Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Newport News Nursing & Rehab during CMS and state inspections, most recent first.
Staff failed to maintain a clean, safe, and homelike environment for a resident whose room remained crowded with boxes and plastic containers, scattered clothing, and multiple open and partially eaten food items left unrefrigerated, creating a sour, spoiled food odor. The resident was observed sitting on a soiled bed encrusted with spilled food while wearing a shirt heavily stained with dried food and liquids. The roommate largely avoided the room and did not explain why when asked. The DON stated that the resident was very resistant to room cleaning and became belligerent when items were moved or trash was discarded, and that the resident had since refused to speak with her.
A facility failed to follow its abuse screening policy and allowed a CNA with a barrier crime conviction for delivery of drugs to a prisoner to work full-time and provide direct care with unrestricted access to residents throughout the building. Surveyors found the CNA had been hired despite the criminal history, and the Administrator confirmed the employee should not have been working there. The issue was cited as IJ and substandard quality of care.
Unsecured medication, chemical, oxygen, and biohazard storage areas: A medication room door was taped open and left unlocked because a broken lock prevented normal access, and the room contained unsecured antibiotics, IV fluids, and a resident’s medications in an unlocked cabinet. Additional tours found unlocked utility and storage rooms with live electrical wires, oxygen cylinders, cleaning chemicals, open sharps containers with blood-tinged needles and syringes, and other accessible biohazard materials.
Inoperable Call Bell System: Surveyors found that a resident with severe cognitive and physical impairments could not reach or use the call bell, and the device did not activate any audible or visual signal. The same problem was also found in another resident’s room and in three additional resident rooms, with staff acknowledging that the audible call bell system was not working and that the facility had a broader call bell issue.
A resident with severe cognitive impairment and multiple comorbidities was subjected to physical and verbal abuse by a CNA during incontinence care. The resident, who had previously shown no resistance to care, became combative when the CNA attempted to clean her. According to an RN’s eyewitness account, the CNA ignored the resident’s request to stop, pushed the resident onto her side while searching for a broken necklace, then punched the resident twice in the back/thigh area and stated she did not care anymore. The resident subsequently ran into the hallway partially unclothed, refused assessment and care, and exhibited agitation and confusion, later telling psychiatry that the CNA had come from behind, grabbed, and started hitting her until staff intervened.
Failure to Assess and Treat Pressure Injuries: Staff did not timely assess, document, or initiate ordered care for two residents with pressure injuries. One resident at risk for skin breakdown had no documented preventive interventions on admission despite prior hospital instructions for heel off-loading, repositioning, and use of wedges/boots, and a heel wound was later found to have progressed without timely staging or measurements. Another resident was admitted with an unstageable sacral pressure ulcer, but nursing documentation lacked wound measurements and description, and wound treatment orders were not entered until the wound physician assessed the resident later.
Unclean and disrepair conditions were observed throughout the facility, including cluttered resident rooms, spoiled food and soiled bedding, dirty and damaged shower rooms, buildup in the dining room, and rooms lacking homelike features such as personal items and clean curtains. Residents also had room disrepair issues, including unpainted wall repairs, a detached closet door, no dresser, and a broken outlet plate exposing the outlet elements near a resident’s bed. One resident had significant cognitive impairment, used a wheelchair, and had poor impulse control and frequent falls.
Incomplete and non-specific care plans were identified for multiple residents. One resident with PTSD had ongoing psych and LCSW involvement, but the care plan did not address the diagnosis, trauma history, triggers, or therapy interventions. Another resident on dialysis had no dialysis care plan, a resident at risk for pressure injuries developed a Stage 3 heel ulcer without a prevention plan, and another resident’s plan used template language, left goals blank or vague, and did not address known medication allergies despite pain medication orders.
Medications were not available as ordered for a resident with severe cognitive impairment and multiple diagnoses, including a right femur fracture, malnutrition history, B12 deficiency, and adult failure to thrive. Record review showed repeated delays and gaps for Enoxaparin and Gabapentin, with notes stating the meds were awaiting pharmacy delivery or had run out. Staff and the DON stated meds should be available for administration, and the Omnicell inventory showed Gabapentin was on hand, but access was not obtained.
Expired medications and medical supplies were found in 2 medication rooms, including the Meadowland and Rosewood Unit med rooms. Surveyors observed multiple expired ostomy supplies, catheter kits, saline enema sets, needles, and other items, and both LPNs interviewed stated expired medications and supplies are expected to be discarded when discovered.
Improper food storage and labeling were found in the kitchen and in two nourishment refrigerators. Opened food items were left undated in dry storage and the walk-in refrigerator, and in the Rosewood and Meadowland unit refrigerators staff found expired, spoiled, unlabeled, and undated items, including soup, salad dressing, apple slices, and milk. An LPN stated resident food brought in by family or visitors was supposed to be labeled with the resident’s name, room number, and date brought in, and that nursing staff were supposed to inspect the refrigerators weekly for out-of-date or spoiled food.
Missed Influenza and Pneumococcal Vaccine Offers and Documentation: The facility failed to document that flu and pneumococcal vaccines were offered and/or provided for several residents with significant medical conditions and varying cognitive status. Records for four residents showed physician orders for annual flu vaccine and Pneumovax if needed, but no documentation of vaccine offers, administration, education, or refusal. Interviews with residents indicated they did not recall being asked about vaccines, and the IP stated she was still catching up on resident vaccination status and accessing immunization history.
Missing COVID-19 Vaccine Education and Documentation The facility failed to document COVID-19 vaccine education, offering, and/or administration for four residents reviewed. One resident had no cognitive impairment and stated no one asked about the vaccine, another had multiple diagnoses and also reported no vaccine discussion, a third had moderate cognitive impairment and could not recall being asked, and a fourth had severe cognitive impairment and could not be interviewed. The IP stated she was catching up on vaccination status and had only recently gained access to the state immunization portal, while the facility policy required residents to be educated, offered the vaccine, and have documentation maintained.
Failure to assess whether a resident could self-administer medication. A resident with multiple diagnoses, including mild cognitive impairment and diabetes, had Neosporin ointment kept at the bedside and stated a family member brought it in for personal use. The clinical record showed no assessment or determination that the resident was safe to self-administer meds, and the DON confirmed the resident had not been assessed.
A resident with CHF, HTN, depression, anxiety, and moderate cognitive impairment had a bedroom clock that was not working and repeatedly showed the wrong time during multiple survey observations. The resident noticed the clock did not work when asked about lunch time, and the DON also observed the incorrect time and stated that clocks in residents’ rooms should be correct.
Failure to Notify Resident of Room Transfers: A resident with PTSD was moved between rooms without proper documented notification for multiple transfers. The resident said staff moved him without telling him, and the DON, DSW, and ASW could not find documentation for one transfer; survey review found 10 of 14 room transfers lacked notification records, despite a facility policy requiring advance written notice to the resident and representative.
