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 Culpeper Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to prevent verbal abuse involving three cognitively intact residents. In one case, a dietary staff member yelled, argued, slammed a door, and used profanity toward a resident. In another incident, an LPN yelled at two residents in the smoking courtyard, telling one to "shut up" after he intervened. These actions violated the facility's zero-tolerance policy for abuse.
Staff did not review or revise the care plans for three residents after incidents of verbal abuse by facility staff, despite written statements and investigations documenting the events. Interviews with the director of discharge planning/social services and a unit manager confirmed that care plans were not updated to reflect the abuse or any interventions, contrary to facility policy.
Staff did not provide or document medically related social services for three residents after incidents of verbal abuse by staff. In each case, the affected residents were not assessed for psychosocial needs, and no interventions or trauma-informed screenings were documented, despite facility policy and staff expectations that such follow-up should occur.
Staff did not document incidents of alleged verbal abuse involving three residents in their clinical records, despite collecting written statements and acknowledging that such events should be recorded. Interviews with the DON and other staff confirmed that allegations of abuse were not entered into the clinical records, contrary to facility policy.
A resident who was cognitively intact reported being yelled at, argued with, and subjected to profane language by a dietary staff member during dinner, resulting in feelings of disrespect. The incident was not followed by a documented psychosocial assessment or trauma-informed screening, and the director of social services was unaware of the event.
Facility staff did not fully document grievances or their resolutions, with numerous grievance forms missing key information such as names, room numbers, dates, and outcomes. The administrator confirmed that grievance documentation was incomplete and did not meet policy requirements, resulting in unresolved or untracked concerns.
A resident's family experienced a significant delay in obtaining the resident's medical records, despite providing required documentation and repeated follow-ups. The process was prolonged due to ongoing requests for additional documents and miscommunication between staff and the legal department, resulting in the records being released thirty-two days after the initial request.
The facility failed to provide adequate supervision for residents smoking and leaving the building. A resident requiring supervision for smoking was observed unsupervised in a non-designated area, while another resident with hemiplegia smoked unsupervised, resulting in a potential burn. Additionally, residents left the facility without proper notification or supervision, despite being moderately impaired or requiring assistance for ambulation. These failures led to Immediate Jeopardy and substandard quality of care findings.
The facility failed to address concerns raised by the resident council about missing clothing during meetings in May and June 2024. Despite documentation of these concerns, no grievances were filed, and there was no evidence of resolution. Staff interviews revealed a lack of communication and documentation, with the director of recreation admitting to not documenting grievances or resolutions. The facility's policy requires documentation and immediate notification of the administrator for urgent issues, but these procedures were not followed.
A resident with diabetes had multiple instances of blood sugar levels exceeding 400, as recorded in June and July 2024, without the physician being notified, contrary to the physician's order. The facility's RN confirmed the requirement to notify the physician and document the communication, but the clinical records lacked evidence of such actions, violating the facility's policy on significant changes in condition.
The facility staff failed to maintain a homelike environment and protect residents' property. During meals, trays and lids were left on tables, causing discomfort. Rooms of two residents were in disrepair, with blue tape and separated baseboards. A resident reported missing clothing over a year, with no resolution. The facility lacked policies for dining and maintaining a homelike environment.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in personal hygiene, oxygen therapy, physician notification for high blood sugar, pressure injury care, and use of splints. Observations and staff interviews revealed that care plans were not followed, resulting in unmet care needs for the residents.
The facility failed to administer an IV antibiotic as ordered for a resident, with six doses not evidenced as given, despite medication availability. Additionally, another resident did not receive timely care for a skin tear, as evidenced by dried blood on her Geri sleeve. Staff interviews revealed non-adherence to medication and wound care protocols.
A resident in a LTC facility experienced a significant medication error when Teflaro, an IV antibiotic, was not administered as ordered on six occasions. The MAR showed discrepancies, and some doses were incorrectly marked as unwitnessed self-administration. Interviews with LPNs revealed that the medication should have been administered promptly, and the facility's policy on the 5 Rights of medication administration was not followed.
The facility staff failed to maintain kitchen sanitation and proper temperature logs. Observations revealed food debris on the kitchen floor and missing freezer temperature checks. The food services manager cited staff shortages for incomplete logs and was unsure about the previous evening's cleaning. The facility's policy mandates frozen foods be stored at 10 degrees or below with daily temperature records, which were not adhered to.
Facility staff failed to follow infection control practices during medication administration for several residents, including improper cleaning of glucometers and handling of medications. Additionally, the facility did not communicate with the local health department during outbreaks of communicable diseases, as required by policy.
Two residents in a LTC facility were found with call bells out of reach, despite staff acknowledging the importance of accessibility. One resident, moderately impaired, was unaware of the call bell's location, while another, severely impaired, had the call bell hanging behind their head. Staff interviews confirmed the expectation for call bells to be within reach, but observations showed otherwise. The facility lacked a specific policy on call bell placement.
