incident was initially reported to staff, but the report to authorities was delayed until the following day, violating the facility's abuse policy. The resident was cognitively intact and later decided to file a police report after consulting with family.
A resident reported being threatened by another resident, but the facility delayed reporting the allegation to authorities, violating the required two-hour reporting window. The incident involved a verbal altercation, and the resident initially did not want to involve the police but later filed a report. The facility's investigation noted no prior threatening behavior from the accused resident, and the reporting delay resulted in a deficiency citation.
The facility failed to provide written bed hold notices to two residents or their representatives during hospital transfers, as required by policy. One resident was transferred for possible stroke symptoms, and another for a change in consciousness and elevated blood pressure. An LPN indicated that bed hold notices should be documented in nurse's notes, but no evidence was found. The facility's policy mandates that these notices accompany discharge/transfer letters and be available in the electronic chart. Administrative staff were informed of the deficiency.
A resident's admission orders were delayed by 20 hours, resulting in a failure to provide immediate care as per hospital discharge instructions. The facility did not complete a nursing admission assessment on the day of admission, and the necessary medications and tube feeding were not administered promptly. An LPN confirmed that orders should be entered immediately, but this was not done, leading to a deficiency.
The facility failed to accurately complete MDS assessments for two residents. One resident was incorrectly coded as not receiving hospice care, despite documentation and orders indicating hospice admission. Another resident's smoking status was inaccurately marked as non-smoker, contrary to records and observations. These errors were acknowledged by the MDS coordinators and nurse.
A resident was administered insulin without a physician's order after being readmitted to the facility. The resident's clinical record lacked medication orders, and the MAR was not updated. A nurse administered insulin due to a high blood glucose level, leading to the resident's transfer to a hospital. Staff confirmed that such actions are outside the scope of practice without a physician's order.
The facility failed to provide adequate ADL care for three residents, resulting in deficiencies in oral care, incontinence care, and mobility assistance. A resident did not receive help with oral hygiene despite requests, another experienced lapses in incontinence care, and a third was not assisted out of bed despite expressing a desire to do so. Staff interviews revealed issues with documentation and staffing, leading to unmet care needs.
Two residents experienced deficiencies in feeding tube management at the facility. One resident was not administered tube feedings per physician orders and was incorrectly given a meal tray despite being NPO. Another resident's feeding tube complications were not addressed or reported to a physician in a timely manner, leading to inadequate care. Staff interviews revealed a lack of adherence to facility policies regarding feeding tube management.
A resident with multiple diagnoses, including diverticulitis and coronary artery disease, did not receive proper monitoring for a midline catheter as required by physician orders. The MAR lacked documentation of monitoring for signs of infiltration or infection on several days. Interviews with LPNs indicated that such care should be documented on the MAR, but the facility lacked a specific midline care policy.
Facility staff failed to accurately assess and document bed rail use for two residents, leading to deficiencies in safety evaluations. Misunderstandings among staff about what constitutes a side rail contributed to the inaccurate documentation. The director of nursing confirmed the errors, acknowledging that the assessments did not align with the facility's policies.
The facility failed to post daily staffing information for one day during a survey. The staffing information was outdated when the surveyor arrived, and the correct information was not posted until later that day. The DON stated that a new staffing coordinator was responsible for posting, but on weekends, the manager on call was responsible. Due to emergencies, the staffing was not updated, and the facility lacked a policy for posting staffing information.
The facility staff failed to act on pharmacy recommendations for two residents, leading to deficiencies in care. A resident on amiodarone did not have recommended TSH, BMP, and CBC tests completed, while another resident with diabetes did not have an HbA1c test done as ordered. The facility's process for handling lab orders was not followed, resulting in non-compliance with physician orders.
A resident with cognitive impairment and dental issues was not provided food in a form suitable for her needs, despite being at risk for malnutrition. The resident and her family reported receiving hard-to-chew foods, and although a mechanical soft diet was discussed, the resident continued to receive inappropriate meals. The facility's policy on meal identification was not properly followed, contributing to the deficiency.
The facility failed to maintain compliance with state laws regarding emergency medical equipment on one unit. An observation revealed that the emergency cart checklist for March 2024 was improperly signed off by a nurse who did not work every day that month. The director of nursing confirmed the responsibility for checking the carts lay with the night shift and the unit manager. The locking system for the carts was implemented in June 2024.
A resident received dialysis treatment three times a week without a contract between the LTC facility and the dialysis center. Despite requests, no contract was provided, violating the facility's policy requiring written and signed agreements for services. The interim administrator and DON were informed, but no further information was obtained before the survey exit.
