Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakhurst Health & Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not follow abuse prevention policies when a resident with multiple medical and psychiatric conditions became verbally aggressive and made threats toward staff after alleging lack of assistance. The incident, which involved police intervention, was not reported to the state agency or APS, and the facility's investigation was incomplete, lacking statements from all involved staff and failing to address the resident's allegations of mistreatment.
A resident with multiple medical conditions became verbally aggressive and made threats toward staff after not receiving assistance, leading to police involvement and an attempted emergency custody order. Despite facility policy requiring immediate reporting of such incidents to state authorities and APS, no report was made because the threats were directed at staff. The incident was not reported as required.
A resident with multiple medical and psychiatric conditions was involved in a verbal altercation after alleging that staff did not provide needed assistance. The facility's investigation focused on the resident's aggressive behavior but did not address the allegation of neglect or include statements from all relevant staff and potential witnesses, resulting in an incomplete investigation as required by facility policy.
A resident with multiple chronic conditions and incontinence waited approximately 35 to 40 minutes for staff assistance after spilling urine and soiling bed sheets. The assigned CNA was occupied with another resident and did not seek help from other staff, resulting in a delay despite facility policy requiring timely response to call lights and care needs.
A resident with multiple chronic conditions reported urinary symptoms and had a physician's order for a urinalysis with culture. Although nursing documentation indicated a urine sample was sent to the lab, there were no results in the clinical record, and the lab had no record of receiving the sample. The cause for the missing sample could not be determined.
A resident with multiple risk factors developed an advanced sacral pressure ulcer that was not identified or treated in a timely manner by staff. After initial discovery, there were significant delays in obtaining physician orders, implementing wound care treatments, and following wound specialist recommendations, including missed treatments and failure to document required repositioning. The facility also delayed obtaining a recommended x-ray to rule out osteomyelitis, and staff interviews revealed lapses in communication and documentation. The facility's QAPI action plan was incomplete and lacked evidence of implementation.
A resident developed an advanced pressure ulcer that was not identified by staff until it contained extensive slough. Initial wound care was performed without a physician order, and there were significant delays in obtaining ongoing treatment orders and implementing wound specialist recommendations, including an x-ray to rule out osteomyelitis. Documentation showed missed wound treatments, lack of evidence for required repositioning, and incomplete records. The facility's QAPI process was incomplete, with no evidence of audits or staff education addressing the deficiency.
Facility staff did not consistently administer medications within one hour of scheduled times for several residents, and failed to notify providers of these delays. Additionally, a resident with an advanced pressure wound did not receive timely or appropriate wound care, with significant delays in implementing specialist recommendations and treatment orders. Staff interviews and facility documentation confirmed that these actions did not meet professional nursing standards.
Staff did not ensure that meals served to residents eating in their rooms were at a palatable and appetizing temperature. Multiple complaints had been logged about cold food, and observations showed that heated pellets or heated insulated bottoms were not used during tray preparation. Food temperatures measured on a test tray were lukewarm, and both the surveyor and dietary manager agreed the food was not appetizing in temperature, despite facility policy requiring otherwise.
Staff failed to ensure that all individuals, including non-dietary personnel, wore required hair restraints while in the kitchen during food preparation and distribution. The maintenance director entered the kitchen and serving line area without a hair net or beard guard, despite a reminder from a dietary aide, and later admitted to frequently entering the kitchen without proper protective coverings, contrary to facility policy.
Staff did not follow enhanced barrier precautions for a resident with multiple open wounds and a Foley catheter. Certified nursing assistants entered the room without PPE, and there was no signage indicating precautions. The care plan did not include EBP, and staff interviews revealed inconsistent understanding of when EBP should be used. The DON confirmed the resident should have been on EBP, but it was not implemented according to facility policy and CDC guidance.
The facility failed to educate and offer the COVID-19 spike vaccine booster for the 2023-2024 season to five residents and five staff members. Clinical record reviews and interviews revealed that neither residents nor staff were provided with necessary information or offered the vaccine, despite its availability. The facility's policies on vaccination were not followed, resulting in a significant deficiency in their vaccination program.
The facility failed to maintain a safe and homelike environment, with issues such as a resident's broken bedside table, a shared bathroom with exposed holes and a dislodged access panel, and a damaged dining room wall. These problems persisted over several days without being reported in the maintenance system, and the maintenance director was unaware of them.
The facility failed to update care plans for two residents, including a change in code status and a fluid restriction, and did not involve two other residents in their care plan meetings. Despite policies requiring timely updates and resident involvement, these deficiencies were observed, with staff citing various reasons for the lapses.
A resident expressed concerns about not receiving showers, and a review of their clinical record showed incomplete documentation of showers provided. Despite a schedule for twice-weekly showers, the record only showed a few instances. CNAs confirmed the schedule, but the facility's protocol was not followed, leading to inaccurate records.
