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 Colonnades Health Care Center during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment regarding hot liquids, leading to incidents where two residents spilled hot coffee, with one requiring first aid. The facility did not consistently monitor coffee temperatures or assess residents' abilities to manage hot liquids safely. Staff interviews and records indicated a lack of proper monitoring and assessment, contributing to the deficiency.
The facility failed to protect residents from abuse, with incidents involving rough treatment by a CNA leading to psychosocial harm for a resident. Reports of abuse were inadequately documented and investigated, with the facility's policies on abuse prevention and reporting not followed. The lack of proper documentation and follow-up on reported incidents resulted in immediate jeopardy and substandard quality of care.
The facility failed to protect residents from abuse, resulting in immediate jeopardy and substandard care. A resident reported rough treatment by a CNA, but the facility did not document or investigate the allegations promptly. The CNA continued to work with residents, and another resident also reported rough treatment, which was not adequately followed up. The facility's abuse prevention policy was not followed, leading to serious deficiencies.
A resident experienced a significant medication error when an antibiotic order was delayed due to a system error that sent the prescription to the wrong pharmacy. The resident, with a complex medical history, missed multiple doses of Cephalexin, which was critical for their treatment. The facility's process for handling medication orders from the hospital was flawed, leading to a delay in delivery and administration.
A resident had unsecured eye drops at the bedside without authorization for self-administration, and a medication cart containing various medications was left unlocked and unattended in a hallway. Additionally, expired Tuberculin Purified Protein vials were found in the medication storage room, not discarded according to FDA guidelines. These deficiencies were noted during a survey and reported to the facility's administration.
The facility was found to have deficiencies in food storage and handling, with expired food bins accessible for distribution and improper glove use by a CNA in the dining room. The dietary manager acknowledged the oversight, and the CNA admitted to not changing gloves, contrary to the facility's infection control policy.
The facility failed to involve direct care staff, residents, and families in the development of its facility assessment. The assessment, updated in May 2024, was completed by administrative and management staff without input from these groups. The facility's policy did not address their involvement, and the administrator confirmed that residents and families were not included due to cognitive impairments. This deficiency was highlighted during a meeting where regulatory changes were discussed.
The facility failed to maintain accurate clinical records for residents, leading to deficiencies in documenting falls and injuries. A resident experienced multiple falls with significant injuries, but the records lacked detailed descriptions and interventions. Another resident had several falls requiring emergency care, yet the records were insufficient. Additionally, an injury of unknown origin was not documented for a resident, despite being reported. These issues indicate a pattern of inadequate documentation affecting resident care.
The facility failed to provide COVID-19 vaccination and education to four residents and three staff members. Residents had signed consent forms, but vaccines were not administered, and there was no documentation of education for staff. The DON admitted to oversight in the immunization process, and the facility lacked evidence of staff education, violating regulatory requirements.
The facility failed to provide mandatory QAPI training to five staff members, including CNAs, an LPN, and an RN. Despite using computer-based training and maintaining a training calendar, none of the employees received QAPI training in 2023 or 2024. Additionally, QAPI meetings were held only with management-level staff, excluding broader staff participation. The deficiency was identified during a survey, and the facility was informed of the findings.
The facility failed to implement its QAPI policy and abuse policy regarding an allegation of abuse and injury of unknown origin for a resident. The facility did not monitor abuse allegations during QAPI meetings, and staff failed to report and investigate a resident's abuse allegation timely. The resident reported rough handling by staff, resulting in bruising, but the incident was not documented or reported to the required agencies until after surveyor intervention.
A resident with dementia receiving psychotropic medication lacked a comprehensive care plan addressing their behavioral health needs. The plan did not specify targeted behaviors, measurable goals, or non-pharmacological interventions. The acting DON noted behaviors such as agitation and hallucinations, but the care plan only addressed elopement risk, failing to meet the facility's policy requirements.
A resident received an incorrect insulin dosage due to a failure to clarify a physician's order. The resident was supposed to receive 86 units of Tresiba, but the MAR indicated 88 units of Lantus Solostar were administered. The discrepancy was not questioned by staff, and the error was confirmed as a typographical mistake by the pharmacy. The attending physician noted no adverse effects on the resident's blood sugar levels.