A facility failed to implement a baseline care plan for a resident with an Aspira drain within 48 hours of admission, as required by policy. The resident, admitted with cancer and other conditions, required maximum assistance for various activities. Despite the comprehensive care plan indicating the need for drain monitoring, the baseline care plan was not executed, as confirmed by staff interviews.
The facility failed to update care plans for two residents, leading to deficiencies in addressing their safety and preferences. One resident required supervision for smoking, but the care plan inaccurately allowed independent smoking, resulting in unsupervised smoking in an unsafe area. Another resident frequently left the facility independently to visit a local drug store, but the care plan did not address this preference or safety concern. Interviews with LPNs confirmed the need for care plan updates, as required by facility policy.
Three residents in an LTC facility were found with deficiencies in ADL care, specifically in personal hygiene and grooming. A resident with paralysis had untrimmed nails, another had dirty fingernails despite needing substantial assistance, and a third with upper extremity impairment had excessively long nails. Staff acknowledged the need for regular grooming, but observations indicated these standards were not met.
A resident with a stage two pressure injury on the sacrum was not properly monitored or documented by the facility staff. Despite treatment orders being in place, the staff failed to consistently document the size and stage of the wound, as required by facility policy. Interviews revealed a lack of proper documentation and tracking, even though the resident was being followed by a wound clinic.
A resident with traumatic brain dysfunction, seizure disorder, and diabetes mellitus was found with excessively long toenails, indicating a failure in providing appropriate toenail care. The resident, dependent on staff for personal hygiene, was supposed to receive toenail care from a podiatrist due to her diabetic condition. However, observations showed that her toenails were not maintained, leading to the deficiency being identified.
A resident with upper extremity impairment was observed without required hand splints on multiple occasions, despite care plan instructions. An LPN indicated that the splints should have been applied by the night shift, but they were not. Administrative staff were informed of the issue.
A resident with an indwelling catheter had their catheter bag improperly maintained, as it was observed touching the floor, contrary to facility policy. Interviews with a CNA and an LPN confirmed the importance of keeping the bag below the bladder and off the floor to prevent infection. The facility's policy also emphasized these practices, and the administrative staff were informed of the deficiency.
The facility staff failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. One resident received less oxygen than prescribed, while another was connected to an empty portable oxygen tank. Despite clear physician orders and facility policies, the staff did not adhere to the required oxygen administration protocols.
A resident continued to receive PRN Zyprexa despite a pharmacy recommendation to discontinue its use. The facility's process for handling pharmacy recommendations was not followed, as the nurse practitioner did not document a response, and the recommendation was not entered into the resident's chart. The facility's policy requires physician review within 30 days, which was not met.
A facility failed to ensure a resident was free from unnecessary psychotropic medication by not documenting the physician's evaluation for the continued use of Olanzapine. The resident, experiencing terminal delirium related to dementia, received the medication as needed, but the facility lacked documentation and a policy for as-needed antipsychotic medications.
Two residents in the facility had unsecured medications in their rooms. A bottle of Nystatin powder labeled for another resident was found in one resident's room, and an inhaler was left unattended in another's. Both medications should have been stored in the medication cart according to facility policy. The incidents were reported to the facility's leadership.
The facility failed to inspect bariatric beds for safety and entrapment risks for two residents. Observations revealed discrepancies between documented and actual beds in use, with no inspections conducted. The director of maintenance could not explain the oversight, despite facility policy requiring regular audits. Facility leadership was informed of the issue.
A floor technician at the facility did not complete the required QAPI training as part of their onboarding process. Although the training was scheduled to be added to their computer-based program, there was no evidence of completion. The facility's assessment and onboarding calendar indicated that QAPI training was part of the general orientation for all staff, but this was not confirmed for the technician.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
Facility staff failed to protect three residents from verbal abuse by staff members. One resident, who was cognitively intact as indicated by a BIMS score of 14, reported that a dietary staff member yelled at him, argued, slammed a door, and used profane language when he requested a sandwich. The staff member admitted to yelling and shutting the door but did not acknowledge wrongdoing. The incident was not initially reported to the unit manager, indicating a lapse in communication and immediate protective measures. Two other residents, both cognitively intact with BIMS scores of 14 and 15, experienced verbal abuse from an LPN in the facility's smoking courtyard. The LPN yelled at one resident to provide a urine sample and, when the other resident intervened, told him to "shut up" and continued to raise her voice. Both residents described the staff member's behavior as verbally abusive and rude, and their statements were consistent and corroborated each other's accounts. The facility's policy states zero tolerance for abuse, including verbal abuse, yet staff members engaged in yelling, use of inappropriate language, and disrespectful interactions with residents. The incidents were substantiated through resident interviews, staff interviews, and review of facility documentation, demonstrating that the facility did not ensure residents were free from verbal abuse as required.