A resident's MDS assessment inaccurately documented no dental problems despite the resident being edentulous. The resident, who had several medical conditions, confirmed having no teeth and was on a soft diet. The MDS coordinator believed the assessment was correct due to feeling something on the gums, but the DON confirmed the resident had no teeth. The MDS should have been marked as edentulous according to the LTC Facility Resident Assessment Instrument Manual.
A facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident using a hoyer lift lacked documentation in their care plan, while another with PTSD had no plan addressing specific trauma or triggers. Additionally, a resident awaiting dentures had no care plan for dental issues, despite being edentulous. Staff interviews revealed a lack of formal documentation and awareness of these needs.
A resident refused lab work, and the facility staff failed to notify the physician, violating professional nursing standards. The physician's order for lab tests was not carried out, and there was no documentation of the refusal or communication with the physician. The assistant director of nursing confirmed that the refusal was not initially documented, contrary to facility policy.
Two residents in an LTC facility experienced deficiencies in ADL care. One resident, needing help with personal hygiene, had long, uneven fingernails due to staff's failure to provide nail care. Another resident, dependent on staff for bathing, reported not receiving scheduled showers, with records confirming missed showers without documentation. Staff interviews and facility policies highlighted inconsistencies in care provision.
A resident with acute angle closure glaucoma did not receive artificial tears in both eyes as ordered by the physician. An LPN administered the drops only to the left eye, missing the right eye. The oversight was acknowledged by the LPN and reported to the facility's administration.
A resident with respiratory conditions was observed receiving oxygen without specific delivery parameters in place. The physician's order only stated 'Oxygen Continuous' without specifying the rate or route. A nurse acknowledged the oversight, and the issue was presented to the facility's administration.
Facility staff failed to identify and document specific trauma or triggers for a resident with PTSD, leading to a deficiency in trauma-informed care. The resident had multiple diagnoses, including PTSD, Alzheimer's, and schizophrenia. Staff interviews revealed a lack of awareness about the resident's PTSD triggers, and the care plan lacked necessary details. The facility administrator was informed, but no further information was provided.
A resident with multiple health conditions did not receive prescribed glasses due to the facility's failure to provide necessary social services. The social worker forgot to follow up on payment arrangements, and the administrator was unaware of the issue, despite the facility's usual practice of covering such costs.
A resident with severe cognitive impairment and multiple diagnoses was on a consistent dose of Seroquel since November 2022. In January 2024, a pharmacist recommended a gradual dose reduction, but there was no documented physician response. The DON stated that psychiatric medication decisions were deferred to psychiatric services, contrary to the facility's policy requiring action on pharmacist recommendations.
A resident with severe cognitive impairment and multiple diagnoses was prescribed Seroquel without an attempted gradual dose reduction (GDR) since August 2022. Despite a pharmacist's recommendation for a GDR in January 2024, there was no documented response or justification for maintaining the current dosage. Interviews revealed that the medical doctor deferred dose reduction decisions to psychiatric services, but no documentation supported the need for ongoing treatment at the current dosage.
A facility failed to label an opened multidose vial of influenza vaccine with an open date, as observed in the medication storage room. An LPN confirmed the absence of the open date and removed the vial. Facility policy requires refrigerated medications to be labeled accordingly. This issue was reported to the DON, Administrator, and Regional Nurse Consultants.
A resident with diabetes and kidney failure did not receive scheduled lab tests as ordered by their physician. The facility's records showed a blank entry for the lab tests, and a nurse confirmed the labs were missed after contacting the lab, which had no results for the date in question. This issue was reported to the facility's administration.
The facility failed to ensure survey results were accessible to residents, staff, or family members. Residents were uncertain about the survey book's location, and it was not found in common areas. The DON and Administrator were unaware of its location until it was found under the receptionist's desk. No signage indicated the book's location.
