Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Henrico Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Hot Water Supply: The facility failed to keep hot water available when the gas supply to the water heater ran low and the supplier did not refill the tanks as expected. The dish machine could not initially reach the required temperature, the dietary manager had to restart the load multiple times, and staff reported the lack of hot water affected resident areas, the kitchen, laundry, and public restrooms.
Loss of Hot Water Throughout Facility: The facility failed to maintain hot water when the gas feeding the water heater was low and the alarm notification did not alert the gas company as expected. Residents reported no hot water in their rooms and public bathrooms, and staff confirmed the outage affected resident areas, the kitchen, laundry, and public restrooms.
A resident with COPD, DM, and CHF had a care plan that included honoring meal preferences, but staff did not follow the posted menu and instead served simplified meals such as sandwiches and hot dogs. The resident and Resident Council reported cold food, repeated menu items, missing supper menus, hard bread products, and lack of utensils, and the cook acknowledged the menu was not followed.
Palatable Food Not Provided: A resident with COPD, DM, and CHF reported that meals were terrible and often consisted of sandwiches and hot dogs, and an observed breakfast tray included hard, unsplit English muffins that the resident said were too hard to eat. Resident Council minutes repeatedly documented complaints of cold food, the same items being served, hard bread products, and missing utensils, and a test tray showed lunch items served at only warm temperatures with coleslaw and ice cream at cold temperatures.
Kitchen Sanitation and Food Storage Deficiencies: Staff failed to maintain sanitary kitchen conditions during a tour. Observations showed dried food spills in the oven, wet nested loaf pans, sugar stored in a bin with trash, uncovered tuna salad sandwiches in the walk-in refrigerator, and vanilla ice cream stored next to raw hamburger in the freezer. The dietary manager acknowledged several of the storage and handling issues during the tour, and facility policies required proper dry storage, covered cold storage, and cleaning and sanitizing of food contact surfaces.
Improper Disposal of Garbage and Refuse: During a kitchen observation, the dumpster area outside the kitchen was found with the dumpster flaps pushed all the way back and debris on the ground, including gloves and diced fruit/vegetables. The dietary manager stated trash would be picked up later and that the flaps were hard to close because trash was being brought out from the kitchen and resident areas throughout the day. Facility policy required garbage and refuse to be collected and disposed of in a safe and efficient manner, and the exterior dumpster area to be kept free of rubbish or other debris.
Failure to Provide and Document Ordered Hospice Services: A resident with cancer, dementia, CKD, malnutrition, and severe cognitive impairment had a hospice POC calling for routine SN, aide, SW, and chaplain visits, but the chart contained no documentation of those visits as ordered. An LPN and the DON could not find hospice visit notes in the record, and the hospice provider later supplied only limited SN and aide documentation with no SW or chaplain visits.
A resident with COPD, DM, and CHF, who was cognitively intact and dependent for several ADLs, was not treated with dignity during a breakfast interaction. When he reported that hard, unsplit English muffins were too difficult to eat and asked for them to be toasted and split, the dietary manager responded loudly and defensively, told him he could split the muffin himself, and said not everyone gets butter. The resident later stated he felt intimidated, not respected, and not treated with dignity.
Resident room heat unit not functioning properly. A cognitively intact resident with multiple chronic diagnoses reported that the room heater had been blowing cold air for several weeks and that the issue had been mentioned to nursing several times without maintenance follow-up. The administrator, LPN, RN, and maintenance director all stated they were not aware of the problem until it was raised during survey interviews, and the maintenance director found the unit still was not producing heat.
A resident with multiple diagnoses, including dysarthria, lymphoma, DM, MDD, HTN, HLD, and cerebral infarction, had a room heat unit that reportedly ran but then blew cold air for several weeks. The resident said the issue had been reported to nursing, but no documentation was found in the chart, and staff interviews showed the administrator, maintenance director, LPN, RN, and CNA were unaware of the problem or the resident’s use of a portable electric heater. Surveyors observed the heater running beside the bed, and the maintenance director stated space heaters were not allowed in resident areas and were prohibited by life safety code.
Failure to provide respiratory care per physician order. A resident with chronic respiratory failure, COPD, CHF, and a history of pneumonia had an order for O2 at 2 L/min via NC, but staff observed the oxygen set at 3 L/min on multiple occasions. An RN acknowledged the discrepancy, and a progress note stated a family member had changed the O2 setting. The facility policy stated oxygen therapy will be administered per provider’s order.
A resident with multiple chronic conditions and severely impaired cognition was receiving trazodone 50 mg QHS for insomnia. The consultant pharmacist recommended a GDR, but the physician approved continuation of the dose without documenting a clinical rationale on the recommendation form; a progress note only stated the resident needed trazodone and that it was a low dose. An LPN and the DON confirmed the denial rationale was not documented.
Expired medications were found in the South Unit medication room during a surveyor inspection. An LPN confirmed that a bottle of Geri Dryl Allergy Relief Liquid and a tube of Venelex Wound Dressing were expired and needed to be discarded. Facility policy states outdated medications must be immediately removed from inventory and disposed of per medication disposal procedures.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
Two residents with intact cognitive abilities and significant medical conditions were subjected to repeated sexual comments, gestures, and advances by a receptionist, including explicit verbal statements and inappropriate physical behavior. Other staff and a transportation driver also experienced or witnessed similar conduct. The incidents were not immediately reported or addressed, resulting in substantiated harm and a failure to uphold residents' rights to be free from abuse.