Failure to Update Care Plans After Verbal Abuse Incidents
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for three residents following incidents of verbal abuse by staff members. For one resident, after reporting that a dietary cook yelled, argued, slammed a door, and used profane language, there was no documentation in the care plan reflecting the incident or any related interventions. The resident was cognitively intact, as indicated by a BIMS score of 14, and the incident was reported to the nurse practitioner, responsible party, and local police, with the staff member suspended. However, the care plan remained unchanged, and interviews with facility staff confirmed that care plans were not reviewed or updated after such incidents. Similarly, two other residents experienced verbal abuse from an LPN, including being yelled at and told to "shut up." Written statements documented these events, but reviews of their comprehensive care plans showed no evidence of review or revision following the incidents. Staff interviews further revealed a lack of understanding or adherence to the policy requiring care plan updates when changes in a resident's condition or circumstances occur, such as after abuse allegations. The administrator and director of nursing were made aware of these concerns, but no additional information was provided before the survey exit.
Failure to Provide Medically Related Social Services After Verbal Abuse Incidents
Penalty
Summary
Facility staff failed to provide medically related social services to three residents following incidents of verbal abuse by staff members. In one case, a resident with a high BIMS score, indicating intact cognitive function, reported being verbally abused by a dietary staff member. The resident expressed feeling disrespected and affected by the incident, and stated that no one had previously asked how the event made him feel. The director of discharge planning/social services was not aware of the incident and did not complete a psychosocial assessment or document any trauma-informed screening for the resident. For two additional residents, written statements documented that an LPN yelled at them and used inappropriate language. Despite these reports, there was no evidence in the clinical records that the residents' psychosocial status was assessed or that psychosocial interventions were implemented following the incidents. The director of discharge planning/social services confirmed that she did not complete a formal assessment or follow-up for these residents after the reported verbal abuse. Interviews with facility staff, including the director of nursing and other clinical staff, revealed an expectation that psychosocial assessments and follow-up with psychiatric or psychological services should occur after allegations of abuse. However, documentation and assessments were not completed as required by facility policy, which states that social work and discharge planning staff are responsible for identifying and assisting with patients' psychosocial and medically related social service needs.
Failure to Document Alleged Abuse Incidents in Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three out of five residents reviewed, specifically by not documenting incidents of alleged verbal abuse in the residents' clinical records. For one resident, who was cognitively intact as indicated by a BIMS score of 14, there was no clinical record documentation of an incident where the resident reported being verbally abused by a dietary staff member. Although the event was recorded in a facility synopsis and statements were obtained, the clinical record lacked any reference to the incident. Interviews with the director of nursing and the administrator revealed inconsistent practices and understanding regarding the documentation of such incidents in the clinical record, despite facility policy requiring accurate and complete records for each patient. Similarly, for two other residents, staff failed to document separate incidents of alleged verbal abuse by an LPN in their clinical records, even though written statements about the events were collected by facility staff. Interviews with nursing staff and the director of nursing confirmed that allegations of abuse should be documented in the clinical records, but this was not done. The lack of documentation was acknowledged by administrative staff during the survey, and no additional information was provided before the survey exit.
Failure to Treat Resident with Dignity During Verbal Altercation
Penalty
Summary
Facility staff failed to treat a resident in a dignified manner during a dinner service. The resident, who was cognitively intact as indicated by a BIMS score of 14 out of 15, reported that a dietary cook yelled at him, argued, slammed a door, and used profane language when he requested a sandwich. The incident was reported to the administrator, and the resident expressed that the event made him feel disrespected and affected him for some time. The resident also stated that no one had previously asked him how the incident made him feel. Interviews with staff revealed that the director of discharge planning/social services was not aware of the incident and did not document any psychosocial assessment or trauma-informed screening for the resident involved. The administrator confirmed that yelling at a resident is not treating them in a dignified manner. Facility policy states that residents have the right to be treated with dignity and respect. No documentation was provided to show that the resident's psychosocial needs were assessed or addressed following the incident.
Failure to Document and Resolve Grievances
Penalty
Summary
Facility staff failed to completely document grievances and the resolution of grievances as required by policy. Review of the Grievance/Concern Logs revealed multiple instances where essential information was missing, such as the first name of the person filing the concern, room number, unit, relationship to the resident, time received, staff title, and documentation of resolution. In several cases, there was no indication of who received the grievance, no date or time of the event, and no administrator review or signature. Some entries only noted that a concern was resolved without providing supporting details or outcomes, while others lacked any documentation of resolution or follow-up. During an interview, the administrator acknowledged that the grievance forms should be fully completed and that documentation of resolution is required. The facility's policy outlines that management staff are responsible for promptly responding to and resolving grievances, with specific procedures for documentation and follow-up in the electronic system. Despite these procedures, the logs reviewed showed consistent failures to document grievances and their resolutions, as well as lapses in administrative oversight and record-keeping.