Employment of CNA with Barrier Crime Conviction: The facility allowed a CNA with a felony conviction for delivery of drugs to a prisoner to continue working and providing direct resident care despite the background check showing a barrier crime. Leadership confirmed the CNA should not have been working, and records showed the CNA was working full-time on the 11 p.m. to 7 a.m. shift with another shift scheduled.
Incorrect MDS Coding for Documented Stage 4 Pressure Wound: A resident with severe cognitive impairment and ADL dependence had a documented right heel pressure wound that was described in the record as Stage 3 and later Stage 4 by a wound care physician and in weekly wound rounds. However, the discharge MDS coded no unhealed pressure ulcers/injuries, and the discharge body audit also stated the skin was intact. The DON and Regional MDS Coordinator reviewed the record and stated the MDS was incorrect.
The facility failed to review and revise care plans for three residents after changes in condition and interventions were documented. One resident with a healed sacral pressure ulcer and multiple chronic conditions had current pressure injury prevention measures in place, but the care plan only addressed monitoring skin changes. A second resident’s fall prevention plan did not include floor mats that were observed on both sides of the bed, and a third resident’s care plan was not updated within 7 days after a fall with injury. An LPN and the DON acknowledged the missing or delayed care plan revisions.
A resident with MS, opioid dependence, hypertensive heart disease, and a hx of stroke had meds found in the room after the nurse attempted morning med pass. The resident said the meds had been dropped, refused a room sweep, and became agitated when the nurse tried to educate her. The resident’s Suboxone order required the nurse to stand and wait until the med was fully taken, and staff stated meds should be administered and consumed in the nurse’s presence before the nurse leaves the room.
A resident with cerebral palsy, stroke, dysphagia, dementia, and contracted hands was left reclined in bed with an untouched breakfast tray and no feeding assistance, despite needing supervision and staff help at times. The resident said the meal was cold, tried to feed herself, and coughed on a biscuit before an LPN entered to assist; the care plan called for upright positioning, supervision, and specialized dining items.
Medication Allergy and Order Administration Failures: The facility failed to follow medication orders and allergy documentation for two residents. One resident had documented allergies to Acetaminophen, Hydrocodone, Oxycodone, and Tramadol, yet Tramadol and Tylenol were prescribed and administered, with no documented clarification, monitoring, or care plan for the allergies. Another resident, who was alert and oriented and used a walker, did not receive several ordered meds including levothyroxine, lisinopril, verapamil, and oxycodone, and the record showed staff were waiting for clarification while the resident and family reported missed pain meds and unmet needs.
Failure to change oxygen tubing weekly for two residents. Oxygen tubing on the concentrator was observed dated beyond the expected weekly change interval, and one resident also had older tubing left on the nightstand. The MARs and care plans directed weekly tubing changes, and an LPN and the DON stated tubing should be changed on the night shift each week.
Missing Dialysis Communication Logs: A resident with ESRD on dialysis, diabetes, major depression, and kidney failure had no completed dialysis communication logs in the record except for one dialysis assessment. The resident was cognitively intact and had orders for dialysis three times per week. An LPN stated the communication book was not returned from the hospital, but also acknowledged missing documentation before and after hospitalization, and a unit supervisor said the book was probably still at the hospital.
A resident with osteoarthritis, HTN, constipation, and pain related to a knee replacement missed ordered meds when the EHR/MAR system went offline. The MAR showed no administration of levothyroxine, lisinopril, verapamil, oxycodone, Miralax, or senna, and nursing notes reflected delays in clarifying BP meds while the resident’s niece reported the meds were available. The resident said she missed pain meds for days and was placed in an adult brief because staff said they could not walk her to the bathroom every time.
A resident on a regular diet with regular liquids was ordered two yogurts for breakfast, but tray observations showed the yogurt was not included. The resident reported not getting what was ordered and said she used to receive yogurt but no longer did after a new company took over. A CNA verified the breakfast tray, and the dietary manager later confirmed yogurt was available.
Infection control practices were not followed during respiratory equipment storage for two residents and during medication administration for another resident. Respiratory tubing and masks were repeatedly observed left out on overbed or bedside tables, open to air or lying on clothing instead of being stored in a bag, despite staff and DON statements that unused delivery devices should be bagged. During med pass, an LPN with nails extending past the fingertips touched a stock Senna bottle with a finger, handled a metoprolol tablet in the palm, and performed a bedside blood sugar check without sanitizing hands before gloving or after glove removal.
A resident with a seizure disorder did not receive prescribed levetiracetam on two occasions due to the unavailability of the liquid form in the facility's Omnicell system. Staff interviews and records confirmed the delay in pharmacy delivery, leading to the missed doses, contrary to the facility's medication administration policy.
A resident with dementia and cognitive deficits eloped from the facility after cutting off a wander guard, due to inadequate supervision. The resident was later found and returned by local authorities. The facility's staff acknowledged the resident's impaired cognitive abilities and psychiatric history, but the MDS assessment was incomplete, highlighting a lack of oversight.
The facility failed to have an Administrator present at a quarterly QAPI meeting, as required by policy. The RVPO, acting as the Administrator, confirmed the meeting's status but was not listed on the attendance sheet. The facility's policy requires the Administrator's presence as a key committee member. No additional information was provided by the staff to address this deficiency.
Failure to Maintain Clean, Safe, and Homelike Resident Room Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for one resident when surveyors observed the resident’s room to be crowded and unclean throughout the survey period. On initial tour and continuing through the end of the survey, the resident’s room on the Meadowdale unit was described as crowded (hoarded) with boxes and plastic storage containers placed in front of and on top of the resident’s wheelchair, overbed table, and air conditioning unit. Articles of clothing were scattered around the room, and there were open containers of butter, food sauces, and food spices spilled on various surfaces. Surveyors also noted partially eaten food items and two drinking glasses partially filled with a dark liquid, with liquid dripped down the sides of the glasses. None of the food items were refrigerated, and the room had a sour, spoiled food smell. The resident was observed sitting on a soiled bed encrusted with spilled food, and the resident’s yellow shirt had a 6-inch by 6-inch stain on the front with dried, spilled foods and liquids. When asked, the resident stated, "I just spilled something on it." The resident’s roommate was not in the room and was observed spending most of the daytime hours in other areas of the facility, including the dining room, facility entry hallway, and nursing station. When the roommate was asked why he stayed out of the room, he did not respond and walked away. The DON reported that the resident was very resistant to cleaning in the room and became very belligerent if items were moved or trash was thrown away, and further stated that the resident refused to speak to her after she had been going in and cleaning the room.