Failure to Report and Investigate Resident Behavioral Incident per Abuse Prevention Policy
Penalty
Summary
Facility staff failed to follow abuse prevention policies regarding the reporting and thorough investigation of a behavioral incident involving a resident. The incident involved a resident with multiple medical diagnoses, including cerebral infarction, diabetes, hypertension, and psychiatric conditions, who was assessed as cognitively intact. On the morning of the incident, the resident became verbally aggressive and made threats toward staff after reporting that he did not receive assistance when requested. The situation escalated to the point where law enforcement was contacted, and an emergency custody order was attempted but not executed. The resident calmed down after police intervention, and no further aggressive behaviors were noted that day. The facility's investigation into the incident included statements from several staff members who witnessed the resident's verbal aggression and threats, which included threats of physical violence and the use of vulgar language. However, the investigation did not include a statement from the certified nurse aide assigned to the resident at the time of the incident, nor did it address the resident's allegation that assistance was not provided or that his rights had been violated. Additionally, there was no documentation of interviews with other residents who may have witnessed or been affected by the incident. Despite the involvement of police and the resident's allegations of mistreatment, the incident was not reported to the state agency or adult protective services as required by the facility's abuse prevention policies. The policies mandate immediate reporting and thorough investigation of all allegations or observations of abuse, neglect, or mistreatment, including communication of findings to appropriate authorities. The failure to report and fully investigate the incident, including all relevant staff and resident interviews, constituted a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Report Resident's Aggressive Incident Involving Staff Threats and Police Involvement
Penalty
Summary
Facility staff failed to report a behavioral incident involving a resident who was cognitively intact and had multiple medical diagnoses, including cerebral infarction, diabetes, and heart failure. The incident involved the resident becoming verbally aggressive and making threats toward multiple staff members after not receiving assistance following an episode of incontinence. The resident made statements threatening physical harm and referenced having family members come to the facility with weapons. Staff attempted to redirect the resident without success, and the situation escalated to the point where law enforcement was contacted. The administrator attempted to obtain an emergency custody order, but the magistrate determined the situation did not meet criteria for involuntary removal. The resident was later assessed by a psychiatry nurse practitioner, who found no credible threat for harm to self or others, and the police did not consider the threats credible. Despite the severity of the incident, which included police involvement, an attempted emergency custody order, and allegations from the resident regarding lack of assistance and violation of rights, there was no report made to the state agency or adult protective services (APS) as required by facility policy. The current administrator confirmed that the incident was not reported, stating the belief that reporting was unnecessary because the threats were directed at staff rather than other residents. Facility policy mandates immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment to the appropriate authorities, but this protocol was not followed in this case.
Failure to Thoroughly Investigate Alleged Mistreatment and Neglect
Penalty
Summary
Facility staff failed to thoroughly investigate a behavioral incident involving a resident with multiple complex medical conditions, including cerebral infarction, diabetes, hypertension, and psychiatric diagnoses. The incident involved a verbal altercation between the resident and staff, during which the resident alleged that staff did not provide assistance after he spilled urine on himself. The resident reported feeling that his rights had been violated and that he was not assisted as requested. The facility's investigation focused primarily on the resident's subsequent verbal aggression and threats toward staff, which led to law enforcement being contacted and the resident being assessed by a psychiatric nurse practitioner. The investigation included statements from several staff members who witnessed or were involved in the incident, but it did not include a statement from the certified nurse aide assigned to the resident at the time of the alleged neglect. Additionally, the investigation did not address the resident's specific allegation that assistance was not provided, nor did it include interviews with other residents who may have witnessed or overheard the incident. The facility's policy requires a thorough investigation of all reports of abuse, neglect, or mistreatment, including interviews with all relevant staff and witnesses, but this was not fully carried out in this case. The deficiency was identified during a review of facility documentation, staff interviews, and clinical records, which revealed gaps in the investigation process. The administrator and regional nurse consultant were unable to provide documentation that the resident's allegation of not receiving assistance was investigated, and the assigned CNA confirmed she had not been interviewed about the incident prior to the survey. The lack of a comprehensive investigation into the resident's allegation of neglect and potential mistreatment constituted a failure to respond appropriately to all alleged violations.
Delay in Timely Incontinence Care Response
Penalty
Summary
Facility staff failed to provide timely incontinence care for a resident who was unable to perform activities of daily living independently. The resident, who had multiple chronic health conditions including cerebral infarction, diabetes, heart failure, and a history of prostate cancer, was assessed as cognitively intact but occasionally incontinent of bladder and frequently incontinent of bowel. On the morning in question, the resident spilled urine while using a urinal and soiled both his brief and bed sheets. He activated the call bell for assistance around 5:00 to 5:30 a.m. and waited approximately 35 to 40 minutes before a certified nurse's aide (CNA) responded to his request for help. The CNA assigned to the resident's care acknowledged that she was occupied with another resident who had an early appointment and required extensive assistance, which delayed her response. The CNA informed the resident of the delay and stated that the resident agreed to wait. However, the resident later expressed dissatisfaction with the wait time, stating that staff should have responded sooner given his condition. The CNA did not seek assistance from other staff members, and the nurse on duty was aware of the resident's request but did not intervene. Facility policy on answering call lights requires staff to make reasonable efforts to ensure timely responses to residents' needs, with response time determined by the urgency of the situation. The resident's care plan specified the need for assistance with activities of daily living, including incontinence care, and directed staff to change briefs every two hours and as needed. Despite these guidelines, the resident experienced a significant delay in receiving necessary care, as confirmed by staff interviews and facility documentation.
