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 Rosedale Health & Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not follow infection control practices by storing unwrapped linen on an open shelf next to an environmental services cart and mops, with administrative staff confirming this was an infection control issue. No relevant policy was provided during the survey.
Staff failed to follow professional standards by not adhering to physician orders for insulin administration, repeatedly administering scheduled medications several hours late for two residents, and not clarifying or timely administering medications for another resident. These actions resulted in medication errors and noncompliance with facility policy requiring medications to be given within one hour of scheduled times.
Staff did not provide required ADL care, including turning and repositioning, for a dependent resident with severe cognitive impairment and a history of CVA and diabetes. Documentation reviews and staff interviews confirmed that on multiple occasions, the necessary care was not performed as required by the resident's care plan.
Staff failed to administer ordered medications and treatments in a timely manner, including delayed IV antibiotics, missed blood glucose checks, and omitted doses of insulin, gabapentin, and trazodone, despite medication availability. Bowel prep for a colonoscopy was not given, resulting in a canceled procedure, and required PICC/midline care was undocumented. Additionally, a GI appointment was not scheduled as ordered, with no evidence of follow-through in the medical record.
Staff did not consistently provide or document Foley catheter care for a resident with neuromuscular bladder dysfunction, despite physician orders and facility policy requiring care every shift. Review of treatment records showed multiple missed entries, and an LPN confirmed that care should be performed and documented each shift.
Facility staff failed to provide and document prescribed oxygen therapy for two residents with chronic respiratory conditions. On multiple occasions, oxygen was not administered or not documented as given according to physician orders, as shown by missing entries on the treatment administration records. Nursing staff confirmed that proper documentation was required and that missing entries meant there was no evidence of care provided.
Facility staff did not document a physician's response to pharmacist recommendations for a resident with multiple chronic conditions, including suggestions regarding prolonged antibiotic use and a dose reduction for Protonix. Despite facility policy requiring documentation of actions taken or explanations for disagreement, no such documentation was found for two separate MRRs.
Two residents were not provided with meals that honored their documented allergies and dietary preferences. One resident, with multiple medical conditions and a need for a gluten-free diet and adherence to Jewish dietary guidelines, was served food containing gluten and not provided with appropriate alternatives. Another resident, who disliked eggs, was served eggs for breakfast. Staff interviews confirmed that the residents' preferences were not met, despite facility policy requiring accommodation of such needs.
Two residents with moderate cognitive impairment and multiple medical conditions did not receive snacks during the day or at bedtime, as required. Observations and staff interviews confirmed that snacks such as milk, applesauce, crackers, and yogurt were not available on the units, with only minimal items found on one occasion. Staff reported that only limited sandwiches were sent for diabetic residents, and the Director of Dietary Services acknowledged there were no set par levels for nourishment items and was unaware of the issue.
Staff failed to consistently provide essential supplies such as urinals, gloves, and cup tops for two residents with incontinence and chronic medical conditions. Multiple staff interviews and supply closet observations confirmed recurring shortages, with staff sometimes needing to retrieve supplies from other rooms or provide bottled water due to missing cup lids. The central supply process did not prevent these shortages, and no supply management policy was provided.
Facility staff failed to treat two residents with dignity and respect, as evidenced by grievances, resident council minutes, and staff interviews describing rude and dismissive behavior by agency RNs and CNAs. One resident, with multiple chronic conditions, reported verbal aggression and profanity from a CNA, while staff confirmed that some agency personnel used curt tones and did not address residents respectfully, contrary to facility policy.
A resident who was cognitively intact and their own responsible party was moved from a private to a semi-private room without receiving written notice or consenting to the new roommate assignment. Despite the resident's resistance and involvement of the ombudsman, staff proceeded with the move, and documentation did not show that the facility's policy for advance notice and consent was followed.
A resident who was cognitively intact and his own responsible party was moved from a private to a semi-private room despite repeatedly refusing the change. Staff proceeded with the move based on payer status and the need for the private room, but there was no documented clinical need or isolation requirement for another resident. The facility's actions did not align with its own policy, which allows residents to refuse certain room changes.
Facility staff did not promptly notify the physician, nurse practitioner, or resident representatives about significant changes in condition for two residents, including delayed antibiotic administration due to pharmacy alerts, unreported high blood glucose requiring additional insulin, and unreported aggressive behavior with refusal of care. Staff interviews and facility policy confirmed that such notifications were required but not completed.
Facility staff did not maintain a clean and homelike environment, as evidenced by rooms with peeling wallpaper and exposed spackled drywall, and failed to provide adequate linens for several residents. Multiple residents and staff reported frequent shortages of towels, washcloths, and bed linens, which hindered the ability to provide basic care such as bathing and incontinence care.