Facility staff failed to accurately document the administration of a medication for a resident. A physician's order required the administration of Micafungin, but the MAR recorded the Director of Nursing's initials for a dose she did not administer. The DON explained that she began passing medications due to a nurse's absence, and the ADON took over without signing her off. The resident did receive the medication, as the ADON restarted the IV, which later infiltrated and was removed. The facility lacked a policy on maintaining accurate medical records.
A resident with severe cognitive impairment and multiple medical conditions was receiving hospice care, but the facility failed to have a hospice care plan available in the medical records. The care plan was only provided after a request to the Vice President of Operations, highlighting a lapse in documentation and coordination with the hospice agency.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to maintain the highest level of well-being for several residents, including Resident #5, who was readmitted to the facility without proper verification of physician orders for blood sugar checks and insulin administration. This oversight led to a critical situation where the resident's blood sugar level reached 579, resulting in a diagnosis of diabetic ketoacidosis and necessitating an emergency transfer to the hospital for an insulin drip. The failure to verify and administer the necessary medications upon readmission was compounded by communication breakdowns among the nursing staff and the on-call nurse practitioner, who refused to confirm orders after 8 p.m. Resident #138 experienced a delay in receiving prescribed medications for over 12 hours after admission. Despite the availability of medications in the Omnicell system, the facility staff did not administer Gabapentin, Buspirone, and Baclofen as ordered. The lack of timely medication administration was attributed to the delay in sending orders to the pharmacy and the unavailability of a code for the Omnicell system for some staff members. Similarly, Resident #139 did not receive several doses of prescribed medications, including Amlodipine, Bactrim DS, and Warfarin, due to delays in pharmacy delivery and failure to utilize the emergency backup medication system. The facility's inability to administer medications promptly upon admission highlights significant lapses in communication, medication management, and adherence to established protocols for new admissions and readmissions.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility staff failed to implement an effective pain management program for two residents, leading to significant deficiencies. For Resident #5, the facility did not obtain and verify physician orders for pain medications upon the resident's readmission with two broken femurs. This oversight resulted in the resident experiencing severe pain, rated as an eight to ten on a scale of zero to ten, and ultimately being transferred to the hospital for inadequate pain control. The clinical record review revealed that the nurse on duty did not confirm orders with the medical doctor or enter them into the medication administration record (MAR). Attempts to verify the orders with the on-call nurse practitioner were unsuccessful, as the practitioner refused to confirm orders after 8 p.m. Consequently, the resident did not receive the necessary pain medication, leading to a hospital transfer. The facility's internal investigation highlighted multiple communication failures and procedural lapses. The nurses responsible for Resident #5's care did not successfully verify the medication orders with the resident's provider group. The on-call nurse practitioner refused to verify the orders, and the facility staff did not escalate the issue to the medical director in a timely manner. The Director of Nursing was not made aware of the situation until the resident was being sent back to the hospital. The facility's policy on pain management was not followed, as the resident's pain was not adequately assessed or managed, resulting in harm. For Resident #138, the facility staff failed to administer physician-prescribed pain medications upon admission. The resident reported experiencing pain upon admission, but the pain medications were not administered as prescribed. The medication administration record (MAR) showed blanks for the scheduled doses, and the controlled medication utilization record indicated that the medication was not received at the facility until two days after admission. The Omnicell inventory list did not include the prescribed medication, and the baseline care plan's approach to pain management was not effectively implemented. This failure to administer pain medication as prescribed led to the resident experiencing unmanaged pain.
Failure to Verify Medication Orders Leads to Resident Harm
Penalty
Summary
The facility staff failed to provide necessary physician services for a resident, leading to significant harm. Upon readmission from the hospital, the resident did not have their medication orders verified by the on-call nurse practitioner. This oversight resulted in the resident experiencing inadequate pain control and a dangerously high blood sugar level, which led to a diagnosis of diabetic ketoacidosis. The resident was subsequently transferred to the hospital for treatment. The clinical record review revealed that the resident returned from the hospital with a discharge summary that included a list of medications to continue. However, there were no physician's medication orders documented upon the resident's readmission to the facility. The medication administration record for the relevant dates also lacked any medication orders. Despite attempts by the nursing staff to confirm the orders with the on-call nurse practitioner, the orders were not verified, and the resident did not receive the necessary medications, including insulin and pain management. Interviews with facility staff highlighted a series of communication failures and procedural lapses. The on-call nurse practitioner refused to verify the medication orders, citing the time of the request as a reason. Additionally, the nursing staff did not follow up adequately to ensure the orders were verified, nor did they escalate the issue to higher authorities in a timely manner. This lack of action and coordination among the staff contributed to the resident's condition worsening, necessitating emergency medical intervention.
