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 Dinwiddie Health And Rehab Center during CMS and state inspections, most recent first.
A resident who was totally dependent for transfers due to left-side hemiplegia was injured during a mechanical lift transfer when staff failed to cross the bottom straps of a U-shaped sling as required by facility policy and manufacturer instructions. The resident slid out of the sling and fell, sustaining acute fractures to the left shoulder and wrist. Multiple CNAs were involved, but none verified the strap configuration before proceeding, leading to the incident.
Facility staff failed to document a comprehensive wound assessment for a resident with multiple diagnoses, including diabetes and end-stage renal disease. The clinical record lacked essential details such as wound measurements, appearance, and condition, contrary to the facility's policy. Interviews with the DON confirmed the deficiency in documentation.
A resident with severe cognitive impairments experienced an unwitnessed fall, and the facility staff failed to perform timely neurological assessments as required by policy. The resident's fall was not immediately followed by neurological checks, despite the facility's policy mandating such evaluations for potential head injuries. The oversight was discovered by the DON the following morning, but the required frequency of checks was not adhered to, highlighting a deficiency in the facility's response to the incident.
A resident in an LTC facility was administered an incorrect dose of oxycodone due to an LPN's error in medication handling. The resident, with a history of diabetes and amputation, was given a 30 mg extended-release tablet instead of the prescribed 20 mg immediate-release for pain. The error was identified through narcotic count discrepancies, and although no adverse effects were reported, the incident highlighted a significant medication error.
A resident's Tramadol, a controlled medication, was improperly stored in a medication cart instead of a lock box as required by facility protocol. The LPN signed out the medication but did not administer it, leaving it unsecured. The DON confirmed the medication was found labeled but not stored correctly, violating the facility's policy for controlled substances.
The facility failed to maintain accurate clinical records for two residents. One resident received an incorrect dose of oxycodone, which was not documented in their clinical record. Another resident's fall was inaccurately documented as witnessed, although it was unwitnessed, leading to discrepancies in the records.
An LPN in a facility was observed dropping a docusate sodium gel cap on the floor and then rinsing it with water before administering it to a resident, contrary to infection control protocols. The DON and a consultant pharmacist confirmed this practice was unacceptable, as facility policy requires contaminated medications to be discarded and reordered.
The facility failed to submit a demand bill to Medicare for two residents who requested it on their SNF ABN forms. Both residents selected the option to have Medicare billed for a coverage decision, but the facility did not continue skilled therapy services or submit claims. Interviews revealed a lack of communication and understanding of the process, leading to the deficiency.
The facility failed to implement its abuse policy for three residents who reported abuse allegations, neglecting to notify required agencies and protect residents during investigations. Additionally, the facility did not conduct criminal background checks for two employees, violating its policy.
A resident with diabetes did not have their insulin administration times updated as recommended by a pharmacist and approved by a nurse practitioner. The insulin was supposed to be given before meals but continued to be administered at incorrect times for over three months. The DON confirmed the oversight, and the issue was discussed with facility leadership.
The facility failed to report abuse allegations involving three residents to APS as required. Despite substantiating one case and terminating the involved CNA, the facility only notified the state survey agency and the ombudsman, omitting APS. The administrator acknowledged the oversight, confirming the deficiency in reporting these incidents.
Two residents reported abuse involving a CNA, but the facility failed to conduct or document any investigation. Despite the administrator's stated protocol for handling such allegations, no credible evidence of investigations was found, violating the facility's abuse prevention policy.
A facility failed to develop a baseline care plan for a newly admitted resident, particularly in nutrition. Despite a Registered Dietitian's note indicating the need for meal assistance, no care plan was completed. The resident's family expressed concerns about communication and meal assistance. Staff interviews revealed a lack of communication and procedure adherence, with the CNA unaware of the resident's needs. The administration was informed of these findings.
A resident with a feeding tube did not receive the prescribed tube feeding due to an error in the start and stop times entered in the physician's order. The LPN was unaware of the correct schedule, and the clinical team failed to catch the mistake, resulting in the resident not receiving the proper nutrition.
