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 Daleville Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain proper food safety standards in the kitchen and nourishment rooms. In the kitchen, the dish machine lacked the correct concentration of sanitizing solution, and wet pans were stacked together. In the nourishment rooms, multiple food items were found unlabeled and undated, contrary to facility policy. The Dietary Manager acknowledged these issues, and the Dish Machine Log lacked the recommended PPM for the sanitizer.
A resident's code status was incorrectly documented as full code, despite having a DNR decision in place in their care plan and clinical record. The resident, who was cognitively intact, had initially rescinded their DNR status upon hospital readmission but later confirmed their wish to remain a DNR. The facility failed to resolve the conflicting documentation before the survey exit conference.
A resident's room in the facility was found to have a strong odor of urine, which was identified by a CNA as coming from the resident's roommate who refused showers. Despite the resident's inability to smell due to sinus issues, the odor was noticeable to staff and surveyors. The issue was discussed with the facility's administrator and DON, and housekeeping was observed cleaning the room.
A resident with severe cognitive impairment and multiple diagnoses, including reliance on tube feeding, did not have weekly weights documented as recommended by the RD. The facility's failure to adhere to the care plan and policy on weight assessment was identified during a survey, with only monthly weights available despite the need for weekly monitoring.
Two residents in the facility were found to have deficiencies in activities of daily living (ADL) care, specifically related to nail hygiene. One resident, with significant cognitive impairment and physical limitations, had long fingernails with debris, while another cognitively intact resident had long, discolored nails and expressed discomfort. Both cases were acknowledged by the facility's administration and nursing leadership.
A resident with multiple diagnoses, including dementia and chronic pain, did not receive the prescribed medication Questran on two occasions due to staff errors. The medication, intended to manage diarrhea, was delivered by the pharmacy but was misplaced on the wrong medication cart, leading to non-administration.
Two residents in the facility did not receive ordered pressure ulcer care. One resident, with multiple diagnoses including pressure ulcers, had a missed dressing change with no wound care notes on record. Another resident, with a history of amputation and pressure ulcers, had multiple blanks in the Treatment Administration Records, indicating missed treatments. The DON confirmed that blanks generally meant treatments were not completed, and the surveyor found no evidence of treatments on specific dates.
A resident with severe cognitive impairment and nicotine dependence was admitted without a completed safe smoking assessment, contrary to the facility's policy. The assessment was only provided as a late entry after surveyor inquiry, highlighting a deficiency in adherence to admission protocols.
Two residents in the facility did not receive their prescribed Magic Cup dietary supplements due to a backorder issue. Despite the dietary manager's claim of substituting with Mighty Shakes, neither supplement was observed on the residents' meal trays. The nursing staff inaccurately documented the provision of Magic Cups in the MARs, leading to a deficiency in maintaining the residents' nutritional status.
A resident with conditions including conjunctivitis and glaucoma did not receive Alaway eye drops as ordered due to a lack of DON approval for the OTC medication. The resident waited 18 days without receiving the medication, which was only signed as administered once in error. The issue was acknowledged by the facility's DON and Administrator, and the resident was later prescribed a different medication.
A resident with type 2 diabetes had elevated blood glucose levels, and the facility failed to act on a pharmacy recommendation to adjust insulin dosage. The resident's medication regimen review was not properly documented or followed up, as required by facility policy, leading to continued elevated glucose levels.
The facility staff failed to maintain accurate clinical records and monitor a resident's weight as ordered. One resident's condition change and hospital transfer were not documented, despite being cognitively intact and reporting symptoms. Another resident's weight monitoring for CHF was inconsistent, with gaps and discrepancies in the EMR. The DON admitted to filling in missing data, raising concerns about reliability.
The facility failed to maintain an effective QAPI Program, resulting in repeated deficiencies in Pharmacy Services. The deficiency involved the lack of evidence that the attending medical provider reviewed and acted upon monthly drug regimen reviews by the pharmacist, affecting a resident. Despite quarterly QAPI meetings, the issue persisted across multiple surveys.