Failure to Screen CNA With Barrier Crime Conviction
Penalty
Summary
The facility failed to implement its abuse policy regarding employee screening by allowing a CNA with a barrier crime conviction to work with unrestricted access to residents throughout the facility. The facility’s policy required screening for abuse, neglect, exploitation, misappropriation, criminal background checks, abuse checks, sworn disclosure statements, and verification of licensure or registration prior to hire, but CNA #3 was hired and continued working despite a criminal history showing a felony conviction for delivery of drugs to a prisoner. On review of employee records, surveyors identified that CNA #3 had been employed since 11/26/24 and had worked direct care shifts in the facility, including the 11:00 PM to 7:00 AM shift on 3/5/26 to 3/6/26. The Administrator stated that CNA #3 should not have been working at the center because of the background check results. The Administrator in Training confirmed that CNA #3 was a full-time employee, worked throughout the entire facility, and was not assigned to a dedicated unit, hall, or set of residents. The non-compliance was determined to constitute Immediate Jeopardy and substandard quality of care on 3/6/26 at 8:10 PM, with the IJ beginning when CNA #3 was hired. Surveyors also reviewed Facility Reportable Incidents from 11/26/24 to the present and interviewed the social worker, DON, and Administrator regarding complaints or abuse allegations involving CNA #3, with no additional information provided before the survey concluded.
Unsecured medication, chemical, oxygen, and biohazard storage areas
Penalty
Summary
The facility failed to ensure that medications, hazardous materials, and biologicals were properly secured on three units. During a tour of the Pinebrook unit, the medication storage room door was found unlocked and unsecured, with the latch taped open so staff could enter without using a key. The room contained a toolbox with unsecured drawers holding multiple antibiotic medications, a bottom shelf with sodium chloride solution bags, and a filing cabinet that was unlocked and contained a shaving kit bag belonging to a resident with several medications inside. Staff interviews confirmed that the medication room door was supposed to be locked, but it had been taped open because a key had broken off in the lock and staff needed access to the room. The unit manager stated the door had been taped open to allow access, and maintenance confirmed the door had been broken for about a month and had to be pried open. Staff also stated they were not aware that resident medications were being stored in the Pinebrook medication storage room, and the DON stated the resident’s medications had been turned over for disposal after the resident transferred back to the facility. A later tour of all units found additional unsecured areas. On Meadowland, an electrical room door was unlocked with live wires exposed, and a clean utility room containing oxygen cylinders was unlocked and unmonitored. On Pinebrook, a storage room containing cleaning supplies was unlocked and unmonitored. On Rosewood, a biohazard room containing open sharps containers with needles and syringes showing a red substance appeared to be blood, along with open boxes of biohazardous materials, was accessible. The beauty salon was also unlocked and had water leaking into an overflowing trash can, with water traveling under a rotting cabinet toward wall outlets.
Inoperable Call Bell System
Penalty
Summary
The facility failed to maintain a working call bell system in resident bathrooms and bathing areas, and surveyors found that multiple resident rooms also had call bells that did not function. The issue was first identified for one resident and then expanded to three additional residents in the sample. The report states that the call bell system was inoperable and that no alternative means to call for assistance was in place for the affected residents at the time of the survey findings. One affected resident had diagnoses including cerebral palsy, left-sided hemiplegia, aphasia, stroke, malnutrition, dysphagia, contractures of both upper extremities, lack of coordination, and dementia. The resident’s most recent MDS indicated severe cognitive impairment, extensive to total dependence for activities of daily living, and dependence on staff for self-care and hygiene. During observation, the resident was lying in bed with the call bell clipped above the head and out of reach, had an untouched breakfast tray in front of her, and was unable to use the standard corded spherical call button because of bilateral hand contractures. Surveyors tested the call bell and found that it did not activate a light at the doorway or provide an audible or visual signal to a centralized location. The roommate’s call bell was also found not to be functioning. A nurse stated that staff had to watch for lights over the doors because the audible bell did not work, and the maintenance director reported that contractors had identified a facility-wide call bell problem and recommended repair, but the system had not been fixed at that time. Surveyors then found three other resident rooms with call bells that were not functioning.
Staff-to-Resident Physical Abuse During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a CNA during incontinence care. The resident had multiple significant medical diagnoses, including severe chronic kidney disease, diabetes, hypertension, deep vein thrombosis, myocardial infarction, history of pulmonary embolism, diabetic retinopathy, delirium, dementia with agitation, pulmonary edema, and spondylosis. An MDS assessment documented severely impaired cognitive skills, and the admission assessment noted the resident had clear speech, was sometimes able to understand instructions, had a pleasant mood, no observed behaviors, was always incontinent of bowel and bladder, had no skin impairments, and ambulated with a walker. Nursing skilled notes in the days immediately prior to the incident documented no voiced complaints and no resistance to care or refusals. On the date of the incident, a change of condition form completed by the primary nurse documented that the nurse witnessed a CNA hit the resident during incontinence care after the resident became aggressive and swung at the CNA, breaking the CNA’s necklace. The form stated that the CNA punched the resident twice in the lower back with her fists. The resident then demonstrated paranoid and aggressive behaviors, refused assistance with changing, refused physical assessment, and ran into the hallway without pants, would not allow anyone to touch her, and sat in a chair in the hall with a sheet over her legs. The nurse practitioner’s note from the same day described the resident as increasingly confused, agitated, and combative, sitting in the hallway soiled in a disposable brief and refusing to allow staff to change her. The NP documented that the resident was unaware of self, surroundings, or location, was attempting to contact her father, and that a thorough review of systems and physical exam could not be completed due to the resident’s mental status. Subsequent documentation showed that after the incident the resident initially refused to speak with social services and was described as agitated, confused, and unwilling to allow staff to assess or change her until a family member arrived. Later nursing notes indicated that the resident calmed, resumed taking medications, and allowed care, with skin assessments revealing no physical injury or pain. Psychiatry later documented the resident’s report that the CNA came from behind, grabbed, and started hitting her, and that she had to defend herself until staff intervened. The facility’s investigation included written statements from the witnessing RN, who reported that the CNA pushed the resident on her side, insisted on finding her broken necklace in the bed or brief despite the resident’s request to stop, and then punched the resident in the thigh/back twice while stating, “I just don’t care anymore.” The CNA’s own written statement acknowledged the resident became combative, broke her necklace and name tag, and that the CNA continued to attempt to provide care despite the resident’s refusals. These events constituted the substantiated incident of staff-to-resident physical and verbal abuse that led to the cited deficiency.
