Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harrisonburg Hlth & Rehab Cntr during CMS and state inspections, most recent first.
Dirty Vents and Dust Buildup in Resident Areas: Surveyors observed layers of sticky dirt and dust in multiple HVAC vents in resident rooms, resident bathroom ceiling vents, and vents at the nurse's station and on the halls. The DOR stated routine cleaning had fallen behind because of other environmental projects and recent sanding in the facility was clogging the vents. The facility did not provide a policy for maintaining a clean and sanitary environment.
Homelike Environment Not Maintained in Resident Rooms, Bathrooms, and Shower Area: A resident with moderate cognitive impairment had scuffed and discolored walls left unrepaired, another resident had a bathroom door that would not close, a loose baseboard held by push pins, and holes left behind after grab bars were removed, and a third resident had moisture-damaged walls and debris buildup in the bathroom. Staff also observed black slime-like buildup in a shower room, brown material in two bathrooms, and two room clocks that were not set to the correct time; the DON, ADM, and maintenance/housekeeping leaders acknowledged the conditions.
Staff failed to maintain a safe, clean, and homelike environment throughout the facility, with multiple resident rooms found cluttered with hoarded items, spoiled food, soiled linens, and stained privacy curtains, and one resident observed lying on a heavily soiled bed partially unclothed. Shower rooms and hallways had black buildup, broken tiles, trip hazards, and grime, while dining and dirty linen rooms contained dirty surfaces, overflowing soiled linens, and unsecured sharps and chemicals accessible near cognitively impaired and ambulatory residents. Housekeeping and laundry services were severely understaffed, resulting in excessive piles of soiled and wet laundry, minimal clean linen on unit carts, and residents lacking adequate bedding and room cleaning for extended periods, as confirmed by a resident, an LPN, and facility records of grievances and Resident Council concerns.
An oxygen E-cylinder was found free-standing and unsecured in a room shared by two residents, while staff gave inconsistent answers about proper oxygen storage and the unit manager stated cylinders should never be left free-standing. In a separate room, a resident was observed using a portable electric heater as the primary heat source after the permanent heating system had been out of service for months, and maintenance could not provide repair documentation.
Failure to inspect bed system and ensure proper mattress fit: A resident with multiple chronic diagnoses and intact cognition was observed in bed with a bariatric mattress that was not centered on the frame and had a 5-inch gap on one side, with grab rails in place. The resident said the mattress had recently been changed and had slipped over, and staff could not show that maintenance had inspected the new mattress/frame setup. The maintenance director and administrator stated there was no evidence the facility had implemented its bed audit program or completed required inspections of beds, mattresses, and rails for entrapment risks.
Staff failed to maintain clean, properly supplied rooms, protect personal property, and process laundry in a timely manner. A resident with complex medical needs did not consistently receive correctly sized fitted sheets for a bariatric mattress, despite an adequate central supply and 24‑hour access to laundry, and staff sometimes used whatever sheets were available instead of obtaining the proper ones. Another resident with severe cognitive impairment remained in a room with damaged walls, visible drips and spatters, trash on the floor, and a persistently dirty floor, while housekeeping and maintenance were unaware or unable to keep up with daily cleaning expectations. Two residents experienced missing personal items, including a shaving mirror and multiple laminated family photos, with incomplete or absent property inventories and grievances that were entered but never investigated or resolved. Multiple residents reported that personal clothing took more than two weeks to be returned from laundry and was often mixed up, and surveyors observed a significant backlog of soiled and clean laundry in the department, with the EVS director acknowledging delays and infrequent handling of lost‑and‑found items.
Resident Group Concerns Not Addressed or Documented: A resident council President and other residents reported they received no feedback, updates, or outcomes on concerns and requests raised in prior meetings. The Activities Director was the designated staff person to help with written requests, but the Administrator stated he received the minutes and concerns and did not provide written outcomes or actions back to the group. Review of six months of council minutes showed no entries under Administrative Resolutions or Resolved from last meeting.
Inaccurate Medicare non-coverage notices were given to three residents. ABNs were marked to show the wrong services ending, including Daily Skilled Nursing Care instead of the actual therapy services, and residents or a POA confirmed the forms were signed but not fully understood. The DON was unfamiliar with the process, while the Discharge Planner acknowledged the forms were incorrectly completed.
Grievances Not Promptly Resolved and Residents Not Informed of Grievance Process: Residents in a group meeting stated they did not know how to file a grievance or the process, despite the administrator saying the process was explained on admission and at meetings. Two residents also had unresolved grievances involving missing personal items; one resident reported a missing shaving mirror for months with no documented investigation or resolution, and another resident had two grievances about missing belongings after room changes with no documented follow-up, findings, or actions taken.
Incomplete Dialysis Communication Logs: A resident receiving dialysis three times weekly had missing dialysis communication logs over a ten-week period. The resident had osteomyelitis, ESRD-related renal dialysis, polyneuropathy, and dementia, and the MDS indicated the resident was cognitively intact. The MR director stated dialysis packets include a communication form to be completed, returned, and scanned, but two forms were later found not scanned and other logs were missing. The DON confirmed the logs had not been completed as they should have been.
Medication Storage and Labeling Deficiencies: Surveyors found expired OTC meds, unlabeled prescription meds, and insulin pens used beyond the allowed open-date period in multiple med rooms and carts. An injectable Haldol vial was stored with OTC meds without a name or Rx label, a syringe with the needle exposed was left on top of a cart, and a drawer contained mixed-route meds, expired meds, and blister packs of Midodrine without resident identifiers or Rx labels. The DON stated nurses were expected to keep med rooms and carts clean, date opened multi-dose meds, and discard meds when completed, discontinued, or expired.
Surveyors found the kitchen and a West Unit pantry were not maintained in a sanitary manner. An open package of sliced ham was left exposed without an open date, and a bag of frozen meatballs in the pantry freezer was also open and unlabeled. Surveyors additionally observed dishwasher trays with missing corked surface pieces and chipped edges. Staff acknowledged the food storage issues, and facility policy required food to be covered, labeled, and dated.
QAPI failed to correct repeated concerns about room cleanliness and linen availability. Surveyors found filthy resident rooms and common areas, soiled linens and clothing, spoiled food, stained curtains, and inadequate linen carts with only minimal supplies. A resident reported his room had not been cleaned for weeks and lacked bed linen, while a housekeeper said daily cleaning was not happening and rooms were often cleaned only every few days or weekly. Laundry areas were overflowing with soiled clothing and linens, and an LPN reported the facility was short on linen and lacked enough laundry staff.
A resident’s room did not have a functioning permanent heating system, and the resident was using a portable electric heater after the boiler coil in the room busted and the unit was taken off-line. In the laundry area, surveyors observed large amounts of soiled and clean laundry waiting to be processed while only part of the washer and dryer equipment was operating; staff reported one washer had broken again and a dryer took longer to heat, with no work order documentation available.
Failure to Maintain Clean and Sanitary Vents: Surveyors observed layers of sticky dirt and dust in HVAC vents in multiple resident rooms, ceiling vents in several resident room bathrooms, and ceiling vents in the South unit nurse's station and East unit halls. The DM stated vents were usually cleaned on a set schedule, but staff had fallen behind because of other environmental projects and recent sanding in the facility had clogged the vents.
A resident with diabetes and an insulin pump was found to have no documented assessment for safe self-administration of medication, despite being cognitively intact and having orders stating the resident manages the pump. The care plan did not address self-administration, the MAR documented blood sugar monitoring and Dexcom changes but not pump insulin administration, and an LPN later confirmed no assessment for the insulin pump or insulin was in the record.
A cognitively intact resident with multiple chronic conditions was verbally abused by a CNA during incontinence care and bedpan assistance. The resident reported that the CNA yelled, pointed a finger in her face, threw a brief onto her legs, told her to change her own brief, and rushed her off the bedpan. A roommate witnessed the CNA throw the brief and heard the CNA yell at the resident, and the facility substantiated the allegation of verbal abuse.
Inaccurate MDS Tobacco Use Coding: A resident with neuropathy, a toe amputation, and depression had an annual MDS that coded Current Tobacco Use as no, even though the smoking safety screen and care plan identified him as a smoker. Surveyors observed the resident smoking off facility property, and the resident stated he smoked multiple times daily and had done so for decades. The MDS coordinator acknowledged the tobacco-use coding was incorrect.
Incomplete Care Plans for Insulin Pump and Dialysis Needs: Two residents had incomplete care plans. One resident with diabetes used a self-managed insulin pump and Dexcom, but the care plan did not address pump management, self-administration of insulin, or monitoring device use. Another resident receiving dialysis had care plan interventions that were not specific to dialysis days, the dialysis center, or the vascular access type and location.
Failure to revise a resident’s care plan for smoking status. A resident was assessed as a current tobacco user and later scored as needing supervision with smoking, but the care plan still listed both independent smoking and supervised smoking interventions, leaving the current status unclear. The MDS coordinator acknowledged the care plan should have been revised to match the resident’s smoking assessment and current status.
Independent LOA Orders Entered Without Proper Clinical Review: Staff entered verbal orders allowing two residents to go out on LOA independently without documented physician approval tied to the therapy findings. One resident had diagnoses including CVA, COPD, and DM, required extensive ADL assistance, and had OT-documented impaired safety awareness; the other resident had a BIMS of 14/15, current tobacco use, and OT documentation stating the resident was not safe using the sidewalks around the facility. The attending physician did not recall being called about either order, and rehab staff stated therapy evaluations were used to determine whether residents could go off property independently.
A resident with a trach, CP, epilepsy, chronic respiratory failure, severe ID, bipolar depression, and dysphagia had tube feeding orders for Osmolite 1.5 at 75 ml/hour from 6:00 PM to 6:00 AM, but staff observed the pump running at the wrong rate and at the wrong time. An LPN said she was unfamiliar with the resident and did not check the feeding, while an RN later started the pump at 9:00 AM based on the MAR even though no order supported that start time. Record review and staff interviews showed the enteral feeding was not followed as ordered.
Improper Disposal of Garbage and Refuse: The dumpster area outside the kitchen was observed with one dumpster overflowing and its top flaps pushed back, a second dumpster open in front of it, and trash scattered across the snow-covered ground and loading dock. The Dietary Manager stated staff kept tossing bags into the open dumpster and did not think closing the top was necessary, and the DON reported the facility had no policy covering trash disposal.