Delayed Release of Medical Records to Resident's Family
Penalty
Summary
Facility staff failed to release the medical records of a deceased resident to the resident's family in a timely manner. The family initially requested the records and provided the necessary authorization and a copy of the death certificate. Despite repeated follow-ups and submission of additional documents, including a power of attorney and an affidavit as requested by the facility's legal department, the process was delayed due to ongoing requests for documentation and miscommunication between facility staff and the legal department. The records were ultimately released thirty-two days after the initial request. Interviews with staff revealed that the standard process involved forwarding requests to the legal department, which would then assign a case number and request any additional documents needed. Staff members were under the impression that records should be released within 30 days, but confusion regarding required documentation for deceased residents contributed to the delay. The family expressed dissatisfaction with the handling of the request, and staff acknowledged the delay was due to the legal department's repeated requests for documents and lack of clarity on the process.
Inadequate Supervision for Smoking and Leave of Absence
Penalty
Summary
The facility staff failed to provide adequate supervision for residents who were smoking and leaving the building, leading to several deficiencies. Resident #148, who was assessed as requiring supervision for smoking, was observed smoking in an outdoor garden area without staff supervision, a safe cigarette disposal receptacle, a fire blanket, or a fire extinguisher. Despite being cognitively intact, the resident's care plan inaccurately allowed for independent smoking, contrary to the Smoking Safety Screen assessment. Similarly, Resident #90, who had hemiplegia and was moderately impaired in decision-making, was observed smoking unsupervised in a non-designated area, with a hole in their t-shirt suggesting a potential burn from a cigarette. The facility also failed to supervise residents leaving the premises. Resident #97, who was moderately impaired in decision-making and required supervision for ambulation, was observed leaving the facility and crossing a busy street without a cane or staff supervision. Despite therapy recommendations for supervision during ambulation, the resident was not adequately assessed for safety during community outings. Resident #120, who was moderately impaired, frequently left the facility without notifying staff or signing out, despite the facility's policy requiring notification and documentation for leave of absence. The resident was able to ambulate safely but did not follow the required procedures for leaving the facility. Additionally, Resident #136, who was not cognitively impaired, was observed leaving the facility daily without signing out, despite being provided with a safety vest for visibility. The resident's care plan noted frequent leave of absence, but there was no evidence of an assessment to determine the resident's safety to leave independently. The facility's failure to implement and enforce its leave of absence policy and smoking supervision requirements resulted in Immediate Jeopardy and substandard quality of care findings.
Failure to Address Resident Council Concerns on Missing Clothing
Penalty
Summary
The facility staff failed to respond to concerns raised by the resident council during their meetings in May and June 2024 regarding missing clothing. Despite the documentation of these concerns in the resident council meeting notes, there was no evidence of any grievances filed or resolutions provided by the facility. The facility's grievance records from May 1, 2024, to the present did not show any grievances related to the missing clothing issue raised by the resident council. Interviews with staff members revealed a lack of communication and documentation regarding the concerns. The environmental service director was unaware of the concerns, and the director of recreation admitted to not documenting grievances or resolutions, although she claimed to have verbally communicated the issue to the director of environmental services and the administrator. The facility's policy requires documentation of council concerns and immediate notification of the administrator for urgent issues, but these procedures were not followed. The regional vice president of operations confirmed the absence of evidence for resolving the concerns.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility staff failed to notify the physician of a change in condition for a resident with diabetes, whose blood sugar levels exceeded 400 on multiple occasions. According to the physician's order dated April 15, 2024, the staff was required to contact the physician if the resident's blood sugar was greater than 400 or less than 60. Despite this directive, the clinical records for June and July 2024 showed several instances where the resident's blood sugar levels were above 400, yet there was no documentation indicating that the physician was notified. Interviews with the facility's registered nurse and administrative staff confirmed the oversight. The registered nurse acknowledged that the protocol required notifying the physician and documenting the communication in the resident's progress notes. However, a review of the resident's clinical records, including medication administration records and progress notes, revealed no evidence of such notifications. The facility's policy on significant changes in condition also mandates that a licensed nurse assess the patient and notify the provider, which was not adhered to in this case.