Failure to Assess and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide treatment and services to prevent and heal pressure injuries for two residents. For one resident, the record showed admission with multiple diagnoses including pathological fracture of the right femur, malnutrition, adult failure to thrive, difficulty walking, lack of coordination, and severe cognitive impairment. The resident was identified on the MDS as being at risk for pressure ulcers, and hospital records before admission documented wounds to the left second and third toes with instructions for aggressive repositioning, heel off-loading, and use of wedges and heel boots. However, the admission record did not document those preventive interventions, and the care plan did not address the resident’s wounds, pressure injury risk, or prevention measures. For that resident, weekly skin checks later documented a right heel reddened area, but there was no description, staging, or measurement at the time it was first noted. The first physician orders for the heel wound were not documented until two days later, and the wound was later described as open, red, and bleeding without staging or measurements. The record then documented the wound as a stage 3 with measurements, and later physician wound rounds documented the right heel as a stage 4. Staff interviews stated residents at risk should be turned and repositioned every two hours and that skin issues should be reported, while the DON stated wounds should be identified before advancing stages and interventions should be implemented for residents at risk. For the second resident, the record showed admission with diagnoses including COPD, sacral pressure ulcer, bipolar disorder, BPH, orthostatic hypotension, CKD, dementia, hip fracture, psychotic disturbance, mood disorder, and protein-calorie malnutrition, with severely impaired cognitive skills on the MDS. Hospital records documented an unstageable sacral pressure injury with eschar and a discharge plan that included daily wound cleanser, hydrophilic dressing, and silicone foam dressing. On admission, nursing documented a sacral wound but did not record measurements or a description of the wound’s appearance, and a subsequent skin assessment also lacked measurements or wound description. The consultant wound physician did not assess the wound until 15 days after admission, at which time treatment orders were entered. The DON and unit manager stated the admitting nurse should have assessed, measured, described, and obtained orders for the pressure ulcer upon admission, and the DON stated there was a delay in care.
Unclean and Disrepair Conditions in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in multiple areas, including nursing units, shower rooms, storage areas, the dining room, and several resident rooms. During the initial tour, one resident’s room on the Meadowdale unit was crowded with boxes and plastic containers blocking airflow to the air conditioning unit, with clothing scattered around, opened food sauces and spices spilled on surfaces, partially eaten mixed food items, several drinking glasses with dark liquid, and a sour spoiled food odor. The resident was sitting on a soiled bed encrusted with spilled food and wearing a sweatshirt stained with dried food and liquids. The roommate was often out of the room during the survey and was found in common areas instead of the room. Surveyors also observed unsanitary and deteriorated conditions in the shower rooms and common areas. In the women’s shower room there was a black substance along corners and caulking and broken tiles in the showers. In the men’s shower room, used soap and hair were in the drain cover, handrail portions and end plugs were broken and on the floor, a shower stretcher had used soap on it, baseboards were detached in places, used shampoo and soap were on the floor, and feces was found in the toilets. On the Rosewood unit, a shower area had a shampoo bottle on the floor, caulking pulled away from tiles with broken tiles on the floor and open holes in the wall, and a shower chair without anti-slip grip on the seat and armrest. Another shower area had lights out and was being used to store wheelchairs. The main dining room sink area and steam table were also observed with black buildup and dirt. Resident rooms were described as lacking personal items, photographs, artwork, clocks, and other features that would make them comfortable and homelike, and divider curtains were stained and unclean. The report also documented room disrepair for two residents and a broken electrical outlet for another resident. One resident reported unsanded and unpainted spackling on the wall, a scraped and unpainted bathroom door, and molding pulling away from the wall, and these conditions were observed by the surveyor. Another resident’s family member reported that the closet door was detached and the resident did not have a dresser like other residents; the surveyor observed the detached closet door and absence of a facility-owned dresser. A third resident, who had a BIMS score of 6, was dependent on staff for transfers, used a wheelchair, had poor impulse control, frequent falls out of bed, and behaviors; the surveyor observed a broken outlet plate with a hole exposing the outlet elements within arm’s reach of floor mats beside the bed.
Incomplete and Non-Specific Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for multiple residents with identified needs. One resident with diagnoses including vascular dementia, schizophrenia, diabetes, PTSD, major depressive disorder, chronic kidney disease, cerebrovascular disease, atrial fibrillation, DVT, anxiety, and peripheral vascular disease had ongoing LCSW and psychiatry involvement for PTSD, including psychotherapy up to twice per month, trauma-informed care, and supportive counseling, but the care plan did not include PTSD-related problems, goals, interventions, the identified trauma, or triggers. An LPN responsible for MDS and care plan development stated the plan mentioned medications but nothing else about PTSD and agreed it should include problems, goals, and interventions. Another resident with ESRD on dialysis, diabetes, major depression, and kidney failure had physician orders showing dialysis three days per week, but the comprehensive care plan did not include a dialysis care plan. The MDS coordinator reviewed the plan and stated there was no dialysis care plan on the current comprehensive care plan. A third resident admitted with diagnoses including pathological fracture of the right femur, malnutrition history, B12 deficiency, adult failure to thrive, difficulty walking, lack of coordination, and unsteadiness on feet had an admission MDS coded as at risk for pressure ulcers/injuries and had prior wound care instructions for repositioning and heel offloading, but the care plan did not include a focus area, goals, or interventions for pressure ulcer prevention. That resident later developed a reddened area on the right heel that was identified as a Stage 3 pressure ulcer, yet the care plan was not updated to reflect the wound or prevention needs. A fourth resident with multiple myeloma, diabetes with diabetic chronic kidney disease, COPD, atrial fibrillation, acute cystitis with hematuria, acute posthemorrhagic anemia, and hemorrhage of the anus and rectum had a care plan that used template language, included unspecified ADL deficits with a blank placeholder for ADLs, had a blank goal for pressure injury risk, and did not address known allergies to four medications despite orders for two of those medications for pain relief. The DON reviewed the plan and stated it was not specific or tailored to the resident.
Medications Not Available as Ordered
Penalty
Summary
The facility failed to provide medications as ordered by the physician for one resident. Resident #113 was admitted with diagnoses including pathological fracture of the right femur, history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty walking, lack of coordination, and unsteadiness on feet. The most recent MDS coded the resident with a BIMS score of 7 out of 15, indicating severe cognitive impairment, and the resident required assistance with ADLs. Review of the clinical record showed repeated documentation that ordered medications were not available for administration. Notes documented that Enoxaparin Sodium was awaiting medication, waiting for pharmacy to send, or that the medication had run out and a refill was requested. Similar documentation was found for Gabapentin, including that the medication was not administered because it was not available and pharmacy delivery was pending. During observation and interviews, staff stated medications should be given as ordered and should be available for administration. The DON stated nurses should check the Omnicell, notify the pharmacy, and inform the physician if medication was not available. The Omnicell inventory list showed Gabapentin 100 mg capsules were available in the Omnicell, but the nurses should have notified the pharmacy to gain access to the medication. The DON also stated Enoxaparin was not available for administration.