Staff did not report incidents of sexual abuse involving a receptionist and multiple individuals to the administrator or authorities within the required two-hour window. The delay in reporting was confirmed through staff interviews and documentation, and the facility's own policy mandates immediate notification of such incidents.
A resident with multiple medical conditions and moderate cognitive impairment was transferred using a Hoyer lift by only one CNA, contrary to facility policy requiring two trained staff. During the transfer, the resident was struck in the head by the lift bar, resulting in a small hematoma. Interviews confirmed that the CNA proceeded alone after calling for help, and both facility policy and best practice guidelines mandate two staff for such transfers.
A resident with multiple medical conditions and moderate cognitive impairment was transferred using a Hoyer lift by a single CNA, contrary to facility policy requiring two trained staff. During the transfer, the lift became unstable and the resident was struck on the head by the sling bar, resulting in a small hematoma. Staff interviews and documentation confirmed that only one CNA was present, and the incident was reported and medically evaluated.
The facility failed to schedule sufficient nursing staff to ensure the highest practicable well-being of residents. A survey revealed that staffing had been an issue over the past year, although it had improved recently. Observations showed residents were well-cared for, but a review of CMS reports for 2024 indicated subpar staffing levels, particularly on weekends. The findings were communicated to the facility's administration.
A resident with multiple medical conditions was not informed of their care plan and rights upon admission to the facility. Despite having no cognitive impairment, the resident did not receive the admission contract and rights information until two days after admission, contrary to the facility's policy. The issue was noted by surveyors and discussed with the facility's administration.
A resident with moderate cognitive impairment was placed in an unfinished room undergoing renovation, resulting in a lack of a comfortable and homelike environment. The room had missing cove base, allowing cold air to enter, and was acknowledged by staff as inappropriate for occupancy. The facility cited a shipment error as the cause of the delay in completing the room.
A resident was discharged from an LTC facility with a Midline IV catheter still in place, increasing the risk of complications. The resident had severe cognitive impairments and required assistance with daily activities. The facility's staff failed to ensure the IV was removed before discharge, with interviews revealing a lack of awareness and communication among staff. The oversight was discovered after a family member reported it post-discharge.
A resident with diabetes and multiple health conditions did not receive appropriate diabetic management at the facility. The care plan was not updated to reflect changes in the resident's condition, and meals provided were not suitable for a diabetic diet. Blood sugar levels were not consistently monitored, and diabetic medications were omitted for a period without physician intervention. The facility's weight monitoring policy was not followed, and staffing levels were noted to be subpar.
Two residents experienced significant safety failures at an LTC facility. One resident, with severe cognitive impairment and a history of elopement, was allowed to smoke outside unsupervised, leading to multiple instances of leaving the facility grounds. Another resident was injured by a falling hammer due to maintenance staff negligence. These incidents highlight the facility's failure to provide adequate supervision and maintain a safe environment.
The facility failed to maintain a sanitary environment, with surveyors observing cockroaches near outdoor grills and a resident reporting mice in her room. The Maintenance Manager confirmed ongoing pest issues, despite weekly pest control treatments. The administrator and DON were informed of these findings.
The facility failed to maintain an effective pest control program, leading to the presence of mice and cockroaches in two units. Surveyors observed cockroaches near grills with food debris, and a resident reported mice in her room, confirmed by photographic evidence. The Maintenance Manager admitted to ongoing pest issues, with weekly treatments by a contractor, but the pest control log showed limited room treatments.
A resident experienced nine elopement or attempted elopement incidents over several months, but the facility staff failed to update the care plan with new interventions to address the issue. The care plan initially identified the resident as at risk for elopement, but despite the incidents, it was not revised. An LPN confirmed that care plans should be updated with any changes in resident care or condition.
Facility staff did not update a resident's care plan after a fall, as required by the facility's Falls Management Program. The resident fell on one occasion, but the care plan was not revised until after a subsequent fall. An RN confirmed that care plans should be updated after each fall, but this was not done in a timely manner.
The facility failed to provide adequate supervision for two residents who required supervision while smoking, as per their assessments. One resident was observed smoking with an oxygen tank without supervision, and another was in a designated smoking area without staff presence. Additionally, the facility did not implement interventions to prevent future falls for a resident who fell twice. The facility's policies on smoking and falls management were not followed, leading to these deficiencies.
A resident was administered Lasix despite having a systolic blood pressure below the physician-ordered parameter. The medication should have been held, but it was signed off as administered. A nurse confirmed the error, and the administrative staff was informed.
