Below average — CMS composite of the measures below.
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 Martinsville Health And Rehab during CMS and state inspections, most recent first.
Food was not stored and prepared in a sanitary manner. Surveyors observed a box of thawed ground meat labeled with an expired use-by date, dried crusty buildup on the dishwasher, and dried food on the oven doors. Surveyors also observed a CNA in the kitchen prep area without a hair covering, and the CNA stated she had not put one on before entering the kitchen.
Incomplete documentation of consultant pharmacist MRRs was found for five sampled residents. The only charting present stated that a chart review was completed, but it did not show whether recommendations were made or not made, and surveyors could not verify the pharmacist’s findings from the clinical record. The DON later provided a separate list of residents without recommendations, but it was not part of the resident record.
Staff failed to honor a resident’s right to dignity and respect when a social worker discussed the resident’s morbid obesity, weight gain, and food intake with the roommate’s mother, despite the resident being cognitively intact and care planned for obesity and weight loss goals. The resident reported feeling humiliated by the disclosure and by statements that the roommate might be moved if food continued to be brought, and the roommate’s mother and the LTC ombudsman both confirmed that personal information about the resident’s weight was shared and that the conversation was upsetting.
A cognitively intact resident with morbid obesity, bed confinement status, and dependence for transfers and ADLs was not accommodated for her repeated request to get out of bed. The resident said she had been in bed for nearly 3 years and wanted to use the Hoyer lift and receive therapy, but staff reported prior lift attempts seemed unsafe or nearly caused the lift to flip. RN staff said she remained in bed and received daily bed baths, while the ombudsman noted her concerns had been raised at care plan meetings and that the facility was restricting her by not getting her up.
Failure to Honor Resident Shower Preference: A cognitively intact resident with hemiplegia and hemiparesis was not given showers according to her stated preference for morning bathing. Her ADL record documented a preference for showers between 4:30 am and 6:30 am and a preference for showering over a bed bath, yet she reported showers were being offered in the evening and that she had gone a week without one despite agreeing to a shower when asked by a CNA.
A resident with COPD, anxiety, HTN, and dementia had advance directive information that was not periodically reviewed with the resident or representative. The resident’s MDS coded severe cognitive impairment, and surveyors found no documentation of review since the prior year. The SW said the review had not occurred because of the resident’s cognitive status and the family not attending care plan meetings.
Late Medicare Non-Coverage Notice: A resident with metabolic encephalopathy, muscle weakness, CKD stage 3, atherosclerotic heart disease, and severe cognitive impairment did not receive a NOMNC at least 2 days before the end of the Medicare Part A covered stay. The NOMNC was issued only after the covered days had already expired, and the administrator stated staff had not realized the coverage had ended when it was given.
Failure to Send Required Transfer Documentation: Facility staff did not provide required transfer/discharge paperwork to the receiving hospital for three residents. One resident with stroke history, dysphagia, diabetes, and psychiatric diagnoses had two acute transfers with no documentation showing what information was sent, and two other residents with significant medical and cognitive conditions also had no evidence that the required face sheet, med list, labs, radiology, or other clinical information was provided with the transfer packet. The DON acknowledged the missing documentation, and the facility policy required these materials to be printed and placed in the transfer envelope.
A resident’s annual MDS was coded to indicate insulin administration even though there was no provider order for insulin and the resident had not received insulin during the look-back period. The resident had chronic respiratory failure, COPD, hypertension, and a BIMS score of 9/15, and RN confirmed the MDS was coded incorrectly.
A resident with COPD, HF, dementia, psychosis, mood disorder, and major depressive disorder did not have a completed PASARR/Level I screening in the record. The surveyor and SW could not locate the form, and the DON stated the resident had been admitted before the requirement. A later-produced form was blank except for demographics and signatures, with a note that the resident refused to participate. The resident also had severe cognitive impairment on MDS and a care plan noting behaviors such as refusing care, striking others, delusions, and refusing dental and vision visits.
Failure to Develop Baseline Care Plans Facility staff did not complete baseline care plans for three residents. One resident had stroke-related deficits, dysphagia, diabetes, and psychiatric diagnoses with moderate cognitive impairment; another was dependent for all ADLs, mobility, and tube feeding with intact cognition; and a third had cerebral infarction, quadriplegia, and cognitive impairment. Records showed incomplete or missing baseline care plans, and one responsible party stated they did not believe they received a summary after admission.
