Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kings Daughters Community Health & Rehab during CMS and state inspections, most recent first.
No licensed nurse was available on a wing for about 12 hours after an LPN left without proper report or narcotic count and no relief nurse took over. Residents reported missed meds, untreated pain, insomnia, anxiety, and distress, and MARs showed bedtime meds were not signed off for multiple residents.
An LPN left a unit without giving report, completing a narcotic count, or ensuring another nurse was present, leaving residents without licensed nurse coverage for about 12 hours. During that time, residents did not receive scheduled bedtime meds, including pain and sleep medications, and staff confirmed no nurse assumed responsibility for the unit overnight. Residents reported untreated pain, missed meds, and distress from having no nurse available.
Failure to provide nighttime pain medication: Residents on one wing went without an LPN for about 12 hours, and three residents reported waiting all night for their meds. MARs showed no nurse signatures for bedtime meds, including pain meds such as Tylenol, Gabapentin, Oxycontin ER, and Tramadol, and residents said they could not sleep or had ongoing pain because the meds were not given.
A resident assessed at moderate risk for pressure injuries developed in-house acquired heel, sacral, and buttocks wounds after ordered prevention measures were not consistently implemented. The record showed a pressure-reducing mattress and wheelchair cushion were ordered, but they were not documented on the treatment record for months, and wound physician off-loading recommendations were not carried out on the care plan or TAR. During wound care and interview, the resident's heels were observed not being off loaded until an LPN later placed a pillow under the legs, and the wounds were later documented as worsening and infected.
A unit was left without an LPN for about 12 hours after the scheduled nurse left without giving report or completing a narcotic count, and the medication cart keys were left on the cart in the narcotic logbook. Staff later confirmed no nurse came in to cover the unit, and residents reported missed pain meds, waiting all night for medications, and being upset and scared by the lack of nursing presence.
An LPN left the west wing without giving report or completing the narcotic count, and no licensed nurse was present on the unit overnight. Residents reported missed bedtime meds, unanswered requests for pain relief, and waiting all night for medications, while MAR review showed no nurse signatures for several scheduled and PRN meds. One resident also reported a pain cream was not applied, and staff described the situation as unsafe because there was no nurse to take over the med cart.
Staff failed to follow infection control practices when gloves were worn in the hallway and a resident’s Foley drainage bag was found on the floor under an over-bed table and excessively full. A CNA stated the bag should have been hanging on the bed frame and needed to be emptied, while other CNAs confirmed gloves should not be worn in hallways. The facility’s policy required Standard Precautions, including hand hygiene and proper PPE use.
Failure to Protect Residents After Allegation of Neglect: An LPN reported that an evening nurse left without giving report or counting narcotics, and no nurse was available on the unit overnight to administer medications. Residents stated they waited for bedtime meds and pain relief, were upset about not having a nurse, and some sought help on another unit. MAR review showed missed bedtime medications for multiple residents, and facility policy defined this type of failure to provide needed care as neglect.
Failure to report an allegation of neglect occurred when an LPN left without report, narcotic count, or cart keys after the relieving nurse called out, and no nurse covered the west wing medication cart until the next morning. Residents reported waiting all night for meds, including pain meds, and MARs showed no nurse signatures for scheduled bedtime medications. The DON stated she did not complete a formal investigation and relied only on the grievance form.
Failure to Investigate Allegation of Neglect: An LPN left the medication cart without a proper handoff, narcotic count, or secure keys, and no nurse covered the west wing overnight. The DON did not complete a formal investigation and relied on the grievance form, while residents reported delayed or missed medications and pain medication requests with no nurse available.
Failure to Include Ordered Pressure Injury Interventions in Care Plans: Two residents had care plans that did not reflect ordered pressure injury prevention and wound interventions. One resident had a pressure-reducing mattress and wheelchair cushion ordered, but these were not added to the care plan despite a Braden score indicating skin injury risk. Another resident’s care plan initially lacked pressure prevention interventions, and ordered mattress and wheelchair cushion support were not timely reflected in the care plan or treatment record; later wound guidance included off-loading, but it was not added to the care or treatment plan.