Missing Required Communication Training for an RN: During record review, an RN’s file was found to lack the required annual communication training. The Regional Director of Clinical Services stated the RN also did not have QAPI and ethics and compliance training because the electronic education program did not trigger those courses. Facility policy requires all nursing staff to complete mandatory annual in-services, including effective communication.
Mandatory annual QAPI training was missing from one RN’s employee record. During record review, the RN also lacked training in communication and ethics and compliance, and the RD of Clinical Services stated the training was not triggered in the electronic education program. Facility policy required all nursing staff to complete annual in-services, including QAPI.
Missing Required Annual Staff Training: An RN’s training record showed missing mandatory annual in-services, including effective communication, QAPI, and ethics and compliance. The Regional Director of Clinical Services stated the training was not triggered in the electronic education program, and the facility policy requires nursing staff to complete these annual in-services.
Facility staff did not follow physician orders for two residents, resulting in one resident not receiving a newly recommended glaucoma medication for over a month due to a missed consultation report, and another resident missing three doses of a prescribed antibiotic after admission because of delays in order entry and verification. These deficiencies were linked to lapses in communication, documentation, and adherence to medication administration policies.
A resident with multiple chronic conditions and bowel incontinence, who was cognitively intact but unable to sense bowel movements due to numbness, did not have a care plan addressing bowel incontinence. Staff interviews confirmed regular checks for incontinence, but review of the clinical record showed that a care plan for this issue was not developed.
Two residents with significant medical conditions and frequent incontinence did not receive timely incontinence care during an overnight shift. Both were found at the start of the day shift with soiled briefs and, in one case, wet bed linens. Staff interviews and facility documentation confirmed that required checks and changes were not performed as outlined in their care plans.
Staff failed to serve palatable and properly heated meals to two residents, as observed during a meal service where food was served lukewarm and described as bland. A test tray confirmed that food temperatures were significantly lower than when prepared in the kitchen, and a resident reported that meals were never served hot. The dietary manager acknowledged that food temperatures dropped while waiting to be served, contrary to facility policy requiring appetizing temperatures.
Three residents did not receive their documented meal preferences, including requests for baked potatoes, dessert, and milk, during a lunch service. Interviews confirmed that these preferences were routinely unmet, and a CNA was unable to explain the omissions despite facility policy requiring accommodation of resident preferences.
A resident did not receive prescribed doses of niacin and oxycodone-acetaminophen because the medications were not available in the facility. Staff documented the unavailability, notified the provider and responsible party, and explained that delays in ordering and pharmacy authorization contributed to the missed doses. The emergency medication supply did not contain the required medications, and facility policies for medication unavailability were not fully effective in preventing the deficiency.
A resident experienced prolonged discomfort and safety concerns due to unresolved maintenance issues, including a non-functioning air conditioning unit, broken closet doors, and a loose ceiling tile. Despite repeated reports to staff and open maintenance work orders, these deficiencies were not addressed in a timely manner, and the facility lacked an effective system for tracking and resolving maintenance requests.
Staff failed to supervise and secure hazardous items, resulting in a resident with dementia ingesting body wash left on her bedside table, leading to severe medical complications. The facility also lacked protocols to monitor hot liquid temperatures, causing the same resident to sustain a coffee burn. Additional observations found unsecured hazardous items accessible to cognitively impaired residents, with staff confirming inconsistent storage practices.
Multiple residents experienced neglect when staff failed to provide timely incontinence care and respond to call bells, resulting in prolonged exposure to urine and feces, skin injury, and psychosocial harm. One resident with quadriplegia was left in feces for over fifty minutes, another was left in feces for two hours leading to significant skin redness and burning, and a third was found by a family member in a saturated brief that had not been changed for eight hours, resulting in moisture-associated skin damage.
Facility staff failed to provide timely incontinence care to three residents who were dependent on staff, resulting in psychosocial harm and the development of incontinence-associated dermatitis. Delays in responding to call lights and incontinence needs led to residents remaining in soiled briefs for extended periods, causing skin breakdown, discomfort, and emotional distress. Staff interviews and documentation confirmed inconsistent practices and lack of timely care.
A resident with a history of severe weight loss and on a full liquid diet continued to lose substantial weight after admission due to the facility's failure to implement timely nutritional interventions, accurately assess malnutrition risk, and promptly arrange a gastroenterology consult. Meal trays were repetitive and sometimes missing prescribed items, and there was a lack of interdisciplinary follow-up despite ongoing weight loss and the development of wounds.
The facility did not maintain an effective pest control program for all units, with a lapse in professional pest control services for two months due to a change in providers. During this period, staff documented sightings of cockroaches in resident areas, and the facility's policy requiring monthly inspections and treatments was not followed.
Staff did not maintain comfortable temperatures in two units when boilers malfunctioned, resulting in residents experiencing cold conditions for several days. A resident and her family reported discomfort and concern, and documentation showed that room temperatures dropped as low as 60°F before temporary heating solutions were implemented.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on several occasions because the medication was not available, despite active physician orders. Interviews with LPNs revealed that medication unavailability was sometimes due to staff not ordering the medication or agency staff being unaware of overstock supplies. Facility policy required staff to notify providers and use backup pharmacy procedures, but these steps were not effectively followed, resulting in missed doses.
Staff failed to follow infection control protocols for handling soiled linen and disposing of incontinent briefs, with observations of dirty linen being transported without bags or gloves, and soiled items left on floors or in unlined trash cans. Interviews confirmed these actions were not in line with facility policy, which requires contaminated laundry to be bagged and handled with protective equipment.
Staff failed to maintain sanitary and comfortable conditions in multiple resident rooms and bathrooms, with persistent soiling, mold, and damaged walls left unaddressed despite daily cleaning policies. Residents reported ongoing concerns about cleanliness, lack of supplies, and communication barriers with housekeeping. Maintenance issues were exacerbated by staffing shortages and unfulfilled renovation promises, resulting in unsanitary and uncomfortable living conditions.
A review of staff records and facility documentation found that five employees had not received required behavioral health training, despite the facility's assessment indicating the need for such competencies to support residents with mental health and behavioral needs. Facility leadership confirmed the absence of training records for these staff members.
Facility staff did not notify the Department of Health Professions (DHP) of abuse or neglect allegations involving two certified nursing assistants, despite reporting these incidents to APS, the ombudsman, and VDH. The administrator acknowledged not following the facility's policy, which requires DHP notification within 24 hours for incidents involving licensed or certified staff.
Staff failed to promptly report allegations of abuse and neglect for two residents. In one instance, a resident was left in a soiled brief for an extended period, with evidence provided by a family member, but the incident was not escalated to management or authorities in a timely manner. In another case, a resident reported being left in feces for hours, resulting in skin irritation and emotional distress, yet the allegation was not promptly reported by the ADON. Both cases demonstrate lapses in timely reporting of suspected abuse and neglect.
Facility staff did not conduct comprehensive investigations into two separate allegations of neglect and possible abuse. In one case, a resident with severe dementia was hospitalized after presumed ingestion of body wash, with multiple staff observing symptoms consistent with ingestion, but only two staff were interviewed and the incident was deemed unsubstantiated. In another case, a resident was found in a wet brief for an extended period, with staff and photographic evidence confirming the neglect, yet the investigation was limited and concerns were dismissed. Both cases show the facility did not follow its own investigation protocols.
Staff did not update a resident's care plan to include nonskid strips as a fall intervention after a fall incident, despite documentation in progress notes and device assessments. Interviews with LPNs and CNAs revealed inconsistent awareness of the intervention, and facility policy required such interventions to be added to the care plan and reviewed by licensed nurses.
A resident with severe cognitive impairment and multiple health issues did not receive required grooming and shower care, despite being dependent on staff for ADLs. Staff accounts and documentation conflicted, with some indicating care was provided and others, including family, observing the resident was not groomed or showered. The facility lacked a policy for ADL care, contributing to the deficiency.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on two occasions, as confirmed by MAR review and resident interview. Facility staff, including LPNs and the DON, indicated issues with medication availability and lack of awareness among agency staff regarding medication storage. Required documentation explaining the missed doses was not present, and the facility's policy for medication administration and documentation was not followed.
Facility staff failed to accurately complete a hot liquid safety evaluation for a resident with behavioral issues and did not properly document or provide clear evidence of a shower for another dependent resident. In both cases, clinical records were incomplete or inconsistent, and staff interviews and documentation did not align, resulting in deficiencies in maintaining accurate resident records.
Dirty Vents and Dust Buildup in Resident Areas
Penalty
Summary
A clean and sanitary environment deficiency was identified after surveyors observed layers of sticky dirt and dust in multiple areas of the facility. The buildup was seen in the vents of the heating/air conditioning units in resident rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34, as well as in the ceiling air vents in resident room bathrooms #84, #27, #8, #5, #35, and #34, and in the ceiling air vents at the South unit nurse's station and on the East unit short hall and long hall. During interview, the Director of Maintenance stated that the vents in resident rooms and bathrooms were typically cleaned once a month and the hall ceiling vents every three months, but that staff had gotten behind because of other environmental projects. The Director of Maintenance also stated there had been a lot of sanding in the facility lately, which was clogging the vents and would likely require an increased cleaning schedule. The Administrator and DON were informed of the concern, and the facility did not provide a policy regarding a clean and sanitary environment.