Failure to Obtain Physician-Ordered Urinalysis with Culture
Penalty
Summary
Facility staff failed to obtain a physician-ordered urinalysis with culture for a resident who reported burning with urination and discolored urine. The resident, who was cognitively intact and had multiple diagnoses including cerebral infarction, diabetes, hypertension, heart failure, and a history of prostate cancer, had a physician's order entered for a urinalysis with culture and sensitivity after reporting symptoms. Nursing documentation indicated that a urine sample was to be sent to the lab several days after the order was placed. Upon review, there were no results of the urinalysis with culture in the resident's clinical record. The regional nurse consultant confirmed that the lab had no record of receiving or processing the urine sample for this resident, despite a note indicating the sample was sent. The reason for the sample not being provided to the lab could not be determined, and no further information was available prior to the end of the survey.
Failure to Timely Identify and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
Facility staff failed to protect a resident from neglect by not providing timely identification and management of a pressure wound. The resident, who was non-verbal and had multiple risk factors including poor mobility, dementia, malnutrition, and incontinence, developed a sacral/coccyx pressure ulcer that was not identified until it was already at an advanced stage with over 70% slough. After initial identification, staff did not obtain a physician order for wound care, nor did they provide any documented treatment for several days. The wound was not assessed or treated again until a wound specialist evaluated the resident five days later, at which point the wound required sharp debridement. Following the wound specialist's assessment, facility staff failed to promptly implement the recommended treatment orders, with further delays in changing wound care orders after subsequent specialist visits. There were multiple documented lapses in providing wound care as ordered, including missed treatments on several days and failure to apply specific interventions such as zinc to the peri-wound area. Additionally, staff did not consistently document or perform required repositioning every two hours, despite active physician orders, and there was no evidence of documentation to support that these interventions were being carried out. The facility also neglected to obtain a timely x-ray to rule out osteomyelitis, despite repeated recommendations from the wound specialist over several weeks. The x-ray order was not transcribed or initiated until more than two weeks after the initial recommendation, and there was confusion and lack of documentation regarding the delay. Interviews with staff and the DON revealed gaps in communication, documentation, and follow-through on wound care protocols, as well as incomplete or missing audits and education records related to wound management. The facility's QAPI action plan was found to be incomplete and lacking evidence of implementation prior to the survey.
Failure to Timely Identify and Treat Advanced Pressure Ulcer
Penalty
Summary
Facility staff failed to identify a pressure ulcer in a resident until it had progressed to an advanced stage, with more than 70% slough present at the time of discovery. Upon identification, staff performed a one-time wound treatment without a physician order and did not obtain ongoing treatment orders or notify the physician. There was no documentation of further wound care or assessment for five days, until a wound specialist evaluated the resident and performed sharp debridement. The wound continued to deteriorate over the following month, eventually exposing bone and requiring additional interventions. Throughout the course of the resident's care, there were repeated delays and omissions in implementing wound care orders and recommended interventions. The facility failed to timely implement wound specialist recommendations, including changes in wound care regimen and obtaining an x-ray to rule out osteomyelitis, which was delayed for 18 days after being recommended. Documentation revealed missed wound treatments, lack of evidence for required repositioning every two hours, and incomplete or missing records of care provided. Staff interviews confirmed that gaps in the treatment administration record indicated missed care, and that there was no documentation to support that repositioning was consistently performed as ordered. The facility's QAPI (Quality Assurance Performance Improvement) process was found to be inadequate, with incomplete forms, lack of root cause analysis, and no evidence of completed audits or education related to the identified deficiency. The DON and other staff were unable to provide documentation of corrective actions, education, or audits that addressed the issues with wound care and documentation. Facility policies reviewed during the survey emphasized the importance of timely identification, assessment, and treatment of pressure injuries, but these standards were not met in the care of the resident.
Failure to Administer Medications Timely and Manage Pressure Wound per Standards
Penalty
Summary
Facility staff failed to administer physician-ordered medications within one hour of the scheduled time for multiple residents. Medication administration records and audit reports showed repeated delays in giving scheduled medications, with some doses being administered several hours late. There was no evidence in the clinical records that the ordering provider or attending physician was notified of these delays. Interviews with staff confirmed that blanks in the medication administration record indicated missed doses, and that late administration should be reported to the physician, but this was not documented as having occurred. One resident with an advanced pressure wound did not receive appropriate management according to professional standards of care. After a pressure ulcer was identified, there were no physician orders for the initial wound treatment, and no evidence that wound care was provided for several days. Recommendations from the wound specialist, including changes in treatment and diagnostic imaging, were not implemented in a timely manner. Documentation showed significant delays in starting recommended treatments and obtaining an x-ray, with the wound deteriorating to a Stage 4 ulcer with visible bone exposure. The facility's own policy required prompt implementation of wound care orders and regular documentation of repositioning, which was not consistently done. Interviews with residents and staff revealed that some residents were aware of missed or delayed medications, while others were non-verbal and could not be interviewed. Staff interviews confirmed that medications should be administered within one hour of the scheduled time and that late administration should be reported to the physician. Facility policies and professional nursing standards cited by the facility emphasized the importance of timely medication administration and proper wound care, but these standards were not consistently followed, resulting in deficiencies in care for several residents.