A resident with schizoaffective disorder, depression, bipolar disorder, suicidal ideations, malnutrition, and severe cognitive impairment did not have a person-centered, comprehensive activity care plan in place when the record was reviewed. Staff acknowledged the activity care plan had not been completed, and the resident’s later care plan included limited activity-related goals and interventions such as short-duration activities, 1:1 activities, encouragement, and step-by-step cueing.
Failure to Review and Revise Activity Care Plan: A resident with CVA, spastic hemiplegia, schizophrenia, depressive disorder, and cognitive communication disorder had an activity care plan that was not reviewed and revised by the IDT as required. The record lacked activity progress notes, the annual recreation assessment was incomplete, and quarterly/annual MDS-related activity reviews were not documented, even though staff acknowledged the resident had improved in group participation and socialization.
Failure to Provide ADL Care: Staff failed to provide showers or daily bed baths for one resident who needed assistance with bathing and failed to perform nail care for another dependent resident. The first resident, who had CVA-related hemiplegia and intact cognition, reported missed showers despite a care plan and ADL schedule calling for regular bathing. The second resident, who was dependent for all ADLs and had a history of stroke, was observed with long, dirty fingernails and stated he wanted them trimmed.
A resident with severe cognitive impairment and multiple psychiatric and medical diagnoses did not receive an ongoing, person-centered activity program reflecting stated preferences such as music, animals, group activities, favorite activities, outdoor time, and religious services. The record lacked an activity care plan and activity progress notes, activity assessments were incomplete, and activity participation documentation included entries later confirmed by staff to be in error because the resident was hospitalized on those dates.
Failure to Enter and Follow Ordered Pressure Ulcer Treatment: A resident with CVA-related hemiplegia/hemiparesis, DM2, and moderate cognitive impairment developed a sacral pressure injury that progressed from stage 2 to stage 3. The NP entered wound care orders for cleansing, Santyl, and a foam dressing, then later ordered collagen, gauze island dressing, and skin prep, but the TAR did not reflect the ordered wound care when reviewed. During observation, the wound orders had only recently been entered, and the dressing was dated the same day; when removed, the area was intact red skin and not blanchable.
A resident with dysphagia and moderate cognitive impairment received a meal tray that was not palatable or attractive. The resident’s mother reported the chicken patty appeared as breadcrumbs on a bun and was dry, and the tray ticket listed peaches and pears that were not observed on the tray. The concern was raised with the administrator, DON, and regional director of clinical services.
Failure to Follow Infection Control Procedures: A resident with a foley catheter had the drainage bag resting on the floor during care, another resident had disposable gloves placed on O2 tubing and on the floor near the O2 concentrator, and a third resident on MRSA contact precautions was assisted by a CNA without PPE while the CNA sat on the resident’s bed. The DON later stated the CNA should have been wearing PPE and should not have been sitting on the bed.
Failure to Offer Recommended Pneumococcal Vaccine: A resident over age 50 with diabetes and dementia had documentation of PPSV23 only, and the IP could not show that a PCV15, PCV20, or PCV21 had been offered after admission. The resident’s MDS showed intact cognition, and the facility policy required review of vaccine history and use of current CDC guidance. A local medical office later confirmed prior pneumonia vaccines, including PPSV23, but no additional vaccine evidence was provided to surveyors.
Food Storage, Cleaning, and Hair Covering Lapses
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner. During an initial kitchen tour, surveyors observed a box of ground meat with a handwritten note stating, "Out to thaw 01/05/26, use by 01/11/26." The dietary manager said the meat would be discarded. Surveyors also observed the dishwasher with a dried, crusty substance on the top corners, and the dietary manager stated that this substance is cleaned off every day but returns the next morning. In addition, the oven had dried food substance on the front outside of the oven doors, and the dietary manager stated the ovens are cleaned weekly. On a follow-up visit to the kitchen, surveyors observed CNA #1 standing in the kitchen prep area without a hair covering. When asked, the dietary manager stated CNA #1 should have been wearing a hair covering and said they had not noticed whether she had one on. Later, CNA #1 stated she had not put on a hair covering before entering the kitchen. The dietary manager also provided an inservice form regarding labeling and dating of thawed food, which stated that ground meat removed from the freezer and placed in the refrigerator for thawing should be labeled with the date of removal and an appropriate use-by date, with the attached retention guide indicating thawed ground meat should be used within 1-2 days.