Incomplete Infection Control Program Documentation
Penalty
Summary
The facility staff failed to maintain a complete infection control program, as evidenced by the lack of infection control surveillance documentation for December 2023 and February 2024, and incomplete tracking for March, April, and May 2024. The surveillance logs for these months were either blank or only contained Antibiotic Medications Reports without essential details such as the date symptoms started, culture results, or radiology reports. This deficiency was identified through staff interviews and facility document reviews. During an interview with the director of nursing, it was revealed that the responsibility for the December 2023 tracking was assigned to the previous assistant director of nursing, but the documentation was not completed. The director of nursing acknowledged that the documentation for March, April, and May 2024 was not an accurate reflection of infection surveillance in the facility. The facility's Infection Prevention and Control Program Policy outlines the need for a systematic approach to prevent, identify, control, and reduce infection risks, which was not adhered to in this instance.
Inadequate Documentation During Resident Transfers
Penalty
Summary
The facility staff failed to provide adequate documentation and information during the transfer of residents to a hospital, as evidenced by the cases of three residents. For one resident, there was no evidence of what documents, if any, were sent to the hospital during multiple transfers. The clinical records lacked documentation of the circumstances necessitating the transfers, and there was no physician's note regarding the transfers. This included missing information such as contact details of the responsible practitioner, resident representative information, advance directives, special instructions for ongoing care, and comprehensive care plan goals. Another resident experienced similar issues, with no evidence of documentation being sent to the hospital during two separate transfers. The nurse's notes did not include details of the documents sent, and there was no record of a physician's note related to the hospital transfers. The facility's policy did not address the necessary documentation requirements for hospital transfers, contributing to the deficiency. A third resident's transfer also lacked evidence of documentation being sent to the hospital and a physician's note regarding the transfer. The nurse's notes did not provide details on the documents sent or the specific needs of the resident that the facility could not meet. Interviews with staff revealed inconsistencies in the documentation process, with some staff unaware of the requirements for hospital transfers. The facility's policy did not adequately address the documentation needed for such transfers, leading to the deficiency.
Failure to Notify Resident Representatives and Ombudsman of Hospital Transfers
Penalty
Summary
The facility staff failed to provide written notification of hospital transfers to the resident representatives and the Ombudsman for three residents. For Resident #36, there was no evidence of written notice for hospital transfers on three separate occasions. The Director of Social Services and Admissions admitted to running the wrong report and not sending written notifications to the resident representative. The facility policy requires that the Social Service or designee ensures the original discharge/transfer letter is given to the resident or guardian and copies sent to the Department of Health and Ombudsman Office. Similarly, for Resident #9, there was no evidence of written notice for two hospital transfers, and for Resident #11, there was no evidence of written notice for one hospital transfer. The Director of Social Services and Admissions acknowledged the oversight in sending the correct reports and written notifications. The Licensed Practical Nurse stated that nurses do not have a role in sending these notifications. The facility's policy outlines the procedure for sending discharge/transfer letters, but it was not followed in these instances.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for several residents, leading to deficiencies in care. For Resident #42, the staff did not adhere to the care plan that required the resident to be out of bed daily before lunch. Despite the resident's clear communication and preference to be up in a wheelchair, observations showed that the resident remained in bed for several days. Additionally, the care plan for tube feeding was not followed, as the resident experienced a clogged feeding tube and missed feedings without proper documentation or timely notification to the physician. Resident #21's care plan was not implemented regarding the monitoring of laboratory tests. The care plan included a physician's order to monitor specific labs due to medication use, but the clinical record lacked evidence of these tests being completed. This oversight was acknowledged by the administrative staff, who noted a lapse in the process of acting on pharmacy recommendations. For Resident #138, the facility staff did not administer pain and anxiety medications as per the care plan. The resident reported not receiving medications for over 12 hours after admission, and the medication administration record confirmed missed doses. Similarly, Resident #11's care plan for oxygen administration was not followed, as the resident was observed receiving a lower oxygen rate than prescribed. These failures highlight significant lapses in following established care plans, impacting the residents' health and well-being.