Deficiencies in Food Safety and Labeling in Kitchen and Nourishment Rooms
Penalty
Summary
The facility staff failed to adhere to professional standards for food service safety in the kitchen and nourishment rooms. In the kitchen, the staff did not maintain the correct concentration of sanitizing solution in the low-temperature sanitizing dish machine. During an inspection, the dish machine's chemical sanitizer concentration was tested using a chlorine test strip, which failed to change color, indicating the absence of sanitizing solution. The Dietary Manager (DM) acknowledged the issue and stated that the dish machine would be serviced, and alternative sanitizing methods would be used in the meantime. Additionally, the surveyor observed wet pans stacked together, which the DM confirmed and stated would be re-washed and allowed to dry. The Dish Machine Log lacked the manufacturer's recommended parts per million (PPM) for the sanitizer, and staff recorded a checkmark if the sanitizer tested okay, without specifying the concentration. In the nourishment rooms on the Blue Ridge and Alleghany nursing units, multiple food items were found unlabeled and undated in the refrigerators. Observations included an open, undated package of sliced deli turkey, undated plastic grocery bags, a pizza box, and take-out containers. The freezer contained unlabeled and undated items, such as a half-full cup of ice cream with a spoon sticking out, a cup with a frozen brown substance, and an open cup of ice. The DM stated that kitchen staff checks the temperature of the nourishment room refrigerators daily and discards expired items. However, the facility policy requires food brought by family or visitors to be labeled and stored distinctly from facility-prepared food, which was not adhered to in this case.
Conflicting Code Status Documentation for a Resident
Penalty
Summary
The facility staff failed to ensure the correct code status was in place for a resident, leading to a deficiency. The resident, who was part of the survey sample, had conflicting documentation regarding their code status. The current code status order was listed as full code, while the comprehensive person-centered care plan and the clinical record's Advanced Directive information tab documented the resident as having a DNR (do not resuscitate) decision in place. Additionally, the resident's clinical record included a completed Durable Do Not Resuscitate (DDNR) Order. The resident's diagnosis list included conditions such as Acute Follicular Conjunctivitis, Chronic Pain Syndrome, Open-Angle Glaucoma, Type 2 Diabetes Mellitus, Schizophrenia, and Congestive Heart Failure. The most recent minimum data set (MDS) indicated the resident was cognitively intact with a BIMS score of 15 out of 15. Upon readmission from a hospital stay, the resident had initially rescinded their DNR status, but later confirmed their wish to remain a DNR. Despite this, the facility did not present further information to resolve the conflicting documentation before the survey exit conference.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility staff failed to provide a clean, comfortable, and homelike environment for Resident #63, as evidenced by the presence of a strong odor of urine in the resident's room. Resident #63, who is cognitively intact with a mental status score of 14 out of 15, has diagnoses including Parkinsonism, hypertension, and is receiving palliative care. During observations on two separate occasions, the surveyor noted the persistent odor of urine in the room. A certified nurse's aide (CNA) identified the odor as urine, attributing it to the resident's roommate who refused to shower. A licensed practical nurse (LPN) also commented on the unbearable smell in the room, although they were unsure of its exact source. The issue was brought to the attention of the facility's administrator and director of nursing. Despite the resident's inability to smell due to sinus problems, the odor was noticeable to staff and surveyors. Housekeeping staff were observed cleaning the room, but no further information was provided regarding the resolution of the odor issue before the surveyor's exit.
Failure to Implement Weekly Weight Monitoring for Resident
Penalty
Summary
The facility staff failed to implement a comprehensive person-centered care plan for a resident, specifically neglecting to follow the registered dietitian's recommendation to weigh the resident weekly. The resident, who had multiple diagnoses including Multiple Sclerosis, Vascular Dementia, and Dysphagia, was severely cognitively impaired and received more than half of their calories through a feeding tube. Despite the care plan goal to monitor the resident's tolerance to tube feeding through weekly weights, the facility did not document these weights as required. The surveyor's review of the resident's clinical records revealed a lack of evidence for weekly weight measurements, despite repeated recommendations from the registered dietitian. The Director of Nursing was unable to provide documentation of weekly weights, only monthly weights were available. The facility's policy on weight assessment and intervention was not adhered to, as it required weights to be recorded in the medical record and addressed in individual care plans. This deficiency was discussed with the facility's administrators and Director of Nursing, but no further information was provided before the exit conference.