Expired Medications and Supplies Found in Medication Rooms
Penalty
Summary
The facility failed to appropriately store medications and medical supplies in 2 of 3 medication rooms, including the Meadowland Unit medication room and the Rosewood Unit medication room. During an inspection of the Meadowland Unit medication room, multiple expired items were found, including an opened box of 2-piece urostomy pouches with an expiration date of 12/2024, an opened box of drainable ostomy pouches with an expiration date of 12/2024, an opened box of ostomy barrier rings with an expiration date of 9/2025, and an opened box of no sting barrier film with an expiration date of 11/9/2025. Additional expired items found in the Meadowland Unit medication room included four saline enema sets with expiration dates of 2/2026, eleven urethral self-catheterization kits with expiration dates of 10/31/2024, a rigid tipped urinary catheter with an expiration date of 8/2/25, and a female luer lock cap with an expiration date of 7/28/25. In the Rosewood Unit medication room, surveyors found a package of 2 needles with an expiration date of 2/20/26, an opened box of 2-piece ostomy pouches with an expiration date of 2/1/26, another opened box of 2-piece ostomy pouches with an expiration date of 12/1/25, and an opened box of closed ostomy pouches with an expiration date of 2/1/26. LPN #3 and LPN #1 both stated that expired medications and supplies are expected to be discarded when discovered.
Improper Food Storage and Labeling in Kitchen and Nourishment Refrigerators
Penalty
Summary
Food was not stored in accordance with professional standards in the main kitchen and in two nourishment room refrigerators. During an initial kitchen tour with the Dietary Manager, opened food items were found in dry storage and the walk-in refrigerator without dates, including half a loaf of bread, a package of hot dog buns, a container of apple cider vinegar, and a package of shredded cheese. The Dietary Manager confirmed these opened and undated items should not have been stored there and discarded them. In the Rosewood Unit nourishment refrigerator, an opened container of soup that expired on 2/14/2026 and an opened bottle of creamy Italian salad dressing without a date were observed. In the Meadowland Unit nourishment refrigerator, several items were not labeled or dated, including packaged apple slices that were spoiled and past the expiration date of 1/31/2026 and a carton of whole milk that expired on 2/16/2026. An LPN stated that resident food brought in by family or visitors was supposed to be labeled with the resident's name, room number, and date brought in, and that nursing staff were supposed to inspect the nourishment refrigerators weekly and discard out-of-date or spoiled food. The facility policy presented required food brought in by family or visitors to be labeled with content and dated, and included practices for labeling, dating, and monitoring refrigerated foods.
Missed Influenza and Pneumococcal Vaccine Offers and Documentation
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccines were offered and/or documented for 4 of 5 sampled residents reviewed for immunization status. The deficiency involved residents with varying cognitive status and medical histories, including chronic respiratory disease, heart failure, diabetes, neurologic disorders, psychiatric diagnoses, and pressure injuries. Clinical record reviews showed that each of the four residents had physician orders for annual flu vaccine and Pneumovax if needed, but their immunization records did not contain documentation that the vaccines were offered or administered. Resident #18 was readmitted after hospitalization for acute on chronic hypoxic respiratory failure and fluid overload secondary to CHF, and her diagnoses included COPD with acute exacerbation, hypertensive heart disease with heart failure, OSA, morbid obesity with alveolar hypoventilation, type 2 diabetes, cocaine abuse, and chronic myeloid leukemia. Her MDS coded her with a BIMS score of 15, and she stated that no one at the facility had asked her about vaccinations or offered any vaccines. Resident #10 had diagnoses including spina bifida with hydrocephalus, type 2 diabetes, hypertension, history of colon cancer, anxiety, depression, and sacral pressure injuries; his MDS also showed a BIMS score of 15, and he stated he did not recall anyone asking him about vaccinations or offering vaccines. Resident #48 had diagnoses including cerebral infarction, type 2 diabetes, mild intellectual disabilities, epilepsy, CHF, major depressive disorder, schizoaffective disorder, bipolar type, violent behaviors, acute respiratory failure with hypoxia, and hypertension; her MDS showed a BIMS score of 9, and she could not remember anyone asking her about vaccinations. Resident #9 had diagnoses including COPD, bipolar disorder, altered mental status, paralytic ileus, dementia without behavioral disturbance, major depressive disorder, sacral pressure ulcer, and type 2 diabetes. His MDS showed a BIMS score of 2, and he was non-interviewable regarding whether he was educated about or offered the pneumococcal vaccine. The Infection Preventionist stated she had only been employed for a few months, was trying to catch up on vaccination status for all residents, was aware that some residents were missing vaccine information, and was working to obtain consents. She also stated she had recently gained access to the State Immunization Information System portal to review vaccination history. The facility policies required annual influenza vaccination offers, assessment for pneumococcal immunization upon admission, and documentation of education, offers, refusals, contraindications, or receipt of the vaccines, but the records reviewed did not show that this had been completed for the sampled residents.
Missing COVID-19 Vaccine Education, Offering, and Documentation
Penalty
Summary
The facility failed to ensure that COVID-19 vaccination education was provided and that the vaccine was offered and/or documented for 4 of 5 residents reviewed in a sample of 46 residents: Residents #18, #10, #48, and #9. The deficiency involved missing documentation in the residents’ immunization records showing no information that they were educated about, offered, or given the COVID-19 vaccine. Resident #18 was admitted and later readmitted after hospitalization for acute on chronic hypoxic respiratory failure and fluid overload secondary to CHF, and her diagnoses included COPD with acute exacerbation, hypertensive heart disease with heart failure, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus, cocaine abuse, and chronic myeloid leukemia. Her most recent MDS coded her with a BIMS score of 15/15, indicating no cognitive impairment. Her record showed no known allergies, and she stated that no one at the facility had asked her about the COVID-19 vaccine, provided education, or offered it. Resident #10 had diagnoses including spina bifida with hydrocephalus, type 2 diabetes mellitus, hypertension, history of colon cancer, anxiety, depression, and sacral pressure injuries, and his MDS also coded a BIMS score of 15/15. His record showed allergies to ciprofloxacin, clonidine, nitrofurantoin, nystatin, trospium, cat dander, Latex, and hydrofera blue 4x4 wound dressing, which were noted as not generally preventing COVID vaccination, and he reported he did not recall anyone asking him about the COVID-19 vaccine or any vaccine. Resident #48 had diagnoses including cerebral infarction due to occlusion or stenosis of the small artery, type 2 diabetes mellitus, mild intellectual disabilities, epilepsy, CHF, major depressive disorder, schizoaffective disorder bipolar type, violent behaviors, acute respiratory failure with hypoxia, and hypertension. Her MDS coded a BIMS score of 9/15, indicating moderate cognitive impairment, and her record listed allergies to ibuprofen, Dilantin, and penicillin, which were noted as not generally preventing COVID vaccination; she stated she could not remember anyone asking her about vaccinations. Resident #9 had diagnoses including COPD, bipolar disorder, altered mental disorder, paralytic ileus, dementia without behavioral disturbance, major depressive disorder, pressure ulcer sacral region, and type 2 diabetes mellitus, and his MDS coded a BIMS score of 2/15, indicating severe cognitive impairment. His record showed no known allergies, and he was non-interviewable regarding whether he had been educated or offered the vaccine. The Infection Preventionist stated she had only been employed for a few months, was trying to catch up on vaccination status, was aware some records were missing vaccine information, and had recently gained access to the State immunization portal. The facility’s COVID-19 vaccination policy stated residents would be educated and offered the vaccine and that documentation would be maintained, but the records reviewed did not show that this occurred for these residents.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess and determine whether it was clinically appropriate for a resident to self-administer medication. Resident #73 was admitted with diagnoses including spinal stenosis with neurogenic claudication, type 2 diabetes with diabetic neuropathy, muscle weakness, need for assistance with personal care, mild cognitive impairment, dependence on wheelchair, ocular hypertension, hypertension, and chronic pain syndrome. The resident’s most recent MDS was coded as a quarterly assessment, and the BIMS score was 12 out of 15, indicating moderate cognitive impairment. During the initial tour, a tube of Neosporin ointment was observed in a bin on the overbed table, and the resident stated that a family member brought it in and that the resident wanted to use it whenever needed, despite knowing it was not supposed to be there. Review of the clinical record, including physician orders, care plan, nursing notes, assessments, and interdisciplinary team meeting notes, showed no indication that the resident had been assessed for or determined safe to self-administer medications. Staff were observed providing care and medication-related services in the resident’s room on multiple days, while the Neosporin remained clearly visible at the bedside and no staff member addressed it. During debriefings, the DON initially stated she thought only one resident had a self-administration assessment, but not this resident, and later stated there were no residents assessed and approved for self-administration of medications. When interviewed, the DON confirmed the resident had not been assessed for self-administration of the medication.