Failure to Maintain Hot Water Supply
Penalty
Summary
The facility failed to maintain the mechanical hot water heater in safe operating condition and failed to ensure hot water was available in the facility from 1/11/26 to 1/13/26. During observation of the kitchen dish washing station on 1/13/25 at 12:45 PM, the dish machine initially registered 155 degrees and the dietary manager restarted the load multiple times and drained the machine, but it still could not reach 165 degrees. The maintenance tech stated the delay in reaching the required temperature was due to the lack of hot water feeding the dish machine and said it was doubtful the 165 degrees could be reached. He also stated the lack of hot water started on 1/11/26 during the night to early morning because the gas supplier did not refill the tanks that feed the water heater and then the dish machine. The dietary manager stated that for the supper meal disposable dishes would be used until hot water was available. On 1/14/26 at 10:15 AM, the maintenance director stated the gas feeding the water heater was low, that the facility used an equipment alarm to notify the gas supplier when it reached 30%, and that the supplier had not received the electronic alarm notification. He stated there was an outstanding bill issue and that the supplier could not come out until 1/13/26. He also stated the lack of hot water affected resident areas, the kitchen, laundry, and public restrooms. The administrator, DON, and clinical compliance specialist/acting regional were informed of the concerns on 1/14/26 at 3:30 PM, and no policy was provided.
Loss of Hot Water Throughout Facility
Penalty
Summary
The facility staff failed to maintain a safe, functional, and comfortable environment when hot water was unavailable in the facility from 1/11/26 through 1/13/26. During initial resident observations on 1/13/26, multiple residents stated there was no hot water in the facility, and when hot water taps were turned on in resident rooms and public bathrooms, no hot water was present. On 1/13/26 at 11:05 AM, CNA #1 stated that the hot water had been out the previous night and that day, and that it may have started earlier, though this was the CNA's first day back. On 1/14/26 at 10:15 AM, the maintenance director stated he checked the boiler room on 1/11/26 and found the gas feeding the water heater was low. He stated the facility used equipment that notified AmeriGas when the level reached 30%, but he did not know why that did not occur. He also stated there was no emergency number to contact the gas company until Monday 1/12/26, that there was an outstanding bill issue, and that AmeriGas had not received the electronic alarm notification. He stated the lack of hot water affected resident areas, the kitchen, laundry, and public restrooms.
Menu Not Followed for Resident Meals
Penalty
Summary
The facility failed to follow the posted menu for one resident who was admitted with COPD, DM, and CHF and whose care plan noted risk for weight fluctuations, loss or malnutrition related to respiratory failure, CHF, severe morbid obesity, high BMI, lymphedema, and refusal to be weighed. The resident’s care plan also directed staff to honor meal preferences. During interview, the resident stated the menus were not followed and that staff did not cook much of the food, serving sandwiches and hot dogs and simply throwing food on the plate. The resident’s MDS showed full BIMS scoring and dependence for mobility-related care with set-up for eating. Resident Council minutes documented repeated complaints that food was cold, the same items were being served, the supper menu was not posted, meals seemed overly simplistic or “kid friendly,” and proper utensils were not provided. On the unit, the posted menus for the dates reviewed included items such as tuna salad sandwiches, hot dogs, chicken salad sandwiches, and spaghetti and meatballs, while the cook stated the facility was on Week 3 of the menu and acknowledged the menu was not followed. The cook said items may not have come in on the truck and was unsure of the ordering period, and also confirmed the menu had not been followed. The facility menu policy stated menus are served as written unless changed for preference, unavailability, or a special meal.
Palatable Food Not Provided
Penalty
Summary
The facility failed to provide palatable food for one resident who was admitted with COPD, DM, and CHF and whose most recent MDS showed a BIMS score of 15/15, dependence for mobility-related ADLs, and set-up for eating. The care plan identified the resident as at risk for weight fluctuations, loss, or malnutrition and included honoring meal preferences. During interview, the resident stated the food was terrible, that the facility did not cook much of the food, and that meals were often sandwiches and hot dogs that were just thrown on the plate. When the resident’s breakfast tray was observed, the resident had already eaten two hard boiled eggs and was finishing cereal, and the English muffins on the tray were brown, hard, and unsplit; the resident stated they were too hard to eat and asked for them to be toasted and split. Resident Council minutes documented repeated complaints that food was cold, the same items were served, menus were not posted, utensils were not proper, and bread products such as English muffins were too hard to eat. During a test tray, lunch items were measured at 107 degrees for the hot dog, 121 degrees for baked beans, 39 degrees for coleslaw, and 27 degrees for ice cream, and the food was described as palatable but only warm in temperature. At a later Resident Council meeting, residents again discussed cold meals, sandwiches, soup not being offered, hard bread products, and chicken tenders that were too hard to bite into; several residents also stated they did not receive a knife to cut food.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility staff failed to maintain the kitchen in a sanitary manner. During a kitchen observation, the bottom oven had dried food spills, two loaf pans were wet and nested together, a 25-pound bag of sugar was stored in a bin with trash such as wrappers and papers, and a tray of tuna salad sandwiches in the walk-in refrigerator was covered only with parchment paper with all four sides exposed to the air. In the chest freezer, a 5-gallon vanilla ice cream carton was stored next to raw hamburger in plastic wrap. The dietary manager accompanied the kitchen tour and was interviewed about each finding. The dietary manager stated the oven was cleaned every other day and the spill must have been from the prior day, said the loaf pans were staggered so they could dry thoroughly, acknowledged the sugar should not have been stored in a bin with trash, stated the sandwiches were prepped for lunch and would be wrapped if sent to the unit, and said the raw meat was being considered for use before deciding to throw it away. Facility policies reviewed stated dry goods must be stored in accordance with FDA Food Code guidance, cold food items must be stored in covered containers and arranged to prevent cross contamination, and utensils and food contact surfaces must be cleaned and sanitized after every use.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of refuse properly and did not maintain a clean dumpster area during a kitchen observation. During an observation of the dumpster area outside the kitchen, the dumpster top flaps were pushed all the way back, and on the ground to the left of the dumpster were black and white gloves and diced fruit/vegetables. When asked about the findings, the dietary manager stated that trash would be picked up later that day and then the area would be swept, and explained that the dumpster flaps were hard to close because trash was being brought out from the kitchen and resident areas throughout the day. The administrator, DON, and clinical compliance specialist/acting regional were informed of the concerns, and the facility policy stated that garbage and refuse are to be collected and disposed of in a safe and efficient manner and that the exterior dumpster area is to be maintained free of rubbish or other debris.