An RN did not clearly pronounce a resident’s death in the record, and there was no physician order or documented authorization to release the body to the funeral home. Staff interviews showed the LPNs and DON understood that an RN was required to pronounce death, document the assessment and time of death, notify the physician, and obtain an order for body release, but the chart lacked documentation that these steps occurred.
Incomplete and inaccurate nurse staffing postings were identified when surveyors requested daily staffing information and several days were not provided. The social worker director stated the daily nursing postings were kept at the time clock and later supplied staffing reports, but the posting reviewed for one day did not include an LPN who was actually working as charge nurse on the west wing unit.
A licensed nurse was not present on a unit for about 12 hours, and residents reported they could not get scheduled or PRN medications during the night. MAR review showed missing signatures and missed bedtime meds for multiple residents, including pain, sleep, cardiac, anxiety, and spasm medications. The DON said she relied on the MAR and narcotic count and did not complete a formal investigation.
Broken Dresser Not Maintained in Safe Condition: A resident’s dresser drawer fell apart while in use, leaving belongings on the floor and striking the resident’s knee. The resident said she had asked several times for the dresser to be replaced because multiple drawer facings came off when opened. The maintenance director said he had assumed she wanted an additional dresser and had not checked the unit, and the dresser was not maintained in safe and functional condition before the surveyor observed it.
The facility did not have an RN on duty for at least 8 consecutive hours on three days, as confirmed by the nursing schedule and staff interviews. The DON reported that the usual weekend RN was on medical leave and there were not enough RNs available, despite having an abundance of LPNs.
Facility staff failed to follow physician orders for medication administration, resulting in multiple medication errors. These included a nurse administering the wrong dose of methadone to a resident, an LPN giving an IV antibiotic at the incorrect time to another resident, a resident receiving another individual's medications including a cancer drug, and a resident being given Percocet instead of prescribed oxycodone. In each case, the errors were documented, the residents were monitored, and no acute changes in condition were observed.
An LPN administered Breo Ellipta inhalation powder to a resident with COPD but did not prompt the resident to rinse and spit their mouth after use, as required by the medication's instructions to reduce the risk of oropharyngeal candidiasis. The LPN acknowledged not providing the prompt, citing the resident's lack of cooperation. This failure to follow professional standards was confirmed during observation and interview.
A resident with multiple medical conditions received treatment for head lice, but staff failed to document the assessment, provider notification, and actions taken in the clinical record. Interviews with LPNs confirmed that required documentation was missing despite treatment being initiated.
An LPN was observed handling oral medications with bare hands during a medication pass for a resident, contrary to facility policy and infection control protocols. The LPN acknowledged the improper practice, and both the unit manager and infection preventionist confirmed that direct hand contact with medications is not allowed. Facility policy requires the use of a medicine cup rather than hands when administering medications.
A resident was scheduled to receive telmisartan 40 MG for hypertension, but the medication was unavailable during a medication pass. An LPN discovered the absence of the medication and contacted the pharmacy to reorder it. The DON and physician were notified, and an order was given to hold the medication until it arrived. The issue arose because the pharmacy sent 20 MG tablets, leading to a shortage. A blood pressure reading showed the resident's blood pressure at 149/71.
No Licensed Nurse Coverage on Unit Overnight
Penalty
Summary
The facility failed to ensure licensed nursing services were available on the [NAME] Wing nursing unit for approximately 12 hours overnight, from about 7:47 p.m. on 1/31/26 until 7:00 a.m. on 2/1/26. During that time, no licensed nurse was available on the unit to provide resident assessments, medication administration, monitoring, physician notification, nursing intervention, or emergency response for the 39 residents living there. The incident occurred after the nurse assigned to the unit left early without giving report to a relief nurse or completing a narcotic count with another nurse. One LPN stated that the nurse who was supposed to relieve her called out at the last minute, leaving no nurse to take report, count narcotics, take the medication cart keys, or assume responsibility for resident care on the unit. The same LPN stated that no nurse came into the facility that night and that there was no nurse on the west wing medication cart until the first-shift nurse arrived the next morning. Residents described missed medications, pain, and distress during the period without nursing coverage. One resident stated she waited all night for medications and was upset that the nurse had left. Another resident reported requesting pain medication several times during the night but receiving none, and said she could not go back to sleep because of pain. A third resident stated she was awake all night waiting for medications and said 12 hours was a long time to go without them. Record review showed no nurse signatures on the bedtime MARs for these residents, including missed or unsigned medications such as melatonin, tizanidine, Tylenol, gabapentin, trazodone, flecainide, oxycontin ER, buspar, metoprolol, and tramadol.