A resident with severe dysphagia and a feeding tube was not receiving the prescribed tube feeding due to an error in the feeding schedule. The registered dietitian entered the wrong start time, leading to the resident missing several hours of nutrition. The LPN was unaware of the correct schedule, and the clinical team failed to catch the error during their order review process.
A facility failed to maintain a medication error rate below 5%, with errors involving the incorrect administration of pantoprazole and Potassium. An LPN crushed a delayed-release pantoprazole tablet against orders, and another LPN administered only half the prescribed Potassium dosage. These incidents were confirmed by the DON and Nurse Consultant.
The facility failed to ensure expired biologicals were not available for use. During a medication storage room review, an LPN found a biological product, Liquid Urine Controls, that had expired and was still stored in the refrigerator. The LPN acknowledged the expiration and removed the product. The facility's policy requires medications and biologicals to be stored properly, which was not followed in this instance. The issue was reported to the DON, Administrator, and Nurse Consultant.
The facility staff failed to properly label and store food in the main kitchen. Observations revealed unlabeled items, including pancake mix, hot dog buns, and milk cups, lacking open and use-by dates. The dietary manager confirmed that these items should have been labeled according to facility policy.
A resident with end-stage renal disease requiring hemodialysis had an incomplete dialysis communication form, missing vital information such as vital signs, weights, and nurse's signature. The LPN responsible acknowledged the oversight, and the DON confirmed the form's purpose for communication with the dialysis center. The resident's care plan required coordination with the dialysis center, but the deficiency was noted during a survey with no further information provided.
An LPN failed to perform hand hygiene between resident contacts during medication administration and blood glucose testing, contrary to the facility's infection control policy. The DON confirmed that hand hygiene is expected between every resident interaction. The deficiency was discussed with facility leadership, but no corrective actions were provided.
A resident's call bell system was found non-functional during a survey, failing to alert staff visually or audibly. The resident, requiring assistance with ADLs and at risk for falls, was unaware of the malfunction. Facility staff confirmed the issue, despite a policy ensuring call light accessibility and regular audits.
Failure to Safely Attach Mechanical Lift Sling Results in Resident Fall and Fractures
Penalty
Summary
Facility staff failed to provide a safe transfer for a resident who was totally dependent on staff for bed mobility and transfers due to left-side hemiplegia following a stroke. During a transfer from bed to wheelchair using a mechanical lift with a U-shaped sling, the staff did not attach the sling according to both facility policy and the manufacturer's instructions. Specifically, the CNA responsible for setting up the sling did not cross the bottom straps between the resident's legs, which is required for safe positioning and to prevent sliding. As a result, the resident slid out of the sling during the transfer and fell to the floor. The incident involved three CNAs assisting with the transfer. One CNA had already attached the sling straps before the others arrived, and none of the assisting staff checked the strap configuration before proceeding. The resident, who was cognitively intact, reported feeling that something was wrong during the lift and subsequently slid out of the bottom of the sling. The fall resulted in acute fractures to the resident's left shoulder (proximal humerus) and left wrist (distal radius), requiring emergency medical attention, immobilization, pain management, and orthopedic follow-up. Prior to the incident, the resident had not experienced problems with lift transfers and had low pain levels. Interviews and documentation confirmed that the facility's expectation and the manufacturer's instructions were for the bottom straps of the U-shaped sling to be crossed between the legs for all such transfers. The CNA who set up the sling initially believed she had attached the straps correctly but later realized during a re-enactment that she had not crossed them. Other staff involved in the transfer did not verify the strap configuration before operating the lift. The failure to follow established procedures directly led to the resident's fall and subsequent injuries.