Deficiencies in Oxygen and Nebulizer Care
Penalty
Summary
The facility staff failed to provide appropriate oxygen-related care and services for three residents. For one resident, the staff did not have a physician's order for the administration of oxygen, despite the resident being observed with a nasal cannula and an oxygen concentrator set at varying levels over several days. The LPN assigned to this resident confirmed the absence of a physician's order, which is against the facility's policy that requires a provider's order for oxygen administration. Another resident was not receiving oxygen at the physician-ordered rate. The resident was observed with an oxygen concentrator set at 2 liters per minute, while the physician's order specified 4 liters per minute. The LPN acknowledged that the order was not being followed. Additionally, a third resident's nebulizer mask was not stored in a sanitary manner, as it was left uncovered on a metal cart. The facility's policy requires nebulizer masks to be stored in a bag when not in use to maintain infection control. The LPN stated that the facility had a lot of agency staff, which made it challenging to adhere to these procedures.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to provide timely and adequate pharmaceutical services for several residents, leading to missed doses of critical medications. For Resident #138, the facility did not administer Morphine Sulfate as prescribed for over 12 hours after admission. The medication administration record showed blanks for several scheduled doses, and the medication was not available until a day after the resident's admission. Interviews with staff revealed issues with accessing medications from the Omnicell system, as some nurses did not have the necessary codes to retrieve medications, including narcotics. Resident #63 experienced multiple missed doses of insulin due to the facility running out of the medication and not having the necessary supplies, such as insulin syringes. The electronic medication administration record indicated several instances where insulin was not administered, with reasons ranging from wrapped lower extremities to lack of a login. Staff interviews highlighted a lack of communication with the pharmacy and physician regarding medication availability and the need for alternative solutions. Other residents, including Residents #48, #16, and #88, also faced issues with medication administration. Resident #48 did not receive Insulin Lispro and Amoxicillin due to unavailability, while Resident #16 missed doses of Revlimid capsules. Resident #88 did not receive Meropenem as ordered for diverticulitis. The facility lacked a clear policy on pharmacy delivery, and there were inconsistencies in the reconciliation of controlled substances during shift changes, as evidenced by the missing reconciliation on Unit 2. These deficiencies indicate systemic issues in medication management and communication within the facility.
Failure to Monitor Resident's Weight for Medication Administration
Penalty
Summary
The facility staff failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, for one resident, the physician had ordered furosemide to be administered twice daily, with an additional dose if the resident experienced a weight gain of more than two pounds in one day. However, the facility staff did not weigh the resident daily as required to determine if the additional dose was necessary. This oversight was identified through a review of the resident's clinical records, which showed no recorded weights for a two-week period, and a facility document that noted the resident refused a monthly weight but did not indicate any attempts to obtain daily weights. During an interview, a registered nurse confirmed that the resident should receive an additional tablet of furosemide if there was a significant weight gain and that daily weights should be documented. The nurse also stated that any refusal by the resident to be weighed should be documented. The interim administrator and the director of nursing were informed of this issue, but no further information was provided before the survey exit.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility staff failed to serve food at a palatable temperature for five residents, as determined through observations, resident interviews, staff interviews, and facility document reviews. Residents reported that the food was often cold, with one resident's family member noting weight loss due to the food being overcooked and inedible. The residents involved had varying levels of cognitive function, with some being cognitively intact and others moderately impaired. The issue was highlighted during a test tray assessment, where food temperatures were recorded as below the expected levels, and staff acknowledged that the food could be warmer. The facility's policy on food temperatures, revised in 2019, states that hot food should be palatable at the point of delivery and transported quickly to maintain temperatures. Despite using domes, bases, hot plates, and steam tables, the facility had ongoing concerns about food temperatures, which had been raised in resident council meetings. The regional dietician confirmed that they were conducting random test trays to address these concerns. The administrative staff, including the interim administrator and regional vice president of operations, were informed of the issue, but no further information was provided before the survey exit.