A facility failed to implement non-pharmacological interventions for pain management for a resident with chronic pain and other medical conditions. Despite being prescribed Oxycodone, there was no documentation of alternative pain management strategies being used prior to medication administration. The DON confirmed that staff should document such interventions, as outlined in the facility's Pain Management Program.
A resident with dementia did not receive individualized care at the facility, as her care plan lacked specific goals and interventions tailored to her needs. Despite experiencing multiple falls and displaying behaviors such as hallucinations, the facility did not implement non-pharmacological interventions or monitor her condition effectively. Interviews with staff revealed a lack of monitoring and absence of a dementia care policy.
A resident receiving psychotropic medications showed symptoms of tardive dyskinesia, yet the facility failed to act on pharmacy recommendations for a gradual dose reduction. Despite multiple recommendations, there was no documented response from the medical provider, and the facility's policy requiring timely action on such recommendations was not followed.
The facility failed to ensure gradual dose reductions and proper documentation for psychotropic medications in several residents. One resident was on a psychotropic medication for 22 months without dose reduction attempts, another received Haldol beyond the 14-day PRN limit without proper documentation, and a third resident's antidepressant use was not monitored as required. These deficiencies highlight lapses in medication management and documentation.
The facility failed to provide timely physician-ordered rehabilitative therapy services to three residents with cognitive impairment. Despite having active orders for therapy evaluations, these residents were not assessed due to the therapy department prioritizing outpatient cases. An LPN indicated that therapy orders should be executed the same day, but the therapy director admitted to delays, placing skilled care residents lower on the priority list.
A resident's power of attorney requested copies of the resident's clinical record, but the facility staff delayed fulfilling the request for over six weeks. The medical records employee was unaware of the request, and the social worker confirmed the delay. The facility's policy requires records to be provided within two business days, but this was not followed.
The facility failed to report allegations of abuse and injuries of unknown origin involving two residents. A resident reported staff being rough, resulting in bruising, but the facility did not document or report it promptly. Another resident's skin tear was not investigated or reported as an injury of unknown origin. The facility's policy mandates reporting such incidents, but it was not followed in these cases.
The facility failed to thoroughly investigate abuse allegations involving a CNA and three residents, as well as an injury of unknown origin for another resident. Despite reports of rough treatment and skin tears, the investigation was incomplete, lacking interviews with other potentially affected residents and documentation of findings. The facility's response to the incidents was inconsistent and did not adhere to their policies on abuse prevention and investigation.
The facility staff failed to follow physician orders for two residents, resulting in medication administration errors. An LPN administered an incorrect dosage of vitamin D3 to one resident, while another resident's medication orders, including Tramadol and KDur, were not implemented as prescribed. The DON suggested a possible delay due to lab work, but no documentation supported this. The facility lacked a policy on physician orders.
Failure to Ensure Safe Management of Hot Liquids
Penalty
Summary
The facility staff failed to ensure the environment was free of accident hazards, specifically regarding the management of hot liquids, which affected multiple residents. Two residents, identified as Resident #105 and Resident #109, experienced incidents where they spilled hot coffee onto their laps. Resident #105 required first aid intervention due to redness on the thighs, while Resident #109 spilled lukewarm coffee and sustained no injury. The facility did not have a consistent system in place to monitor the temperatures of hot liquids being served, and residents' abilities to manage hot liquids were not assessed. Observations revealed that the coffee temperature was not consistently monitored, and the facility's dietary staff did not record or monitor the temperature of hot liquids during each meal. The coffee machine's temperature was initially set too high, and the dietary staff confirmed that they did not cool down the coffee before placing it in the lobby. The facility's documentation showed multiple omissions in the meal service temperature logs, indicating a lack of proper monitoring. Interviews with staff and review of clinical records indicated that Resident #105 had previously been identified with self-feeding issues, prompting a physician order for lightweight mugs. However, the facility failed to assess residents for their ability to manage hot liquids safely, particularly those with cognitive or visual impairments. The facility's interim administrator and DON acknowledged the deficiency and initiated a performance improvement plan, but the plan was still in process and had not been completed at the time of the survey.
Removal Plan
- Residents were assessed for hot liquid safety and referred to Occupational Therapy.
- Director of Nursing will conduct an assessment of all current residents for accident hazards such as risk of burns from hot liquids.