Incomplete Documentation of Consultant Pharmacist Drug Regimen Reviews
Penalty
Summary
Facility staff failed to ensure the consultant pharmacist documented findings in the clinical records after completing monthly drug regimen reviews for five sampled residents, identified as Resident #2, Resident #5, Resident #6, Resident #9, and Resident #55. During clinical record review, surveyors could not determine whether the pharmacist had made recommendations during the reviews because the only documentation present stated, "chart review completed by consultant pharmacist," with no reference to whether a recommendation was made or not made. At the end-of-day meeting on 01/13/2026, the Administrator, DON, and Regional Nurse Consultant reviewed the incomplete records issue, and the DON later provided a list of residents who did not have recommendations after pharmacist review; however, that list was not part of the residents' clinical records. The facility policy provided on 01/15/26 stated that resident-specific MRR recommendations and findings are documented and that a record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format within 48 hours of MRR completion.
Failure to Protect Resident Dignity and Privacy When Discussing Weight and Food
Penalty
Summary
Facility staff failed to treat a cognitively intact resident with dignity and respect by disclosing her personal health and weight information to her roommate’s mother. The resident, who had diagnoses including morbid obesity due to excess calories and a BMI of 73.4, had a care plan noting her obesity, history of weight fluctuations, and desire to lose 100 pounds while on a special diet. The resident reported that the facility social worker called her roommate’s mother and told her to stop bringing the resident food, stated that the resident had gained 20 pounds, and said that if the food deliveries did not stop, the roommate would be moved. The resident stated this was none of the roommate’s business, that she felt stepped on, humiliated, and never received an apology. The roommate’s mother confirmed that the social worker called her about bringing food to the resident and discussed the resident’s weight gain, which she felt was the resident’s personal information and should not have been shared. She stated she only brought the resident iced tea, hot coffee, fresh fruits, and salads. The local LTC ombudsman reported that the resident called her crying and very upset that the social worker had contacted the roommate’s mother, and further stated that the roommate’s mother was upset that the social worker said her daughter would be moved if she continued to bring food to the resident, which the mother perceived as retaliation. The facility’s written policy, “Your Rights and Protections as a Nursing Home Resident,” stated that residents have the right to be treated with dignity and respect, which was not followed in this instance.
Failure to Accommodate Resident’s Preference to Get Out of Bed
Penalty
Summary
The facility failed to accommodate a cognitively intact resident’s expressed preference to get out of bed. The resident had diagnoses including morbid obesity due to excess calories and bed confinement status, and the care plan documented the resident’s desire to lose weight, need for extensive to total assistance with ADLs, and transfer assistance using a Hoyer lift with at least 2 staff. During interview, the resident stated she had been in bed for almost 3 years, wanted to get out of bed, and said the lift would hold her weight; she also stated she wanted therapy but had been told she had plateaued. Staff interviews showed the facility had attempted to use the lift but reported it almost flipped or seemed unsafe, and the administrator stated the last attempt caused the lift to shimmy. RN staff stated the resident had not been getting out of bed and received daily bed baths. The administrator later stated the facility had a lift pad and wheelchair for the resident, while the DON stated the lift was rated for up to 600 lbs and said the resident would be pulled with a sheet in an emergency. The ombudsman reported the resident had raised concerns about not getting out of bed at several care plan meetings and stated the facility was restricting her by not getting her up.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to honor a cognitively intact resident’s choice regarding shower timing and bathing preference. Resident #10 had diagnoses including hemiplegia and hemiparesis following a cerebrovascular disease affecting the left non-dominant side, and the most recent MDS coded the resident with a BIMS score of 15 out of 15 and partial/moderate assistance needed for bathing. The resident’s care plan included encouragement of choices with care, and the ADL sheet documented a preference for showers between 4:30 am and 6:30 am and a preference for showering over a bed bath. During interview, the resident stated that showers were being given in the evening, but she preferred morning showers, and she reported not receiving a shower for a week despite being told someone would come after she agreed to one. She also stated that a CNA washed her off in the morning because she was itching. The facility’s Resident Rights document stated that the resident has the right to choose activity schedules and health care consistent with interests, assessment, and plan of care, but staff did not honor the resident’s stated shower preference.