Failure to Document Wound Assessment
Penalty
Summary
The facility staff failed to adhere to professional standards of care regarding wound documentation for a resident, identified as Resident #6, who was part of the survey sample. The resident was admitted with multiple diagnoses, including a femur fracture, peripheral vascular disease, diabetes, end-stage renal disease, anemia, coronary artery disease, cancer, congestive heart failure, and a cerebrovascular accident. Despite being assessed as cognitively intact, the resident's clinical record lacked a comprehensive assessment of a wound on the right lower leg. The documentation only noted the wound as unstageable and a diabetic ulcer, without providing essential details such as measurements, shape, appearance, color, drainage, pain status, or the condition of the surrounding skin. Interviews with the Director of Nursing (DON) revealed that the facility's policy required nurses to document detailed descriptions of wounds, including size, appearance, location, and color. However, the DON confirmed that the clinical record for Resident #6 did not meet these expectations. The facility's policy on wound documentation outlined specific elements that should be included in a complete wound assessment, such as the type of wound, anatomical location, degree of skin loss, measurements, wound characteristics, and the condition of the peri-wound skin. Despite these guidelines, the necessary documentation was not present in the resident's clinical record, leading to the identified deficiency.
Failure to Perform Timely Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility staff failed to perform timely neurological assessments following an unwitnessed fall for a resident, identified as Resident #10, in the survey sample. Resident #10, who was admitted with diagnoses including metabolic encephalopathy, depression, dementia with severe agitation, cognitive communication deficit, and hypertension, experienced an unwitnessed fall on the evening of 7/8/24. Despite the resident's significant cognitive impairments, which rendered them unable to accurately report the incident, no neurological checks were initiated immediately following the fall to assess for possible head injury. The facility's policy required a neurological evaluation to be completed by a licensed nurse in such cases, but this was not adhered to. The Director of Nursing (DON) discovered the oversight on the morning of 7/9/24 and initiated a neuro sheet, but the clinical record showed no neurological checks were documented immediately after the fall. Subsequent checks were recorded on 7/9/24 at 7:31 a.m. and 8:35 a.m., with no checks documented on 7/10/24, and one check completed on 7/11/24. The facility's policy outlined a specific frequency for neurological evaluations following incidents involving potential head trauma, which was not followed in this case. This deficiency was discussed with the administrator, DON, and regional consultant during meetings, but no further information was provided before the survey concluded.
Significant Medication Error in LTC Facility
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of an incorrect dose of oxycodone. The resident, who was cognitively intact and had a medical history including diabetes with peripheral angiopathy, below-knee amputation, anemia, and hypertension, was prescribed oxycodone 20 mg immediate-release every four hours as needed for pain and oxycodone 30 mg extended-release every 12 hours for pain management. On a specific date, an LPN administered a 30 mg extended-release tablet instead of the ordered 20 mg immediate-release tablet for a prn dose, which was discovered when narcotic counts did not match at the end of the shift. The error was confirmed through interviews and document reviews, revealing that the LPN mistakenly pulled the wrong medication card. The facility's policy on medication administration was not followed, as the LPN did not correctly verify the medication before administration. Although the resident reported no adverse effects from the incorrect dose, the error was significant due to the potential risks associated with extended-release oxycodone, which includes serious respiratory depression. The incident was reviewed with the facility's administration, but no further information was provided before the survey concluded.
Improper Storage of Controlled Medication
Penalty
Summary
The facility staff failed to properly store a controlled medication for a resident, identified as Resident #7, who was admitted with diagnoses including chronic kidney disease, atherosclerotic heart disease, hypertension, benign prostatic hyperplasia, and gout. The resident was assessed as cognitively intact. A physician's order dated June 9, 2024, prescribed Tramadol 50 mg to be administered as needed for pain management. On June 13, 2024, an LPN signed out one tablet of Tramadol for the resident but did not administer it, leaving the medication unsecured in the medication cart. The Director of Nursing (DON) confirmed that the Tramadol was found in a medicine cup in the cart, labeled with the resident's name but not stored in the narcotic lock box as required by facility protocol. The LPN reported that the resident was asleep when she attempted to administer the medication and forgot to return to give it. Facility policy mandates that controlled medications like Tramadol be stored securely in a lock box and counted at each shift change. The facility's policy also requires that unused doses be destroyed following facility procedures. The incident was reviewed with the administrator, DON, and regional consultant, with no additional information provided before the survey concluded.