- Residents identified at risk; nursing will initiate a care plan with interventions to mitigate hazards such as risk of burns from hot liquids.
- Residents identified at risk will be evaluated by occupational therapy.
- Director of Nursing will educate all team members on hazards such as the risk of burns from hot liquids and appropriate serving temperature prior to being permitted to work.
- Dietary manager will educate dietary team members on the importance of completing and documenting temperatures on hot liquids during each meal prior to being permitted to work.
- New admissions will be assessed for hazards such as risk of burns from hot liquids, with interventions initiated and a referral to occupational therapy.
- Hot beverage station located at the concierge's desk will be removed.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility staff failed to protect residents from abuse, resulting in multiple incidents involving four residents. Resident #5 and Resident #20 reported physical and verbal abuse by a certified nursing assistant (CNA1), who was described as rough during care. Resident #20 experienced psychosocial harm and reported feeling intimidated and dehumanized by the CNA's actions. Despite these reports, the facility's documentation was inadequate, with no records of the abuse allegations or interviews in the residents' clinical records. The facility administrator and social service director failed to conduct a thorough investigation, and the allegations were initially deemed unsubstantiated. Resident #7 reported rough treatment by staff, which was not properly documented or reported to the required agencies. The acting director of nursing (DON) was informed of the allegation by a surveyor but failed to follow up appropriately. The administrator was aware of the situation but did not ensure that the allegation was reported or investigated. Additionally, Resident #177 sustained a skin tear, and a staff member reported rough treatment by CNA1, but the incident was not investigated or documented properly. The anonymous staff member who reported the incident received a dismissive response from the administrator. The facility's failure to report and investigate these allegations of abuse led to the identification of immediate jeopardy and substandard quality of care. The facility's policies on abuse prevention, reporting, and investigation were not followed, and staff members were not adequately trained or informed about their responsibilities as mandated reporters. The lack of documentation and follow-up on reported incidents contributed to the facility's inability to protect residents from abuse and neglect.
Removal Plan
- The administrator and current on shift skilled team members will be educated by the regional director of resident care/designee to prevent, protect, respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy.
- The administrator will complete a facility reportable incident for an allegation of abuse of Resident #7 to required agencies.
- The administrator and/or designee will interview resident #7 and have a nurse complete a physical assessment.
- An assessment will be conducted for current residents in skilled nursing by the administrator and/or designee who are alert and oriented for safety and care concerns in the community to include abuse.
- The administrator and/or designee will place additional signage around the community advising of the abuse coordinator and grievance coordinator.
- The regional director of resident care and/or the acting director of nursing will re-educate all skilled team members on how to prevent, protect, and how to respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy. All skilled team members will be trained prior to them being able to work.
- Any concerns identified will be addressed as per our policy and procedures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to effectively administer its resources to ensure residents were free from abuse, leading to immediate jeopardy and substandard quality of care. Resident #20 reported being treated roughly by a certified nursing assistant (CNA1), which was communicated to the social worker. Despite the report, there was no documentation of the abuse allegation in the resident's clinical record. The social service director confirmed the rough treatment allegations from both Resident #20 and her roommate, Resident #5. However, the facility administrator did not take immediate action to protect the residents or initiate an investigation, allowing CNA1 to continue working with the residents. The facility's administration was further questioned about the lack of documentation and timely reporting of the abuse allegations to regulatory agencies. The administrator admitted that not all nursing staff had received the necessary education on abuse prevention. The MDS coordinator had reported the abuse allegations to the administrator, but CNA1 continued to provide care until the following day. The facility's failure to remove CNA1 immediately after the initial report allowed the potential for further abuse. Additionally, Resident #7 reported rough treatment by staff, which was not documented in her clinical record. The director of nursing was informed of the allegation but did not follow up adequately. The administrator, who was also the abuse coordinator, failed to report the incident as an abuse allegation, instead reporting it as an injury of unknown origin only after being questioned by the surveyor. The facility's policy on abuse prevention and reporting was not followed, contributing to the identification of immediate jeopardy and substandard quality of care.