Homelike Environment Not Maintained in Resident Rooms, Bathrooms, and Shower Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents and in several common areas. Resident #227, whose most recent BIMS score was 12 out of 15 indicating moderate cognitive impairment, had a large black scuff mark and multiple discolored yellowish painted areas on the wall in the room. The resident stated the scuff and wall discoloration had been reported many times and had remained unaddressed for a long time. Staff interviews confirmed there were no active work orders for the room, and the maintenance director and administrator stated the walls were old, the building was being repainted, and the scuff would be covered when painted. Resident #228, whose BIMS score was 15 out of 15, had a bathroom door that would not fully close, a bathroom baseboard separating from the wall and held with push pins, and small round holes in the wall behind the toilet from removed grab bars. The resident stated the baseboard had been coming off, the door was warped, and the holes remained after the grab bars were removed. The maintenance director acknowledged the door needed to be trimmed to close properly and that the holes behind the toilet needed to be filled and painted. The administrator observed the room and stated the condition looked like a repair that would be done at home. Resident #237, whose BIMS score was 15 out of 15, had a bathroom with significant moisture damage beside the toilet, bubbled and uneven wall surfaces, and blackened debris buildup between floor tiles. The resident described the bathroom as nasty and said staff had told him it would be fixed, but no one had come to do it. Housekeeping stated bathrooms were cleaned daily, but the director of housekeeping observed the floor needed cleaning and said it could not be completely cleaned because it needed replacement. The maintenance director stated the bathroom tiles should have been replaced and that the wall needed repair, while the administrator noted the bathroom floor had not yet been replaced. Additional areas were also found not maintained in a clean or homelike condition. The South hallway shower room had black slime-like buildup between the white tiles on the lower portions of the shower walls, and the director of housekeeping stated the buildup was an ongoing problem due to moisture in the room. Two room bathrooms contained brown splatter or brown material on the toilet riser, toilet bowl, toilet rim, wall above the trash can, and floor, and the director of housekeeping stated one of the bathrooms needed to be cleaned. Two room clocks were also observed to be inaccurate, with the administrator acknowledging that one clock was an hour behind and another was not set to the current time.
Widespread Environmental Uncleanliness, Hoarding, and Inadequate Linen and Housekeeping Services
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment across all three nursing units, public spaces, and the building as a whole. During an initial tour and subsequent observations over several days, multiple resident rooms were found crowded with boxes, food items, personal items, and plastic storage containers placed in front of and on top of air conditioning/heating units, restricting air flow. Rooms contained balled-up clothing in beds with soiled linens, soiled clothing scattered around, and large open containers of sauces and spices spilled over overbed tables and bedside cabinets. Privacy curtains in semi-private rooms had stains and brown smears causing them to stick together, and partially eaten cornbread squares with visible blue mold were present. Various food and drink items in cups and plastic glasses were mixed and unidentifiable, none were refrigerated, and rooms had a sour spoiled food smell combined with a strong urine odor. One resident was observed lying on a soiled bed encrusted with spilled food, wearing a black sweatshirt with a large dried food/liquid stain on the front and no clothing from the waist down, partially covered by a soiled sheet. The roommate’s side of the semi-private room appeared similarly unclean and cluttered. Several rooms were noted to have hoarding conditions, and the administrator acknowledged awareness of the hoarding but stated he had not cleaned certain areas to avoid upsetting residents. Throughout the survey, shower rooms were observed with a black substance along corners and caulking, broken tiles, used soap and hair in drain covers, and hallway floors with holes creating trip hazards. Baseboards were knocked down in places, and main hallways and resident room floors had black track marks, a sticky substance, food crumbs, wrappers, and built-up crusts of dirt and black grime in corners. Housekeeping and laundry services were found to be inadequate for the 180-bed facility. On one day, only one housekeeper was present, who reported being unable to complete all necessary work, and the environmental services director confirmed she was also the only laundry attendant. The laundry room contained excessive accumulations of soiled clothing and linens, including piles stacked over five feet high, overflowing bins, bags of wet laundry piled halfway up the laundry room doors, and washers and dryers full of linen and clothing sitting idle. Linen carts on all three units contained only a few sheets, pillowcases, towels, and gowns, with no washcloths or blankets, and resident rooms lacked facility-provided bedspreads, with some residents using personal blankets instead. A resident reported not having enough linen for his bed, lacking a bedspread, and that his room had not been cleaned for about two weeks; his room was observed with trash under both beds, black scuff marks on the floor, and cobwebs in corners. Grievances and Resident Council minutes documented repeated concerns about rooms not being cleaned and personal items missing. Additional observations included dirty dining room tables and floors with paint spatters and greasy black substances, stained chairs stacked in the dining room, dirty linen rooms with soiled items overflowing onto floors, and unsecured rooms containing sharps containers with blood, biohazardous waste in red bins, and chemicals accessible near cognitively impaired and ambulatory residents.
Unsecured Oxygen Cylinder and Portable Heater Used as Primary Heat Source
Penalty
Summary
The facility failed to maintain a safe environment when an oxygen E-cylinder was found free-standing and unsecured in a resident room shared by two residents. During initial rounds, surveyors observed the oxygen tank sitting upright on the floor, not in a stand or holder, with the gauge reading full. A later observation confirmed the tank remained free-standing near the wall and close to one resident’s bed, with a wheelchair positioned against it. Staff interviews showed inconsistent understanding of proper oxygen storage, with one LPN stating tanks were placed on the back of a wheelchair or in storage, and another stating tanks must be in a holder or attached to a wheelchair so they do not fall over. The unit manager stated oxygen should be stored in a caddy and never free-standing. Resident #108 was admitted with diagnoses including COPD, CKD stage 3A, heart failure, hypertension, chronic respiratory failure, major depressive disorder, diabetes mellitus type 2, and anxiety. The resident had an order for oxygen at 3 liters per minute via nasal cannula and was cognitively aware per the most recent MDS. Resident #142 was admitted with diagnoses including non-Alzheimer’s dementia, hypertension, diabetes mellitus type 2, and mood disorder, and the most recent MDS indicated cognitive impairment with impaired safety awareness. The surveyor interviews and observations established that the unsecured oxygen cylinder was present in the room occupied by these two residents. The facility also failed to ensure that an electric space heater was not being used as the primary source of heat in another resident’s room. Resident #80, who had diagnoses including neuropathy, respiratory failure, and chronic kidney disease, was observed using a portable electric heater to heat the room. The resident stated the permanent heating system had not been working for months. The maintenance director later explained that a coil had busted in the room’s heating unit, causing water to escape and the unit to be taken off-line, and that a portable heater had been placed in the room because the resident refused to move. The maintenance director was unable to provide documentation for a work order or repair quote, and the administrator later stated awareness of the heater use and that an HVAC company had been contacted for an estimate.
Failure to Inspect Bed System and Ensure Proper Mattress Fit
Penalty
Summary
The facility failed to ensure proper fitting of a mattress and bed frame for one resident and failed to conduct regular inspections of bed frames, mattresses, and bed rails for possible entrapment risks as part of its maintenance program. Resident #130 was admitted with diagnoses including polyarthritis, chronic respiratory failure, diabetes, Crohn's disease, anemia, glaucoma, Asperger's syndrome, irritable bowel syndrome, obstructive sleep apnea, bipolar disorder, and GERD, and the MDS assessed the resident as cognitively intact. On 2/10/26, Resident #130 was observed in bed with the mattress not centered on the bed frame and an approximately 5-inch gap between the bed frame edge and the mattress on the left side facing the foot of the bed. Raised grab rails were present on both sides near the headboard. The resident stated he had changed from a concave mattress to a standard bariatric mattress about a month earlier, that the current mattress had slipped over, and that he used the bed rails to move about in bed. The unit manager stated the current mattress had been installed on 1/21/26 and was not sure whether maintenance had inspected the frame with the current mattress. The maintenance director later stated there was no record of installing or checking the bed frame and mattress, and that if notified of the mattress change he would have inspected it to ensure proper fit and eliminate potential entrapment risks. The administrator and maintenance director also stated the facility had an audit policy for beds, mattresses, and rails, but there was no evidence the program had been implemented and no evidence that required inspections for entrapment risks had been completed.
Failure to Maintain Clean, Homelike Environment and Safeguard Residents’ Personal Property and Laundry
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment and to protect residents’ personal property. One cognitively intact resident with multiple chronic conditions, including polyarthritis, chronic respiratory failure, diabetes, Crohn’s disease, and bipolar disorder, did not consistently receive properly sized fitted sheets for a bariatric mattress. Surveyors observed an ill‑fitting sheet that did not cover the entire mattress, and the resident reported that the correctly sized orange‑trimmed bariatric sheets were often unavailable on the unit. Staff interviews confirmed that the resident had voiced concerns about sheet availability, that the unit linen room sometimes lacked the needed sheets, and that CNAs sometimes used whatever sheet was available at shower time instead of obtaining the correct size from the laundry, despite 24‑hour access to clean linen and an adequate central inventory of the correct sheets. Another resident with COPD, mood disorder, chronic pain syndrome, major depressive disorder, and severely impaired cognition was found in a room where housekeeping was not maintained. Over multiple days, surveyors observed scraped and damaged drywall, missing sections of wall, brown/tan drips and spatters on the wall, paper trash and candy wrappers on the floor beside and under the bed, and a dirty floor with black/gray film, drips, footprints, and black/brown specks near the toilet. A family member reported having to pick up trash from the floor and stated that housekeeping "could be better." The maintenance director was unaware of the wall damage and reported no work order had been entered, while the housekeeping supervisor and housekeeper acknowledged that rooms and bathrooms were supposed to be cleaned daily but that room changes and deep cleans sometimes prevented the housekeeper from getting to all rooms each day, resulting in some rooms only being cleaned every other day. The facility also failed to protect residents’ personal property and to process laundry in a timely manner. One resident with moderately impaired cognition reported that pictures and other personal items were lost during room changes, particularly laminated pictures of family and pets, and that grievances had been filed without any response or apparent search for the items. Records showed two room changes and two grievances documenting missing glasses, fingernail clippers, hats, a fan, and multiple laminated pictures, with no investigation, findings, or actions recorded. Interviews with the administrator, housekeeping supervisor, social services director, and unit manager revealed that no personal belongings inventory had been completed on admission, no department had been assigned to investigate the grievances, and personal items left in a room for pest treatment were not accounted for. Another cognitively intact resident reported a shaving mirror missing for about six months; the property list did not specifically list the mirror, lacked the resident or responsible party signature, and had no dates or signatures for items added or removed, contrary to facility policy. In addition, multiple residents reported problems with timely return of personal clothing from laundry, stating that laundry sometimes took more than two weeks to be returned, was not returned in the order sent, and that they received items that were not theirs while not receiving items sent earlier. A tour of the laundry department revealed large amounts of mixed soiled facility and resident laundry in bags at the bottom of the chute, multiple bins of soiled laundry awaiting washing, tables piled high with clean facility linen to be folded, and a long rack of clean resident clothing awaiting return to units. The EVS director acknowledged that laundry sometimes became backed up, that delays occurred, and that unlabeled items were placed in lost and found, which was only brought to units about once every two months, despite a stated goal of returning resident laundry within three days.