Failure to Maintain Licensed Nurse Coverage on a Nursing Unit
Penalty
Summary
The facility failed to ensure sufficient licensed nursing staff on the west wing, leaving one of the nursing units without a licensed nurse for approximately 12 hours. The unit manager, an LPN, left the unit and clocked out without another nurse present to provide resident coverage, administer medications, complete a narcotic count, or receive report. The medication cart keys were left in the narcotic logbook on top of the cart, and no oncoming nurse arrived until the next morning. During the overnight period, residents on the unit did not have access to licensed nursing assessment, medication administration, or nursing intervention in response to changes in condition or emergencies. Interviews with staff confirmed that no nurse assumed responsibility for the unit that night. One LPN reported that the scheduled nurse called out at the last minute, that she contacted the DON and administrator for guidance, and that she was told to take the medication cart keys even though no resident report had been given and no narcotic count had been completed. She stated no licensed nurse came into the facility that night to assume responsibility for the unit, medication cart keys, or medication administration coverage. Resident interviews confirmed negative outcomes during the period without nurse coverage. One resident reported not receiving bedtime pain medication and said it was upsetting when there was no nurse. Another resident stated she requested pain medication several times during the night and could not sleep because of pain. A third resident stated she waited all night for medications and was upset that the nurse had left. Clinical record review showed no nurse signatures on the bedtime MARs for multiple residents, including medications such as melatonin, tizanidine, Tylenol, gabapentin, trazodone, flecainide, oxycontin ER, buspirone, metoprolol, and tramadol.
Failure to Provide Nighttime Pain Medication
Penalty
Summary
Facility staff failed to ensure pain management was provided to residents who required it, consistent with professional standards of practice, the comprehensive person-centered care plan, and resident goals and preferences. Survey findings identified harm for three residents, R6, R7, and R8, after staff failed to have a licensed nurse on the west wing for approximately 12 hours to assess, monitor, and administer medications during the night shift. An LPN stated that no nurse came to the facility that night and there was no nurse on the west wing medication cart until the nurse from first shift arrived the following morning at 7:00 a.m. The LPN also stated that LPN2 apparently passed medications on west wing unit A hall but did not pass any medications on the B hall. She stated that some residents on the B hall complained and went to the east unit to ask for medications, but the nurse there said she did not have keys to the medication cart and gave them grievance forms. Resident interviews confirmed that the residents were waiting for medications throughout the night and did not receive their bedtime doses. R8 stated that Tramadol helps keep her legs from hurting and that she asked when she would get her medicine, but was told no nurse was there to give bedtime medication. R7 stated she requested pain medication several times during the night and could not go back to sleep because of pain. R6 stated she was awake all night waiting on her medications and said 12 hours was a long time to go without any of her medications. MAR review showed no nurse signatures for bedtime medications on 1/31/26 for R6, R7, and R8, including pain medications such as Tylenol, Gabapentin, Oxycontin ER, and Tramadol.