Failure to Promote Resident Dignity in Toileting Assistance
Penalty
Summary
The facility staff failed to promote dignity for a resident, identified as Resident #137, by instructing her to urinate in her pants instead of providing appropriate toileting assistance. The resident, who was alert, oriented, and fully aware of her toileting needs, reported that staff would not assist her in getting out of bed to use the restroom until she had been screened by therapy. During interviews, the resident expressed feelings of embarrassment and a lack of dignity due to being told to urinate in her diaper overnight without being offered a bedpan. Interviews with facility staff, including a CNA and an RN, revealed inconsistencies in the understanding and implementation of toileting assistance for new admissions. The CNA stated that she would check with a nurse regarding discharge paperwork before assisting a resident out of bed, while the RN indicated that a bedpan should be offered to continent residents who cannot get out of bed. Both staff members acknowledged that telling a resident to urinate in their pants would undermine their dignity. The facility's policy on resident rights emphasizes the importance of treating residents with dignity, which was not upheld in this instance.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of abuse within the required two-hour timeframe. A resident, identified as R21, reported being threatened by another resident, R64, over the weekend. The incident was reported to the facility staff on July 1, 2024, but the report was not made to the appropriate authorities until July 2, 2024, which is beyond the stipulated timeframe in the facility's abuse policy. The policy mandates that any allegations of abuse or serious bodily injury be reported to the Department of Health immediately, but not later than two hours after the allegation is made. R21, who was cognitively intact according to a recent BIMS assessment, initially reported the incident to the social worker, expressing that they did not want to involve the police at that time. However, R21 later decided to file a police report after discussing the matter with their family. The facility's documentation shows that the grievance form was completed on July 1, 2024, but the report to the state agency was not sent until July 2, 2024. Interviews with facility staff, including the director of social services and the director of nursing, confirmed the delay in reporting the incident. The director of social services acknowledged that the incident was reported to him and that he had informed the former administrator. Despite the resident's initial reluctance to involve law enforcement, the facility's policy required immediate reporting of such allegations. The director of nursing confirmed that the reporting timeframe for allegations of abuse is two hours, and the failure to adhere to this timeframe constituted a breach of the facility's abuse policy.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident, identified as Resident #21 (R21). On July 1, 2024, R21 reported to the facility staff that they had been threatened by another resident, identified as Resident #64 (R64), over the weekend. Despite this report, the facility did not notify the appropriate authorities until July 2, 2024, which was beyond the required two-hour reporting window for allegations of abuse. The facility's policy mandates immediate reporting of such allegations to the Administrator/Abuse Coordinator and to local and state agencies within two hours if the allegation involves abuse or serious bodily injury. R21, who was cognitively intact according to their most recent MDS assessment, initially did not want to involve the police but later decided to file a police report after discussing the incident with their family. The incident involved a verbal altercation where R64 allegedly threatened to harm R21. The facility's director of social services/admissions coordinator documented the grievance and reported it to the former administrator, but the report to the authorities was delayed until the following day. The director of nursing confirmed that the reporting timeframe was not adhered to, as the allegation should have been reported on the day it was made. The facility conducted an investigation into the incident, which included psychiatric evaluations for both residents involved. It was noted that R64 had no prior history of threatening behavior and that R21 had a history of attention-seeking behaviors. Despite these findings, the facility acknowledged the delay in reporting the allegation of abuse, which was a violation of their policy and resulted in a deficiency being cited by the surveyors.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility staff failed to provide a written bed hold notice to two residents or their representatives upon hospital transfer, as required by facility policy. For one resident, a nurse's note documented that the resident was assessed by a physician's assistant and nurse practitioner and was sent to the hospital for further evaluation due to symptoms of a possible stroke. Despite the transfer, there was no evidence of a written bed hold notice being provided. An interview with an LPN revealed that while a bed hold notice is supposed to be provided, practices may vary by facility, and such documentation would typically be found in a nurse's note. Similarly, another resident experienced a change in level of consciousness and elevated blood pressure, prompting a transfer to the hospital. Again, there was no evidence of a written bed hold notice being provided. The facility's policy states that a bed hold notice should accompany the discharge/transfer letter, and these notices should be available in the electronic chart. The facility's administrative staff, including the Administrator and Director of Nursing, were informed of these findings, but no further information was provided by the end of the survey.
Delayed Entry of Admission Orders for Resident
Penalty
Summary
The facility staff failed to ensure that admission orders were promptly entered into the electronic medical record for a resident, resulting in a delay of 20 hours after the resident's admission. The resident was admitted at 5:09 p.m., but the necessary medical orders, including medications and tube feeding instructions, were not entered until the following day. This delay in entering orders meant that the resident did not receive the prescribed medications and care as per the discharge documents from the hospital, which included medications for pain, high blood pressure, and other conditions. The clinical record review revealed that there was no nursing admission assessment completed on the day of admission. Despite the facility's policy requiring immediate verification and transcription of orders into the electronic medical record, this process was not followed. An LPN interviewed during the survey confirmed that orders should be entered as soon as possible and not delayed for 20 hours. The interim administrator and the director of nursing were informed of these findings, but no further information was provided before the survey exit.