Resident Group Concerns Not Addressed or Documented
Penalty
Summary
The facility failed to demonstrate a response, action, or rationale regarding concerns and requests raised by the Resident Group. During a Resident Group meeting on 02/11/26, the President and six other residents stated they had received no feedback, updates, or outcomes about concerns or requests voiced in prior meetings. The President reported that the Activities Director, the facility-designated staff person approved by the resident group, was responsible for aiding and responding to written requests from the meetings, and that she had been told she could not take notes during the meeting because the Activities Director would take notes and forward the requests and concerns to the Administrator. During an interview later that day, the Administrator stated he had received meeting minutes, requests, and concerns from the Resident Council Group meetings from the Activities Director before her termination approximately two weeks earlier. He also stated that he had not communicated or provided written outcomes, results, or actions regarding those requests and concerns to the Resident Council President or group. Review of six months of Resident Council meeting minutes showed no entries or answers under the Administrative Resolutions or Resolved from last meeting sections. The concerns were again addressed with the Administrator, DON, and Regional Nurse Consultant on 02/12/26, and no additional information was provided before exit.
Inaccurate Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide detailed and accurate notification regarding the ending of Medicare-covered services for 3 of 3 residents reviewed. For Resident #155, the Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN) was signed, but the form was check-marked to show Daily Skilled Nursing Care would end even though the resident had been receiving Physical Therapy and Occupational Therapy that were actually ending. Resident #155 confirmed the signature but could not remember the details and stated the ABN was discussed, though neither document was fully understood. For Resident #93, the ABN was signed and marked to show Physical Therapy, Occupational Therapy, and Daily Skilled Nursing Care would end, but the Discharge Planner confirmed the resident had been receiving Speech Therapy prior to the ABN and that the form had been marked incorrectly. For discharged Resident #200, the ABN issued to the resident's wife/POA was also marked for Daily Skilled Nursing Care ending, although the resident had been receiving Physical Therapy before the ABN was issued. The Discharge Planner confirmed the incorrect marking and stated the ABN is intended to identify the specific services ending so the resident or responsible party can make an informed decision, but the forms reviewed did not clearly identify the correct services.
Grievances Not Promptly Resolved and Residents Not Informed of Grievance Process
Penalty
Summary
The facility failed to honor residents’ right to voice grievances without discrimination or reprisal and failed to make prompt efforts to resolve grievances for two residents. During a resident group meeting, seven of seven residents, including the president, stated they did not know how to file a grievance or the process. The administrator stated the grievance policy was available and that the process was explained on admission and often at resident meetings, but no additional information was provided before the survey ended. For one resident, who had diagnoses including cerebral infarction, congestive heart failure, peripheral vascular disease, and a chronic sacral ulcer, the resident stated a mirror used for shaving had been missing for about six months and had been reported without resolution. The grievance summary dated 9/2/25 documented a missing brown leather mirror fold-up, but the sections for resolved date, summary of investigation, summary of findings, and summary of actions taken were blank. The DON stated that after a report of a missing item, it is turned into a grievance and filed, and the grievance officer reviews it and emails the responsible department, but the DON and administrator both stated this grievance did not appear to have been assigned or processed. For another resident, who had diagnoses including cerebral infarction, atherosclerotic heart disease, liver cirrhosis, peripheral vascular disease, dementia, anxiety, insomnia, seizures, urinary retention, and COPD, the resident reported missing personal items after room changes, including laminated pictures of his children and pets. Two grievances were documented for missing items after room transfers, but both forms had no investigation, findings, or actions taken documented. Staff interviewed about the grievances stated they were aware of the concerns or had not been assigned to investigate them, and the administrator stated no response or actions had been taken and that no department or staff person had been assigned to investigate the grievances.
Incomplete Dialysis Communication Logs
Penalty
Summary
The facility failed to ensure dialysis communication logs were completed for one resident who was receiving dialysis three times a week. The resident had diagnoses including osteomyelitis, renal dialysis related to end stage renal failure, polyneuropathy, and dementia, and the most recent MDS indicated the resident was cognitively intact. Review of the clinical record showed the dialysis communication log was last completed consecutively on 11/25/25, with only two additional communication entries dated 12/1/25 and 12/27/25 over the ten-week period reviewed. The medical records director stated that a dialysis packet is sent with the resident and includes a communication form that should be completed, returned to the facility, and scanned into the electronic record, but two communication forms were later found that had not been scanned, and the missing communication logs were not found. The DON later stated the communication logs were reviewed and had not been completed and should have been.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications used in the facility were labeled in accordance with currently accepted professional principles, including prescription labels and use within expiration dates, in 2 of 3 medication storage rooms and 4 of 9 medication carts. During inspection of the West Unit medication storage room, surveyors found multiple expired over-the-counter medications and supplies, including vitamin D3, vitamin C, calcium with vitamin D3, multivitamins, magnesium, zinc, and lab collection tubes with various expiration dates. The same room also contained non-medication items under the sink, including caution tape, a floor cleaner, a battery for a mechanical lift, a bath basin, and glass flower vases. In the South Unit medication storage room, surveyors observed over-the-counter Tylenol, lab collection tubes, and a vial of injectable Haldol stored with over-the-counter medications without a name or prescription label. The medication refrigerator contained an opened bottle of Aplisol and two bags of IV Vancomycin with a used-by date. On medication carts in the West, East, and South Units, surveyors found expired over-the-counter medications, insulin pens that were opened beyond the allowed 28-day period, and a syringe with the needle exposed on top of a cart. One LPN acknowledged the exposed syringe was not acceptable and stated it had been left there while putting other medications away. Surveyors also found a small drawer on one medication cart containing medications stored without separation by route, without resident identifiers or prescription labels, and with expired or completed courses of medications. These included eye drops, erythromycin eye drops that the Unit Manager said had been completed, powdered prednisone vials, liquid lidocaine vials without names or dates, and Midodrine tablets in blister packs that were cut from pharmacy cards and sent with residents to dialysis without resident name or prescription label. The DON stated she expected nurses to keep medication rooms and carts clean, date multi-dose vials and bottles when opened, and discard medications when completed, discontinued, or expired. The facility policy required medications to be stored in pharmacy containers with labels, separated by route, and expired medications removed from active supply and destroyed.
Food Storage and Sanitation Deficiencies in Kitchen and West Unit Pantry
Penalty
Summary
The facility failed to maintain the main kitchen in a sanitary manner when surveyors observed a package of sliced ham on the top shelf that was open and exposed to air/elements without an open date. During the kitchen tour, the Assistant Dietary Manager stated, "They know better than that." The Dietary Manager later stated that the missing open date and exposed food item had not been seen before and that she was not aware this could be an issue. Surveyors also observed two trays in the dishwasher area with missing pieces of the corked surface and two trays with chipped edges. In addition, an inspection of the unit pantries found a bag of frozen meatballs in the freezer section of the West Unit pantry that was open and exposed to air/elements without an open date or name. The West Unit Manager stated the meatballs would need to be discarded because there was no open date or name. Facility policies reviewed by surveyors required food to be stored properly in covered, labeled, and dated containers and required outside food items to be labeled and dated with the patient's name, room number, and use-by-date.
QAPI Failure to Sustain Cleanliness and Linen Availability
Penalty
Summary
The facility failed to maintain an effective QAPI program to correct previously identified concerns related to a clean, comfortable, homelike environment and the availability of sufficient linen for resident care. Surveyors found the facility unclean across all three resident units, with severely soiled floors, overcrowded rooms, and inadequate linen supplies. Linen carts contained only a few pillowcases and about two towels, with no washcloths or blankets available, and several resident rooms lacked facility-provided bedspreads, leaving some residents using personal blankets from home. Multiple resident rooms were observed with boxes, food items, personal belongings, and plastic storage containers placed in front of and on top of air conditioning/heating units, restricting airflow. Rooms contained soiled linens, balled-up clothing, spilled sauces and spices on overbed tables and bedside cabinets, stained privacy curtains, spoiled food with visible blue mold, and mixed food and drink items that were unidentifiable. One resident was observed lying on a soiled bed encrusted with spilled food, wearing a sweatshirt stained with dried food and liquids, and was naked from the waist down and partially covered by a soiled sheet. The roommate’s side of the semi-private room was described as similar. Resident and staff interviews confirmed ongoing problems with housekeeping, laundry, and missing personal items. A resident reported his room had not been cleaned for approximately two weeks and that there was not enough linen for his bed or a bedspread. A housekeeper stated she was the only housekeeper working that day, that daily room cleaning did not occur, and that rooms were often cleaned only every three to four days or once a week. Laundry observations showed excessive piles of soiled clothing and linens stacked in the laundry room, overflowing bins, wet laundry piled in front of the doors, and washers and dryers full of items sitting unattended. An LPN reported the facility was short on linen, lacked enough laundry staff, and that laundry left too long became molded and was thrown away. Grievances and Resident Council minutes also reflected repeated concerns about rooms not being cleaned and personal items missing and not returned.
Failure to Maintain Heating and Laundry Equipment
Penalty
Summary
The facility failed to ensure a functioning heating system for one resident in room [ROOM NUMBER]. During an interview, the resident stated the permanent heating system had not been working for months and that a portable electric heater was being used to heat the room. The maintenance director later explained that the facility’s heat came from a boiler system, that a coil had busted in the resident’s room causing water to escape, and that the heating unit had been taken off-line. The maintenance director stated the resident refused to move out of the room, so a portable heater was placed there, and estimated the heating system may have been down since October 2025. No work order or repair quote documentation was available at the time of the interview. The facility also failed to maintain essential laundry equipment. During a tour of the laundry department, large amounts of mixed soiled facility and resident personal laundry were observed in bags on the floor at the bottom of the laundry chute, along with multiple rolling bins of soiled laundry waiting to be washed and folded, piles of clean facility linen, and clean resident clothing ready to be returned to the units. Only two of four washers and two of four dryers were observed operating. The EVS Director stated that three of four washers and three of four dryers were operable, but also said the washer had recently been repaired and then broke again. The maintenance director stated one broken washer had been repaired but needed a part that had not been obtained, and said the malfunctioning dryer worked but took longer to heat and was used last. No work order documentation for the washer was provided.