Failure to Provide and Document Ordered Hospice Services
Penalty
Summary
The facility failed to arrange for hospice services or assist with transfer to a facility that would arrange hospice services for one resident who had diagnoses including atherosclerosis, diabetes, lung cancer, adult failure to thrive, protein-calorie malnutrition, chronic kidney disease, major depressive disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and insomnia. The resident’s MDS assessed severely impaired cognitive skills, and the clinical record showed a physician’s order for hospice services and a plan of care for hospice due to cancer. The resident’s hospice plan of care called for a skilled nurse visit once per week with additional visits as needed, hospice aide visits twice per week, a social worker visit once per month, and a chaplain visit once per month with additional visits as needed. Review of the clinical record found no documentation of hospice nurse, aide, social worker, or chaplain visits as listed in the hospice plan of care. An LPN caring for the resident stated hospice nurses and aides usually left notes in a designated book, but no such book was found at the nursing desk and she had no notes from the hospice provider; she also stated she did not recall routine visits and had not seen hospice aides in the facility. The DON likewise found no hospice notes in the resident’s chart and medical records had no visit notes from the hospice agency. After the DON requested records, the hospice provider sent copies showing only two nurse practitioner visits, one skilled nurse visit, and two hospice aide visits since 11/1/25, with no social worker or chaplain visits documented. The hospice contract stated the hospice would provide services called for in the hospice plan of care and that all IDG members would document care and services provided at each visit.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to promote dignity and respect for Resident #55, who was admitted with diagnoses including COPD, diabetes mellitus, and CHF. The resident’s most recent annual MDS coded him as cognitively intact with a BIMS score of 15 out of 15, dependent for mobility, transfers, bathing, and dressing, and set-up for eating. His care plan noted he was at risk for weight fluctuations, loss, or malnutrition, refused to be weighed, and requested large portions, with an intervention to honor resident meal preference. During observation of breakfast, the resident had eaten two hard boiled eggs and was finishing cereal when he asked for the cloche to be lifted and requested the English muffins be picked up because they were hard and unsplit. The dietary manager entered the room and immediately stated the reason he did not get scrambled eggs was because he wanted hard boiled eggs, then spoke in a loud voice when questioned about the hard English muffins, stating the facility gives residents what they want and that the muffins were not hard when they left the kitchen. The resident stated the muffin was too hard to eat, that he had his teeth, and asked why it was not split, toasted, and buttered. The dietary manager responded that he could split the muffin himself and that not everyone gets butter. The resident later stated the interaction was “b--- s---,” that the staff member tried to intimidate him, and that he did not feel respected or treated with dignity. The administrator, DON, and clinical compliance specialist/acting regional were informed of the concerns, and the facility policy stated residents are to be free from verbal abuse and treated with consideration, respect, and full recognition of dignity and individuality.
Resident Room Heat Unit Not Functioning Properly
Penalty
Summary
Facility staff failed to provide a comfortable, homelike room environment for one resident when the heat unit in the resident’s room had not been functioning properly for several weeks. The resident was admitted with diagnoses including dysarthria, lymphoma, diabetes, major depressive disorder, hypertension, hyperlipidemia, and cerebral infarction, and the MDS assessed the resident as cognitively intact. During interview, the resident stated the room heat unit would run and then blow cold air, and that the room was sometimes cool because the heat did not stay on. The resident also stated the problem had been reported to nursing several times, but maintenance had not worked on the unit. The administrator stated she was not aware of the problem until it was brought to her attention. The maintenance director stated he was asked to check the unit after the concern was raised, reset it, and found that it did not continue functioning and was not producing heat the next morning. He stated he had not received any verbal reports or work orders about the unit before that time and noted that the facility’s heat units were old and being replaced throughout the facility. The LPN caring for the resident and the RN assigned to management rounding both stated they had not been informed of any problem with the room heat unit.