Failure to Review Advance Directive Information
Penalty
Summary
The facility failed to periodically review Resident #50’s advance directive information with the resident and/or the resident’s representative. Resident #50 had diagnoses including chronic obstructive pulmonary disease, anxiety disorder, hypertension, and dementia, and the quarterly MDS assessment coded the resident as having severe impairment in cognitive skills for daily decision making. During record review, surveyors could not locate documentation showing the resident’s advance directive information had been reviewed since 01/17/24. The Social Worker stated that advance directive information had not been reviewed with the resident because of the resident’s cognitive status and because the resident’s family did not attend care plan meetings. Later the same day, the Social Worker provided evidence that the resident’s legal representative was contacted by phone and the advance directive information was reviewed.
Late Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of one resident’s Medicare Part A covered stay. Resident #20 had diagnoses including metabolic encephalopathy, muscle weakness, chronic kidney disease stage 3, and atherosclerotic heart disease of the native coronary artery. The most recent quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Resident #20’s last covered day of Medicare Part A services was [DATE]. A NOMNC was not issued until [DATE] and was signed by the resident’s representative after the covered days had already expired. During an interview on [DATE] at 8:49 AM, the administrator stated the NOMNC was not issued on time and that staff did not realize the resident’s covered days had already expired when it was issued. The concern was discussed again at the end-of-day meeting on [DATE] with the administrator, DON, and regional nurse consultant. The facility policy titled Advance Beneficiary Notice-ABN stated that the facility will give a completed copy far enough in advance for the beneficiary to make an informed decision without undue pressure.
Failure to Send Required Transfer Documentation
Penalty
Summary
Facility staff failed to provide required transfer/discharge documentation to the receiving healthcare institution for three sampled residents. The deficiency involved resident transfers to hospitals or emergency departments, and the record review showed no evidence that the required resident information was sent with the residents at the time of transfer. The facility policy titled, Transfer a Resident to a Hospital, required staff to print the resident’s face sheet, current medication list, pertinent labs/radiology reports, and other clinical information related to the transfer reason, and to place the printed content into a transfer envelope. For one resident, the clinical record showed two transfers for acute evaluation after changes in condition. The resident had a history that included stroke with hemiplegia and hemiparesis, dysphagia, type II diabetes, schizophrenia, bipolar disorder, anxiety disorder, and epilepsy, and had moderate cognitive impairment on the most recent MDS. On one occasion the resident was noted to have low blood pressure, elevated temperature, rhonchi, diaphoresis, and decreased responsiveness, and on another occasion the resident was sent out for evaluation and treatment. The record contained a verbal report note, but there was no documentation showing what information was sent with the resident to the hospital for either transfer. For two other residents, the records also failed to show that required transfer information was provided to the receiving acute care facility. One resident had diagnoses including volume depletion, atherosclerotic heart disease, schizoaffective disorder, kidney failure, and acute or chronic malnutrition, and was severely cognitively impaired on the most recent MDS. The other resident had diagnoses including adult failure to thrive, cerebral infarction, and polyneuropathy, and was cognitively intact. In both cases, the clinical record did not contain evidence that the required resident information was sent with the resident during transfer, and the DON acknowledged that the facility staff was not sending the required documentation with residents upon transfer/discharge.
Incorrect MDS Coding for Insulin Administration
Penalty
Summary
Facility staff failed to ensure an accurate MDS assessment for one resident whose annual MDS with an ARD of 09/30/25 was coded to show insulin administration even though there was no provider order for insulin and the resident had not received insulin during the look-back period. The resident’s diagnoses included chronic respiratory failure, COPD, and hypertension, and the Section C BIMS score was 9 out of 15, indicating moderately impaired cognitive skills for daily decision making. During record review, the surveyor could not find a current or discontinued order for insulin. RN #1 later confirmed that the MDS had been coded incorrectly and stated that a modification MDS had been completed.