Medication Error Due to Pharmacy Order Miscommunication
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically involving the administration of an antibiotic. The resident, who had a history of Parkinson's, recurrent falls, and other medical conditions, returned to the facility from the hospital with a prescription for Cephalexin to be taken four times daily. However, the medication was not administered as prescribed, resulting in a two-day delay and multiple missed doses. The medication administration record (MAR) indicated that the antibiotic was pending delivery, and the order was discontinued before the full course was completed. The deficiency was further compounded by a system error where the order was mistakenly sent to a local retail pharmacy instead of the facility's contracted pharmacy. This error was not immediately identified, leading to a delay in the delivery of the medication. Interviews with the nursing staff revealed that the facility's process for handling medication orders from the hospital involved entering the orders into the computer system, which then sent them to the pharmacy. However, due to the system defaulting to the wrong pharmacy, the order was not filled in a timely manner. The facility's Director of Nursing (DON) acknowledged the issue and noted that the system sometimes defaults to the retail pharmacy, which contributed to the delay. The DON also confirmed that there was no specific policy regarding physician orders, although the expectation was that orders be carried out as given by the doctor. The attending physician was informed of the delay and indicated that the duration of the antibiotic course would need to be extended to ensure the resident received all prescribed doses.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility staff failed to ensure the secure storage of medications for one resident, identified as R128, who had eye drops at the bedside that were not secured. The eye drops, labeled as Carboxymethylcellulose Refresh 1%, were obtained from a hospital and were not authorized for self-administration by the resident, as there was no documentation in the resident's care plan indicating the ability to self-administer medications. Interviews with the nursing staff revealed a lack of clarity regarding the process for evaluating a resident's capability to self-administer medications and the proper storage of such medications. Additionally, the facility staff did not secure a medication cart containing over 75 cards of medications, which was left unattended and unlocked in a hallway. The cart contained various medications, including pain medications, vitamins, and syringes with needles. The surveyor observed multiple staff and residents passing by the cart, posing a risk of unauthorized access to the medications. The nurse responsible for the cart was unaware of how it became unlocked and confirmed that no one else had keys to access it. Furthermore, the facility staff failed to discard expired medications in the medication storage room. Two multi-dose vials of Tuberculin Purified Protein were found in the refrigerator, both past their open dates, with one vial being expired for over 30 days. The facility's policy on medication storage did not address the specific expiration guidelines for these vials, and the staff did not adhere to the FDA's recommendation to discard the vials after 30 days of being opened. These deficiencies were brought to the attention of the facility administrator and director of nursing during an end-of-day meeting.
Deficiencies in Food Storage and Sanitary Practices
Penalty
Summary
The facility was found to have deficiencies in food storage and handling practices. During an inspection of the main kitchen, four large food bins containing rice, flour, sugar, and bread crumbs were labeled with expired dates and were accessible for distribution. The dietary manager acknowledged the oversight, indicating that either the bins were not relabeled when new food was added or the food was indeed expired. The facility's policy on food storage mandates that all food items be labeled, dated, and rotated to maintain a First In First Out system, and expired food should be discarded. This policy was not adhered to, leading to the potential distribution of expired food items. Additionally, the facility staff failed to maintain sanitary practices in the dining room. A certified nursing assistant (CNA) was observed wearing the same pair of gloves while performing various tasks, including repositioning residents, rearranging chairs, touching cabinets, and serving food, without changing gloves or performing hand hygiene. The CNA admitted to not changing gloves but acknowledged the need to do so. The facility's infection prevention and control program emphasizes the importance of hand hygiene and the proper use of gloves, stating that gloves are not a substitute for hand hygiene and should be changed after contact with a resident or the surrounding environment. This failure to follow proper glove use and hand hygiene protocols could lead to the spread of infection among residents.
Lack of Involvement in Facility Assessment Process
Penalty
Summary
The facility staff failed to ensure the active involvement of direct care staff, residents, resident representatives, and family members in the development of the facility assessment. The assessment, updated on May 23, 2024, and reviewed with the governing body on May 16, 2024, did not include input from these groups. The individuals involved in completing the assessment were the administrator, director of nursing, governing body representative, medical director, social services coordinator, resident assessment coordinator, and dietary services manager. This lack of involvement was confirmed during an interview with the facility administrator, who stated that the process primarily involved the DON and assistant director of nursing, and that residents and families were not involved due to the cognitive impairment of most long-term residents. The facility's policy titled "Facility Assessment Process" was reviewed and indicated that the facility uses an assessment tool to collect necessary information about residents' needs and the resources available to meet those needs. However, the policy did not address the involvement of direct care staff, residents, or families in the assessment process. During an end-of-day meeting on November 1, 2024, the facility administrator, management team, and corporate staff were informed of recent regulatory changes requiring such involvement, highlighting the deficiency in the current assessment process.