Failure to Maintain Clean and Sanitary Vents
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in nine resident rooms, six resident room bathrooms, and two units. During observation, layers of sticky dirt and dust were seen in the vents of the heating/air conditioning units in rooms #86, #26, #19, #12, #6, #5, #3, #41, and #34, as well as in the ceiling air vents in resident room bathrooms #84, #27, #8, #5, #35, and #34. Dust and dirt were also observed in the ceiling air vents at the South unit nurse's station and on the East unit short hall and long hall. During interview, the Director of Maintenance stated the vents in resident rooms and bathrooms were typically cleaned monthly and the hall ceiling vents every three months. The Director of Maintenance said staff had fallen behind on cleaning the vents because of other environmental projects and that recent sanding in the facility had caused the vents to clog, meaning the maintenance staff would probably need to increase the cleaning schedule. The Administrator and DON were informed of the concern, and the facility did not provide a policy regarding a clean and sanitary environment.
Failure to Assess Self-Administration of Insulin Pump
Penalty
Summary
The facility failed to assess one of 43 residents for safe self-administration of medication. The resident had diagnoses including hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder, and asthma, and the MDS assessed the resident as cognitively intact. The resident stated that she had used an insulin pump for years to manage diabetes, that the pump also monitored blood sugar levels, and that her family member supplied needed items. The clinical record included a physician order for a Lispro insulin pump stating that the resident manages the pump, as well as an order for Dexcom changes with family to provide supplies. The resident’s care plan did not include problems, goals, or interventions related to self-administration of medications. The January 2026 MAR documented Dexcom changes every 10 days and blood sugar checks before meals and at bedtime, but did not mention administration of Lispro insulin via the insulin pump. The LPN unit manager stated she was not sure an assessment for self-administration had been completed, and later reviewed the record and found no documentation of an assessment for self-administration of the insulin and/or insulin pump. The facility policy required a licensed nurse to assess the patient’s ability to self-administer medication and complete a Medication Self-Administration Safety Screen assessment.
Resident subjected to verbal abuse during incontinence care
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a CNA during incontinence care and bedpan assistance. The resident had diagnoses including hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder, and asthma. During the incident, the resident reported that the CNA raised her voice, pointed a finger in the resident’s face, threw a clean brief onto the resident’s legs, told the resident to change her own brief, and rushed the resident while assisting her off the bedpan. The resident stated she felt upset by the way she was treated and reported the incident to nursing. The investigation documented that the resident told the DON the CNA would not let her assist as she liked, shook her finger at her, threw the brief on the bed, and told her to change the brief herself. The resident’s roommate stated she saw the CNA throw the brief toward the resident and heard the CNA yell at the resident to change the brief herself. The facility determined the allegation was substantiated and identified the CNA as the staff member involved. The report also documented that the CNA was an agency staff member and had received abuse-prevention education and a criminal background check before working in the facility. The resident was assessed after the incident, and subsequent interviews documented that she was doing okay and had no further concerns. The facility’s policy defined verbal abuse to include threats, ridicule, humiliation, and disparaging or derogatory language. The deficiency was cited because the staff member’s conduct during care did not protect the resident from verbal abuse, as confirmed by the resident’s account and the roommate’s witness statement.
Inaccurate MDS Tobacco Use Coding
Penalty
Summary
The facility failed to provide an accurate annual MDS assessment for one resident with diagnoses including idiopathic neuropathy, left toe amputation, and depression. The resident’s 3/11/26 annual MDS coded Section J1300, Current Tobacco Use, as no, while the resident’s smoking safety screen dated 1/29/26 coded the resident as yes for smoking. The comprehensive care plan dated 4/14/25 also identified that the resident preferred to smoke cigarettes and included interventions related to smoking policy education, OT referral as needed, and smoking assessment as needed. During observations on 6/8/26 and 6/9/26, the resident was seen smoking outside off facility property. In an interview on 6/9/26, the resident stated he smoked about eight to ten times a day and had been smoking for over thirty years. When the MDS coordinator reviewed the annual assessment on 6/10/26, the coordinator stated that Section J1300 was coded incorrectly by an agency person working at the facility and that the MDS would be revised. The Administrator, DON, Regional Director of Clinical Services, and Regional Director of Operations were informed of the findings.
Incomplete Care Plans for Insulin Pump and Dialysis Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with diabetes who used a self-managed insulin pump and Dexcom monitoring device. The resident was admitted with diagnoses including hip fracture, diabetes, anemia, osteoporosis, hypothyroidism, cerebral infarction, major depressive disorder, and asthma, and the MDS assessed the resident as cognitively intact. The clinical record included a physician order for a Lispro insulin pump stating the resident manages the pump, and another order for Dexcom changes with family providing supplies. However, the revised care plan did not include problems, goals, or interventions related to self-administration of insulin, insulin pump management, or Dexcom use; it only addressed diabetes-related risk and insulin administration as ordered. The facility also did not complete a full dialysis-related care plan for another resident with osteomyelitis, renal dialysis related to end stage renal failure, polyneuropathy, and dementia. The record showed dialysis interventions were not specific to dialysis days, the dialysis center, the type of vascular access, or the location of the vascular device. The DON reviewed the care plan and stated the resident had been readmitted from the hospital and that a dialysis care plan template had been generated on admission, but the template was not properly filled out.
Failure to Revise Smoking Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #215 regarding smoking status. The resident’s most recent annual MDS with an ARD of 2/2/2026 assessed the resident as a current tobacco user, and the care plan documented that the resident prefers to smoke cigarettes, with interventions including both "May smoke independently" and "Supervise with smoking." The most recent smoking safety screen dated 3/13/2026 assessed the resident as scoring a five, indicating the resident required supervision with smoking, and the care plan section of that assessment also listed both independent smoking and supervision interventions. During interview on 6/10/2026, the MDS coordinator stated the care plan was developed to correspond with the MDS assessment and was revised as needed, but after reviewing the resident’s care plan and smoking assessment, she stated it should have been revised because it was not clear which smoking status was current. The facility policy on care planning stated that care plans would be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment. The Administrator and DON were made aware of the concern on 6/10/2026, and no further information was provided prior to exit.
Independent LOA Orders Entered Without Proper Clinical Review
Penalty
Summary
The facility staff failed to meet professional standards when an order was entered for a resident to go out on leave of absence independently without documented physician approval. Resident #205 was admitted with diagnoses including CVA, COPD, and DM. The resident’s most recent quarterly MDS coded a BIMS score of 15 out of 15, but also showed the resident required maximum assistance for hygiene and bathing and supervision for bed mobility, transfers, dressing, and eating. The care plan identified the resident as needing assistance with ADLs, and therapy documentation noted the resident had fluctuating medical status and that a Hoyer lift was appropriate when the resident was fatigued. The record also showed an OT evaluation documenting modified independence in decision-making and impaired safety awareness. Despite this, an order audit report documented that a verbal order for the resident to go out on LOA independently was created by the Regional Director of Clinical Services. When the resident was observed outside the facility, the resident was in a grassy area next to the sidewalk and road smoking with another resident. During interview, the resident stated that the other resident pushed the wheelchair and got it up onto the grass, and the resident identified the area as off facility property. The attending physician stated he did not remember being called about the order and said that if there was a safety issue, the order would not have been given or approved. The Director of Rehab Services stated that therapy evaluations were used to determine whether residents could go off property independently and that R205 needed supervision because of uneven surfaces, but no new evaluation had been completed before the order was entered. Facility staff also described the independent LOA order as meaning the resident had been assessed by therapy and was independent, with sign-out and documentation required when the resident left and returned. For Resident #216, the facility staff also failed to follow professional standards when obtaining verbal orders. The resident’s annual MDS showed a BIMS score of 14 out of 15 and documented current tobacco use. The resident stated that he previously could go to the courtyard and smoke anytime, but later had to sign out and go off property to smoke outside scheduled times, using sidewalks that were not safe and not cleared during inclement weather. The resident reported a prior fall while stepping over snow on the sidewalk that caused a cut on his arm. An order audit report documented a verbal order for the resident to go out on LOA independently, created by the Regional Director of Clinical Services. However, an OT evaluation in the record stated that the resident could safely access the smoking courtyard and navigate the ramp and doorways independently, but would not be safe using the sidewalks surrounding the facility because of uneven terrain, steep grades, railroad tracks, and broken concrete. The OT recommended the resident use public transport whenever leaving the facility to improve safety and decrease fall risk associated with the surrounding sidewalks. The attending physician stated he did not recall being called about the independent LOA order and said he would not have given or approved it if there was a safety issue. The Director of Rehab Services stated that R216 was planned to be reevaluated because concrete work had started, but the reevaluation had not been completed when the LOA order was placed.