Inaccurate Documentation of Medication Error and Fall Incident
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for two residents, leading to deficiencies in documentation. For Resident #8, there was no documentation in the clinical record regarding a medication error where the resident was administered an incorrect dose of oxycodone. The medication administration record showed that the resident received a 30 mg extended-release tablet instead of the ordered 20 mg immediate-release tablet. Although the error was noted in a medication error report and the resident was monitored with no negative outcomes, the clinical record did not reflect the error or the incorrect dosage administered. For Resident #10, inaccurate documentation was entered regarding the circumstances of a fall. The nursing note initially stated that the fall was witnessed, with the resident putting herself on the floor. However, further investigation revealed that the fall was unwitnessed, as confirmed by other staff members and a CNA's written statement. The LPN responsible for the documentation inaccurately recorded the fall as witnessed to avoid initiating neurological checks required for unwitnessed falls. This discrepancy in documentation was identified during a review by the director of nursing and other staff members.
Infection Control Breach During Medication Administration
Penalty
Summary
During a medication pass observation, an LPN was observed administering medications to a resident. While handling a docusate sodium gel cap, the LPN accidentally dropped the capsule on the floor. Instead of discarding the contaminated medication, the LPN put on gloves, picked up the capsule, and rinsed it with water before administering it to the resident. The LPN justified this action by stating that the gel coating of the capsule would not be harmed by water. The Director of Nursing (DON) and a consultant pharmacist were interviewed regarding this incident. Both confirmed that the practice of rinsing and administering a dropped medication was unacceptable due to infection control concerns. The facility's policy on medication storage clearly states that contaminated medications should be immediately removed and reordered if necessary. The DON acknowledged that the LPN misunderstood the protocol, thinking it was permissible to rinse the gel-coated capsule.
Failure to Submit Demand Bill to Medicare
Penalty
Summary
The facility staff failed to submit a demand bill to Medicare as requested by two residents, identified as R4 and R36, on the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) forms. Both residents had selected option 1 on the SNF ABN, indicating their desire for Medicare to be billed for a coverage decision. Despite this selection, the facility did not continue skilled therapy services or submit claims to Medicare for these residents, as confirmed by the business office manager (BOM) and therapy manager. Resident R4 was receiving skilled therapy services from late November to late December 2023, and was issued a Notice of Medicare Non-Coverage (NOMNC) and SNF ABN on December 19, 2023. Similarly, Resident R36 was receiving skilled care with Medicare as the primary payer from late November 2023 to early January 2024, and was issued the same notices on January 8, 2024. Both residents selected the option to have Medicare billed, but the facility did not follow through with the billing process, as confirmed by the BOM and therapy manager. Interviews with the social worker (SW) and therapy manager revealed a lack of communication and understanding of the process following a resident's selection on the SNF ABN form. The SW indicated that once the forms were uploaded into the system, no further action was taken to notify relevant departments about the residents' selections. The therapy manager confirmed that therapy services did not continue after the skilled services ended, as there was no notification of a demand bill request. The facility's policy and CMS instructions clearly state that when a resident selects option 1, the SNF must submit a claim to Medicare, which was not done in these cases.
Failure to Implement Abuse Policy and Conduct Background Checks
Penalty
Summary
The facility staff failed to implement their abuse policy for three residents who reported allegations of abuse. For one resident, the facility administrator notified the state survey agency and the ombudsman but failed to notify adult protective services and the department of health professions after the allegation was substantiated. The staff member involved was terminated, but the necessary notifications were not completed as per the facility's policy. For two other residents, the facility administration allowed the alleged perpetrator, a CNA, to continue working without taking measures to protect the residents during the investigation. The facility also failed to report the allegations and the results of their investigations to adult protective services and local law enforcement. There was no evidence to indicate that investigations were conducted for these allegations, and the CNA's personnel file lacked documentation of the abuse investigations. Additionally, the facility staff failed to obtain criminal background checks for two employees. The human resource manager confirmed that the background checks had not been done, which was a violation of the facility's policy that requires criminal background checks for all new employees in accordance with Virginia Law. This oversight was acknowledged during a meeting with the facility's administrator, DON, and clinical nurse consultant.