Missing PASARR Screening for Resident with Severe Cognitive Impairment
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one sampled resident. The resident had diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, psychosis, mood disorder, and major depressive disorder. The quarterly MDS assessment showed a brief interview for mental status score of 00 out of 15, indicating severe cognitive impairment. The care plan documented behaviors including refusing showers or baths, refusing staff assistance, physically striking others, refusing a room change, delusions about being watched through cameras, and refusing to see the dentist and optometrist. The surveyor could not locate a Level I PASARR in the clinical record and the social worker also could not find one, stating there was an old UAI but no PASARR with it. During the survey, the DON stated the resident came before the requirement and thought that was why it was missing. Later, the social worker produced a Level I PASARR form that contained only demographic information, the social worker's signature, date, facility address and phone number, and a handwritten note stating the resident refused to participate and said she had done it before. The facility policy stated a PASSR should be obtained for every new admission and that for long-term care residents already in the facility without a Level I screening, designated staff should complete the screening. The report also cited Virginia DMAS guidance stating that all persons must be screened and that if a resident refuses or cannot participate, the facility must still complete the screening.
Failure to Develop Baseline Care Plans
Penalty
Summary
Facility staff failed to develop a baseline care plan for 3 of 38 sampled residents, including Resident #4, Resident #64, and Resident #94. Resident #4 had diagnoses including a history of stroke with hemiplegia and hemiparesis, dysphagia, type II diabetes, schizophrenia, bipolar disorder, anxiety disorder, and epilepsy, and had a BIMS score of 10/15 indicating moderate cognitive impairment. The record showed that a baseline care plan was initiated when the resident was initially admitted in April 2024, but only the primary language and allergies sections were completed, with the remainder blank, including the section for review with the resident or family member. After a lengthy hospital stay in December 2025, a baseline care plan was generated again, but it was incomplete and not reviewed with the resident or family. Resident #64 had diagnoses including a history of stroke, peripheral vascular disease, muscle weakness, protein calorie malnutrition, major depressive disorder, and anxiety, and had a BIMS score of 14/15 indicating intact cognition. The resident was dependent on staff for all ADLs, all mobility, and was tube fed with NPO orders. A baseline care plan was initiated on 9/30/25, but the form was mostly blank, including the section identifying who it was reviewed with, and the resident's responsible party stated they did not believe they received a baseline care plan shortly after admission. For Resident #94, a closed record review showed diagnoses including cerebral infarction, adult failure to thrive, diabetes, quadriplegia, and muscle weakness, with MDS coding indicating memory problems and moderate impairment in daily decision making. The surveyor could not find evidence that a baseline care plan had been developed, and the DON stated they were unable to find one.
Failure to Develop a Person-Centered Activity Care Plan
Penalty
Summary
Facility staff failed to develop and implement a person-centered, comprehensive activity care plan for one resident with multiple psychiatric and medical diagnoses, including schizoaffective disorder, depression, bipolar disorder, suicidal ideations, acute or chronic malnutrition, and a history of mental and behavioral disorders. The resident’s most recent quarterly MDS, with an ARD of 1/10/26, showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. Review of the clinical record and comprehensive care plan found no evidence of a person-centered activity care plan at the time of the survey review. On 1/14/26, the surveyor interviewed staff and reviewed the resident’s care plan, and the staff member agreed that an activity care plan had not been completed. The resident’s later reviewed care plan included a focus statement about having a short attention span and interventions such as holding an object for 5 minutes three times a week, needing encouragement to participate in activities, receiving 1:1 activities if less involved in groups, shorter duration activities, and assistance with easier instructions, cuing, and breaking tasks into smaller steps. The facility policy titled Activity Care Plan stated that individualized activity care plans are to be developed and maintained for each resident and integrated into the total care plan.