Inadequate Documentation of Falls and Injuries
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for several residents, leading to deficiencies in documenting falls and injuries. Resident R12 experienced multiple falls, some resulting in significant injuries, including a subarachnoid hemorrhage and parietal fracture. The clinical records for R12 did not include detailed descriptions of the falls, the resident's condition following the falls, or the facility's response and interventions. Despite requests from the survey team, the facility was unable to provide adequate documentation from the clinical records, and the details were only provided later in a separate document prepared by the resident assessment coordinator. Similarly, Resident R7 had eleven falls, some resulting in injuries that required emergency room visits. The clinical records for R7 also lacked detailed documentation of the falls, including contributing factors and interventions implemented to prevent recurrence. The survey team requested a timeline of R7's falls and interventions, but the initial documentation provided was insufficient. The resident assessment coordinator later provided a more detailed timeline, but these details were not found in the original clinical records. Additionally, the facility failed to document an injury of unknown origin for Resident R177. The resident had two skin tears that were not documented in the clinical record, despite being reported by a licensed practical nurse. The facility's documentation did not include an incident report or details of the injury, and the acting director of nursing acknowledged that such incidents should have been charted. These deficiencies highlight a pattern of inadequate documentation and record-keeping within the facility, affecting the care and safety of the residents.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility staff failed to provide education and offer COVID-19 immunizations to four out of five residents sampled for immunizations. Specifically, residents R7, R17, R76, and R20 did not have proper documentation or evidence of being offered education or the COVID-19 vaccine. R7 had a signed consent form dated 10/18/24, but the vaccine had not been administered by 10/31/24. R17 had a signed consent form dated 10/17/24, but the resident had not been immunized, and the form was incomplete regarding other vaccines. R76's records showed no information on COVID-19 immunization status, and R20 had a signed consent form dated 10/17/24, but the vaccine had not been given by 10/31/24. The Director of Nursing (DON) confirmed the oversight in the immunization process, stating that it was her first time managing this responsibility and that it was a work in progress. The DON explained that the social worker typically initiates the process by obtaining consents and that the facility had recently conducted a flu clinic. However, there was a lack of follow-up and documentation for COVID-19 vaccinations. The DON also admitted to not being familiar with the Virginia Immunization Information System (VIIS) portal, which could have been used to verify residents' immunization statuses. Additionally, the facility failed to provide evidence of COVID-19 immunization education for three staff members sampled, including an LPN, a CNA, and another employee. The general manager stated that Costco provided education, but there was no documentation to confirm that staff received this education. The facility's policy requires documentation of education regarding the benefits and potential risks of the COVID-19 vaccine, but this was not adhered to, leading to a deficiency in compliance with regulatory requirements.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five staff members, including certified nursing assistants, a licensed practical nurse, and a registered nurse. This deficiency was identified during a survey where the education and training records of these staff members were reviewed. The facility's general manager confirmed that all staff education was conducted through computer-based training using Relias, and a training calendar was maintained. However, the review of the training records revealed that none of the five employees had received QAPI training in 2023 or 2024, despite it being listed as mandatory in the 2023 training outline. Further investigation revealed that the facility's QAPI meetings were held monthly but only included management-level staff and the medical director, excluding other staff members. The facility administrator confirmed this practice and described the meetings as opportunities to discuss pertinent topics like fall prevention. However, the administrator did not provide evidence of QAPI training for the broader staff, which is a regulatory requirement. The surveyor informed the facility administrator and management staff of these findings, but no additional information was provided to demonstrate compliance with the mandatory training requirement.