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care for two residents, resulting in deficiencies related to personal hygiene. Resident #31, who has a diagnosis of hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, was observed with long fingernails containing debris. The resident's Minimum Data Set (MDS) assessment indicated a high level of dependency in personal hygiene, with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, suggesting significant cognitive impairment. Despite these needs, the resident's fingernails were not maintained, as confirmed by the Director of Nursing (DON) during an observation. Similarly, Resident #63, who is cognitively intact with a BIMS score of 14 out of 15, was found to have long and discolored fingernails. The resident expressed discomfort and had previously requested assistance with nail care, as well as inquired about haircuts. The resident's care plan included assistance with grooming to maintain dignity, yet this was not adequately provided. The issue was acknowledged by the facility's administration and nursing leadership during discussions with the surveyor.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility staff failed to follow medical provider orders for a resident, resulting in the non-administration of the medication Questran on two separate occasions. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had a diagnosis list that included Adult Failure to Thrive, Fecal Abnormalities, Dementia, Paroxysmal Atrial Fibrillation, and Chronic Pain. A hospice nurse progress note indicated that the resident experienced multiple episodes of diarrhea, and an order for Questran was placed to manage this condition. However, the medication was not administered on the specified dates of 3/29/24 and 4/03/24, with staff citing reasons such as awaiting pharmacy delivery and unavailability. Upon investigation, it was revealed that the pharmacy had delivered a 22-day supply of Questran on the same day the order was received, but the medication was misplaced on the wrong medication cart. The facility's Director of Nursing later found the unopened tin container of Questran powder. Despite the pharmacy's timely delivery, the medication was not administered as ordered, leading to the deficiency noted by the survey team.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide treatment as ordered for pressure ulcers for two residents. Resident #68, who was admitted with multiple diagnoses including pressure ulcers, had an order for daily dressing changes to a sacral wound. However, the Treatment Administration Record was blank for a specific date, indicating a missed treatment. The nursing progress note on that date documented the resident's refusal of a shower but agreement to a bed bath, yet there were no wound care notes. The surveyor attempted to speak with the wound care nurse about the missed treatment but was unsuccessful. Resident #35, with diagnoses including pressure ulcers and a history of amputation, also had orders for daily dressing changes to a stage 3 sacral wound. The Treatment Administration Records for March and April contained multiple blanks, suggesting treatments were not completed. The Director of Nursing confirmed that blanks generally indicated missed treatments, although the surveyor found that most blanks were on days when the treatment nurse had assessed or completed treatments. However, there was no evidence of treatments completed on two specific dates. The administrator and director of nursing were informed of these concerns during a summary meeting.
Failure to Complete Safe Smoking Assessment on Admission
Penalty
Summary
The facility staff failed to complete a safe smoking assessment for a resident upon admission, which was a requirement according to the facility's smoking policy. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, dementia, Alzheimer's disease, and nicotine dependence, was identified as a smoker. The resident's cognitive impairment was severe, with a mental status score of 5 out of 15, indicating a need for careful assessment and supervision regarding smoking. Despite the facility's policy that mandates a smoking assessment upon admission, the surveyor could not locate this assessment in the resident's clinical record. The issue was brought to the attention of the administrator and the DON, who later provided a late entry for the assessment dated the day of admission. However, this late entry did not align with the facility's policy of conducting the assessment upon admission, leading to the deficiency noted by the surveyor.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility staff failed to provide the health care provider ordered therapeutic diet for two residents, leading to a deficiency. Resident #54, diagnosed with Parkinson's disease and dysphagia, was supposed to receive a Magic Cup three times a day with meals as per the provider's order. However, during a surveyor's observation, it was noted that Resident #54's meal tray contained chocolate ice cream instead of the prescribed Magic Cup. The Dietary Manager admitted that the facility had been out of Magic Cups for two weeks and was substituting with Magic Shakes, although neither was observed on the resident's meal tray. Despite this, the nursing staff documented in the Medication Administration Records (MARs) that the Magic Cup had been provided, with some entries left blank, indicating possible omissions or unavailability. Similarly, Resident #25, who had diagnoses including type 2 diabetes mellitus, dysphagia, and dementia, was also affected by the facility's failure to provide the ordered Magic Cup with meals. The resident's care plan included maintaining adequate nutritional status with the prescribed diet. However, during the survey, it was observed that the resident's meal tray did not contain a Magic Cup or a substitute Mighty Shake. The dietary manager confirmed the unavailability of Magic Cups and the substitution plan, but the resident reported not receiving either supplement. The resident's clinical record indicated a weight loss trend, although it was not deemed significant at the time. The deficiency was discussed with the facility's Administrator and Director of Nursing, who acknowledged the backorder issue with Magic Cups and the substitution with Mighty Shakes. However, the surveyor noted discrepancies in the documentation and the actual provision of the dietary supplements, highlighting a failure in ensuring the residents received their prescribed nutritional support.