Failure to Review and Revise Activity Care Plan
Penalty
Summary
The facility failed to ensure Resident #9’s comprehensive person-centered activity care plan was reviewed and revised by the interdisciplinary team. Resident #9 had diagnoses including cerebrovascular disease, spastic hemiplegia affecting the right dominant side, schizophrenia, depressive disorder, and cognitive communication disorder. The most recent annual MDS, with an ARD of 12/20/25, coded the resident as rarely/never understood, with short- and long-term memory problems and moderate impairment in decision-making. The current comprehensive activity care plan was initiated on 4/6/25 and last revised on the same date, with no changes identified to the focus, goal, or interventions. The clinical record did not contain activity progress notes, and the Recreation Services Assessment for the annual review dated 12/30/24 was followed by a Recreation Services Assessment dated 12/19/25 that was blank and noted as incomplete. The completed MDS schedule showed annual and quarterly assessments on 12/20/25, 9/29/25, and 6/29/25, with no evidence of a completed activity assessment, activity care plan review, or activity progress notes. During interview, OS#5 stated the care plan was supposed to be updated quarterly, annually, and with the MDS, acknowledged the annual activity assessment was not completed, and agreed the resident’s improved group participation and increased socialization should have been reflected in the activity plan of care.
Failure to Provide ADL Care
Penalty
Summary
Facility staff failed to provide ADL care for two dependent residents. Resident #10 had diagnoses including hemiplegia and hemiparesis following a cerebrovascular disease affecting the left non-dominant side and a contracture of the left hand. The resident’s MDS indicated intact cognition and need for partial/moderate assistance with showering and bathing. The care plan directed staff to encourage choices with care and provide all needed assistance with ADLs and mobility. The resident told the surveyor that showers were supposed to be provided on Mondays, Thursdays, and Saturdays, but that they had not had a shower in a week and that a CNA had asked if they wanted a shower but no one ever came. The resident also stated they preferred morning showers. Review of the ADL sheets showed the resident preferred showers over bed baths and that there were multiple periods when the resident was neither offered nor received a shower or bed bath. Facility staff also failed to perform nail care for Resident #64, who had diagnoses including a history of stroke, peripheral vascular disease, muscle weakness, protein calorie malnutrition, major depressive disorder, and anxiety. The resident’s MDS showed a BIMS score of 14/15 and that the resident was dependent on staff for all ADLs, including bathing, dressing, and mobility. During observation, the resident’s fingernails were long, jagged, and had brownish/black material caked under each nail. The resident indicated he did not like his nails that long and wanted staff to trim them, but could not say when they had last been cleaned or trimmed. On a later observation, the nails were still long and dirty, and the DON stated nail care was done as needed. The resident’s nails were later observed to be clean and trimmed.
Incomplete Activity Assessment and Lack of Person-Centered Activity Plan
Penalty
Summary
The facility failed to provide an ongoing, person-centered activity program to support Resident #80’s choice, interests, and physical, mental, and psychosocial well-being. Resident #80 had diagnoses including volume depletion, atherosclerotic heart disease, schizoaffective disorder, depression, bipolar disorder, suicidal ideations, acute or chronic malnutrition, and a personal history of mental and behavioral disorders. The most recent quarterly MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The admission MDS indicated preferences that were somewhat important to the resident included listening to music, being around animals, doing things with groups of people, doing favorite activities, going outside in nice weather, and participating in religious services or practices. A review of the clinical record and comprehensive person-centered care plan showed no evidence of a person-centered activity care plan or activity progress notes for Resident #80. The Activity Participation Review dated 1/9/26 was blank and marked in progress, and the Recreation Services Assessment dated 1/13/26 was blank and incomplete. The hand-written activity participation records showed only five activities in December 2025 and three entries in January 2026, but staff later confirmed that the resident was in the hospital on some of the dates documented and agreed those entries were marked in error. Staff also agreed the assessments were not completed and that a comprehensive person-centered activity care plan was not completed for the resident.
Failure to Enter and Follow Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to provide ordered treatment for a pressure ulcer for one sampled resident with a history of stroke with hemiplegia and hemiparesis, dysphagia, type II diabetes, schizophrenia, bipolar disorder, anxiety disorder, and epilepsy. The resident’s annual MDS assessment showed moderate cognitive impairment. On 1/3/26, a stage 2 pressure injury to the sacrum was documented, and the resident was noted to be repositioned every 2 hours with incontinent care provided. Later that day, the NP entered wound care orders for cleansing the wound, applying Santyl, and covering it with a foam dressing, with daily dressing changes, but the TAR for January 2026 showed only a barrier cream order to the sacrum every shift and after incontinent episodes, without the cleansing step or dressing order. On 1/8/26, the resident was documented as having a stage 3 pressure wound to the sacrum measuring 1.4 x 1.2 x 0.2, with orders for collagen sheet, gauze island dressing, and skin prep. When the TAR was reviewed on 1/13/26, those wound orders had not been entered. During wound care observation on 1/14/26, the surveyor noted the wound care orders from 1/8/26 had only been placed on the TAR that day, and a dressing already on the wound was dated 1/14/26. When the dressing was removed, intact red skin was observed under it; the area was not blanchable but was not open. The DON stated there was no wound care policy when asked for one.