Deficiencies in Homelike Environment and Property Protection
Penalty
Summary
The facility staff failed to serve lunch in a homelike manner for three residents, as observed on a specific date. During the meal, staff left meal trays and plate lids on the tables, which the residents found uncomfortable due to limited space. Interviews with the residents confirmed their dissatisfaction with the arrangement, and a CNA acknowledged that this practice was not homelike and suggested that the trays and lids could be placed back on the meal carts during meals. The facility lacked a policy regarding dining, which contributed to this deficiency. In another instance, the facility staff failed to maintain the rooms of two residents in good repair. Observations revealed blue tape along the baseboards and electrical outlets, with portions of the baseboard separated from the wall, exposing dried adhesive. Interviews with the residents indicated that these issues had persisted for a long time without resolution. The maintenance technician confirmed the lack of open work orders for these repairs and acknowledged that the rooms did not appear homelike due to the visible tape and disrepair. Additionally, the facility staff failed to protect a resident's property from loss, as the resident reported multiple missing clothing items over the course of a year. Despite reporting the issue to various staff members, the resident's clothing was not found, and they were given lost and found clothing as a replacement. The facility's grievance logs did not document any grievances for the missing items, and interviews with staff revealed a lack of consistent procedures for addressing such issues. The facility's policy on personal belongings outlined steps for marking and storing items but did not ensure the protection of the resident's property.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to implement comprehensive care plans for several residents, leading to deficiencies in care. For Resident #89, the staff did not assist with personal hygiene as outlined in the care plan. The resident was observed multiple times with a brown substance under their fingernails, indicating a lack of proper hygiene care. Despite the care plan indicating the need for staff assistance with personal hygiene, there was no documentation of care refusal, and staff interviews confirmed that fingernails should be cleaned during daily care. Resident #13's care plan for oxygen therapy was not implemented correctly. The resident was observed with a nasal cannula attached to an empty portable oxygen tank, contrary to the physician's order for continuous oxygen at 2L/min. The LPN interviewed was unsure why the resident was on a portable tank in their room and acknowledged that the tank should not have been empty or set to zero. For Resident #106, the facility staff failed to notify the physician of blood sugar levels exceeding 400, as required by the care plan. The resident's medication administration records showed multiple instances of high blood sugar levels without documented physician notification. Additionally, Resident #86's care plan for pressure injury care was not followed, as there was inconsistent documentation of the sacrum pressure injury's measurements and stage. Lastly, Resident #56 was observed without the prescribed splints for their contractures, despite the care plan specifying their use for a set duration each shift.
Failure to Administer Medication and Provide Wound Care
Penalty
Summary
The facility staff failed to administer an IV antibiotic medication, Teflaro, as ordered for Resident #269 on six occasions. The medication was scheduled to be given three times a day, but there were multiple instances where doses were not administered, as evidenced by the Medication Administration Record (MAR). The facility's Regional Director of Clinical Services confirmed that a coding error in the system marked some doses as 'Unwitnessed self-administration,' which was not possible given the medication's route. Despite the availability of the medication, as confirmed by the pharmacy delivery manifest, there was no evidence that the doses were administered as ordered. Additionally, the facility staff failed to provide appropriate care for a skin tear on Resident #151's right arm. The resident was observed with dried blood on her Geri sleeve, indicating a lack of timely wound care. The resident reported that the blood had been there for more than a day, and the skin tear was possibly due to the wheelchair. The facility's Skin Observation Tool confirmed the presence of a skin tear, but there was no evidence of assessment, cleaning, or treatment of the wound as per the facility's protocol. Interviews with facility staff, including LPNs and administrative staff, revealed a lack of adherence to medication administration protocols and wound care procedures. The staff acknowledged that missed doses could impact treatment effectiveness and that proper wound care involves assessment, cleaning, and notifying the nurse practitioner. Despite being made aware of these deficiencies, no further information or corrective actions were provided by the facility before the survey's conclusion.
Significant Medication Error Due to Missed Doses
Penalty
Summary
The facility staff failed to prevent a significant medication error for one resident, who was cognitively intact and able to make daily life decisions. The resident was prescribed Teflaro, an intravenous antibiotic, to be administered three times a day. However, the medication was not administered as ordered on six occasions over a three-day period. The medication was available for administration, but there was no evidence that it was given at the scheduled times, resulting in a significant medication error. The MAR revealed discrepancies in the administration of Teflaro, with some doses marked as unwitnessed self-administration, which was not possible given the medication's route. Interviews with LPNs indicated that the medication should have been administered as soon as it was available, and any missed doses should have been communicated to the Nurse Practitioner. The facility's policy on medication administration, which includes the 5 Rights, was not followed, leading to the deficiency. The facility's administrative staff was made aware of the findings, but no further information was provided by the end of the survey.
Kitchen Sanitation and Temperature Log Deficiencies
Penalty
Summary
The facility staff failed to maintain the kitchen in a safe and sanitary manner, as observed during a survey. On the specified date, food debris such as crumbs, onion skins, lettuce, and paper were found on the kitchen floor. Additionally, there was a lack of documentation for freezer temperature checks, with no evidence of a second temperature check on one day and no morning check on the following day. During an interview, the food services manager acknowledged that the temperature logs were not completed as required at the beginning and end of each shift, citing staff shortages as a reason. The manager also admitted that the kitchen floor needed sweeping and was unsure if it had been cleaned the previous evening. The facility's policy requires that frozen foods be stored at a target temperature of 10 degrees or below, with daily temperature records maintained, but these procedures were not followed as per the observations.