Failure to Implement Abuse Policy and QAPI Procedures
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policy regarding abuse, as well as its abuse policy concerning an allegation of abuse and an injury of unknown origin for one resident. The facility did not communicate or monitor feedback of allegations of abuse during QAPI meetings as directed in their policy. Specifically, the QAPI meeting minutes from October 23, 2024, did not indicate that abuse allegations were monitored or discussed, which was confirmed by the facility administrator. For one resident, identified as Resident #7, the facility staff failed to implement their abuse policy by not reporting the allegation of abuse timely to the required regulatory agencies and failing to initiate an investigation. The resident reported that staff were rough when assisting her, which was corroborated by bruising on her wrist. Despite this, there was no documentation regarding the bruising, and the acting director of nursing (DON) did not follow up adequately on the resident's statement. The DON's interview revealed a lack of proper investigation and documentation of the incident. The facility's administrator was unaware of any abuse reports in process and acknowledged that the resident's allegation had not been reported to the required agencies. The facility's policy mandates that all team members report known or suspected abuse to local and state authorities, but this was not adhered to in the case of Resident #7. The failure to report and investigate the allegation was only addressed after the surveyor's intervention, highlighting a significant lapse in the facility's adherence to its abuse prevention and reporting policies.
Inadequate Care Plan for Resident's Behavioral Health Needs
Penalty
Summary
The facility staff failed to develop a comprehensive care plan for a resident with dementia, who was receiving psychotropic medication for behavioral health needs. The care plan did not specify the targeted behaviors being treated with the medication, nor did it include measurable goals or a projected reduction/endpoint for the medication. Additionally, the care plan lacked documentation of the resident's behaviors that required management by psychotropic medication and did not list any non-pharmacological interventions for staff to use when providing care in the presence of these behaviors. During interviews, the acting Director of Nursing (DON) acknowledged that staff should be monitoring and documenting the resident's behaviors. The DON described the resident's behaviors as including agitation, aggression, hallucinations, delusions, and unusual behavior such as pushing away aides. Despite these observations, the care plan only noted the resident as an elopement risk and wanderer, with interventions that did not address the specific behaviors or the use of psychotropic medication. The facility's policy on individualized care plans requires the interdisciplinary team to develop comprehensive plans addressing the resident's most acute problems, including behavioral health care needs, which was not adequately done in this case.
Failure to Clarify Insulin Dosage Order
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice for a resident, identified as R102, by not clarifying a physician's order for insulin administration. The resident was admitted to the facility following an acute care hospitalization with discharge orders to receive Tresiba FlexTouch insulin at 86 units nightly. However, the facility's medication administration record (MAR) indicated that Lantus Solostar was being administered at 88 units nightly. A fax from the pharmacy recommended a therapeutic interchange to Lantus Solostar at 86 units, but the MAR showed a discrepancy with 88 units being administered. This inconsistency was not questioned by the nursing staff, and the Assistant Director of Nursing Services (ADNS) acknowledged that the pharmacy enters therapeutic interchange orders into the electronic health record. Interviews with the attending physician and the facility's contracted pharmacy confirmed that the correct dosage should have been 86 units, and the 88 units was a typographical error. The attending physician noted that the difference in dosage did not pose a significant risk to the resident, as their blood sugars were not adversely affected. However, the failure to clarify the insulin order was acknowledged by the facility's interim administrator and director of nursing, who confirmed that the nurses should have followed professional standards by seeking clarification. The report highlights a lapse in following proper procedures for medication administration, as outlined in the Lippincott Manual of Nursing Practice, which emphasizes the importance of questioning incomplete or incorrect medical orders.