Failure to Obtain Ordered Medication for Resident
Penalty
Summary
The facility staff failed to obtain a provider-ordered medication, Alaway eye drops, for a resident diagnosed with conditions including Acute Follicular Conjunctivitis and Open-Angle Glaucoma. The resident, who was cognitively intact, reported eye redness and itching and had been waiting 18 days for the medication. The order for Alaway was placed on 3/25/24, but the medication was not delivered due to it being an over-the-counter (OTC) medication requiring approval from the Director of Nursing (DON), which was not obtained. The medication was only signed as administered once, on 4/01/24, due to being unavailable, and the order was automatically discontinued on 4/05/24. The pharmacy representative confirmed that the order was received but not sent due to the lack of DON approval. A nurse had contacted the pharmacy on 3/29/24, but the issue was not resolved. The Licensed Practical Nurse (LPN) who signed the Medication Administration Record (MAR) on 4/01/24 admitted to signing it in error as the medication was not available. The resident received a new order for a different medication, Ketotifen, on 4/05/24, which was administered starting 4/06/24. The facility's DON and Administrator acknowledged the delay in obtaining the Alaway eye drops, and no further information was provided before the exit conference on 4/10/24.
Failure to Act on Pharmacy Recommendations for Diabetic Resident
Penalty
Summary
The facility staff failed to review and act upon a monthly medication regimen review for a resident, identified as Resident #234. The resident's diagnoses included type 2 diabetes mellitus, and they were cognitively intact with a mental status score of 14 out of 15. The resident's care plan indicated a risk for complications associated with hyper or hypoglycemia due to diabetes and insulin therapy. Despite being on the list of residents with medication regimen reviews and recommendations for February 2024, the surveyor could not locate the medication regimen review/recommendation form in the clinical record. The Director of Nursing (DON) later provided a copy of a Note to Attending Physician/Prescriber form from the pharmacy, dated February 21, 2024, which recommended increasing the Lantus dosage due to elevated blood glucose levels. However, this form had not been signed by the physician/provider. The resident's clinical record for March 2024 showed an order for Lantus at the same dosage as before, indicating no change had been made in response to the pharmacy's recommendation. The resident's blood glucose levels remained elevated, averaging 300. The facility's policy on Medication Regimen Reviews requires the Consultant Pharmacist to provide a written report to attending physicians within 24 hours of identifying a non-life-threatening medication irregularity and to follow up if no action is taken. Copies of these reports, including physician responses, are to be maintained as part of the permanent medical record. The failure to review and act upon the pharmacist's recommendation was discussed with the administrator and DON, but no further information was provided before the survey exit.
Deficiencies in Documentation and Monitoring for Two Residents
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for two residents, leading to deficiencies in documentation and monitoring. For one resident, the staff did not document a change in the resident's condition that resulted in an acute care hospital admission. The resident, who was cognitively intact, reported being sent to the hospital after experiencing symptoms for several days, including a high fever and multiple infections. Despite a progress note from a family nurse practitioner indicating the resident's symptoms and treatment plan, there was no subsequent documentation of the resident's condition change or hospital transfer. For another resident, the facility staff failed to monitor the resident's weight as ordered, which was crucial for managing the resident's congestive heart failure. The electronic medical record showed inconsistencies in weight documentation, with gaps and discrepancies between recorded weights and the resident's account of being weighed. The DON acknowledged that nurses filled in missing data in the EMR, leading to questions about the reliability of the recorded weights.
Repeated Deficiencies in Pharmacy Services Due to Inadequate QAPI Program
Penalty
Summary
The facility staff failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by repeated deficiencies in the area of Pharmacy Services. The deficiency was identified during the standard recertification surveys conducted on 4/11/19, 5/27/21, and 2/16/23, and was cited again on the current survey dated 4/10/24. The issue involved the failure to provide evidence that the attending medical provider reviewed and acted upon monthly drug regimen reviews completed by the pharmacist. This deficiency was noted for one of the five residents reviewed during the current survey. On 4/10/24, the surveyor met with the Administrator to discuss the facility's QAPI Program. The Administrator indicated that QAPI meetings were held at least quarterly to review facility statistics for trending and to develop action plans as needed. However, no further information regarding the concern of drug regimen reviews was presented to the survey team before the exit conference on 4/10/24.
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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 31 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 Daleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Glebe | 1.8 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center | 5.3 mi | ★★★★★ | 0 | 0 |
| Springtree Healthcare & Rehab Center | 6.6 mi | ★★★★★ | 4 | 0 |
| Star City Rehabilitation And Nursing | 7 mi | ★★★★★ | 0 | 0 |
| Our Lady Of The Valley | 8.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.