Failure to Implement Pressure Injury Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate pressure injury prevention interventions were implemented and followed for one resident, R2, who was assessed as moderate risk for pressure ulcer development on admission with a Braden Scale score of 13. On 10/4/25, R2's skin was documented as warm and dry with no impairments noted, but later records showed a suspected deep tissue injury to the heel, followed by a small wound to the right heel with protective dressings applied to both heels and legs. A later skin assessment documented left heel pressure injury, right heel pressure injury, and buttocks moisture associated skin damage, all acquired in house. Physician orders dated 10/5/25 included a pressure reducing mattress and pressure reducing cushion for the wheelchair, but the treatment record did not show these devices were implemented during October or November 2025. The wound physician's summary also included off-loading, close monitoring, education and counseling, and debridement as needed, but those off-loading recommendations were not implemented on the care plan or treatment administration record. During wound care observation, R2's heels were not off loaded before treatment, and R2 was observed lying on her back with her feet not off loaded until an LPN later placed a pillow under her legs. By 12/19/25, the medical record documented worsening bilateral heel wounds with soreness, infection, erythema, warmth, drainage, and cellulitis with ulceration in the center of both heels. The wound nurse treated a stage 3 sacral wound and a stage 4 left heel pressure ulcer, and all of R2's wounds were identified as in house acquired. Facility staff interviews indicated that pressure reducing mattresses, wheelchair cushions, and off-loading should be used for residents at risk, and the DON stated the skin and wound care had not been robust in the past.
No Nurse Coverage on Unit Overnight
Penalty
Summary
The facility failed to ensure that a licensed nurse remained present on an entire nursing unit for approximately a 12-hour period, leaving the unit without a nurse to administer scheduled medications, assess residents for changes in condition, communicate with the physician, receive new orders, initiate emergency measures, or provide skilled nursing care. The incident involved the west wing unit, where the scheduled nurse left the facility after a last-minute callout situation and no other nurse assumed responsibility for the medication cart, narcotic count, or resident care coverage for the night shift. According to staff interviews, the unit manager left the facility without giving report or completing a narcotic count, and the medication cart keys were left inside the narcotic logbook on top of the cart. The DON stated she was informed that the unit manager had left and that the keys had been left on the cart, and she later learned that no nurse came into the facility that night. The oncoming nurse the next morning reported that there were no nurses to receive report from, no narcotic count had been completed, and the medication cart keys were still in the narcotic logbook on the cart. Resident interviews confirmed that residents on the unit did not receive nursing coverage during the night and were unable to obtain needed medications. One resident stated that pain medication was requested several times during the night but no nurse was available to give it, and that the resident could not go back to sleep because of pain. Another resident stated that tramadol helps with leg pain and recalled asking why medication was so late, being told that no nurse was present to give bedtime medication. Additional residents stated they waited all night for medications, were upset that no nurse was on the unit, and described the situation as scary and upsetting.
No Licensed Nurse Coverage Led to Missed Medications and Unaddressed Resident Needs
Penalty
Summary
The facility failed to ensure licensed nurse coverage on the west wing nursing unit, and there was no licensed nurse available on that unit to administer medications, assess residents, respond to changes in condition, provide treatments, or ensure resident safety. The deficiency involved the evening of 1/31/26, when the unit manager left the facility without giving report or completing a narcotic count, and left the medication cart keys in the narcotic book on top of the medication cart. A nurse who had been asked to work as an aide stated she did not feel comfortable taking the medication cart because she had not received report and had not counted narcotics with the departing nurse. The aide stated that the nurse who was supposed to relieve the departing nurse called out at the last minute, and no nurse came in to the facility that night. She reported that there was no nurse on the west wing medication cart until the first-shift nurse arrived the following morning. She also stated that residents on the west wing, including those on the B hall, complained about not receiving medications and some went to the east unit seeking medication assistance. She identified residents who complained about missed medications and one resident who reported that a pain cream was not applied. Resident interviews and record reviews confirmed missed bedtime medications on the west wing. One resident stated she waited all night for medications and was told no nurse was present to give bedtime medicine. Another resident stated she requested pain medication several times during the night and did not receive it because there was no nurse on the unit. A third resident stated she was awake all night waiting for medications and said 12 hours was a long time to go without them. Review of the MARs showed no nurse signatures for bedtime medications for these residents, including medications for insomnia, spasms, pain, anxiety, atrial fibrillation, and scheduled cardiac medication. Facility policy stated medications are to be administered by licensed nurses and signed on the MAR after administration, and the pain management policy required assessment and reassessment of pain management by staff.