Failure to Implement Non-Pharmacological Pain Management
Penalty
Summary
The facility staff failed to implement non-pharmacological interventions for pain management for a resident who required such services. The resident, who had diagnoses including post-surgical hip repair, chronic kidney disease, major depression, and chronic pain, was assessed as cognitively intact with a score of 12 out of 15 on the MDS. Physician orders indicated that the resident was prescribed Oxycodone for severe pain, and the medication administration record showed that the resident received Oxycodone on three occasions. However, there was no documentation of non-pharmacological interventions being used prior to administering the medication. During an interview, the DON acknowledged that staff should be using and documenting non-pharmacological interventions before administering pain medication, but the progress notes did not reflect this practice. The facility's Pain Management Program also emphasized the use of multiple non-drug therapies to meet residents' individual needs, with all interventions to be evaluated and documented similarly to medication therapy. The deficiency was presented to the administrator and general manager, but no additional information was provided before the exit conference.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility staff failed to provide appropriate dementia care with individualized interventions for a resident diagnosed with unspecified dementia. The resident, who was hard of hearing and had impaired vision, did not have a care plan that included specific goals or approaches tailored to her needs. The care plan lacked guidance on how to address the resident's behaviors, such as verbal aggression and hallucinations, and did not consider internal or external triggers related to her sensory impairments. Additionally, the care plan did not include non-pharmacological interventions or meaningful activities based on the resident's preferences and routine. The resident experienced 11 falls in 2024, some resulting in significant head injuries requiring hospital visits, yet there were no interventions in place to address these incidents. Interviews with facility staff revealed a lack of monitoring for behaviors and side effects related to the resident's dementia care. The facility also did not have a policy regarding dementia care, as confirmed by the facility administrator. The acting director of nursing acknowledged the need for routine monitoring of behaviors and resident-specific approaches, but no evidence of such practices was found in the resident's records.
Failure to Respond to Pharmacy Recommendations for Medication Dose Reduction
Penalty
Summary
The facility staff failed to respond to a medication regimen review and recommendations from the pharmacy for a resident receiving two psychotropic medications. The resident, who was observed to have symptoms indicative of tardive dyskinesia, was receiving Buspirone for anxiety and Remeron for major depressive disorder. Despite pharmacy recommendations for a gradual dose reduction (GDR) of these medications, there was no documented response or action taken by the facility's medical provider. The pharmacy had made recommendations on two occasions, suggesting a dose reduction or documentation of contraindications, but the forms remained blank with no physician response. Interviews with the acting Director of Nursing (DON) and the physician revealed a lack of communication and documentation regarding the pharmacy's recommendations. The DON indicated that the process of handling pharmacy recommendations was still being worked out, and the physician admitted to not having documented any rationale for not attempting a dose reduction. The facility's policy requires that medication regimen review recommendations be acted upon within 30 days, but this was not adhered to in this case. The deficiency was discussed with the facility administrator and management staff, but no additional information was provided to address the issue.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure a gradual dose reduction for a resident who was on a psychotropic medication for 22 consecutive months. The resident was observed to have symptoms indicative of tardive dyskinesia, prompting further investigation into their medication regimen. Despite pharmacy recommendations for a dose reduction, there was no evidence that these were reviewed or addressed by the physician. The physician admitted to not documenting the rationale for not attempting a dose reduction, which is required by the facility's policy. Another resident was found to be receiving an antipsychotic medication, Haldol, beyond the 14-day limit for PRN orders without appropriate clinical indication documented. The facility staff also failed to monitor and document the resident's behaviors and side effects associated with the use of Haldol. Interviews with hospice and facility staff revealed a lack of communication and documentation regarding the necessity and monitoring of the medication, despite the resident experiencing multiple falls and injuries. Additionally, the facility failed to document the assessment and monitoring of an antidepressant medication for a third resident. The physician's order required monitoring for side effects, mood, and behavior, but the necessary scheduling details were not completed, resulting in a lack of documentation. The DON acknowledged the oversight, which led to the resident not being properly assessed as required by the facility's policy.
Failure to Provide Timely Rehabilitative Services
Penalty
Summary
The facility staff failed to provide physician-ordered rehabilitative therapy services to three residents with a BIMS score of 12 or less, indicating cognitive impairment. These residents had active physician orders for therapy evaluations dating back to December 23, 2024, but had not been evaluated by the therapy department as of January 8, 2025. The delay in providing these services was attributed to the therapy department's focus on a large outpatient caseload, which took precedence over the skilled care residents. Interviews with facility staff revealed a breakdown in the process of executing physician orders. A Licensed Practical Nurse (LPN) stated that therapy orders should be communicated to the therapy department and carried out the same day they are given. However, the therapy director admitted that the skilled care residents were not prioritized and were placed on a list based on the order date, leading to the delay. This oversight was acknowledged by the facility's interim administration, who were informed of the issue on the evening of January 8, 2025.