Unpalatable Meal Tray Served to Resident with Dysphagia
Penalty
Summary
Food was not provided in a palatable and attractive manner for one sampled resident with dysphagia following cerebral infarction. The resident’s clinical record showed diagnoses including dysphagia, and the most recent MDS indicated a BIMS score of 9 out of 15, reflecting moderate cognitive impairment. The care plan identified a potential for swallowing difficulty related to dysphagia and directed that the resident receive the ordered diet. During observation, the resident’s mother told the surveyor she was concerned about the meal tray and stated the resident had received a hamburger bun with what appeared to be breadcrumbs instead of a ground breaded chicken patty. The mother described the food as dry and said she did not know how the resident was supposed to eat it on a bun. The surveyor observed the tray ticket listing ground breaded chicken patty for bun, hamburger bun, mayonnaise, Parmesan & herb roasted cauliflower, chopped oven browned potatoes, and sliced peaches and pears, but no peaches or pears were observed on the tray or in a dish. The concern was discussed with the administrator, DON, and regional director of clinical services.
Failure to Follow Infection Control Procedures
Penalty
Summary
The facility failed to follow its established infection control program for three sampled residents. For one resident with a history of stroke with hemiplegia and hemiparesis, dysphagia, type II diabetes, schizophrenia, bipolar disorder, anxiety disorder, and epilepsy, the annual MDS showed moderate cognitive impairment. During wound care observation, the resident’s foley catheter drainage bag was observed resting on the floor while the bed was in the low position. The infection preventionist stated the bag should not be on the floor and raised the bed to hang the bag on the bed frame. For another resident with peripheral vascular disease, anxiety disorder, cognitive communication deficit, dementia, and dependence on supplemental oxygen, the most recent significant change MDS showed severe cognitive impairment. During a facility tour, two gloves were observed hanging on the resident’s oxygen tubing near the floor by the oxygen concentrator. On a later observation, two gloves were seen on the floor under the resident’s bed near the oxygen concentrator. For a third resident with acute cystitis without hematuria and severe cognitive impairment, the care plan and physician’s orders required contact precautions for MRSA. During observation, a CNA was in the resident’s room without PPE, and later was seated on the resident’s bed assisting with fluids while still not wearing PPE. The CNA stated they did not know whether PPE was required, and the DON later stated the CNA should have been wearing PPE and should not have been sitting on the resident’s bed.
Failure to Offer Recommended Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for one sampled resident, Resident #14. Resident #14 was older than 50 years and had diagnoses including diabetes and dementia. The quarterly MDS assessment dated 12/12/25 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. During review of the resident’s vaccination status, the Infection Preventionist could provide documentation only that Resident #14 had received Pneumovax 23 on 04/05/23, and no evidence was provided that the resident had been offered or received a subsequent pneumococcal conjugate vaccine after admission. The facility policy titled Pneumococcal Vaccinations stated that the admitting nurse would review the medical record and resident history to determine whether pneumococcal vaccine had ever been given and then determine what vaccine, if any, was recommended per current CDC guidance. The CDC guidance cited in the report stated that adults over 50 years old who previously received only PPSV23 should receive one dose of PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose. A local medical office later confirmed that Resident #14 had received two pneumonia vaccines there, including an unspecified pneumococcal vaccine on 06/11/14 and PPSV23 on 08/22/16, but no further information was provided to the survey team before exit.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Martinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mulberry Creek Nursing & Rehab Center | 1.3 mi | ★★★★★ | 0 | 0 |
| King's Grant Lacy Health Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Stanleytown Health And Rehabilitation Center | 7.8 mi | ★★★★★ | 0 | 0 |
| Eden Rehabilitation And Healthcare Center | 11.7 mi | ★★★★★ | 4 | 1 |
| Unc Rockingham Rehab & Nursing Care Center | 13.4 mi | ★★★★★ | 0 | 0 |
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