Infection Control Lapses With Gloves and Foley Drainage Bag
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident with a Foley catheter. During an initial tour of the east wing nursing unit, staff members were observed wearing gloves in the hallway, and the resident’s Foley catheter drainage bag was found lying on the floor with an over-bed table sitting on top of it. The drainage bag was also observed to be excessively full. A CNA later stated that urine bags should be hanging on the bed frame and said the bag needed to be emptied because it was about to burst. Facility interviews confirmed that staff knew gloves should not be worn in the hallway and should be removed before leaving a resident’s room, with hand hygiene performed afterward. The facility’s infection control policy stated that all staff are to follow Standard Precautions, including hand hygiene and proper use of PPE. The facility’s QAPI minutes also referenced staff carrying linen unbagged to the soiled utility and gloves in the hallway, with an analysis noting rushing and not doing what they were supposed to do.
Failure to Protect Residents After Allegation of Neglect
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy after an allegation of neglect was reported. Staff interviews and resident interviews described an overnight event on the west wing nursing unit in which there was no nurse on the unit to provide medications or respond to resident needs. An LPN stated that the nurse who was supposed to relieve the evening nurse called out at the last minute, there was no relief nurse to take report or count narcotics, and the evening nurse left without giving report or counting narcotics with her. The LPN said she refused to take the medication cart because she had no report and had not counted narcotics, and she reported the situation to the DON and administrator. The LPN stated that no nurse came into the facility that night and that the west wing medication cart remained without a nurse until the first-shift nurse arrived the next morning. She also stated that residents on one hall complained about not receiving medications, and that some residents went to the east unit seeking medications but were told the nurse there did not have the medication cart keys. Residents interviewed confirmed that they had no nurse on the unit that night, that they were waiting for bedtime medications, and that they were upset about not receiving pain medication and other ordered medications. Clinical record review showed no nurse signatures on the MARs for bedtime medications for three residents on the evening in question. One resident did not receive scheduled medications including melatonin, tizanidine, Tylenol, and gabapentin. Another resident did not receive bedtime medications including melatonin, trazodone, flecainide, oxycontin ER, and buspirone. A third resident had no signature for scheduled metoprolol and nightly PRN tramadol. Facility documentation defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and staff interviews reflected that failure to provide medications and treatments was considered neglect.
Failure to Report Allegation of Neglect
Penalty
Summary
Failure to timely report an allegation of neglect occurred when staff did not follow the facility abuse policy after a west wing medication coverage issue on 1/31/26. An LPN stated that the nurse scheduled to relieve the evening LPN called out at the last minute, leaving no relief nurse to take report, count narcotics, or take the medication cart keys. The LPN said she did not feel comfortable taking the medication cart without report or a narcotic count, and no nurse came to the facility that night, leaving the west wing medication cart without a nurse until the first shift nurse arrived the next morning at 7:00 a.m. Resident interviews and record review showed residents did not receive scheduled bedtime medications and were upset about the lack of nursing coverage. One resident stated she asked why her medicine was so late and was told no nurse was there to give it at bedtime. Another resident reported requesting pain medication several times during the night and said there was no nurse to provide it, leaving her unable to sleep because of pain. A third resident said she waited all night for medications and was upset that the nurse had left. MAR review showed no nurse signatures for bedtime medications for three residents, including medications such as melatonin, tizanidine, Tylenol, gabapentin, trazodone, flecainide, oxycontin ER, buspirone, metoprolol, and tramadol. The DON stated she did not do a formal investigation and only went by what was on the grievance form.