Infection Control and Communication Failures
Penalty
Summary
The facility staff failed to implement proper infection control practices during medication administration for multiple residents. For Resident #45, the blood glucose glucometer was not cleaned before or after use, contrary to the facility's policy and the manufacturer's recommendations. The registered nurse (RN) involved acknowledged the oversight and admitted to using an alcohol swab instead of the recommended bleach wipes due to unavailability. This failure to adhere to infection control protocols was also observed with Resident #25, where the same RN did not clean the glucometer before or after use. In another instance, the RN used her fingers to handle medications for Resident #132, which is against the facility's medication administration policy. The RN was observed picking up a dropped medication with her fingers and placing it into a medication cup, which she later admitted was not the correct procedure. Similarly, for Resident #118, an LPN dropped medications on the top of the medication cart and then administered them to the resident without ensuring the surface was clean, acknowledging that the medications could have been contaminated. Additionally, the facility failed to communicate with the local health department during outbreaks of communicable diseases. The facility's infection preventionist, who had been in the position for only two weeks, was unaware of the contact process and had not been able to obtain accurate information on whom to contact. This lack of communication was contrary to the facility's policy, which mandates reporting outbreaks to the local health department.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility staff failed to maintain the call bell in a position accessible to two residents, Resident #89 and Resident #13, leading to a deficiency. For Resident #89, who was moderately impaired in making daily decisions and dependent on staff for toileting and personal hygiene, the call bell was observed on the floor, out of reach. Despite the resident's care plan encouraging the use of the call bell for assistance, the resident was unaware of its location. Interviews with staff confirmed that the call bell should be within reach at all times, yet it was not, indicating a lapse in adherence to the care plan. Similarly, for Resident #13, who was severely impaired in decision-making and required assistance with ADLs due to advanced age and chronic health conditions, the call bell was found hanging out of reach behind the resident's head. Observations confirmed that the call bell remained inaccessible even after staff entered and exited the room. Staff interviews reiterated the importance of keeping the call bell within reach, but the call bell's placement did not reflect this practice. The facility's administrative staff, including the administrator and regional vice president of operations, were informed of the issue. However, it was noted that the facility lacked a specific policy regarding call bell placement, which may have contributed to the oversight. No further information or corrective actions were presented before the survey exit.
Failure to Implement Baseline Care Plan for Resident with Aspira Drain
Penalty
Summary
The facility staff failed to implement a baseline care plan for Resident #470, who was admitted with diagnoses including cancer, congestive heart failure, and adult failure to thrive. The resident, who was not cognitively impaired, required maximum assistance for bed mobility, transfer, hygiene/bathing, and supervision for eating. The comprehensive care plan dated 7/10/24 indicated that the resident had an Aspira drain, with interventions to drain and change the dressing as ordered. However, the baseline care plan to monitor the Aspira drain was not implemented within the required 48 hours of admission. Interviews with facility staff revealed a lack of adherence to the facility's Baseline Care Plan policy, which mandates the development and implementation of an individualized care plan within 48 hours of admission. LPN #2 acknowledged that a resident with a drain should have it included in the baseline care plan. The deficiency was brought to the attention of the facility's administrative and clinical leadership, but no further information was provided prior to the survey exit.
Failure to Update Care Plans for Resident Safety and Preferences
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for Resident #148 to reflect the need for supervision during smoking. Despite being assessed as requiring supervision on the Smoking Safety Screen, the care plan inaccurately documented that the resident may smoke independently. Observations revealed that the resident smoked unsupervised in a garden area without proper safety measures, such as devices for safe disposal of cigarette butts or fire safety equipment. Interviews with the resident and staff confirmed the discrepancy between the care plan and the resident's assessed needs. For Resident #120, the facility staff did not update the comprehensive care plan to address the resident's preference and safety concerns related to ambulating offsite independently to a local drug store. The resident, who was moderately impaired in decision-making ability, frequently left the facility without notifying staff or signing out. Physical therapy notes from the previous year indicated the resident's ability to ambulate safely over various surfaces, but the care plan lacked interventions for independent leave of absence to the drug store. Interviews with LPNs revealed that the care plans should have been updated to reflect the residents' current conditions and preferences. The facility's policy requires care plans to be updated as changes occur and reviewed quarterly. Despite being informed of these findings, the administrative staff, including the administrator and the Director of Nursing, did not provide further information by the end of the survey.
Deficiencies in ADL Care and Personal Hygiene
Penalty
Summary
The facility staff failed to provide adequate ADL care for three residents, resulting in deficiencies related to personal hygiene and grooming. Resident #90, who was moderately impaired in making daily decisions and required assistance for personal hygiene, was observed with untrimmed long fingernails on the right hand. Despite the resident's inability to trim their nails due to paralysis, the facility's care plan indicated the need for staff assistance, which was not provided as evidenced by multiple observations of the untrimmed nails. Resident #89, also moderately impaired and dependent on staff for personal hygiene, was observed with a brown substance underneath their fingernails on multiple occasions. The resident expressed that the staff did their best, but the observations indicated a lack of proper cleaning and grooming. The care plan required staff assistance for personal hygiene, yet there was no documentation of care refusal, suggesting a failure in providing necessary assistance. Resident #151, with an upper extremity impairment, was observed with excessively long and yellow fingernails. The facility's staff, including CNAs and LPNs, acknowledged that nails should be groomed weekly, but the observations showed that this standard was not met. The clinical record did not indicate any refusal of grooming assistance, highlighting a deficiency in the facility's adherence to its care protocols for grooming and personal hygiene.