Broken Bedroom Clock Not Corrected
Penalty
Summary
The facility failed to provide reasonable accommodation of a resident’s needs and preferences when the clock in Resident #68’s bedroom was not working and continued to display the wrong time. Resident #68 was admitted with diagnoses including congestive heart failure, hypertension, depression, and anxiety, and had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. During the survey, the clock in the resident’s room was observed multiple times to show 8:20 and the hands were not moving. The incorrect clock time was observed during the initial tour and on several subsequent rounds over multiple days, with the clock still showing 8:20 each time. When asked what time lunch was served, Resident #68 looked at the clock and stated the clock did not work. The DON also toured the room and noted that the clock showed 8:20, and stated that it was important for clocks to be correct in residents’ rooms.
Failure to Notify Resident of Room Transfers
Penalty
Summary
The facility failed to provide proper notification of a room transfer for Resident #13 and failed to document notification for multiple room changes. During interview, the resident stated the facility moved him from his previous room without notification, and staff placed his belongings on the bed and wheeled him into the new room while they were fixing up the prior room. The resident’s record showed a diagnosis of PTSD, with a plan of care to decrease triggers for him. The record also showed prior room transfer notifications that were signed by the resident on 4/23/2021, 2/17/2025, and 5/14/2025. Survey review found that 10 of 14 room transfers lacked documentation of notification, including transfers on 5/20/2021, 6/1/2021, 9/1/2021, 9/24/2021, 1/10/2022, 1/19/2022, 2/26/2025, 5/21/2025, 8/5/2025, 8/12/2025, and 2/4/2026. Staff interviews with the DSW, ASW, and DON could not produce documentation of notification for the 8/12/2025 room transfer. A nursing progress note stated the resident was made aware of a return to room, but it did not identify the room the resident was in or the room he was being transferred to. The facility policy required advance written notice of room changes to the resident and representative, including the reason for the move.
Employment of CNA with Barrier Crime Conviction
Penalty
Summary
The facility failed to prevent the employment of a CNA who had been convicted of a barrier crime, despite the conviction disqualifying the employee from working in a nursing home. During review of employee records, the CNA’s Virginia Department of State Police criminal history and sex offender record showed a guilty felony conviction for delivery of drugs to a prisoner. The CNA was identified as one of 25 employees reviewed and had been hired on 11/26/24. Interviews with facility leadership confirmed that the CNA should not have been working at the center based on the background check results. The Administrator in Training stated the CNA was a full-time employee working the 11 p.m. to 7 a.m. shift and had worked the prior night from 11:22 p.m. to 7:35 a.m.; the payroll record also showed the CNA was scheduled to work again that night. The CNA had direct care access to residents with unrestricted and unsupervised access before being suspended and later resigning.
Incorrect MDS Coding for Documented Stage 4 Pressure Wound
Penalty
Summary
The facility failed to accurately code the discharge MDS for Resident #113 by indicating that the resident had no unhealed pressure ulcers or injuries, even though the clinical record documented a Stage 4 pressure wound on the right heel. Resident #113 was admitted with diagnoses including pathological fracture of the right femur, history of malnutrition, B12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty walking, lack of coordination, and unsteadiness on feet. The admission MDS coded severe cognitive impairment with a BIMS score of 7 out of 15, and the resident required assistance with ADLs. Section M of the admission MDS indicated no pressure ulcers or wounds on admission. Review of the closed record showed that pressure ulcers were documented in the chart as pressure ulcers, wounds, or pressure injuries. Physician progress notes, physician orders, and nursing notes documented a Stage 3 pressure wound on the right heel, and a consultant wound care physician identified the wound as Stage 4 on the right heel. Weekly wound round notes continued to document the right heel wound as Stage 4 through the last evaluation noted in the record. Despite this documentation, the discharge MDS was coded as 0 for unhealed pressure ulcers/injuries, and the discharge body audit also documented the skin as intact. During interview, the DON and Regional MDS Coordinator reviewed the record and stated the discharge MDS was incorrect and should have reflected the documented pressure ulcer.
Care plans not updated after pressure injury prevention changes and falls
Penalty
Summary
The facility failed to review and revise comprehensive care plans for three residents after changes in condition and interventions were documented. For one resident with COPD, dementia, chronic kidney disease, malnutrition, and a history of a sacral pressure ulcer that was healed as of 12/1/25, the care plan was last revised on 1/20/26 and only addressed monitoring for new pressure injuries. Current physician-ordered prevention measures included a pressure relief cushion to the wheelchair, barrier cream to the buttocks, a protective silicone foam dressing to the sacrum three times weekly, skin prep to the heels three times weekly, a pressure relief mattress, and off-loading of the heels/feet, but these interventions were not added to the care plan. The resident was observed in bed with a pressure relief mattress in use and heels/feet elevated on cushions. For another resident identified as a fall risk, the care plan addressed fall prevention and an actual fall, but it did not include floor mats placed on both sides of the bed. The resident was observed in bed with floor mats in place on both sides of the bed on two separate occasions. During interview, the LPN responsible for care plan updates reviewed the plan and stated that the floor mats should have been included as an intervention, and acknowledged that the mats were in place even though they were not documented in the care plan. For a third resident with diagnoses including a pathological fracture of the right femur, malnutrition, B12 deficiency, adult failure to thrive, difficulty walking, lack of coordination, and unsteadiness on feet, the care plan was not reviewed or revised after a fall with injury documented on 6/19/23 until 7/11/23. The care plan still reflected an actual fall with no injury and was not updated within 7 days of the fall. The DON stated that care plans should be reviewed and revised after any falls within 7 days.