Unsafe Room Heating and Unauthorized Space Heater Use
Penalty
Summary
Facility staff failed to maintain a safe room environment for one resident when a portable electric heater was found in use in the resident’s room. The resident was admitted with diagnoses including dysarthria, lymphoma, diabetes, major depressive disorder, hypertension, hyperlipidemia, and cerebral infarction, and the MDS assessed the resident as cognitively intact. During interview, the resident stated the room heat had not been working properly for several weeks, that the unit would run and then blow cold air, and that the room was sometimes cool because the heat did not stay on. The resident said the issue had been reported to nursing several times, but maintenance had not worked on the unit, and the resident had purchased and used an electric heater when the room felt cool. A small electric heater was observed on the floor beside the resident’s bed while it was running and blowing warm air. The resident stated staff had told him not to use the heater because it was a safety issue, but he did not think staff knew he was using it. Review of the clinical record showed no documentation of reported problems with the room heat during the prior several weeks. Interviews with the administrator, maintenance director, LPN, RN, and CNA indicated none of them were aware of the heater or the heating problem before the survey observation, and the maintenance director stated space heaters were not allowed in resident areas and that life safety code regulations prohibited their use in resident living/use areas.
Failure to Provide Oxygen Therapy Per Physician Order
Penalty
Summary
The facility failed to provide respiratory care services for one resident with chronic respiratory failure, atrial fibrillation, and CHF. The resident’s comprehensive care plan identified a risk for respiratory complications related to COPD, respiratory failure, supplementary oxygen requirement, and a history of pneumonia and congestion, with an intervention to administer oxygen as ordered. The physician order dated 1/12/26 specified oxygen at 2 liters per minute via nasal cannula, and the January TAR documented oxygen at 2 liters per minute on 1/13/26 for day, evening, and night shifts. However, observations on 1/13/26 and 1/14/26 showed the oxygen set at 3 liters per minute. During an interview, RN #3 observed the oxygen at 3 LNC, stated it was ordered for 2 LNC, and said she would check the orders and change it. A progress note later documented that the resident’s oxygen had been changed by a family member to 3 L/min, and the family member was informed of the doctor’s order and the oxygen was changed back to 2 L/min. The facility’s Respiratory Care & Oxygen Equipment policy stated oxygen therapy will be administered per provider’s order.
Failure to Document Rationale for Denied GDR of Trazodone
Penalty
Summary
The facility failed to document a clinical rationale for denying a recommended gradual dose reduction of trazodone for one resident. The resident had diagnoses including atherosclerosis, diabetes, lung cancer, adult failure to thrive, protein-calorie malnutrition, chronic kidney disease, major depressive disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and insomnia, and the MDS assessed the resident with severely impaired cognitive skills. The resident had a physician’s order for trazodone 50 mg at bedtime for insomnia, and the medication was administered as ordered. The consultant pharmacist issued a recommendation asking whether a dose reduction could be attempted because the resident had been taking trazodone 50 mg nightly without a GDR. The physician responded to continue trazodone 50 mg but did not document any reason on the recommendation form why the dose reduction was not approved. A physician progress note stated the nurse was discussed with, that the resident’s Seroquel had recently been stopped, that she needed trazodone, and that it was a low dose, but it did not document a clinical contraindication for the denied dose reduction. The LPN and DON confirmed the physician did not document the reason for denying the dose reduction on the pharmacy recommendation form, and no additional rationale was provided during the survey.
Expired Medications Found in South Unit Medication Room
Penalty
Summary
The facility failed to ensure medications used in the South Unit medication room were within expiration date. During an inspection of the medication room with an LPN, surveyors found one bottle of Geri Dryl Allergy Relief Liquid with an expiration date of 4/2025 and one tube of Venelex Wound Dressing with an expiration date of 2/2025. When the expired medications were shown to the LPN, she stated they needed to be discarded because they were expired. The facility policy on storage of medications states that outdated, contaminated, or deteriorated medications are to be immediately removed from inventory and disposed of according to medication disposal procedures.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Sexual Abuse by Staff Member
Penalty
Summary
Facility staff failed to protect two residents from sexual abuse, resulting in harm. One resident, with diagnoses including mechanical complications of a hip prosthesis, chronic kidney disease, and major depressive disorder, was cognitively intact and reported multiple inappropriate sexual comments and gestures from a receptionist. These included explicit verbal statements, the display of a sexually explicit image, and suggestive gestures such as blowing kisses and making smacking sounds. The resident reported these incidents to the Activities Assistant and expressed feelings of humiliation, anger, and emotional distress during interviews. A second resident, also cognitively intact and with diagnoses such as metabolic encephalopathy, cirrhosis, muscle wasting, and end-stage renal disease, reported that the same receptionist made explicit sexual comments on more than one occasion, including while the resident was being informed about transportation. The receptionist also attempted to lure the resident into a darkened office. These incidents were corroborated by staff interviews and a closed record review. Additional staff members, including a CNA and a Transportation Driver, reported similar inappropriate sexual advances and physical attempts by the receptionist. The CNA did not immediately report the incident to management, only disclosing it when questioned days later. The facility's policy clearly states that residents have the right to be free from all forms of abuse, including sexual abuse, but staff failed to prevent or promptly address the receptionist's actions, resulting in substantiated harm to multiple individuals.