Enteral Feeding Not Administered Per Physician Order
Penalty
Summary
The facility failed to ensure enteral nutritional feeding was administered according to the physician’s order for one resident who was admitted with diagnoses including pulmonary embolism, tracheostomy, cerebral palsy, generalized epilepsy, neuromuscular dysfunction of the bladder, chronic respiratory failure, severe intellectual disabilities, bipolar depression, and dysphagia. The resident’s MDS coded cognitive status as unable to complete the interview and identified tube feeding as a nutritional approach. On 2/11/26 at 11:00 AM, the resident’s enteral pump was observed running Osmolite 1.5 at 60 ml/hour, and the feeding bottle was dated 2/10/26 with a hang time of 6:16 PM. The physician’s order dated 2/10/26 at 9:18 PM directed Osmolite 1.5 at 75 ml/hour for 12 hours daily from 6:00 PM to 6:00 AM for a total volume of 900 ml. Interviews and record review showed the feeding was not being managed according to the order. An LPN stated she was not familiar with the resident and had not checked the enteral feeding because it was not due to come down on her shift, even though she had administered 9:00 AM medications. The MAR showed the new 75 ml/hour order was initialed by another LPN on the night shift, but on 2/12/26 at 9:30 AM the pump was again observed running at 75 ml/hour when it should have been stopped at 6:00 AM. The RN stated she started the pump at 9:00 AM based on the MAR, but no order to start the feeding at that time was found. The Unit Manager reviewed the orders and stated the 2:00 PM hang time and 12:00 noon take-down orders should have been discontinued when the prior 22-hour order was discontinued, and the Regional Director of Clinical Services stated nurses were expected to follow physician orders and monitor pump settings.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly in the dumpster area outside the kitchen. During observation with the Dietary Manager, one dumpster was seen with its top flaps pushed all the way back and resting on the edge of the loading dock while it was overflowing with bags of trash. A second dumpster was positioned in front of the open, overflowing dumpster with its side door open. The snow-covered ground around both dumpsters was littered with gloves, paper towels, candy wrappers, straws, plastic cup lids, forks, and spoons. The loading dock was also observed with pieces of trash, two wheelchairs, and two mattresses. When interviewed, the Dietary Manager stated the waste disposal company comes twice a week, usually on Mondays and Thursdays, but there had been delay because of snow and icy conditions. The Dietary Manager also stated staff kept throwing bags into the dumpster while it was open and did not think shutting the top was necessary because it was easier to toss the bags in. The DON reported that the facility did not have a policy covering disposal of trash.
Missing Required Communication Training for RN
Penalty
Summary
The facility failed to provide required annual communication training for RN #1, who was one of ten employee records reviewed. During employee record review on 2/11/2026, the RN’s training file was requested and found to not include the required communication training. On 2/12/2026, the Regional Director of Clinical Services stated that the RN also did not have training in QAPI and ethics and compliance, explaining that these trainings were not triggered in the electronic education program for her to take. The facility policy for continuing training states that all nursing staff must participate in mandatory annual in-services, including effective communication.
Missing Required QAPI Training for RN
Penalty
Summary
Mandatory annual training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not provided for one of ten employee records reviewed, RN #1. During review of employee training records on 2/11/2026 at approximately 12:20 p.m., RN #1’s record did not show the required QAPI training. On 2/12/2026 at 12:36 p.m., the Regional Director of Clinical Services stated that the RN also did not have training in communication, QAPI, and ethics and compliance, and explained that the training was not triggered in the electronic education program for her to take. The facility policy stated that all nursing staff must participate in mandatory annual in-services, including Quality Assurance Performance Improvement. The Administrator and the President of Operations were informed of the findings on 2/12/2026 at 12:45 p.m.
Missing Required Annual Staff Training
Penalty
Summary
The facility staff failed to provide required annual training in ethics and corporate compliance for RN #1, one of ten employee records reviewed. During review of the employee training records, RN #1 was found to not have the required training in communication. The Regional Director of Clinical Services stated that the RN also did not have training in communication, QAPI, and ethics and compliance because it was not triggered in the electronic education program. The facility policy for continuing training requires all nursing staff to participate in mandatory annual in-services, including effective communication.
Failure to Administer Medications as Ordered and Implement Physician Recommendations
Penalty
Summary
Facility staff failed to follow physician orders for two residents, resulting in deficiencies related to medication administration and care coordination. For one resident with a history of glaucoma and multiple other diagnoses, an eye physician recommended the addition of Dorzolamide-Timolol eye drops to the resident's existing glaucoma treatment. The recommendation was made during an on-site consultation, but the report was sent to an outdated email address and was not received by current facility staff. As a result, the new medication order was not reviewed or implemented, and the resident did not receive the recommended eye drops for over 30 days. Interviews with staff revealed a lack of awareness regarding the new recommendation, and the facility's process for updating consultant contact information was not followed, leading to the oversight. In a separate incident, another resident was admitted with physician orders for an antibiotic to be administered four times daily. Upon review, it was found that the antibiotic was not initiated until the following day at noon, resulting in three missed doses. The delay was attributed to the late entry and verification of the medication orders in the electronic system, despite the medication being available in the facility's backup supply. The DON and Regional Director of Clinical Services were unable to clarify why certain doses were missed after the orders were entered into the system. Facility policies require that medications be administered according to prescriber orders and that consultation reports be reviewed and implemented as indicated. In both cases, failures in communication, documentation, and timely order entry led to residents not receiving prescribed treatments as ordered by their physicians.
Failure to Develop Care Plan for Bowel Incontinence
Penalty
Summary
Facility staff failed to develop a care plan addressing bowel incontinence for one resident, despite the resident being assessed as bowel incontinent on the most recent MDS and having diagnoses including diabetes, congestive heart failure, respiratory failure, and peripheral vascular disease. The resident, who was cognitively intact, reported numbness from the waist down and an inability to sense bowel movements, requiring frequent checks by staff. Interviews with a CNA and the MDS coordinator confirmed that the resident was regularly checked for incontinence and that a care plan for bowel incontinence should have been in place but was missed. Review of the clinical record and care plan revealed no documentation of a bowel incontinence care plan for this resident.
Failure to Provide Timely Incontinence Care for Two Residents
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents who were unable to perform activities of daily living independently. One resident, with diagnoses including quadriplegia and spinal cord compression, was assessed as cognitively intact and frequently incontinent of bowel and bladder. On the early morning in question, the resident was found soaked at the start of the day shift, indicating that incontinence care had not been provided during the previous shift. The resident did not recall receiving care during the night and reported sleeping through most of it. Staff interviews and facility documentation confirmed that the resident was not checked or changed prior to the day shift, despite care plan interventions requiring frequent checks and changes. Another resident, with a history of COPD, diabetes, BPH, congestive heart failure, and dementia, was also assessed as cognitively intact and frequently incontinent. This resident was found with a heavily soiled brief and wet bed linens at the start of the day shift. The resident's roommate reported that the assigned CNA did not provide a brief change during the last round of the shift. Staff interviews and facility investigation corroborated that incontinence care was not provided as required by the resident's care plan, which called for frequent checks and changes. In both cases, the lack of timely incontinence care was identified through staff and resident interviews, review of facility documentation, and clinical record review. The findings were discussed with facility leadership, and the facility's own investigation supported the evidence of failure to provide care as outlined in the residents' care plans. No skin issues were identified for either resident following the incidents.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
Facility staff failed to serve palatable and appropriately heated meals to two residents out of a sample of eleven. During a lunchtime meal service observation, several residents were noted not eating, and one resident specifically complained that her food was not served hot, which she preferred. A test tray conducted during the same meal service revealed that the baked ham, scalloped potatoes, and mixed vegetables were served at lukewarm temperatures (121.6°F, 138.4°F, and 129.7°F, respectively), despite being much hotter in the kitchen prior to service. The vegetables and potatoes were also described as bland and lacking seasoning. The dietary manager acknowledged that food temperatures dropped significantly due to hot plates sitting and waiting to be served on the cart. Resident interviews confirmed dissatisfaction with meal temperatures, with one resident stating that her meals were never served hot. Facility documentation reviewed indicated a policy requiring food to be palatable, attractive, and served at a safe and appetizing temperature. The dietary manager stated that food should be served below 150°F to prevent scalding, but acknowledged the temperature drop before service. The deficiency was brought to the attention of facility leadership during an end-of-day meeting.
Failure to Honor Resident Meal Preferences During Service
Penalty
Summary
During a lunchtime meal service, three residents did not receive their stated meal preferences as documented on their meal tickets. Specifically, two residents had requested baked potatoes and milk with their meals, while another resident preferred dessert and milk. These preferences were not honored during the observed meal service. Resident interviews confirmed that one resident consistently did not receive dessert or milk without specifically asking, another did not receive milk or condiments, and a third seldom received milk or the requested baked potato. A Certified Nursing Assistant (CNA) reviewed a meal ticket and was unable to explain why the baked potato was not served, indicating a lack of awareness or communication regarding resident preferences. Facility documentation stated that menus are to be served as written unless changes are made in response to resident preference, unavailability, or for special meals. Despite this policy, the observed meal service did not accommodate the residents' documented preferences, resulting in a failure to provide meals according to individual needs and requests.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
Facility staff failed to provide ordered medications for a resident, specifically niacin and oxycodone-acetaminophen, as prescribed by the medical provider. The clinical record review showed that the resident had active orders for oxycodone-acetaminophen for pain management and niacin as a supplement. The medication administration records indicated missed doses of both medications over several days, with documentation codes referencing unavailability and progress notes explaining that the medications were not on hand, were in transit, or awaiting delivery from the pharmacy. The emergency medication supply (Omnicell) did not contain the required strength of oxycodone-acetaminophen or niacin. Interviews with nursing staff revealed that when medications were not available, they notified the provider and responsible party, and documented the situation in the medical record. Staff explained that over-the-counter medications like niacin were typically ordered through a supply company with less frequent deliveries, and that the pharmacy required an authorization form to dispense such medications. Delays in returning the authorization form contributed to the delay in obtaining niacin for the resident. The pharmacy confirmed that they did not receive the necessary authorization to dispense niacin until several days after the initial order, resulting in a gap in administration. Facility policy required staff to search for missing medications, contact the pharmacy, and use the emergency kit if necessary. The policies also required provider notification and documentation when medications were unavailable. Despite these policies, the resident did not receive the ordered medications as scheduled, and there was a lack of documentation explaining the hold on niacin for certain days. The deficiency was identified through interviews, record reviews, and review of facility documentation, which confirmed that the facility did not have the medications available for administration as ordered.
Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
Facility staff failed to provide a safe, functional, and comfortable environment for a resident who reported multiple unresolved maintenance issues in his room. The resident expressed concerns about a non-functioning air conditioning unit, which had not been operational for several weeks despite rising temperatures and his pre-existing breathing issues. He also reported that the closet doors were broken, making the drawers inaccessible, and that a ceiling tile was out of place and appeared as if it could fall. The resident stated he had reported these issues to staff multiple times, but no corrective action had been taken. Direct observation by the surveyor confirmed the air conditioning unit was not working, the closet doors posed a safety hazard, and the ceiling tile was not properly secured. A review of facility maintenance work orders revealed that requests for repairs to the air conditioning unit and closet doors had been entered but remained open and unresolved for an extended period. Interviews with the maintenance director and staff indicated a lack of an effective system for tracking and addressing maintenance requests, with reliance on verbal reports and handwritten notes rather than the facility's electronic system. The maintenance director acknowledged that the electronic system was not being monitored and that many issues were prioritized informally, leading to delays in addressing non-urgent repairs. These actions and inactions resulted in the resident continuing to live in an environment that was not safe, functional, or comfortable.