Inaccurate MDS Assessments for Hospice and Smoking Status
Penalty
Summary
The facility staff failed to provide accurate MDS assessments for two residents, leading to deficiencies in their care documentation. For Resident #48, the MDS assessment dated 7/20/24 incorrectly coded the resident as not receiving hospice care, despite the comprehensive care plan and physician orders indicating hospice admission. This discrepancy was identified during an interview with the MDS coordinators, who acknowledged the error and stated that the RAI standard was followed for MDS completion. The incorrect coding in Section O of the MDS failed to reflect the resident's hospice status, which is crucial for ensuring appropriate care and services. For Resident #58, the facility staff inaccurately coded the resident's smoking status in the MDS dated 2/24/24, marking 'No' for current tobacco use. However, the clinical record and care plan documented the resident as a smoker, with interventions in place for smoking safety. An observation confirmed the resident was smoking outside, and the MDS nurse admitted the coding error. The RAI Manual emphasizes the importance of accurate smoking status documentation to facilitate care planning and support for smoking cessation, which was not reflected in the MDS.
Insulin Administered Without Physician's Order
Penalty
Summary
The facility staff failed to adhere to professional standards of practice by administering insulin to a resident without a physician's order. The incident involved a resident who was readmitted to the facility after a hospital discharge. Upon review, it was found that the resident's clinical record did not contain any physician's medication orders upon readmission. Additionally, the Medication Administration Record (MAR) for the resident did not show any medication orders for the dates in question. On the evening of the incident, a nurse documented a late entry note indicating that the resident was in severe pain and had not received insulin or glucose checks since a few days prior. The nurse administered insulin after discovering the resident's blood glucose level was critically high. Subsequently, emergency services were called, and the resident was transferred to a hospital. Interviews with facility staff confirmed that administering insulin without a physician's order is outside the scope of practice for nurses.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care for three residents, leading to deficiencies in oral care, incontinence care, and mobility assistance. Resident #33, who was not cognitively impaired, reported not receiving assistance with oral hygiene despite requesting help. The facility's documentation for personal hygiene was incomplete, and interviews with staff confirmed that oral care should be provided daily, yet there was no evidence of this care being documented. Resident #46, who was moderately cognitively impaired and dependent on staff for toileting, experienced lapses in incontinence care. The ADL records showed missing documentation for incontinence care on multiple dates, and the resident reported not being changed since the night shift. Interviews with staff revealed that incontinence care should occur every two to three hours, but there was no specific policy in place to ensure this care was consistently provided. Resident #42, who was severely impaired in decision-making and dependent on staff for transfers, was not assisted out of bed despite expressing a desire to do so. The resident had not been out of bed for five days, contrary to their care plan, which indicated a preference to be up daily before lunch. Staff interviews highlighted issues with staffing and communication, as the resident's requests were not documented or acted upon, resulting in the resident remaining in bed for an extended period.
Deficiencies in Feeding Tube Management
Penalty
Summary
The facility staff failed to provide appropriate care and services for feeding tubes for two residents, leading to deficiencies in their care. For Resident #139, the staff did not administer tube feedings according to the physician's orders. Upon admission, the resident was supposed to be NPO (nothing by mouth) and receive tube feedings only. However, the resident was given a meal tray, and there was no documentation of tube feedings being administered at the scheduled times. The facility's policy required immediate entry of orders into the system, but this was not done, resulting in a lack of proper care documentation. For Resident #42, the facility staff failed to address and notify the physician of feeding tube complications in a timely manner. The resident, who was assessed as severely impaired and dependent on a feeding tube, experienced a clogged tube. Despite the resident's complaints of pain and hunger, there was no documentation of the physician being notified or an order to hold the tube feeding on the day the issue occurred. The facility's policy required immediate notification of the physician if the tube became unusable, but this was not followed, leading to a delay in addressing the resident's needs. Interviews with staff revealed a lack of adherence to facility policies regarding feeding tube management. LPNs and the director of nursing acknowledged the importance of timely notification and intervention when feeding tube issues arise. However, the documentation and actions taken did not align with these expectations, resulting in inadequate care for the residents involved. The facility's failure to follow its own policies and procedures contributed to the deficiencies identified during the survey.