Medication Administration Not Observed to Completion
Penalty
Summary
The facility failed to ensure that medications were taken and consumed in the presence of the nurse for one resident. The resident was admitted with diagnoses including multiple sclerosis, opioid dependence, hypertensive heart disease, and a history of stroke. The most recent MDS coded the resident with a BIMS score of 14 out of 15 and indicated the resident needed partial to moderate assistance with most ADLs, including transfers, toileting, bathing, dressing, and grooming. On 4/25/26, a nurse went to administer the resident’s morning medications and found a Suboxone film and two Tylenol tablets in the resident’s room. The resident stated she had dropped them, and the nurse observed the Suboxone was slightly wet in one cup and the two Tylenol were in another cup on top. The nurse told the resident she would need to do a room sweep for other medications, but the resident refused and became agitated. The nurse attempted to educate the resident about the danger of not taking medication, but the resident did not want to hear it. The resident’s order for Suboxone required the film to be given sublingually three times per day, with the nurse to stand and wait until the resident fully swallowed with water and to take the medication cup up. An LPN stated that medications should be administered and taken in front of the nurse before the nurse leaves the room, and the DON stated that it was the facility’s expectation that all nurses ensure medications are taken in the presence of the nurse.
Failure to Assist Resident With Meal and Feeding Support
Penalty
Summary
Facility staff failed to provide assistance with activities of daily living for a resident with cerebral palsy, left-sided hemiplegia, aphasia, stroke, malnutrition, dysphagia, contractures of both upper extremities, lack of coordination, and dementia. The resident’s most recent MDS indicated severe cognitive impairment, extensive to fully dependent assistance with ADLs except eating, and that staff feeding was necessary at times. The care plan identified swallowing problems related to cerebral palsy and dysphagia following stroke, with interventions including eating in an upright position, supervision during meals, and use of specialized dining items. On observation, the resident was lying reclined in bed with an untouched breakfast tray sitting in front of her, including scrambled eggs, a biscuit, and sausage. The resident indicated the meal was cold and that she wanted to eat, then attempted to feed herself with contracted hands while reclined and unable to adequately manage the food. She began coughing when trying to eat the biscuit, and a staff LPN entered the room to assist. At the time of the observation, no feeding assistance had been provided, the resident was alone, and the specialized cup and three-section plate identified in the care plan were not present.
Medication Allergy and Order Administration Failures
Penalty
Summary
The facility failed to ensure care and services met professional standards of practice for two residents. For one resident, the clinical record showed documented allergies to Acetaminophen, Hydrocodone, Oxycodone, and Tramadol on admission, yet Tramadol was prescribed and administered multiple times, and Tylenol Extra Strength was also ordered and administered despite the allergy documentation. The record included a nursing progress note stating the resident’s daughter called to report the resident was allergic to Tramadol after the medication had already been given, and the nurse practitioner discontinued the medication. The record also showed an electronic alert identifying a possible drug allergy for Tylenol Extra Strength, but there was no documentation that staff clarified the order, monitored for allergic reaction, or developed a care plan addressing the known allergies and signs and symptoms of allergic reaction. The resident’s physician and psychiatric nurse practitioner notes also documented the same medication allergies, while one admission note listed no known drug allergies. The nurse practitioner interviewed by surveyors stated she did not see documentation explaining why Tramadol and Tylenol were ordered despite the allergy documentation. The Director of Nursing stated residents should not receive medications to which they are allergic unless the physician has determined the medication is safe, and that nurses should clarify allergy questions and document conversations and monitoring. The record did not show documentation of those actions for this resident. For the second resident, the facility failed to administer medications in accordance with physician orders. The resident, who was alert and oriented and used a walker, was ordered Levothyroxine, Lisinopril, Miralax, Senna, Verapamil, and Oxycodone, but the MAR showed none of these medications were given on one documented day. Nursing notes later stated staff were waiting for a call from the on-call doctor to clarify BP medications, and another note documented that the niece reported the medications were with the resident upon arrival to the facility. The resident stated she was placed in an adult brief because staff said they could not come walk her to the bathroom every time, and she reported missing pain medication for days. The SBAR note also documented the niece’s complaint that the resident had been without pain medication and on the toilet in pain for 2 hours.
Failure to Change Oxygen Tubing Weekly for Two Residents
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards of practice for 2 residents by not changing oxygen tubing weekly as ordered. For Resident #11, who was admitted with diagnoses including congestive heart failure, hypertension, diabetes, and renal disease, the oxygen tubing on the concentrator was observed dated 2/18/2026 during the initial tour, and tubing dated 1/27/2026 was also found on the nightstand. The resident stated the nurses dated the tubing when they changed it and that the tubing had not been changed in 2 weeks. An LPN stated oxygen tubing was changed on the night shift each week, and the DON stated it should be changed every Tuesday on the night shift and the old tubing should be removed from the bedside. The MARs showed an order to change tubing, mask and/or nasal cannula every Tuesday and as needed for hygiene, and the care plan included weekly and PRN oxygen tubing changes. For Resident #68, who was admitted with diagnoses including congestive heart failure, hypertension, depression, and anxiety, the oxygen tubing on the concentrator was also observed dated 2/18/2026. The resident stated the nurses would date the tubing when they changed it. An LPN stated oxygen tubing was changed on the night shift each week, and the DON stated it should be changed every Tuesday on the night shift. The MARs showed the same order to change tubing, mask and/or nasal cannula every Tuesday and as needed for hygiene, and the care plan included weekly and PRN oxygen tubing changes. The facility policy on Oxygen/Respiratory Care stated oxygen tubing should be changed weekly and as needed.
Missing Dialysis Communication Logs
Penalty
Summary
The facility failed to ensure dialysis communication logs were completed for one resident who required dialysis services. Resident #3 had diagnoses including end stage renal disease with dialysis, diabetes, major depression, and kidney failure, and the most recent MDS dated 2/16/26 indicated the resident was cognitively intact. Physician orders showed the resident went to dialysis three days per week. Review of the resident’s facility and dialysis communication logs and assessments found only one dialysis assessment dated [DATE] had been completed, with no other communication logs located in the record. During interview, an LPN stated the resident had recently been admitted to the hospital and the hospital did not send the communication book back, but also acknowledged there was missing documentation of a communication log before and after hospitalization and could not locate any communication logs in the clinical record. A unit supervisor stated the communication book was probably still at the hospital and the assessment forms were kept in the book. The facility policy stated there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff.