Failure to Timely Report Sexual Abuse Allegations
Penalty
Summary
Facility staff failed to ensure that an incident involving sexual abuse was reported to the facility administrator and appropriate authorities within the required two-hour timeframe. On 3/29/25, a transporting driver and a CNA experienced inappropriate sexual behavior from a receptionist, including attempts to touch the driver in a sexual manner and making inappropriate noises toward the CNA. The CNA did not report these incidents to management until several days later, on 4/2/25, when questioned by the DON. The facility's policy requires immediate reporting of abuse allegations, no later than two hours after the incident. The delay in reporting was confirmed through staff interviews and review of written statements. The administrator acknowledged that a facility-reported incident was eventually filed and that sexual abuse was substantiated for four individuals. However, documentation showed that the report to the Office of Licensure and Certification was not made until 3/31/25, and the initial internal reporting by staff did not occur within the required timeframe, constituting a failure to follow established abuse reporting protocols.
Failure to Follow Two-Staff Protocol During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to follow professional standards of quality by not ensuring that two trained staff members assisted with mechanical lift transfers for a resident. The resident, who had multiple diagnoses including chronic kidney disease, diabetes with kidney complications, hemiplegia, and muscle weakness, was cognitively moderately impaired according to a recent MDS assessment. During an incident, the resident was being transferred with a Hoyer lift by a single CNA, contrary to facility policy and best practice, which require two trained staff for such transfers. The resident reported being struck in the head by the Hoyer lift bar during the transfer, resulting in a small hematoma. Interviews with the resident, CNA, and DON confirmed that only one staff member was present during the transfer and that the incident occurred when the lift became unstable. The CNA acknowledged that standard protocol requires two staff for mechanical lift transfers and that she had called for help but proceeded alone when no one responded. Facility policy, as well as external best practice guidelines, specify the need for two trained staff to ensure safe operation and positioning during mechanical lift use. The facility leadership confirmed the policy and had no additional information to provide regarding the incident.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide the required two-person assistance during a mechanical lift transfer for a resident with multiple medical conditions, including chronic kidney disease, diabetes with kidney complications, hemiplegia, and muscle weakness. The resident, who had moderately impaired cognitive abilities, was being transferred by a CNA using a Hoyer lift when the lift's leg became caught on a roommate's bed, causing the lift to tip. During this incident, the resident was struck on the head by the Hoyer lift sling bar, resulting in a small hematoma. The CNA admitted to performing the transfer alone after calling for help and receiving no response, despite facility policy requiring two trained staff for such transfers. Interviews with staff confirmed that only one CNA was present during the transfer, and both the DON and other nursing staff acknowledged that this was not in accordance with standard protocol. Documentation in the clinical record and facility forms corroborated the resident's report of being hit in the head and the subsequent development of a hematoma. The incident was further substantiated by medical notes and an emergency department evaluation, which found no acute injuries but confirmed the occurrence of head trauma. The facility's mechanical lift policy explicitly states that two trained staff must assist with mechanical lift transfers, which was not followed in this case.
Insufficient Nursing Staff Scheduling
Penalty
Summary
The facility staff failed to schedule sufficient nursing staff to maintain the highest practicable well-being of each resident. During a survey conducted from February 19 to February 25, 2025, a complaint regarding insufficient nursing staff was investigated. Although the complaint was initially received by the state agency on February 8, 2024, no specific dates or date ranges were provided for the alleged staffing issues. Interviews with residents and nursing staff revealed that staffing had been problematic at times over the past year, but had improved in recent months. Observations during the survey showed residents dressed in clean clothing, no pervasive odors, and residents engaged in activities, therapies, and leisure activities. A review of residents' clinical records indicated that care, including activities of daily living, medication administration, therapies, and dining activities, was ongoing and appeared sufficient at the time of the survey. Staffing schedules and time clock punches were also reviewed and found to be adequate currently. However, a review of CMS payroll-based journal submissions and CMS Compare reports for fiscal year 2024 revealed that the facility had received a one-star rating out of five for staffing levels, indicating subpar staffing during that period, with particularly low staffing on weekends in the third and fourth quarters of 2024. The findings were communicated to the Administrator and corporate representatives at the end of the survey on February 24, 2025.
Failure to Inform Resident of Rights and Care Plan Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was informed, in advance, of the care to be provided and their rights upon admission. This deficiency was identified for one resident in a survey sample of 12. The resident, who had a range of medical conditions including Type 2 diabetes, kidney transplant status, end-stage renal disease, pulmonary hypertension, nutritional anemia, and multiple rib fractures, was admitted to the facility. Despite having no cognitive impairment, as indicated by a perfect score on the Brief Interview for Mental Status, the resident was not provided with the admission contract and rights information until two days after admission. The Director of Nursing stated that the admission packet is typically discussed and forms signed upon admission or within 24 hours if the admission occurs after hours. However, a review of the facility's Admission Policy indicated that the Admission Director is responsible for ensuring all documents are completed, copied, and filed appropriately at the time of admission. The discrepancy between the policy and the actual practice led to the resident not being informed of their rights and care plan in a timely manner. This issue was brought to the attention of the Administrator and Director of Nursing during an end-of-day meeting, but no further information was provided.