Failure to Serve Meals at Appetizing Temperatures for Room-Tray Residents
Penalty
Summary
Facility staff failed to serve meals at a palatable and appetizing temperature to multiple residents eating in their rooms across all four wings. Review of resident council minutes and grievance logs revealed repeated concerns about cold food being served in resident rooms over several months. During an observation of the evening meal service, it was noted that residents in the dining room were served first, while trays for residents eating in their rooms were prepared afterward and placed in a transport cart. The facility used insulated plate bottoms and lids but did not utilize heated pellets or heat the insulated bottoms, contrary to standard practices observed in other facilities. The dietary manager confirmed that neither the insulated bottoms were heated nor were heated pellets used, regardless of the type of plate bottom available. When the last tray was served to a resident, a test tray's food temperatures were measured and found to be below appetizing levels: Swedish meatballs at 123.2°F, rice at 116°F, and green beans at 114.6°F. Both the surveyor and dietary manager agreed that the hot foods were lukewarm and not appetizing, though the flavor was acceptable. Facility policy requires that food be served at a safe and appetizing temperature, but this was not followed during the observed meal service. The deficiency was reviewed with facility leadership, confirming the failure to maintain appropriate food temperatures for residents eating in their rooms.
Failure to Enforce Hair Restraint Use in Kitchen During Food Service
Penalty
Summary
Facility staff failed to ensure that all individuals entering the main kitchen during food preparation and distribution wore appropriate hair restraints, as required by facility policy. During observation of the lunch meal service, the maintenance director entered the kitchen and approached the serving line without donning a hair net or beard guard. Despite a dietary aide's verbal reminder, the maintenance director proceeded behind the serving line, interacted with the dietary manager, and remained in the food preparation area without the required protective coverings. The dietary manager later confirmed that all persons entering the kitchen are expected to wear hair coverings. In an interview, the maintenance director admitted to frequently entering the kitchen without wearing a hair net or beard guard, stating he was unaware of the requirement and that no one had previously informed him. The facility's policy, reviewed by the surveyor, clearly states that dietary staff must wear hair restraints to prevent hair from contacting food. The deficiency was brought to the attention of the facility administrator and regional nurse during the end-of-day meeting.
Failure to Implement Enhanced Barrier Precautions for Resident with Multiple Wounds
Penalty
Summary
Facility staff failed to implement and adhere to their infection prevention and control program by not following enhanced barrier precautions (EBP) for a resident with multiple open wounds and a Foley catheter. During observations, certified nursing assistants entered the resident's room without donning any personal protective equipment (PPE), and there was no signage on the door to indicate any type of precautions. The resident, who had a stage IV pressure ulcer to the sacrum and three stage III pressure ulcers to the right foot, was not identified as requiring EBP in the care plan, and no physician orders for EBP were present. Interviews with staff revealed a lack of awareness and inconsistent understanding of when EBP should be implemented. Certified nursing assistants stated that no residents were currently on precautions and that signage would be present if precautions were needed. One LPN reported only using gloves for wound care and was unfamiliar with the need for EBP in the absence of a known multidrug-resistant organism (MDRO). The director of nursing, who had recently started at the facility, acknowledged that the resident should have been on EBP and noted gaps in staff education and infection control processes. Review of facility policy and CDC guidance confirmed that residents with wounds or indwelling medical devices should be placed on EBP, regardless of MDRO status. The facility's failure to implement EBP for the resident with multiple wounds and a Foley catheter was not in accordance with national standards or the facility's own policy, as evidenced by the lack of PPE use, absence of signage, and omission from the care plan.
Failure to Educate and Offer COVID-19 Vaccine Booster
Penalty
Summary
The facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season to five residents and five staff members. Clinical record reviews revealed that none of the sampled residents had been offered the COVID-19 spike vaccine. The Director of Nursing (DON), who also served as the facility's Infection Preventionist, confirmed during an interview that the residents had not been offered the vaccine. The DON mentioned that the facility could obtain vaccines through their pharmacy, but they had not yet administered the current boosters. The contracted pharmacy confirmed that the facility had not placed any orders for the COVID-19 spike immunization, despite its availability since November 2023. The facility's policy on COVID-19 vaccination for residents outlined procedures for validating vaccination status, educating residents, and obtaining consent prior to vaccination. However, the facility did not adhere to these procedures, as evidenced by the lack of documentation and education provided to the residents. The policy also required screening for prior immunization and contraindications, but there was no evidence that these steps were followed for the sampled residents. Similarly, the facility failed to provide education and information regarding the 2023-2024 COVID spike vaccine to the sampled staff members. Interviews with the DON and the Human Resources Manager revealed that there was no systematic approach to educating staff about the vaccine. The facility's policy required offering vaccinations and providing educational materials to employees, but this was not implemented. The lack of documentation and education for both residents and staff highlights a significant deficiency in the facility's vaccination program.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility staff failed to maintain a safe, comfortable, and homelike environment in one of the nursing units and the main dining room. On the 300 unit, a resident's bedside table was missing two of its three drawers, which had been in this condition for weeks. The resident confirmed the issue, and a CNA acknowledged the problem, stating that it was not fixed because the resident was expected to go home. The maintenance director was unaware of the issue but indicated that a replacement could be made immediately. In the shared bathroom between four residents, there was a large, exposed hole in the wall behind the toilet, and an access panel cover was dislodged, allowing cold air to enter. These issues were observed over several days without repair. The maintenance director was not informed of these problems and attempted to fix the access panel but was unable to do so immediately. The facility uses an electronic system for maintenance work orders, but none of these issues were reported in the system. In the main dining room, the cove baseboard was damaged, exposing large holes in the wall. This damage was noted over several days without repair. The maintenance director explained that the damage was due to staff pushing food carts against the wall and that repairs were delayed due to upcoming renovations. The facility administrator confirmed the planned renovations, which would include replacing all furniture in resident rooms. However, no maintenance work orders were submitted for these issues.