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect reported after an LPN left the west wing medication cart without giving report to a relief nurse or completing a narcotic count with another nurse. The LPN stated she left early, did not properly hand off the cart, and left the narcotic keys in the narcotic book on top of the medication cart. Another LPN stated the scheduled relief nurse had called out, no nurse took report or counted narcotics, and she did not feel comfortable taking the cart because the handoff had not occurred. She also stated no nurse came to the west wing medication cart that night, and the cart remained unattended until the first-shift nurse arrived the next morning. The DON stated she did not conduct a formal investigation and relied on the grievance form, and she told a resident she did not think it was right for the LPN to leave. Residents on the unit described missing medications and pain medication during the night, with one resident stating there was no nurse to give bedtime medication, another stating she requested pain medication several times with no nurse available, and another stating 12 hours without medications was a long time and that the unit was upset about not having a nurse all night. Facility policy defined alleged violation and neglect, including failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Failure to Include Ordered Pressure Injury Interventions in Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for two residents, including failure to include ordered wound and pressure injury interventions. For one resident, a physician order for a pressure-reducing mattress and a pressure-reducing cushion for the wheelchair was noted, but these interventions were not implemented on the care plan. The resident’s Braden Scale score on admission was 16, which was identified as placing the resident at risk for skin injury. During interview, the RN/MDS coordinator stated that if off-loading was entered by the physician, it was supposed to be on the care plan. For the second resident, the care plan did not include pressure prevention interventions upon admission, even though a pressure-reducing mattress and wheelchair cushions had been ordered. The pressure-relieving/reducing device on the bed was not added to the care plan until months after the order, and the treatment record did not show the mattress or wheelchair cushions implemented during the earlier months when they had been ordered. The resident’s Braden Scale score was 13, indicating moderate risk, and a wound physician summary later documented off-loading, close monitoring, education and counseling, and debridement as needed for the right heel, but off-loading was not added to the care plan or treatment plan. The facility policy stated that the interdisciplinary team shall develop a relevant care plan with measurable goals and interventions, and that evidence-based interventions for prevention will be implemented for residents at risk or with pressure injuries.
Failure to Document Death Pronouncement and Body Release
Penalty
Summary
Professional standards of quality care were not met for one resident when the facility failed to ensure that an RN pronounced the resident’s death in accordance with facility practice and failed to have a physician order or documented authorization to release the body to the funeral home. After the resident was found with no signs of life, an LPN documented that the DON was notified and that an RN would come to the building to pronounce the resident. Facility staff interviews showed that the LPNs and DON understood that an RN was required to pronounce death, that the RN should document the assessment and time of death, notify the physician, and obtain an order to release the body. The DON also stated that if no RN was in the building, another RN would be called in to pronounce the resident. The clinical record review showed a progress note stating the resident had no signs of life and that the DON was notified, but there was no documentation that the RN who was supposed to pronounce the resident actually did so, no note that the physician was notified, and no physician order to release the body to the funeral home. A later note documented that the funeral home was notified, but there was no progress note documenting when the body was released. When asked for a policy on pronouncing death and release of the body, the DON provided only a residents’ rights and advance directives policy and stated there was no specific policy on pronouncing death.
Incomplete and Inaccurate Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure complete nurse staffing information was available for review. During a review of facility documentation and staff interviews, surveyors requested the staff posting for January 2026, but several days of postings were not provided. A second request was made for the last week of January, and the facility provided assignment sheets for the 25th and 31st, along with as-worked schedules for the 25th, 29th, 30th, and 31st. A third request resulted in the social worker director providing copies of staffing information submitted for the payroll-based journal report for the 25th and the 29th through the 31st. On interview, the social worker director stated that daily nursing staff postings were posted at the time clock and corrected for call-offs, and then later provided daily staffing reports for the 25th, 29th, 30th, 31st, and several days in May. When the daily postings were reviewed, the posting provided for the 31st did not list an LPN who was working as the charge nurse on the west wing unit, making the posting inaccurate for that day. The concern was discussed with the DON and the regional director of clinical services during an end-of-day meeting, and no additional information was provided before exit conference.