Failure to Administer Significant Medications During EHR Downtime
Penalty
Summary
The facility failed to provide significant medications for one resident during a loss of the electronic health records and medication administration system. Resident #107, who had diagnoses including osteoarthritis, left knee artificial joint replacement with instability, constipation, hypertension, and macular degeneration, used a walker for ambulation and was documented as alert, oriented, and able to make her own decisions. Review of the physician’s orders and MAR showed orders for levothyroxine 88 mcg daily, lisinopril 20 mg daily, Miralax 17 g daily, senna 8.6 mg two tablets daily, verapamil 240 mg in the evening, and oxycodone 10 mg every 6 hours as needed for pain. The MAR documented that none of these medications were given on 4-8-25, including levothyroxine, lisinopril, verapamil, and oxycodone, which were identified as significant medications. Nursing documentation on 4-9-25 stated staff were waiting for a call from the on-call doctor to clarify BP medications, and another note recorded that the resident’s niece said the medications were with the resident upon arrival to the facility. An SBAR note documented the niece’s complaint that the resident had been without pain medication and on the toilet in pain for 2 hours on 4-7-25. The resident stated during interview that she was placed in an adult brief because staff said they could not come walk her to the bathroom every time, and that she missed her pain meds for days. The AIT and DON stated the software for the clinical record and medication administration had gone offline and that staff had a way to print a hard copy from a computer in the front lobby, but staff did not do that.
Failure to Provide Ordered Yogurt at Breakfast
Penalty
Summary
Facility staff failed to provide food in accordance with the physician’s order for Resident #23, who was ordered a regular diet with regular liquids and to be served two yogurts for breakfast. During interview, the resident stated concerns about not getting what was ordered and reported that food was sometimes cold; the resident also said she used to receive yogurt but no longer did since the new company took over, although she wanted it. On observation of breakfast trays, the resident’s meals included items such as a hashbrown patty, biscuits, cereal, coffee, and milk, but yogurt was not present as ordered. A CNA verified the breakfast tray, and the dietary manager later reviewed the meal ticket and acknowledged that yogurt was on hand and would take care of the concern.
Infection Control Lapses in Respiratory Equipment Storage and Medication Administration
Penalty
Summary
The facility failed to follow established infection control practices in the storage of respiratory equipment for Residents #18 and #40. Resident #18, who had diagnoses including COPD with acute exacerbation, chronic hypoxic respiratory failure, heart failure, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, type 2 diabetes, cocaine abuse, and chronic myeloid leukemia, was observed multiple times with her nasal cannula tubing, nebulizer mask, and non-invasive ventilator mask hanging on an overbed table or lying out in the room, not stored in a bag. Resident #18’s BIMS score was 15 out of 15. Resident #18 stated she had not seen staff store the equipment in a bag and was not aware it should be bagged when not in use. Resident #40, who had diagnoses including aphasia following cerebral infarction, polyneuropathy, metabolic encephalopathy, ADHD, anxiety, depression, and hypertensive heart disease without heart failure, was also observed with a nebulizer mask lying open to air on top of clothing on the bedside table on multiple occasions. Resident #40’s BIMS score was 12 out of 15. The resident had an order for budesonide via nebulizer twice daily. During interview, the DON stated respiratory delivery devices should be stored in a plastic bag when not in use, and the facility policy titled Oxygen Administration stated delivery devices should be kept covered in a plastic bag when not in use. The facility also failed to follow established infection control practices during medication administration for Resident #21. An LPN was observed with fingernails extending past the fingertips while passing medications, placing a finger inside a stock bottle of Senna and then dropping a pill into a medication cup from the fingernail. The LPN also removed a half tablet of metoprolol from a blister pack into the palm before placing it into the medication cup. The LPN then administered the medications and performed a bedside finger stick blood sugar test without sanitizing hands before donning gloves and without sanitizing hands after removing gloves. During interview, the LPN stated the process was done incorrectly and described the correct procedures for removing medications and performing finger stick blood sugar testing. Facility policies stated direct care staff may not wear nails extending beyond the fingertip, medications are not to be touched by the bare hand, and staff are to sanitize hands before and after removing gloves during finger stick blood sugar tests.
Medication Administration Deficiency
Penalty
Summary
The facility staff failed to administer a medication per physician order for a resident, identified as Resident #8, who was admitted after an acute care hospital stay with diagnoses including syncope, seizure disorder, diabetes mellitus, alcohol dependence, and HIV. The resident's cognitive abilities were intact, as indicated by a perfect score on the Brief Interview for Mental Status. The deficiency occurred when the resident did not receive the prescribed levetiracetam on two occasions, as the medication was not available in the required liquid form in the facility's Omnicell system. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the medication was unavailable due to a delay in delivery from the pharmacy. The medication administration record and progress notes confirmed the missed doses and the staff's attempts to obtain the medication. The facility's policy required medications to be administered according to prescriber orders, which was not adhered to in this instance. The findings were shared with the facility's administration, but no additional information was provided to address the deficiency.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility staff failed to protect a resident from leaving the premises without supervision, resulting in an elopement incident. The resident, who was diagnosed with unspecified dementia, cognitive communication deficit, anxiety disorder, peripheral vascular disease, and type 2 diabetes mellitus, was admitted to the facility on 5/4/23. The resident's cognitive abilities were impaired, and a psychiatric evaluation recommended the use of a wander guard due to poor insight, judgment, and safety awareness. Despite these precautions, the resident managed to cut off the wander guard and leave the facility without staff knowledge on 10/5/24. The staff initiated the elopement process and contacted local authorities, who located the resident at a nearby store and returned him to the facility. Interviews with facility staff revealed that the resident's cognitive level fluctuated daily, and the resident had a significant psychiatric mental health history. The MDS assessment for the resident was incomplete due to the Social Services Department not conducting the necessary interview, which further highlighted the resident's cognitive deficits. The facility's Missing Patient/Resident document defined elopement as leaving the premises without authorization or necessary supervision, which placed the resident at risk for harm or injury. Despite the incident, the facility's administration did not express any concerns or provide additional comments during the final interview with surveyors.
Administrator Absence at QAPI Meeting
Penalty
Summary
The facility failed to have an Administrator present for a quarterly Quality Assurance Performance Improvement (QAPI) meeting, as required by their policy. The attendance sheet for the QAPI meeting held on 9/24/2024 did not include the signature of an Administrator. During an interview, the Regional Vice President of Operations (RVPO), who had been acting as the facility's Administrator since the previous Administrator left, confirmed that the meeting was indeed a quarterly QAPI meeting. However, the absence of the Administrator's signature on the attendance sheet was noted. The facility's policy mandates the presence of the Executive Director (Administrator) as one of the four essential members of the QAPI committee. Despite being given an opportunity to provide additional information, the facility staff did not present any further evidence to support compliance with this requirement.
What surveyors are citing around you — mapped
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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 166 citations issued within 25 miles in the last 12 months — including the 2 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 Newport News
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Lifelong H & R Warwick Forest | 1.6 mi | ★★★★★ | 0 | 0 |
| Old Dominion Rehabilitation And Nursing | 2.9 mi | ★★★★★ | 22 | 1 |
| The Chesapeake | 3.2 mi | ★★★★★ | 14 | 0 |
| Newport Post Acute | 4.1 mi | ★★★★★ | 0 | 0 |
| Regency Health And Rehabilitation Center | 4.7 mi | ★★★★★ | 2 | 0 |
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