Care Plan Deficiencies and Lack of Resident Involvement
Penalty
Summary
The facility failed to review and revise the care plans for two residents, Resident #9 and Resident #32, in a timely manner. Resident #9's care plan was not updated to reflect a change in code status from full code to Do Not Resuscitate (DNR) after the power of attorney signed a DNR form and the physician placed the order. Despite the expectation that care plans should be updated within 24-48 hours of receiving new orders, the care plan remained unchanged. Similarly, Resident #32's care plan did not include a physician-ordered fluid restriction, and there was no documentation of this restriction in the medication administration record, treatment administration record, or activity of daily living record. The facility also failed to involve two residents, Resident #6 and Resident #25, in their care plan meetings. Resident #6 was not aware of care plan meetings and was not invited to attend them. The social worker responsible for notifying residents and their families about these meetings cited various reasons for the lack of documentation and notification, including technical issues and interruptions. The last documented care plan meeting for Resident #6 was in July 2023, with no evidence of involvement in subsequent meetings. Similarly, Resident #25 was not involved in care plan meetings, and there was no evidence of their participation or notification. The social worker provided evidence of meetings held, but there were instances where meetings proceeded without the resident or a nursing representative present. The facility's policy emphasizes the importance of resident involvement in care plan development, but this was not adhered to in these cases.
Inaccurate Documentation of Resident Showers
Penalty
Summary
The facility staff failed to maintain an accurate clinical record for a resident, identified as R25, regarding the documentation of showers provided. During an interview, R25 expressed concerns about not receiving showers, which was corroborated by a review of the resident's clinical record. The review revealed that R25 had only four documented showers in January 2024 and two in February 2024, despite the facility's protocol of providing showers twice weekly. Interviews with CNAs confirmed that showers were scheduled and should be documented in the ADL section of the clinical record. The facility administrator and Corporate Director of Clinical Services acknowledged that the skin care alert forms, which indicated additional shower dates, were not part of the clinical record and that the documentation was incomplete and inaccurate. The facility's policy requires detailed documentation of showers, including date, time, and any skin assessments, which was not adhered to in this case. The Assistant Director of Nursing confirmed that the issue was related to documentation, as the skin care alerts did indicate showers were given.
Inaccurate MDS Assessment for Edentulous Resident
Penalty
Summary
The facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident #44, who was part of a survey sample. The deficiency was noted when the resident's admission MDS inaccurately documented that the resident had no dental problems, despite the resident being edentulous, meaning having no natural teeth. The resident had been admitted with several diagnoses, including osteoarthritis, depressive disorder, Parkinson's disease, heart failure, and spinal stenosis, and was assessed as cognitively intact. During an interview, the resident confirmed having no teeth and was on a soft diet due to the inability to chew, which was consistent with the clinical record that documented the resident's edentulous status. The inaccuracy in the MDS assessment was further highlighted during interviews with the registered nurse MDS coordinator and the director of nursing. The MDS coordinator initially believed the assessment was correct, stating that she felt something on the resident's gums during an examination, which led her to not mark the resident as edentulous. However, the director of nursing confirmed that the resident had no teeth, as they had been removed in preparation for dentures. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual clearly defines edentulous as having no natural permanent teeth, and the coding instructions require marking the resident as edentulous if they lack all natural teeth. This discrepancy was discussed with the facility's administration, but no further information was provided before the survey concluded.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #49, who has multiple diagnoses including osteoporosis and rheumatoid arthritis, was observed using a hoyer lift for transfers. However, the care plan did not document the use of the hoyer lift, the size of the sling, or the level of assistance required. Interviews with staff revealed that information about the use of the hoyer lift was communicated informally among CNAs and nurses, rather than being documented in the care plan. Resident #21, diagnosed with PTSD among other conditions, did not have a care plan addressing the specific trauma, behaviors, or triggers related to PTSD. Interviews with the social worker and nursing staff indicated a lack of awareness about the specific causes and triggers of the resident's PTSD, which were not documented in the care plan. This omission left the staff without guidance on how to manage the resident's PTSD-related behaviors effectively. Resident #44, who was edentulous and awaiting dentures, did not have a care plan addressing dental issues. The resident's admission assessment noted the absence of natural teeth and ill-fitting dentures, yet the care plan failed to reflect these dental needs. Interviews with the MDS coordinator and DON confirmed that dental issues were not assessed or included in the care plan, resulting in a lack of documented interventions for the resident's edentulous status.