Resident Placed in Unfinished Room During Renovation
Penalty
Summary
The facility staff failed to provide a comfortable and homelike environment for Resident #5, who was admitted on February 11, 2025, with diagnoses including a wedge compression fracture, type 2 diabetes mellitus, major depressive disorder, and muscle weakness. The resident's cognitive abilities were moderately impaired, as indicated by a BIMS score of 12 out of 15. During an observation on February 18, 2025, it was noted that the cove base was missing around the entire perimeter of the resident's room and bathroom, allowing cold air to flow into the room. Resident #5 expressed dissatisfaction with the room's condition, stating that it felt unfinished and cold. Interviews with facility staff revealed that the room was under renovation and had been in its current state for about a month. The Maintenance Director acknowledged that the room was not appropriate for a resident due to its condition. The Regional Maintenance Director explained that the delay in completing the room was due to a shipment error of materials. The Administrator admitted that the room was the only available option for Resident #5 at the time of admission, but declined to comment on its appropriateness. Despite the facility's claim that the issues were resolved, the report highlights the deficiency in providing a safe and comfortable environment for the resident.
Failure to Discontinue Midline IV Before Resident Discharge
Penalty
Summary
The facility failed to properly discontinue a Midline Intravenous Catheter before discharging a resident, identified as Resident #12, which increased the risk of complications such as infections, bleeding, and dislodgement. Resident #12 was admitted to the facility with diagnoses including bacterial infections and a femur fracture, and was noted to have severely impaired cognitive abilities. The resident required various levels of assistance for daily activities and was at risk for pressure ulcers. The resident was receiving hydration therapy through a Midline IV catheter, which was not removed prior to discharge. The timeline of events indicates that the Midline IV was intermittently present and absent in the resident's medical records, with no clear documentation of its removal before discharge. Interviews with facility staff revealed a lack of awareness and communication regarding the presence of the Midline IV. A CNA did not notice the IV on the day of discharge, and an LPN confirmed the presence of the Midline IV but was not involved in the discharge process. The Assistant Director of Nursing (ADON) acknowledged that the IV should have been removed by a Registered Nurse, but the abrupt discharge due to a change in transportation plans may have contributed to the oversight. The Director of Nursing (DON) confirmed that the facility was informed by a family member about the oversight after the resident was discharged. The DON and ADON discussed the incident but did not document it due to the closure of the resident's chart. The report highlights the procedural lapse in ensuring the Midline IV was discontinued, as well as the communication breakdown among staff members involved in the discharge process.
Failure in Diabetic Management and Care Plan Updates
Penalty
Summary
The facility staff failed to maintain industry standards of diabetic management for a resident with multiple health conditions, including diabetes mellitus, morbid obesity, and congestive heart failure. The resident's care plan was not updated to reflect significant changes in their condition, such as the removal of diabetic medication management, therapeutic diet, and blood sugar checks. Despite the resident's worsening respiratory illness and significant weight gain, there was no assessment or monitoring conducted, and the care plan was not adjusted accordingly. The resident's meals were not aligned with their dietary needs, as observed during interviews and meal observations. The resident expressed dissatisfaction with the meals provided, which were high in carbohydrates and not in line with a diabetic diet. The facility's dining services staff acknowledged that the meals were inappropriate for a morbidly obese diabetic resident. Additionally, the resident's blood sugar levels were not consistently monitored, and there was a period where diabetic medications were omitted without physician intervention. The facility's policy on weight monitoring was not followed, as the resident was not weighed monthly, and there was no documentation of refusals until much later. The lack of proper assessments and updates to the care plan, along with the failure to provide appropriate meals and medication management, contributed to the deficiency. The facility's staffing levels were also noted to be subpar, which may have impacted the quality of care provided to the resident.
Supervision and Safety Failures Lead to Resident Elopement and Injury
Penalty
Summary
The facility staff failed to ensure adequate supervision and safety for two residents, leading to significant deficiencies. Resident #3, who had severe cognitive impairment and a history of elopement, was allowed to smoke outside unsupervised. Despite being assessed as high risk for elopement, the resident was able to leave the facility grounds multiple times, sometimes purchasing alcohol or wandering off to nearby stores. The facility's wander guard system was bypassed by staff, allowing the resident to exit the building without proper supervision, which posed an immediate jeopardy to the resident's safety. Resident #3's clinical records revealed numerous instances of elopement, with the resident leaving the facility unsupervised on several occasions. The resident's cognitive impairments and history of alcohol dependence further exacerbated the risk of harm. Despite these risks, the facility failed to implement effective measures to prevent the resident from leaving the premises, resulting in repeated incidents of elopement and potential harm. In a separate incident, Resident #4 was injured when a hammer fell from the roof, striking the resident on the head. The maintenance staff had failed to remove tools from the roof after repairs, leading to this accident. Resident #4, who had no cognitive impairment, required emergency room evaluation following the incident. The facility's failure to ensure a safe environment and remove potential hazards resulted in this preventable accident.