Delayed Response to Clinical Record Request
Penalty
Summary
The facility staff failed to respond timely to a clinical record request for a resident whose power of attorney requested copies of the resident's clinical record. The request was made on December 21, 2023, but the records were not received until February 3, 2024, resulting in a delay of over six weeks. During a closed clinical record review, no information was found regarding the request for clinical records being made. The medical records employee, who had been in the role for about two months, was unaware of the request and reported that the social worker had handled it. The social worker confirmed the request and provided documentation showing that the records were eventually shipped and received. The facility's policy, in accordance with 42 CFR 483.10(b)(2), requires that access to records be provided within 24 hours and copies within two business days, excluding weekends and holidays. However, the facility did not adhere to this policy, resulting in a significant delay. The findings were reviewed with the facility administrator, acting director of nursing, and corporate staff, but no additional information was provided.
Failure to Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility staff failed to report an allegation of abuse involving Resident #7 (R7) in a timely manner. R7 reported to a surveyor that staff were rough when assisting her, which was corroborated by bruising on her right wrist. Despite this, the facility did not document the bruising or report the allegation to the required agencies promptly. The acting director of nursing (DON) was informed of the allegation but did not take immediate action to report it, and the facility administrator was not initially aware of the situation. Additionally, the facility failed to report a skin tear on Resident #177 (R177) as an injury of unknown origin. An anonymous staff member reported the incident to the administrator, but no investigation was conducted, and the incident was not reported to the appropriate authorities. The administrator claimed to be unaware of the allegation, and no documentation was provided to show that an investigation had been conducted. The facility's policy requires all team members to report known or suspected abuse, neglect, or exploitation to local and state authorities. However, in both cases involving R7 and R177, the facility did not adhere to this policy, resulting in a failure to report and investigate the allegations of abuse and injuries of unknown origin in a timely and appropriate manner.
Inadequate Investigation of Abuse Allegations and Injury
Penalty
Summary
The facility staff failed to conduct a thorough investigation into allegations of abuse involving three residents. Two residents reported that a certified nursing assistant (CNA1) was rough during care, with one resident describing the treatment as being slapped with a washcloth. Despite these reports, the facility's investigation was inadequate, as it did not include interviews with other residents who might have been affected. The acting director of nursing only performed skin checks on the two residents who reported the abuse, and the social service director was unable to provide documentation of interviews with other residents who had previously complained about the CNA. The facility's documentation and interviews revealed inconsistencies and a lack of follow-through in addressing the abuse allegations. The administrator and other staff members were aware of the complaints, but the investigation was not comprehensive. The social service director documented interviews with the two residents but could not locate the documentation or recall the names of other residents who had complained. Additionally, the administrator's actions were inconsistent, as she initially stated that the abuse allegations were unsubstantiated, yet the CNA was terminated for her behavior. In a separate incident, the facility staff failed to investigate an injury of unknown origin for another resident who suffered a skin tear. A staff member reported the incident to the administrator, but there was no evidence of an investigation or determination of the cause of the injury. The facility's documentation did not mention the skin tear, and the administrator's response to the report was dismissive. Despite requests for evidence of an investigation, the facility did not provide any documentation, indicating a failure to adhere to their own policies on abuse, neglect, and exploitation prevention and investigation.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility staff failed to follow physician orders for two residents, leading to deficiencies in medication administration. For one resident, an LPN administered only one tablet of vitamin D3 25 mcg instead of the prescribed two tablets. This error was observed during a medication pass, and the LPN acknowledged the mistake upon review of the physician's order. The resident's clinical record confirmed the order for two tablets daily, and this issue was discussed with the facility's administration and nursing staff without further information provided. For another resident, the facility staff did not carry out physician orders for several medications, including Tramadol, KDur, and Fibercon. The physician had documented a plan to restart these medications, but the orders were not implemented as intended. The Tramadol order was never executed, and substitutions for KDur and Fibercon were delayed. The DON, who signed the order, suggested that the physician might have instructed her to wait for lab results, but no documentation of such a conversation or lab work was available. The facility lacked a policy regarding physician orders, and no additional information was provided before the survey concluded.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedars Healthcare Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Monroe Health & Rehab Center | 0.9 mi | ★★★★★ | 20 | 0 |
| The Laurels Of Charlottesville | 1.1 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Peace Inc | 1.5 mi | ★★★★★ | 15 | 0 |
| Charlottesville Health & Rehabilitation Center | 2.1 mi | ★★★★★ | 7 | 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.