Failure to Notify Physician of Lab Work Refusal
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice for a resident who refused lab work. The physician had ordered a series of lab tests, including Valproic Acid level, CMP, CBC, and LFT, to be conducted on a specific date. However, the resident refused the lab draw, and there was no documentation indicating that the physician was notified of this refusal. This lack of communication and documentation was identified during a clinical record review. The assistant director of nursing confirmed that the standard procedure when a resident refuses lab work is to notify the physician, update the chart, and inform the responsible parties. However, in this case, the refusal was not documented in the chart initially. The facility's policy on requesting, refusing, and discontinuing care or treatment requires that the healthcare practitioner be notified of any refusal of treatment, which was not followed in this instance. The deficiency was highlighted during an end-of-day meeting with the facility administration.
Deficiencies in ADL Care and Shower Provision
Penalty
Summary
The facility staff failed to provide adequate ADL care for two residents, leading to deficiencies in personal hygiene and bathing routines. Resident #3, who was assessed as needing help with personal hygiene, was observed with long, uneven fingernails. Despite being cognitively intact, Resident #3 required assistance with self-care due to limited mobility and impaired balance. The care plan for Resident #3 included regular nail care, which was not adhered to, as evidenced by the resident's untrimmed nails and the staff's uncertainty about the responsibility for nail care. Resident #1, who depended on staff for assistance with bathing, expressed concerns about not receiving showers as scheduled. The resident was supposed to receive showers twice a week, but records showed that showers were missed on eight scheduled days without documentation explaining the omissions. The resident's complaints during a group meeting and subsequent interviews highlighted the inconsistency in shower provision, with the resident stating that showers were often overlooked and not provided weekly. Interviews with staff, including CNAs and the DON, confirmed the scheduled shower routine and the lack of documentation for missed showers. The facility's policy required at least two full baths or showers per week, but this was not consistently followed for Resident #1. The facility administration attempted to provide evidence of shower provision through Skin Care Alert forms, but these did not explicitly indicate that showers were given, as confirmed by the administrator.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication according to physician orders for one resident. During a medication administration task, an LPN was observed administering artificial tears to only the left eye of a resident, despite the physician's order requiring one drop in both eyes three times a day for eye lubrication due to acute angle closure glaucoma. The oversight was acknowledged by the LPN, who admitted to missing the right eye drop during the administration. This incident was later reported to the facility administrator and regional nurse consultants, but no additional information was provided.
Lack of Oxygen Delivery Parameters for Resident
Penalty
Summary
The facility failed to ensure proper parameters were established for the administration of supplemental oxygen for a resident. The resident, who had a history of respiratory failure, asthma, chronic obstructive pulmonary disease, emphysema, and was dependent on supplemental oxygen, was observed receiving oxygen via nasal cannula at 2 liters per minute. However, the physician's order for oxygen, dated and revised, only stated 'Oxygen Continuous' without specifying the rate of delivery or the route of administration. During an interview, a registered nurse acknowledged the absence of specific parameters for oxygen delivery and indicated the need to inform the physician. This deficiency was presented to the facility's administrator and director of nursing, but no additional information was provided before the exit conference.
Failure to Identify PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility staff failed to identify and document the specific trauma or triggers related to post-traumatic stress disorder (PTSD) for one resident, leading to a deficiency in providing trauma-informed care. The resident, who was part of the survey sample, had multiple diagnoses including PTSD, Alzheimer's disease, schizophrenia, bipolar disorder, anxiety, major depressive disorder, and cerebral infarction. Despite these complex conditions, the care plan for the resident did not include details about the specific cause of the PTSD, the behaviors associated with it, or the triggers that could lead to re-traumatization. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's PTSD triggers. The social worker mentioned that changes in the smoking schedule and delays in meals made the resident nervous, while the registered nurse noted that family dynamics contributed to the resident's anxiety. However, neither could specify the trauma or triggers. The Minimum Data Set (MDS) coordinator also acknowledged the absence of this critical information in the care plan. The facility administrator and regional nurse consultants were informed of these concerns, but no additional information was provided to address the deficiency.