Failure to Monitor Midline Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate care and services for a midline catheter for a resident diagnosed with respiratory failure, hypertension, diverticulitis, and coronary artery disease. The resident, who was not cognitively impaired, required maximum assistance for bed mobility, transfer, hygiene, and setup for eating. The comprehensive care plan indicated the resident was on antibiotics for pneumonia, and the physician's orders required the IV dressing to be changed every seven days or as needed, with monitoring for signs of infiltration or infection. However, the medication administration record (MAR) showed that monitoring for signs or symptoms of infiltration or infection was not documented on several days, specifically on 10/27, 10/28, 10/29, and 10/30, before the midline was discontinued on 11/1. Interviews with two LPNs revealed that the care of the midline catheter, including monitoring for infection and infiltration, was supposed to be documented on the MAR. However, the facility did not have a specific midline care policy in place. The administrator and director of nursing were informed of these findings, but no further information or corrective actions were provided before the exit of the surveyors.
Inaccurate Bed Rail Assessments for Two Residents
Penalty
Summary
The facility staff failed to complete accurate bed rail assessments for two residents, leading to deficiencies in documentation and safety evaluations. For one resident, the assessment tool inaccurately documented the presence of grab bars on both sides of the bed, marking 'no' to the use of devices that could be considered restraints. Interviews with staff revealed a misunderstanding of what constitutes a side rail, as the LPN believed grab bars or halo bars were not considered side rails. The director of nursing was not familiar with the specific resident but acknowledged that beds typically have rails unless removed. The facility's policy requires evaluation of entrapment zones whenever bed rails or similar devices are used, but this was not properly documented or assessed. Similarly, for another resident, the assessment tool failed to accurately document the presence of halo bars attached to both sides of the bed, again marking 'no' to the use of restraint devices. The LPN reiterated the same misunderstanding regarding what constitutes a side rail. The director of nursing confirmed the assessment was incorrect, as the resident did have halo bars, which were removed on the day of the interview. These findings were communicated to the interim administrator and the director of nursing, highlighting a lapse in the facility's adherence to its own policies and procedures regarding bed rail assessments.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility staff failed to post daily staffing information for one of the four days reviewed during a survey conducted from 9/15/24 to 9/18/24. On 9/15/24, upon entering the facility at 3:00 PM, the surveyor observed that the staffing information posted in the main lobby was dated 9/13/24. The correct staffing information for 9/15/24 was not posted until 6:00 PM. During an interview on 9/18/24, the Director of Nursing explained that a new staffing coordinator had been hired, and it was her responsibility to post the staffing information. However, on weekends, the manager on call was responsible, but due to emergency situations, the staffing information was not updated. The facility did not have a policy regarding the posting of daily staffing information, and no further information was provided before the survey exit.
Failure to Act on Pharmacy Recommendations for Lab Tests
Penalty
Summary
The facility staff failed to act upon pharmacy recommendations in a timely manner for two residents, leading to deficiencies in their care. For Resident #21, the pharmacy consultation report dated 5/6/24 recommended monitoring thyroid stimulating hormone (TSH) levels due to the use of amiodarone, with the physician approving the order on 5/14/24. However, the clinical record did not show evidence of the laboratory tests being completed or results being available for the basic metabolic panel (BMP), complete blood count (CBC), or TSH. Interviews with staff revealed that the process for lab orders involved placing lab slips in a book for the phlebotomist to draw the labs, but no labs had been drawn for Resident #21 since February 2024. Similarly, for Resident #63, the pharmacy consultation report also dated 5/6/24 recommended monitoring hemoglobin A1c (HbA1c) levels due to a diabetes diagnosis, with the physician approving the order on 5/14/24. The clinical record failed to show evidence of the HbA1c test being completed. Although a BMP and CBC were completed on 6/28/24, there was no record of the HbA1c test. Staff interviews indicated that the process for handling pharmacy recommendations involved emailing them to the director of nursing, who would then print and place them in a folder for the physician's review. However, the HbA1c test was not conducted as ordered. The facility's policy on Medication Regimen Review, revised on 6/1/24, emphasized the importance of acting upon pharmacy recommendations. Despite this, the facility staff did not follow through with the necessary lab tests for both residents, resulting in a failure to comply with the physician's orders. The interim administrator, director of nursing, regional director of clinical services, administrator in training, and regional vice president of operations were informed of these concerns, but no further information was provided before the surveyors exited.