Missed Medication Administration When No Nurse Was Present on the Unit
Penalty
Summary
The facility failed to provide pharmaceutical services to meet residents’ needs when a licensed nurse was not on the medication cart to administer medications for approximately 12 hours on 1/31/26. Staff interviews indicated that one LPN passed medications on one hall but did not pass medications on another hall, and residents on the affected hall reported that they went without medication administration during the night. One LPN stated she expected to be notified about which residents received medications and which did not, but she was not called that evening. Resident interviews described the impact of the missed medication administration. One resident stated that there was no nurse on the unit, that it was snowing, and that she asked when she would receive her bedtime medication but was told no nurse was present to give it. Another resident stated that she requested pain medication several times during the night and there was no nurse to provide it, and she could not sleep because of pain. A third resident stated she stayed awake all night waiting for medications and was upset that the nurse had left the unit. Clinical record review confirmed missing nurse signatures on the MARs for bedtime medications on 1/31/26 for multiple residents. One resident did not receive scheduled medications including melatonin, tizanidine, acetaminophen, and gabapentin. Another resident had no documented administration of bedtime medications including melatonin, trazodone, flecainide, oxycontin ER, and buspirone. A third resident’s MAR showed no signature for scheduled metoprolol and PRN tramadol could not be requested because there was no nurse available to administer it. The DON stated she was aware of the grievance but did not conduct a formal investigation and relied on the MAR and narcotic count, which she said were correct.
Broken Dresser Not Maintained in Safe Condition
Penalty
Summary
Resident #7’s room furnishings were not maintained in safe and functional condition when a dresser drawer broke apart during use. On 5/13/26 at 11:15 am, the resident was observed holding the facing of a dresser drawer after the drawer had fallen apart, and her belongings were lying on the floor. While the surveyor was present, a maintenance assistant entered the room and initially began to repair the wrong piece of furniture before being redirected to the broken dresser drawer. The assistant picked up the broken wood, said someone would sweep the floor, and stated the drawer would be fixed. The resident reported that the drawer facing had struck her knee when it fell apart. During interview, Resident #7 stated she had asked several times for the dresser to be replaced because two to three drawer facings would come off when the drawers were opened and the dresser was broken. The maintenance director stated he had assumed the resident wanted an additional dresser and did not check the dresser, and he was unaware it was broken until the previous day when repairs were initiated. Facility documentation stated the facility would provide a safe, clean, comfortable, and homelike environment and allow residents to use personal belongings to the extent possible, but the dresser in the resident’s room had not been maintained in safe and functional condition before the surveyor’s observation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours per day on three separate days in December 2025. Review of the as-worked nursing schedule confirmed that no RN was present on 12/7/25, 12/13/25, or 12/14/25. During interviews, the scheduler stated that no RNs were available to work on those dates, and the DON confirmed that the RN who typically worked weekends was on medical leave. The DON also noted that while there were sufficient licensed practical nurses available, there was a shortage of RNs to cover the required shifts. No additional information was provided by the facility administration prior to the end of the survey.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Facility staff failed to follow physician orders for medication administration for four residents, resulting in multiple medication errors. In one instance, a registered nurse administered methadone 5 mg to a resident with chronic pain and multiple comorbidities, despite a physician order for 2.5 mg. The error occurred on the day the dosage was changed, and the nurse reportedly pulled the wrong medication supply card. The resident was assessed after the error, with no changes in condition noted. Another resident with osteomyelitis and severe cognitive impairment received intravenous ertapenem at the wrong time. The LPN administered the antibiotic six hours earlier than scheduled, after confusing it with another IV antibiotic. The error was documented, and the resident was monitored, with no new care orders issued in response. Additionally, a resident with multiple chronic conditions received another resident's medications, including a cancer medication, during an evening medication pass. The incident was reported, and the resident was monitored, with no acute distress or changes in condition observed. In a separate incident, a resident with Alzheimer's disease and other significant health issues was given Percocet 10-325 mg instead of the prescribed oxycodone 2.5 mg for pain management. The error occurred when a new nurse pulled the incorrect medication supply card. The resident was assessed and remained at baseline, with no changes in condition following the error. In all cases, the errors were documented, and the responsible staff members were no longer employed at the facility at the time of the survey.