Failure to Implement Insulin Administration Time Change
Penalty
Summary
The facility staff failed to implement a change in insulin administration times for a resident with multiple diagnoses, including diabetes and severely impaired cognitive skills. The resident was prescribed Humulin 70/30 insulin to be administered twice daily. A pharmacy recommendation, approved by a nurse practitioner, suggested changing the administration times to 30 minutes before breakfast and dinner to better align with the insulin's short-acting component. However, this change was not entered into the electronic health record, and the insulin continued to be administered at 9:00 a.m. and 9:00 p.m. for over three months. The director of nursing acknowledged that the pharmacy's recommendation was not implemented, despite the nurse practitioner's approval. The failure to update the medication administration record (MAR) resulted in the continued administration of insulin at the incorrect times. This oversight was confirmed during an interview with the director of nursing and was discussed with the facility's administrator and nurse consultant, with no additional information provided before the survey concluded.
Failure to Report Abuse Allegations to APS
Penalty
Summary
The facility staff failed to report allegations of abuse involving three residents to Adult Protective Services (APS) as required. Resident #18 reported verbal abuse by a CNA, which was substantiated, leading to the CNA's termination. However, the facility only notified the state survey agency and the ombudsman, omitting APS and the Department of Health Professions. Similarly, Resident #210 and Resident #211 reported abuse involving another CNA, but these allegations and the results of the investigations were not reported to APS. During the survey, the facility's administrator and corporate clinical specialist were unable to provide evidence that the required notifications to APS had been made. The facility's policy mandates timely reporting of such incidents to APS and other agencies, but this protocol was not followed in these cases. The administrator acknowledged the oversight when questioned by the surveyor, confirming the deficiency in reporting these incidents as per the facility's policy.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility staff failed to investigate allegations of abuse involving two residents, as identified during a survey of 37 residents. Specifically, one resident reported an allegation of abuse involving a certified nursing assistant (CNA) on a specific date, and another resident reported a similar allegation involving the same CNA on a different date. Despite these reports, there was no documented evidence to indicate that any investigation was conducted by the facility staff. During interviews, the facility administrator described the protocol for handling abuse allegations, which includes immediate investigation, notification of relevant agencies, and documentation of the investigation process. However, upon review, the facility's Corporate Clinical Specialist confirmed that there was no credible evidence of investigations being conducted for the reported allegations. The facility's policy on abuse prevention mandates immediate review and investigation of reported incidents, but this was not adhered to in these cases.
Failure to Develop Baseline Care Plan for Nutrition
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, specifically in the area of nutrition. The resident, who was newly admitted, had diagnoses including dementia, urinary tract infection with sepsis, and hypertension. Despite a Registered Dietitian's note indicating the resident required assistance with meals, no nutrition care plan was completed. During an interview, the resident's family expressed concerns about the lack of communication regarding the resident's care needs, particularly the need for assistance with eating. A Certified Nursing Assistant (CNA) was observed removing the resident's meal tray without being aware of the resident's need for help with eating. Interviews with staff revealed a breakdown in communication and procedure. The CNA stated that they typically receive reports from the charge nurse and inquire about residents' needs upon arrival. However, the CNA was not informed of the resident's need for meal assistance. The MDS coordinator and nurse consultant indicated that the baseline assessment should include nutrition, with the nurse conducting the initial assessment and dietary following up. The Registered Dietitian confirmed that they inform nurses of residents needing meal assistance, but the list of residents requiring such assistance was not available on the unit at the time. The facility's administration was made aware of these findings, but no further information was provided.