Failure to Assist Resident in Obtaining Prescribed Glasses
Penalty
Summary
The facility staff failed to provide necessary social services to assist a resident, identified as Resident #32, in obtaining prescribed glasses. The resident, who has diagnoses including congestive heart failure, schizophrenia, chronic kidney disease, hypertension, depression, and anxiety, was assessed as cognitively intact. Despite attending an optometrist appointment and receiving a prescription for glasses, the resident had not received them by the time of the survey. Interviews revealed that the social worker was aware of the resident's lack of funds and had intended to discuss payment with the resident's daughter but forgot to follow up. The facility administrator was unaware of the situation and stated that the facility would typically cover such costs. This oversight resulted in the resident not receiving the prescribed glasses, impacting their quality of life.
Failure to Respond to Pharmacist's Recommendation for Dose Reduction
Penalty
Summary
The facility staff failed to respond to a pharmacist's recommendation for a gradual dose reduction (GDR) of Seroquel for one resident. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and Alzheimer's disease, had been on a consistent dose of Seroquel since November 2022. Despite the pharmacist's suggestion in January 2024 to reduce the dose to ensure the resident was on the lowest effective dose, there was no documented response from the physician. The Director of Nursing (DON) indicated that the medical doctor had deferred decisions on psychiatric medication dose reductions to psychiatric services. However, the facility's policy required that recommendations from the consultant pharmacist be acted upon and documented by the facility staff or prescriber. The lack of response to the pharmacist's recommendation was noted during a survey, and the facility administrator and regional nurse consultants were informed of the issue, but no further information was provided.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility staff failed to ensure that a resident was free of unnecessary medications, specifically regarding the antipsychotic medication Seroquel. The resident, who had diagnoses including nontraumatic intracerebral hemorrhage, dementia, major depressive disorder, Alzheimer's disease, and anxiety disorder, was assessed with severe cognitive impairment. Despite the resident's stable condition, as noted in psychiatric assessments and staff interviews, there was no documented attempt to reduce the Seroquel dosage since August 2022, nor was there any clinical justification provided for not attempting a gradual dose reduction (GDR). The consulting pharmacist recommended a GDR in January 2024, suggesting a reduction from 100 mg to 75 mg at bedtime, but there was no documented response from the provider to this recommendation. Interviews with facility staff, including a certified nursing assistant and the director of nursing, revealed that the medical doctor had deferred dose reduction decisions to psychiatric services, and there was no indication that the psychiatric nurse practitioner had documented any need for ongoing treatment at the current dosage. The lack of action and documentation regarding the GDR for Seroquel led to the deficiency finding.
Failure to Label Opened Medication Vial
Penalty
Summary
The facility failed to ensure that a multi-dose vial of medication was labeled with an open date, which is necessary for safe administration and storage. During an observation of the medication storage room on the nursing unit, an opened multidose vial of the influenza vaccine was found in the refrigerator without an open date on the label. A licensed practical nurse (LPN) present during the observation confirmed the absence of the open date and removed the medication from the refrigerator. The facility's policy on medication storage requires that medications needing refrigeration must be stored in a refrigerator and labeled accordingly. This information was presented to the Director of Nursing, Administrator, and two Regional Nurse Consultants, but no further information was provided before the exit conference.
Failure to Obtain Physician-Ordered Lab Services
Penalty
Summary
The facility staff failed to obtain physician-ordered laboratory services for a resident diagnosed with diabetes and kidney failure. The resident's physician order set included a directive for a Complete Blood Count (CBC) and A1C test to be collected every three months. However, the lab results for the scheduled collection date in December were missing, and the treatment administration record (TAR) for that date showed a blank box, indicating the order was not completed. During an interview, a registered nurse confirmed that the labs were not collected as the lab had no results for that date. This deficiency was presented to the facility's administrator and director of nursing, with no additional information provided before the exit conference.
Survey Results Accessibility Deficiency
Penalty
Summary
The staff at the facility failed to ensure that the survey results were readily accessible to residents, staff, or family members. During a Resident Council meeting, residents expressed uncertainty about the location of the survey result book. Subsequent observations confirmed that the book was not found in any common areas accessible to residents or the public. Interviews with the DON and the Administrator revealed that neither was aware of the book's location. The Administrator eventually found the book under the receptionist's desk, although it was supposed to be on a shelf in the lobby. Additionally, there was no signage indicating the location of the survey result book anywhere in the facility. These findings were presented to the Administrator, Assistant Director of Nursing, and nurse consultants.
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 23 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 Fork Union
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chelsea Rehabilitation And Healthcare Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Dillwyn | 20.8 mi | ★★★★★ | 0 | 0 |
| Louisa Health & Rehabilitation Center | 20.8 mi | ★★★★★ | 0 | 0 |
| Albemarle Health & Rehabilitation Center | 20.9 mi | ★★★★★ | 10 | 1 |
| Westminster Canterbury Blue Ri | 21.7 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.