Sanitation and Pest Control Deficiency
Penalty
Summary
The facility failed to maintain a sanitary environment for residents, staff, and the public, as observed during a survey conducted on 9/3/2024. During the initial tour, three grills were found outside a wing of the facility, with soiled aluminum foil sheets and food debris on the grates. Large cockroaches were seen near the grills, indicating a pest issue. The grills remained in place until 9/5/2024, despite the administrator being informed of the findings. Additionally, a resident's family member reported a rodent issue in her mother's room, with mice observed running from the bathroom to a hole under the sink. The family member provided photographic evidence of the mice. Further investigation revealed a small hole under the sink and a medium-sized hole in the bathroom of the resident's room, with traps set to capture rodents. The Maintenance Manager acknowledged ongoing issues with mice and insects, noting that a pest control contractor visits weekly to treat common areas and specific rooms. The pest control log confirmed recent treatments in several rooms, including the affected resident's room. The administrator and Director of Nursing were informed of these findings on 9/4/2024.
Ineffective Pest Control Program
Penalty
Summary
The facility staff failed to maintain an effective pest control program, resulting in the presence of pests, including mice and cockroaches, in two units of the facility. During an initial tour, surveyors observed several large cockroaches near grills outside a unit, with food debris present on the grills. The grills remained in place for two days after the issue was reported to the administrator. Additionally, a resident's family member reported seeing mice in her mother's room, with the resident confirming the presence of multiple mice and capturing photographic evidence. A subsequent inspection of the room revealed holes under the sink and in the bathroom, along with traps set for pests. The Maintenance Manager acknowledged ongoing issues with mice and insects, stating that a pest control contractor visits weekly to treat common areas and specific rooms. However, the pest control log indicated that recent treatments were limited to certain rooms and common areas, suggesting a lack of comprehensive pest management. The administrator and Director of Nursing were informed of these findings, but no further information was provided regarding corrective actions or follow-up measures.
Failure to Update Care Plan After Elopement Incidents
Penalty
Summary
The facility staff failed to review and revise the care plan for a resident after multiple incidents of elopement or attempted elopement. The resident experienced nine such incidents between May 23, 2024, and August 23, 2024. The care plan initially identified the resident as being at risk for elopement due to exit-seeking behavior, with goals and interventions set to monitor and prevent elopement. However, despite these incidents, the care plan was not updated to include new interventions to address the recurring issue. An interview with an LPN confirmed that care plans should be updated with any changes in resident care or condition, including elopement incidents. The deficiency was brought to the attention of the Administrator during an end-of-day meeting, but no further information was provided.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan for Resident #4 after the resident sustained a fall on 3/30/24. A nurse's note documented that the resident slid out of bed on that date, but the care plan, dated 3/13/24, was not updated to reflect this incident until after the resident experienced another fall on 4/19/24. During an interview, RN #3 stated that care plans should be reviewed and revised after each fall, typically during the shift of the incident or the following day. The facility's Falls Management Program policy requires a licensed nurse to review, revise, and implement interventions to the care plan based on post-fall investigation findings, device assessment review, and fall risk scoring tool review. However, this protocol was not followed for Resident #4's fall on 3/30/24.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility staff failed to provide adequate supervision for two residents who were assessed as requiring supervision while smoking. Resident #10 was observed smoking a cigarette outside the facility with an oxygen tank attached to their wheelchair, without any staff supervision. The resident's smoking assessment indicated a need for supervision, but the care plan incorrectly allowed for independent smoking. Similarly, Resident #11 was observed smoking in the designated smoking area with an oxygen tank turned off, but without staff supervision. The resident's assessment also required supervision, yet the care plan permitted independent smoking. Additionally, the facility staff did not implement interventions to prevent future falls for Resident #4, who experienced two falls within a short period. The resident first slid out of bed, and despite this incident, no interventions were documented or implemented to prevent further falls. Consequently, the resident fell again a few weeks later. The facility's falls management program requires a systematic approach to address falls, including revising and implementing interventions based on post-fall investigations, but this was not followed. Interviews with the director of nursing and a registered nurse confirmed the lack of appropriate supervision and intervention. The director of nursing acknowledged the need for supervision for residents using oxygen while smoking, and the registered nurse stated that interventions should be implemented after a fall, tailored to the resident's cognitive status and the circumstances of the fall. The facility's policies on smoking and falls management were not adhered to, leading to these deficiencies.
Failure to Hold Medication as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medication, specifically in the administration of Lasix (furosemide), for one of the residents in the survey sample. The physician's order required that the medication be held if the resident's systolic blood pressure was less than 110. However, the resident was administered furosemide on two occasions, despite having systolic blood pressures of 103 and 99, respectively, as documented in the medication administration records (MARs). This indicates that the medication was not held as per the physician's parameters. During an interview, a registered nurse confirmed that the medication should have been held on those occasions and acknowledged that it appeared to have been administered instead. The facility's pharmacy policy mandates that medications be administered according to the prescriber's written orders, which was not adhered to in this case. The administrative staff, including the administrator and the director of nursing, were informed of this concern.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 250 citations issued within 25 miles in the last 12 months — including the 13 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Highland Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hanover Health And Rehabilitation Center | 5.8 mi | ★★★★★ | 5 | 1 |
| Covenant Woods Nursing Home | 5.9 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Mechanicsville | 6.3 mi | ★★★★★ | 0 | 0 |
| Vcu Health Children's Services At Brook Road | 7.8 mi | ★★★★★ | 0 | 0 |
| The Virginia Home | 8.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.