Failure to Implement Tube Feeding Order
Penalty
Summary
The facility failed to meet professional standards of practice by not accurately implementing the tube feeding physician order for one resident. The resident, who had diagnoses including dysphasia, cerebral infarction, dementia, and a feeding tube, was observed not receiving the prescribed tube feeding on two separate occasions. The physician's order required the resident to receive 60cc of Isosource 1.5 per hour over 20 hours, totaling 1200cc. However, the resident was not receiving the tube feeding as ordered, with the feeding apparatus noted to be unused during observations. The deficiency was attributed to an error in entering the start and stop times for the tube feeding order, which resulted in the resident not receiving the proper amount of nutrition. The LPN assigned to the resident was unaware of the correct feeding schedule and mistakenly believed the feeding had been completed. The error was not caught by the clinical team, which reviews orders every 24 hours, or by the night shift, which is responsible for ensuring the accuracy of new orders. The registered dietitian admitted to entering the incorrect start time for the tube feeding, which contributed to the oversight.
Failure to Maintain Nutritional Parameters for Resident with Feeding Tube
Penalty
Summary
The facility failed to maintain the nutritional parameters for a resident with a feeding tube, leading to a deficiency. The resident, who had severe dysphagia, cerebral infarction, dementia, and was cognitively impaired, was observed not receiving the prescribed tube feeding. The physician's order required the resident to receive 1200cc of isosource 1.5 at a rate of 60cc per hour over 20 hours. However, observations revealed that the feeding tube was not in use during the day, and the resident was not receiving the required nutrition. The deficiency was attributed to an error in the feeding schedule, where the registered dietitian mistakenly entered the start time as 8:00 PM instead of 12:00 PM. This error resulted in the resident not receiving the proper amount of tube feeding for several hours. The LPN assigned to the resident was unaware of the correct feeding schedule, and the clinical team did not catch the error during their order review process. The facility's process for ensuring the accuracy of new orders was insufficient, as the error went unnoticed until it was brought to the attention of the director of nursing and administrative staff.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. This was observed during a medication administration session where an LPN crushed a pantoprazole 40 mg delayed-release tablet for a resident, despite the physician's order indicating it should be taken whole. The LPN initially stated that all medications for the resident were to be crushed but later acknowledged that pantoprazole should not be crushed due to its delayed-release formulation. The Director of Nursing and the clinical nurse consultant confirmed that the medication should have been administered whole, as per the facility pharmacist's guidelines. In another incident, a different LPN failed to administer the correct dosage of Potassium to a resident. The LPN administered only 20 meq of Potassium instead of the prescribed 40 meq, due to a misunderstanding about the availability of the medication in the stat box. The LPN signed off on the medication administration record as if the correct dosage had been given. Upon review, the Nurse Consultant and Director of Nursing confirmed that the resident should have received a total of 40 meq as per the physician's order. These errors were brought to the attention of the facility's administration, but no further information was provided.
Expired Biologicals Found in Medication Room
Penalty
Summary
The facility failed to ensure that expired biologicals were not available for use. During a medication storage room review conducted at 11:12 a.m., the medication room on the 100 unit was inspected with an LPN. A biological product, specifically Liquid Urine Controls, was found to have expired and was still being stored in the refrigerator. The LPN reviewed the biological product and its expiration date, acknowledged that it had expired, and subsequently removed it from the medication storage room. The facility's policy titled 'Medication Storage' states that medications and biologicals are to be stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. This policy was not adhered to, as evidenced by the presence of the expired biological product in the medication room. The information regarding this deficiency was presented to the Director of Nursing, Administrator, and the Nurse Consultant, but no further information was provided.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility staff failed to properly store food in the main kitchen, as observed during a survey. Specifically, dietary staff did not label food products with an open date and a use-by date. During a kitchen tour, it was noted that a package of buttermilk pancake mix was wrapped in plastic wrap and placed on a shelf without any labeling. Similarly, hot dog buns were found in a Ziploc bag without labels indicating the open or use-by date. Additionally, in the stand-alone cooler, three cups filled with milk were covered with lids and placed on a tray without any labeling to indicate the product, date prepared, date opened, or use-by date. The dietary manager confirmed that per facility policy, these items should have been labeled with the product name, open date, and use-by date. The facility's policy on 'Safe Food and Supply Storage' requires that dry goods be securely closed and identified, and refrigerated items be labeled with an open and use-by date.