Failure to Ensure Resident Rinsed Mouth After Inhaled Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of care during medication administration for one resident diagnosed with chronic obstructive pulmonary disease (COPD). During a medication pass observation, an LPN administered Breo Ellipta (fluticasone furoate-vilanterol) inhalation powder to the resident, followed by other prescribed oral medications. The LPN did not prompt or request the resident to rinse and spit their mouth after using the inhaler, despite the medication's pharmacy label and manufacturer's instructions clearly stating that rinsing the mouth after each use is necessary to reduce the risk of oropharyngeal candidiasis. Upon inspection of the medication and interview with the LPN, it was confirmed that the LPN did not ask the resident to rinse their mouth, stating that the resident does not cooperate with this instruction. The clinical record included a physician's order for daily use of Breo Ellipta for COPD, and the manufacturer's instructions were available on the medication cart. The deficiency was reviewed with facility administration, and no additional information was provided before the end of the survey.
Incomplete Documentation of Lice Assessment and Treatment
Penalty
Summary
Facility staff failed to ensure a complete and accurate clinical record for one resident who was admitted with multiple diagnoses, including schizoaffective disorder, hypertension, insomnia, protein-calorie nutrition issues, and dysphagia. The resident was assessed as cognitively intact. Physician orders were documented for the treatment of head lice, including the use of a RID Super Max 5-in-1 kit, daily nit combing, and contact precautions, with treatment initiated and later discontinued within a specified period. Despite the initiation of lice treatment, the clinical record lacked documentation regarding the assessment of head lice, associated symptoms, or notification to the provider. Interviews with staff revealed that the CNA reported signs of lice to the LPN supervisor, who stated that the provider was notified and treatment started immediately. However, both the infection preventionist and the unit manager acknowledged that there should have been documentation of the assessment, provider notification, orders, and actions taken, but no such note was entered in the clinical record.
Failure to Follow Infection Control Practices During Medication Pass
Penalty
Summary
During a medication pass observation on the East unit, an LPN was seen administering oral medications to a resident by removing tablets from supply bottles and handling them directly with bare fingers before placing them in a medicine cup. The LPN had used hand sanitizer prior to starting the medication pass but did not use gloves or another barrier when handling the pills. The medications administered included aspirin, simethicone, omeprazole, and vitamin D. When questioned, the LPN acknowledged that touching pills with bare hands was not a good habit. The unit manager confirmed that nurses were not permitted to touch pills directly during medication administration. The infection preventionist further clarified that pills from bubble packs should be popped directly into the medicine cup, and those from bottles should be poured into the cap and then into the cup, without direct hand contact. Facility policy also specified that staff should use a medicine cup and not their hands when administering medications.
Medication Unavailability for Resident
Penalty
Summary
The facility staff failed to ensure that medication was available for administration to a resident during a scheduled medication pass. During an observation, it was noted that a resident was supposed to receive telmisartan 40 MG for hypertension at 9:00 AM, but the medication was not available. The LPN checked the medication cart and the medication room, and upon finding it unavailable, contacted the pharmacy to reorder the medication. The Director of Nursing was informed, and the physician was notified, resulting in an order to hold the medication until it arrived later in the day. The deficiency was further highlighted when the LPN confirmed that the medication had not arrived by 2:45 PM, and a blood pressure reading was taken, showing the resident's blood pressure at 149/71 with a pulse of 71. The Director of Nursing explained that the pharmacy had sent 20 MG tablets instead of 40 MG, leading to the staff administering two pills to meet the required dosage, which resulted in running out of the medication. This information was presented to the Director of Nursing, administrator, and nurse consultant, but no additional information was provided before the exit conference.
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What surveyors actually found near you
We read the 41 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Staunton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Staunton Post Acute & Rehabilitation | 0.5 mi | ★★★★★ | 6 | 1 |
| Augusta Medical Ctr Skilled Ca | 6.4 mi | ★★★★★ | 0 | 0 |
| Shenandoah Nursing Home | 6.7 mi | ★★★★★ | 0 | 0 |
| Augusta Nursing And Rehabilitation | 7.5 mi | ★★★★★ | 5 | 0 |
| River Edge Rehabilitation And Nursing | 10.2 mi | ★★★★★ | 4 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.