Failure to Monitor and Document Pressure Injury
Penalty
Summary
The facility staff failed to properly assess and monitor a pressure injury for a resident, identified as Resident #86, who was part of a survey sample. The deficiency was noted when the staff did not document the size and stage of the pressure injury on the sacrum when treatment was initiated on 5/31/24. Furthermore, the staff failed to monitor the wound with weekly measurements to track healing progress. The resident was cognitively intact, as indicated by a perfect score on the BIMS, and had a documented stage two pressure injury on the most recent MDS assessment. The wound care physician had documented the pressure injury as a stage two, measuring approximately 1x1x0.1 cm, and treatment orders were put in place. However, the Skin Observation forms from May to July 2024 lacked consistent documentation of measurements and staging of the pressure injury. Interviews with the wound nurse and other nursing staff revealed a lack of proper documentation and tracking of the wound, despite the facility's policy requiring weekly skin assessments and documentation of any skin impairments. The director of nursing confirmed that the resident was being followed by a wound clinic, but this did not absolve the facility from its responsibility to track the wound. The facility's policy required licensed nurses to assess and document any skin impairments weekly, but this was not adhered to in the case of Resident #86. The deficiency was communicated to the facility's administrative and clinical leadership, but no further information was provided before the survey exit.
Failure to Provide Appropriate Toenail Care
Penalty
Summary
Facility staff failed to provide appropriate toenail care for Resident #56, who was observed with toenails between one and one and a half inches long on multiple occasions. The resident, who is dependent on staff for personal hygiene, was admitted with diagnoses including traumatic brain dysfunction, seizure disorder, and diabetes mellitus. According to the resident's care plan, she requires total assistance for personal hygiene. Interviews with facility staff revealed that while daily nail care is provided, toenail care for diabetic residents is typically performed by a podiatrist. Despite this protocol, the resident's toenails were not adequately maintained, leading to the deficiency being identified during the survey.
Failure to Apply Splints for Resident with Upper Extremity Impairment
Penalty
Summary
The facility staff failed to apply right- and left-hand splints for Resident #56, who was observed without the splints on multiple occasions. The resident was noted to have functional limitations in range of motion and an upper extremity impairment on both sides, as documented in the most recent Minimum Data Set (MDS) assessment. The resident's care plan specified the need for bilateral upper extremity splints to be worn for four hours each shift, totaling eight hours daily, as tolerated. Despite these instructions, the resident was observed without the splints on three separate occasions. Interviews with facility staff revealed a lack of adherence to the care plan. An LPN stated that the need for splints would typically be communicated through the care plan rather than physician's orders or medical administration records. The LPN acknowledged that the resident should have been wearing the splints and suggested that the night shift staff might have forgotten to apply them. The administrative staff, including the administrator and director of nursing, were informed of the issue, but no further information was provided before the surveyors exited the facility.
Failure to Maintain Sanitary Conditions for Urinary Catheter Bag
Penalty
Summary
The facility staff failed to maintain a urinary catheter collection bag in a sanitary manner for a resident identified as having an indwelling catheter. During observations, the resident was found with the catheter bag touching the floor, which is against the facility's policy. The resident, who was moderately impaired in making daily decisions, stated that the staff were responsible for the catheter care. The comprehensive care plan for the resident noted the presence of a Foley catheter. Interviews with a CNA and an LPN confirmed that the catheter bag should be kept below the bladder for proper drainage and to prevent infection, and it should not touch the floor due to sanitary concerns. The facility's policy on urinary catheterizations also specified that drainage bags should be maintained below the bladder and not touch the floor. The administrative staff, including the administrator and the director of nursing, were informed of the issue, but no further information was provided before the survey exit.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. For one resident, the staff did not administer oxygen at the physician-prescribed rate of five liters per minute. Despite the care plan and physician's order specifying this rate, observations on multiple occasions revealed that the resident was receiving only two and a half liters per minute. An LPN confirmed that the oxygen concentrator should have been set to the five-liter line as per the order. The facility's policy on respiratory care emphasized following the provider's order, but this was not adhered to in this case. For another resident, the staff failed to provide oxygen as ordered, as the resident was observed with a nasal cannula attached to an empty portable oxygen tank set at zero. The physician's order required oxygen at two liters per minute via nasal cannula, but the resident was not receiving any oxygen due to the empty tank. An LPN stated that portable tanks should be checked every two hours to ensure they are not empty, and it was unclear why the resident was on a portable tank in their room. The facility's policy required oxygen therapy to be administered per the provider's order, but this was not followed, resulting in the resident not receiving the necessary oxygen therapy.