Failure to Provide Appropriate Food Form for Resident with Dental Issues
Penalty
Summary
The facility staff failed to prepare food in a form that met the needs of a resident, identified as Resident #46, who was moderately cognitively impaired and had significant dental issues, including missing, broken, or loose teeth. Despite being at risk for malnutrition and having a comprehensive care plan that highlighted oral health needs, the resident was initially provided with a regular diet. The resident and her family reported issues with the food being too hard to chew, such as pizza and hard chicken tenders, which were not suitable given her dental condition. Although a trial of a mechanical soft diet was discussed and agreed upon by the resident and her family, the resident continued to receive meals that were not fully aligned with her dietary needs. For instance, her lunch tray included turkey, which she found inedible, and she reported that the dietician had not addressed her concerns. The facility's policy required meal identification cards to include specific dietary information, but it appears this was not adequately implemented for Resident #46, leading to the deficiency.
Failure to Maintain Emergency Medical Equipment Compliance
Penalty
Summary
The facility staff failed to comply with state laws and regulations regarding the maintenance of emergency medical equipment on one of two units. During an observation of the emergency carts on both units, it was noted that both carts had a locking device in place, which could not be opened without breaking the lock. The Emergency Cart Daily Checklist for Unit 2 in March 2024 was reviewed, revealing that the cart was signed off as being checked on March 1, 2024. However, from March 2, 2024, through March 31, 2024, the checklist was signed off by the same person with their signature on March 2, 2024, and a line drawn down for the entire month, ending on March 31, 2024. The nurse who signed the checklist was no longer employed at the facility and was unavailable for an interview. During an interview with the director of nursing, it was confirmed that the nurse did not work every day in March, and the responsibility for checking the emergency carts fell to the night shift, with the unit manager being responsible if it was not done. The director of nursing also mentioned that the facility had many agency nurses working there, and the nurse who signed it off was responsible for checking it. The locking system for the emergency carts was implemented in June 2024.
Lack of Contract with Dialysis Center
Penalty
Summary
The facility staff failed to establish a contract with a dialysis center where a resident was receiving treatment. The resident attended the dialysis center three times a week as per physician orders, which specified the days and times for dialysis, the catheter site, and the transport arrangements. Despite requests for the contract on two separate occasions, no contract was provided before the survey exit. The facility's policy requires that a contract be approved, in writing, and signed by both the vendor and the facility administrator before services are provided. The interim administrator and the director of nursing were informed of these findings, but no further information was obtained before the survey exit.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for a resident, identified as Resident #18, by inaccurately documenting the administration of a medication. A physician's order dated March 19, 2024, required the administration of Micafungin, a medication used to treat fungal infections, in a specific dosage. The medication administration record (MAR) for March 2024 documented this order, and the initials of the Director of Nursing (DON) were recorded for the 9:00 a.m. dose on March 21, 2024. However, during an interview, the DON stated that she did not administer the medication. She explained that she had begun passing medications due to the absence of a nurse, but when the Assistant Director of Nursing (ADON) took over, he did not sign her off. The DON confirmed that the resident did receive the medication, as the ADON had restarted the IV, which later infiltrated and was removed. The facility did not provide a policy on maintaining an accurate medical record, and the interim administrator and DON were informed of these findings.
Failure to Provide Hospice Care Plan
Penalty
Summary
The facility failed to provide a Hospice Care Plan for a resident who was receiving hospice care. The resident, who had been admitted to the facility after an acute care hospital stay, had significant medical conditions including hemiplegia, type 1 diabetes mellitus with diabetic neuropathy, and cerebral vascular disease. The resident's cognitive abilities were severely impaired, as indicated by a score of 7 out of 15 on the Brief Interview for Mental Status (BIMS). The resident was coded as receiving hospice care, and the physician's order summary included a directive for hospice evaluation and treatment. The person-centered care plan noted the need for hospice care due to cerebral vascular disease, with goals and interventions outlined to ensure the resident's comfort and dignity. Despite these documented needs and directives, a review of the medical records on a specified date revealed that no hospice care plan was available for review. The hospice care plan was only provided after a request was made to the Vice President of Operations, who obtained it from the hospice agency. The Director of Nursing confirmed that the hospice care plan should have been uploaded to the resident's medical record but was not. The findings were shared with the facility's administration, but no additional information was provided to address the deficiency.
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 188 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Virginia Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Virginia Beach Healthcare And Rehab Center | 0.1 mi | ★★★★★ | 8 | 2 |
| Bay Pointe Rehabilitation And Nursing | 0.2 mi | ★★★★★ | 0 | 0 |
| Westminster-canterbury On Chesapeake Bay | 4.2 mi | ★★★★★ | 0 | 0 |
| Rosemont Health & Rehab Center, Llc | 4.7 mi | ★★★★★ | 0 | 0 |
| Birchwood Park Rehabilitation | 4.9 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.