Failure to Prevent Resident Access to Hazards and Inadequate Hot Liquid Safety
Penalty
Summary
Facility staff failed to provide adequate supervision and maintain an environment free from accident hazards, resulting in multiple incidents of resident harm. One resident with severe dementia ingested an unknown amount of body wash that had been left accessible on her bedside table. This resident was known to be impulsive, grab at objects, and was not oriented, requiring total care. Staff interviews and clinical documentation confirmed that the body wash was left within reach after a bed bath, and the resident subsequently ingested it, leading to respiratory distress, hospitalization, intubation, and the need for a tracheostomy and feeding tube. The incident was not directly witnessed, but multiple staff and the resident's roommate confirmed the presence of the body wash and the resident's symptoms following ingestion. Additionally, the facility did not have a system or protocol in place to monitor the temperature of hot liquids served to residents. This failure resulted in another incident where the same resident spilled hot coffee on herself, causing redness and requiring medical attention. Review of the resident's hot liquid safety evaluation revealed inaccuracies and omissions, as the assessment did not reflect the resident's documented agitation, impulsivity, and behavioral symptoms. Staff interviews confirmed that coffee temperatures were not routinely checked, and observations during the survey found that coffee was being served at temperatures exceeding safe limits. Further observations during the survey revealed that hazardous items, such as toiletry products and cleaning supplies, were left unsecured in resident rooms and common areas, including shower rooms with open doors and accessible gallon jugs of shampoo and body wash. Residents with cognitive impairment and poor safety awareness were found to have access to these items, and staff interviews confirmed a lack of consistent practice regarding the storage of potentially hazardous materials. These deficiencies were found to have the potential to affect multiple residents across all nursing units.
Failure to Provide Timely Incontinence Care and Call Bell Response Resulting in Neglect and Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care and respond to call bells for multiple residents, resulting in neglect, skin injury, and psychosocial harm. One resident, who was cognitively intact and completely dependent on staff for all activities of daily living due to quadriplegia, was left sitting in feces for over fifty minutes after activating the call light. The resident reported feeling humiliated and unimportant, and was observed to be emotionally distressed. The resident's care plan indicated a high risk for pressure ulcers and required prompt incontinence care, but staff did not respond in a timely manner, and the call bell system showed the call had been active for over fifty minutes before staff entered the room. Another resident, who was dependent on staff for toileting and had no cognitive impairment, reported being left in feces for approximately two hours. The resident described that after activating the call bell and informing a CNA of the need for incontinence care, the CNA turned off the call light and did not return. The resident was eventually assisted by another CNA, who found fecal material on the resident's thighs, bed pad, and sheets, and observed significant skin redness and burning. The resident reported the incident to staff and Adult Protective Services, and photos documented the extent of the soiling and skin injury. A third resident, with severe cognitive impairment and dependent on staff for care, was found by a family member in a saturated brief and wet bedding. The family member marked the brief and found it unchanged eight hours later. Staff interviews confirmed that incontinence rounds were expected every two hours, but the resident's brief was not changed as required, resulting in moisture-associated skin damage. Staff acknowledged that the resident was wet enough to require a change, and documentation showed redness and treatment for skin damage following the incident.
Failure to Provide Timely Incontinence Care Resulting in Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care to multiple residents who were dependent on staff for activities of daily living, resulting in psychosocial and physical harm. One resident with quadriplegia, who required total assistance, was observed to have his call light engaged for over 50 minutes before staff responded to his request for incontinence care. The resident reported routinely waiting extended periods for care, which led to feelings of anger, humiliation, and being unimportant. Clinical records indicated that this resident developed incontinence-associated dermatitis (IAD) on both buttocks, with wound care documentation confirming new skin breakdown attributed to delayed incontinence management. Another resident, who was dependent for toileting and had no cognitive impairment, reported being left in feces for approximately two hours after notifying staff of the need for a brief change. The resident described significant discomfort, burning, and emotional distress as a result of the delay. Observations and interviews confirmed that the resident's skin was red and irritated, and photographic evidence showed feces on the resident's thighs, bed pad, and sheets. Staff interviews corroborated the delay, and the resident reported the incident to multiple facility leaders, who were unaware of the situation until informed by surveyors. A third resident, with severe cognitive impairment and a history of urinary tract infection, was found to have remained in the same brief for eight hours, as confirmed by staff interviews and photographic evidence provided by the resident's daughter. The resident's brief was saturated, and skin assessments documented redness and moisture-associated skin damage to the coccyx and groin areas. Staff interviews revealed inconsistent practices regarding the frequency of incontinence care and reliance on visual indicators rather than direct assessment, contributing to prolonged exposure to moisture and subsequent skin breakdown.
Failure to Timely Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
Facility staff failed to ensure that a resident with a history of significant weight loss maintained acceptable nutritional status. Upon admission, the resident had already experienced a 40-pound weight loss due to self-imposed starvation and was placed on a full liquid diet per hospital discharge instructions. Despite this, the resident lost an additional 18 pounds in the first nine days at the facility and a total of 24 pounds over five weeks. Observations revealed that the resident's meal trays were repetitive and sometimes missing prescribed items, such as ice cream, which the resident expressed a preference for and was ordered to receive. The facility did not implement timely interventions to address the resident's ongoing weight loss. There was a delay in initiating nutritional supplements, with the first supplement order not placed until nearly a month after admission. The registered dietician's initial malnutrition screening inaccurately assessed the resident as low risk and did not account for the significant weight loss. There was also a lack of documented follow-up or reassessment by the dietician until several weeks later, during which time the resident continued to lose weight and developed wounds. Additionally, the facility failed to promptly arrange a necessary gastroenterology appointment to address the resident's underlying condition of achalasia, which restricted dietary advancement. Staff interviews revealed confusion and lack of communication regarding the scheduling of this appointment, with no evidence of attempts to secure an earlier consultation until several weeks after admission. The facility's own policies required timely weight monitoring, interdisciplinary review, and provider notification for significant weight changes, but these procedures were not followed, resulting in the resident's continued decline.
Failure to Maintain Consistent Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program across all three units. Although a tour of the nursing units did not reveal immediate concerns, interviews and document reviews showed that the facility did not have pest control services in place for the months of January and February 2025. The administrator confirmed that pest control was not present during these months due to a change in service providers, acknowledging that this lapse was an oversight. During the period without pest control coverage, work orders documented the presence of cockroaches in a resident's nightstand and sightings of roaches in a resident's bathroom. The facility's policy required monthly inspections and treatments by a corporate-approved contractor, which was not followed during the lapse. Staff interviews indicated that pest sightings were reported and addressed internally, but the absence of professional pest control services during the specified months led to the deficiency.
Failure to Maintain Safe and Comfortable Temperatures Due to Boiler Malfunction
Penalty
Summary
Facility staff failed to maintain a comfortable and safe environment for residents by not ensuring adequate internal temperatures in two of three units due to malfunctioning boilers. The east and west wings experienced significant heating issues when the primary boilers were not operating properly. Residents and their family members reported that it was cold in the facility, with one resident stating she had to use multiple sheets and still felt cold, and her family member expressing concern to the point of requesting a welfare check from the police department. Documentation and interviews revealed that the facility's boilers had ongoing mechanical problems, including frequent shutdowns, water leaks, and malfunctioning recirculating pumps. Service logs indicated repeated failures and the need for manual resets to restore heat. The administrator and maintenance staff confirmed that the boilers would often trip and require intervention, and that parts were difficult to obtain due to the manufacturer no longer being in business. During this period, the facility resorted to using portable heaters and spot coolers to provide some heat, but temperature monitoring showed that several resident rooms remained below comfortable levels, with some rooms measuring between 60-67°F. The deficiency was further substantiated by service technician reports, which described a cracked heat exchanger and the inability of staff to consistently reset the boiler to maintain adequate temperatures. The lack of a reliable heat source persisted until a temporary boiler was installed, but prior to this, residents in affected wings were exposed to uncomfortably low temperatures for an extended period. The facility's failure to maintain a safe and comfortable environment directly impacted residents' well-being during the time the boilers were inoperable.
Failure to Provide Ordered Glaucoma Medication Due to Unavailability
Penalty
Summary
Facility staff failed to ensure that a resident received Latanoprost eye drops for glaucoma as ordered by the physician. The medication order, active since 2/14/24, required the drops to be administered at bedtime in both eyes. Clinical record review and interviews revealed that the resident did not receive the eye drops on multiple occasions, specifically on 1/16/25, 3/2/25, and 3/4/25, due to the medication not being available. Documentation indicated that the drops were reordered or that the pharmacy was contacted, but the medication was still not administered as prescribed. Interviews with two LPNs indicated that medication unavailability could be due to staff not ordering the medication or agency staff being unaware of overstock supplies stored in the medication room refrigerator. Facility policy required nurses to notify the provider and discuss alternatives or activate backup pharmacy procedures when medications were unavailable. Despite these policies, the resident's medication was not consistently available or administered as ordered, and the issue was brought to the attention of the facility administrator and DON.