Failure to Act on Pharmacy Recommendation for PRN Antipsychotic Use
Penalty
Summary
The facility staff failed to act on a pharmacy recommendation for a resident, identified as Resident #79, regarding the discontinuation of PRN use of the antipsychotic medication Zyprexa. The pharmacy recommendation, dated April 24, 2024, suggested discontinuing the PRN use of Zyprexa due to its limited effectiveness for short-term use and recommended considering an alternative medication. Despite this recommendation, no response was documented by the physician or prescriber, and the resident continued to receive PRN Zyprexa. Interviews with administrative staff revealed that the pharmacist's recommendations are placed into a computer portal, which is checked regularly by the Director of Nursing. These recommendations are then printed and given to the assigned nurse practitioner for documentation and implementation. However, in this case, the nurse practitioner did not document a response to the pharmacy's recommendation, and the recommendation was not entered into the resident's chart. The facility's policy requires the physician to review and sign the Medication Regimen Review within 30 days, but this was not adhered to in the case of Resident #79.
Failure to Document Evaluation for Continued Use of Antipsychotic Medication
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary psychotropic medication. Specifically, for Resident #79, the staff did not ensure that the physician or prescribing practitioner evaluated the resident for the continued use of the as-needed antipsychotic medication Olanzapine and documented the rationale for its continued use. The clinical record review revealed a physician's order for Olanzapine as needed for terminal delirium related to dementia, and the resident received the medication on a specific date in June 2024. During an interview, the Director of Nursing acknowledged that as-needed antipsychotic medications should only be ordered for up to 14 days. However, due to the resident's hallucinations and behaviors, the hospice physician wanted to continue the use of Olanzapine. Despite this, the facility could not provide documentation that the physician evaluated the resident for the continued use of the medication or documented the rationale for its continued use. Additionally, the facility lacked a policy regarding as-needed antipsychotic medications.
Medication Security Lapses in Resident Rooms
Penalty
Summary
The facility staff failed to secure medications in a safe and secure manner for two residents. In the first instance, a bottle of Nystatin powder labeled for a different resident was found on the bedside table of Resident #32, who was not in the room at the time. When questioned, Resident #32, who was not cognitively impaired, stated they did not notice the bottle. The LPN acknowledged that the medication was not Resident #32's and should have been locked in the medication cart. The facility's policy requires that medications be locked when not attended by authorized personnel. In the second instance, an inhaler prescribed to Resident #519 was found unattended on the bedside table. The LPN confirmed that the inhaler should have been stored in the medication cart and not used without supervision. The facility's policy mandates that medications be stored securely and only accessible to authorized personnel. Both incidents were reported to the facility's administrative and clinical leadership.
Failure to Inspect Bariatric Beds for Safety
Penalty
Summary
The facility staff failed to perform necessary safety inspections on bariatric beds for two residents, leading to a deficiency. For Resident #86, the staff did not inspect the bariatric bed for safety and entrapment risks, despite the resident being observed in bed with two half side rails. The bed inspection book indicated that the bed in use was not the same as the one documented, and no inspection had been conducted for the current bariatric bed. The director of maintenance, when interviewed, was unable to provide a reason for the lack of inspection, despite the facility's policy requiring annual and intermittent audits of bed systems. Similarly, for Resident #124, the staff also failed to inspect the bariatric bed for safety and entrapment. The resident was observed in bed with two half side rails, and the bed inspection book again showed a discrepancy between the documented bed and the one in use, with no inspection performed. The director of maintenance confirmed the process for inspecting bariatric beds but could not explain why the inspection was not completed. The facility's administrative and clinical leadership were informed of these concerns, but no further information was provided before the survey exit.
Failure to Complete QAPI Training for New Staff Member
Penalty
Summary
The facility staff failed to ensure that a floor technician, identified as OSM #5, completed the mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program. OSM #5 was hired on June 1, 2023, but there was no evidence provided that they had completed the QAPI training. During an interview, ASM #4, the regional vice president of operations, mentioned that the QAPI training was scheduled to be added to OSM #5's computer-based training program in August. However, it was unclear if the training was included in the system upon hire. Further investigation revealed that the QAPI training was supposed to be part of the general orientation and onboarding education for all staff, as confirmed by ASM #2, the director of nursing. The facility's assessment and the Relias 2024 Onboarding All Employees calendar documented that the course "Quality & You: QAPI" was included in the onboarding education for all staff. Despite this, no additional information or evidence of completion was provided for OSM #5 before the exit interview with the facility's administrative staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Culpeper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Culpeper | 1.1 mi | ★★★★★ | 0 | 0 |
| Mountain View Nursing Home | 13.3 mi | ★★★★★ | 3 | 0 |
| Dogwood Village Of Orange County Health And Rehab | 15.2 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Madison | 17.7 mi | ★★★★★ | 1 | 0 |
| Poplar Hill Health And Rehab | 20.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.