Incomplete Dialysis Communication Form for Resident
Penalty
Summary
The facility staff failed to document a complete and accurate clinical record for a resident, identified as Resident #22, who was part of a survey sample. Resident #22, who was cognitively intact, had multiple diagnoses including end-stage renal disease requiring hemodialysis. During an interview, the resident mentioned attending dialysis twice a week and using a communication book for these visits. However, the dialysis communication form dated February 6, 2024, was found incomplete. The section labeled 'Facility Completes This Information' was entirely blank, missing vital signs, weights, pain presence, vascular access type, acute problems, medication changes, and needed labs. Additionally, there was no nurse's name or signature on the form. The licensed practical nurse (LPN) responsible for Resident #22 on the day of the survey stated that the resident left for dialysis before her shift began and acknowledged that the form should have been completed before and after the dialysis treatment. The Director of Nursing (DON) confirmed that the form was intended for communication with the dialysis center and should have been filled out by the nursing staff. The resident's care plan emphasized the need for coordination with the dialysis center and regular communication via pre/post-treatment notes. This deficiency was discussed with the facility's administration, including the DON and a nurse consultant, but no additional information was provided before the survey concluded.
Infection Control Deficiency: Hand Hygiene Lapses
Penalty
Summary
The facility staff failed to adhere to infection control practices for hand hygiene on one of the nursing units, specifically during medication administration and blood glucose testing. On February 5, 2024, observations were made of an LPN who did not perform hand hygiene between resident contacts. The LPN administered medication to one resident and assisted them with water without performing hand hygiene before returning to the medication cart. Subsequently, the LPN applied gloves without hand hygiene and conducted blood glucose testing on another resident. After completing the test, the LPN removed the gloves and used alcohol-based hand sanitizer. The facility's Director of Nursing (DON) was interviewed and stated that hand hygiene is expected to be completed between every medication pass and resident contact. The facility's hand hygiene policy requires employees to perform proper hand hygiene procedures to prevent infection spread, including before and after direct resident care and contact. The deficiency was discussed with the facility administrator, DON, and clinical nurse consultant during an end-of-day meeting on February 7, 2024. No additional information was provided regarding corrective actions or follow-up measures.
Non-Functional Call Bell System for Resident
Penalty
Summary
The facility staff failed to ensure that a functional call bell system was available for a resident, identified as Resident #3 (R3), in a survey sample of 37 residents. During multiple observations and interviews conducted on February 5th and 6th, 2024, it was noted that the call bell at R3's bedside was not operational. When engaged, the call bell did not illuminate the light outside the room nor did it provide an auditory signal to alert staff. R3, who was sitting in a wheelchair at the bedside, was unaware of the malfunction. Both a surveyor and facility staff, including an LPN and a CNA, confirmed the call bell's failure to function properly. R3's clinical records indicated that they required assistance with all activities of daily living (ADLs) and were at risk for falls, with a care plan intervention specifying the need for a reachable call light. The facility's policy mandates that call lights be accessible and functional to ensure prompt response to residents' needs. Despite the facility administrator's claim of regular audits, the last documented audit was conducted on November 29, 2023, and no additional issues were found after a subsequent audit prompted by the surveyor's findings.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hiram W Davis Medical Ctr | 3.1 mi | ★★★★★ | 6 | 0 |
| Petersburg Healthcare Center | 5.9 mi | ★★★★★ | 20 | 1 |
| Battlefield Park Healthcare Center | 5.9 mi | ★★★★★ | 2 | 0 |
| Colonial Heights Rehabilitation And Nursing Center | 7.3 mi | ★★★★★ | 5 | 0 |
| Wonder City Rehabilitation And Nursing Center | 10.3 mi | ★★★★★ | 21 | 1 |
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