Failure to Follow Infection Control Standards for Soiled Linen and Brief Disposal
Penalty
Summary
Facility staff failed to adhere to infection control standards regarding the handling of soiled linen and disposal of incontinent briefs across all three units. Multiple observations revealed staff transporting dirty linen without using bags, carrying it against their bodies, and not wearing gloves. Dirty linen was found on the floor in shower rooms and resident rooms, and soiled incontinent briefs were disposed of in trash cans without liners. Staff interviews confirmed that these practices were not in accordance with facility policy, which requires contaminated laundry to be bagged at the site of generation and handled with appropriate personal protective equipment. Further observations showed that during resident care, staff placed soiled linen directly on the floor rather than in designated bags or carts. Some staff acknowledged the improper handling when questioned and indicated awareness of the correct procedures. Facility documentation reviewed stated that contaminated laundry must be bagged and handled with protective gear, but these protocols were not consistently followed as evidenced by the surveyor's findings.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to maintain a sanitary, clean, and comfortable environment in multiple resident rooms and bathrooms across several units. Observations revealed brownish/black substances on bathroom walls and trashcans, persistent soiling and sticky floors, and missing or damaged wall plaster with visible mold and musty odors. In several instances, these unsanitary conditions remained unaddressed over multiple days, despite daily cleaning schedules outlined by facility policy. Staff interviews confirmed that cleaning was not consistently performed as required, with some staff unaware of ongoing issues and others acknowledging that bathrooms had been in poor condition for extended periods. Residents reported ongoing concerns about the cleanliness of their rooms and bathrooms, with some expressing fear of using the facilities due to the level of filth and lack of cleaning. One resident noted a lack of paper towels for several days, requiring family to bring supplies from outside. Staff interviews further revealed communication barriers between residents and housekeeping staff, and a lack of follow-through on promised renovations and repairs, particularly in bathrooms where mold and water damage were present. Maintenance staff were not always aware of the problems, and the maintenance department had open positions, including a vacant director role, which contributed to delays in addressing these issues. Facility documentation confirmed that daily cleaning tasks were not being completed as required, with specific failures to clean toilets, sinks, floors, and to remove visible stains and debris. The administrator and corporate staff were made aware of these deficiencies during the survey, and acknowledged the poor state of repair and cleanliness in resident areas. The lack of consistent cleaning and maintenance resulted in unsanitary and uncomfortable living conditions for residents on multiple units.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
Facility staff failed to provide behavioral health training to five out of eight employees reviewed during an extended survey. The survey included a review of staff interviews, staff records, and facility documentation, which revealed that there was no credible evidence that these employees had received the required behavioral health training. The facility assessment, last reviewed on 8/6/25, indicated that the facility serves residents with mental health and behavioral needs and outlined the necessity for staff competencies in managing psychiatric symptoms, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. Despite being asked to provide evidence of behavioral health training for the selected employees, the facility was unable to produce documentation showing that the identified staff had completed such training. The administrator, DON, and corporate staff confirmed that they could not locate the required training records for these employees. The facility's own assessment highlighted the need for behavioral health competencies, particularly for memory care units, but the training records for the reviewed staff did not reflect completion of this requirement.
Failure to Report Abuse Allegations to DHP as Required by Policy
Penalty
Summary
Facility staff failed to implement their abuse policy regarding timely reporting of allegations involving licensed staff to the Department of Health Professions (DHP) for two residents out of a sample of 26. In both cases, allegations of abuse or neglect involving certified nursing assistants were reported to Adult Protective Services (APS), the ombudsman, and the Virginia Department of Health (VDH), but there was no evidence that DHP was notified as required by facility policy. Documentation for one incident showed confirmation of notifications to APS, ombudsman, and VDH, but not to DHP. In the other case, similar notifications were made, but again, DHP was not notified. During interviews, the administrator initially claimed to have sent the report to DHP, but upon review, the documentation provided was addressed to VDH, not DHP. The administrator later admitted to not faxing allegations to DHP unless they were substantiated, contrary to the facility's written policy, which requires notification within 24 hours for incidents involving licensed or certified staff. No additional information was provided prior to the survey exit.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
Facility staff failed to timely report allegations of abuse and neglect for two residents. In the first case, a resident's daughter discovered her father had not been changed for approximately eight hours, as evidenced by a marked brief and photographs. The resident was found with a saturated brief, red and irritated skin, and poor grooming. Although the incident was reported to a charge nurse and later discussed with a unit manager, neither staff member escalated the allegation to upper management or regulatory authorities in a timely manner. Documentation and witness statements were delayed, and the issue was not brought to the administrator's attention until days after the incident. In the second case, a resident reported to a CNA and later to the ADON that she had been left in a soiled brief with feces for nearly two hours, resulting in skin irritation and visible soiling of her bed and body. The resident expressed emotional distress over the incident and provided photographic evidence. The ADON acknowledged being informed but did not immediately report the allegation to appropriate authorities. The administrator was not made aware of the situation until after the resident had already been visited by Adult Protective Services. In both cases, the facility failed to follow timely reporting protocols for suspected abuse and neglect.
Failure to Conduct Thorough Investigations into Allegations of Neglect and Abuse
Penalty
Summary
Facility staff failed to conduct a thorough investigation into two separate allegations of neglect and possible abuse involving two residents. In the first case, a resident with severe dementia was presumed to have ingested a body wash, resulting in hospitalization for acute hypoxic and hypercapnic respiratory failure. Multiple staff members observed symptoms consistent with soap ingestion, such as foaming at the mouth, pink-tinged bubbles, and respiratory distress. Despite these observations and statements from several staff and the resident's roommate, the facility's internal investigation was limited to interviews with only two staff members and a review of hospital records. The facility concluded the incident was unsubstantiated due to lack of direct witness, despite substantial circumstantial evidence and staff testimony indicating otherwise. In the second case, the facility failed to thoroughly investigate an allegation of neglect regarding timely incontinent care for another resident. The resident's daughter reported that her father had not been changed for an extended period, and staff witness statements, as well as photographic evidence, confirmed the resident was found in a wet brief that had been marked earlier in the day. Staff interviews revealed inconsistencies in care documentation and a lack of timely intervention. The administrator, who also served as the abuse coordinator, acknowledged the situation but did not conduct a comprehensive investigation, relying instead on limited staff interviews and dismissing the daughter's concerns. Both incidents demonstrate a failure by facility staff to follow their own abuse and neglect investigation policies, which require immediate and thorough internal investigations, including collecting evidence and interviewing all relevant witnesses. The lack of comprehensive investigations in both cases was directly observed and documented by surveyors, who noted that the facility did not meet its own standards for responding to allegations of abuse and neglect.
Failure to Revise Care Plan with Fall Interventions
Penalty
Summary
Facility staff failed to review and revise the care plan to include fall interventions for one resident. Specifically, after a fall incident, a progress note indicated that nonskid strips should be placed by the resident's bedside as a new intervention. However, this intervention was not added to the resident's care plan, despite documentation in a device assessment that it had been. Multiple staff interviews revealed inconsistent knowledge about whether nonskid strips were in place for the resident, and staff relied on care plans and other documentation to implement interventions. Housekeeping staff were responsible for removing nonskid strips after resident discharge, but there was no clear record of the intervention being implemented for the resident in question. A review of facility policies showed that interventions identified after falls or through device assessments were to be incorporated into the care plan and reviewed by licensed nurses. The care plan for the resident did not reflect the intervention for nonskid strips, even though it was documented elsewhere as necessary. The deficiency was identified through observation, staff interviews, and review of clinical records and facility documentation, and was communicated to facility leadership.
Failure to Provide ADL Care and Grooming
Penalty
Summary
Facility staff failed to provide adequate activities of daily living (ADL) care, specifically grooming and showering, for one resident who was dependent on staff for these needs. The resident, who had severe cognitive impairment and multiple diagnoses including urinary tract infection, muscle weakness, and underweight status, did not receive a shower or proper grooming on the day in question. Staff statements conflicted regarding whether a shower was provided, with one CNA documenting that a shower was given, while both an LPN and a physical therapist assistant indicated the resident was not showered and remained in bed for much of the morning. The resident's daughter also reported that her father was not groomed and appeared unshowered, with greasy hair. Review of facility documentation showed inconsistencies between staff statements and recorded care, as the CNA had documented both a bed bath and a shower, but other staff and family observations contradicted this. The facility did not have a policy for ADL care, and the incident was confirmed through interviews and record reviews. The lack of consistent and accurate care documentation, as well as the absence of a clear ADL policy, contributed to the failure to provide necessary hygiene and grooming for the resident.
Failure to Administer Physician-Ordered Eye Drops and Inadequate Documentation
Penalty
Summary
Facility staff failed to administer Latanoprost eye drops as ordered by the physician for a resident with glaucoma. The resident reported during an interview that he frequently did not receive his prescribed eye drops. Review of the clinical record and medication administration record (MAR) confirmed that the eye drops were not administered on two specific dates, with one date left blank on the MAR and the other marked as held, without any documentation explaining the omission. The physician's order for the eye drops had been active since February and remained so at the time of the survey. Interviews with the DON and two LPNs revealed that medication administration was inconsistent, particularly when medications were not available or when agency staff were unaware of where extra supplies were stored. The facility's policy required medications to be administered as ordered and documented immediately after administration, but this was not followed in the resident's case. No documentation was provided in the nursing progress notes to explain why the medication was not given, and the DON acknowledged that blanks on the MAR indicated the medication was not administered and should have been explained.
Failure to Accurately Complete Safety Evaluation and Maintain Clinical Records
Penalty
Summary
Facility staff failed to accurately complete and document a hot liquid safety evaluation for a resident with a history of agitation, restlessness, and impulsive behavior. Despite multiple progress notes indicating the resident was agitated and required lorazepam in the week prior to the evaluation, the hot liquid safety form did not reflect these behaviors. Required sections indicating risk factors were not properly checked, and the form was left incomplete, omitting the necessary indication that the resident was at risk for injury from hot liquids. Additionally, staff failed to maintain accurate clinical records for another resident who was dependent for activities of daily living and had severe cognitive impairment. There were conflicting accounts regarding whether the resident received a shower, with CNA documentation indicating a shower was given, while statements from other staff, including an LPN and a physical therapist assistant, indicated the resident was not showered. The resident's daughter also reported that her father did not appear to have been showered, providing photographic evidence of poor hygiene and soiled bedding. The facility did not have a policy for activities of daily living documentation, and the inconsistencies in staff statements and documentation led to uncertainty about the care provided. The lack of accurate and complete clinical records for both residents was confirmed through staff interviews, clinical record reviews, and supporting documentation.
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 48 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Harrisonburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunnyside Presbyterian Retirement Community | 1 mi | ★★★★★ | 2 | 0 |
| Blue Ridge Rehabilitation And Nursing | 1.7 mi | ★★★★★ | 2 | 0 |
| Vmrc, Complete Living Care | 3.1 mi | ★★★★★ | 0 | 0 |
| Bridgewater Home , Inc. | 7.4 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of New Market | 18 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 October 2026) and official state health department websites.