Facility staff did not include PICC/midline care in the comprehensive care plan for a resident with multiple complex diagnoses, despite documentation and staff acknowledgment of the need. The care plan addressed other risks but omitted interventions for the PICC/midline, and no relevant policy was provided.
A resident with hypertension did not receive prescribed doses of Verapamil and Prazosin because staff failed to obtain the medications when they were unavailable in the Omnicell. The MAR showed missed administrations, and staff did not follow procedures to secure the medications or notify the provider, resulting in non-compliance with facility policy requiring administration of medications as ordered.
A resident with severe cognitive impairment and multiple medical conditions did not receive a chest x-ray as promptly as ordered by the physician. Staff were unable to schedule the x-ray after hours and deferred the task to the next shift, resulting in a delay beyond the facility's typical 24-hour timeframe for such services.
Facility staff did not document a resident's blood sugar value after a physician-ordered recheck, despite the recheck being performed and signed off by an LPN. The clinical record lacked the numerical blood sugar reading, and the responsible nurse acknowledged the documentation requirement but could not recall the incident. The facility also lacked a policy on maintaining a complete and accurate clinical record.
Facility staff did not consistently implement or document incontinence care interventions for three residents with significant physical impairments and incontinence needs, despite comprehensive care plans specifying frequent assistance and hygiene. ADL records showed multiple missing entries for bowel and bladder care, and an LPN confirmed that lack of documentation meant the care plan was not implemented. Leadership was informed of these deficiencies.
Facility staff did not provide or document required incontinence care for three dependent residents with complex medical needs. Despite care plans specifying frequent checks and assistance, ADL records showed multiple instances of missing documentation for bowel and bladder elimination across various shifts. CNA interviews indicated uncertainty about care time frames, and administrative staff were informed of the deficiencies.
The facility failed to implement comprehensive care plans for several residents, including those with C-diff, dialysis AV fistulas, colostomies, and incontinence needs. Staff did not adhere to infection control measures, failed to document necessary assessments, and did not provide required care as outlined in the care plans.
Facility staff failed to adhere to transmission-based precautions for residents with C-diff and COVID-19. A resident with C-diff was visited by staff without proper PPE, and hand hygiene was not performed correctly. Another resident with C-diff had staff enter without PPE and use ineffective hand sanitizer. A COVID-19 positive resident was visited by staff without the required N95 mask, gown, gloves, or eye protection. These actions violated facility policies and CDC guidelines.
The facility failed to provide incontinence care for three residents who were dependent on staff for toileting hygiene. Despite care plans and facility policies requiring regular checks and peri-care, documentation revealed lapses in care provision. Staff interviews confirmed expectations for care and documentation, but these were not consistently met, resulting in deficiencies.
A resident did not receive documented colostomy care on multiple occasions, as required by their care plan. Facility staff interviews revealed that CNAs were responsible for emptying and burping colostomy bags, while nurses were to change the bags and document the care. However, the eTARs lacked evidence of care being provided on several dates, indicating a failure to adhere to the facility's policy for licensed nurse-provided colostomy care.
A resident, identified as severely cognitively impaired and requiring moderate assistance for eating, did not receive feeding assistance on a specific date, as per the facility's records. Despite having a care plan and physician's order for a mechanically soft diet, the resident did not eat on that day. Interviews with staff revealed communication gaps regarding feeding assistance needs, and the resident's family had expressed concerns about inadequate food intake. The administrative staff was made aware of the issue.
A resident with end-stage renal disease did not receive complete dialysis care as the facility staff failed to monitor the dialysis AV fistula for function on several occasions. The physician's orders required daily assessment for thrill and bruit, and signs of infection every shift, but the records lacked evidence of these assessments. The facility's policy emphasized preventing infection and maintaining catheter patency, yet the necessary documentation was missing, leading to a deficiency finding.
Failure to Follow Infection Control Practices for Linen Storage
Penalty
Summary
Facility staff failed to implement proper infection control practices regarding linen storage. During a review of the unit linen closets, it was observed that packs of blankets wrapped in plastic were stored on shelves next to an unwrapped blanket and sheet, which were placed on an open shelf adjacent to an environmental services cart and mops. When questioned, an administrative staff member acknowledged that unwrapped linen should not be stored next to the environmental services cart and confirmed this was an infection control issue. Additionally, the facility was unable to provide a policy related to linen storage or infection control practices during the survey. No further information or documentation was provided by the facility prior to the survey exit.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice for three residents, resulting in multiple deficiencies related to medication administration and adherence to physician orders. For one resident, staff did not follow the physician's order to contact the physician before administering insulin when the resident's blood sugar exceeded 400. Instead, insulin was administered first, and the physician was contacted only after the medication failed to reduce the blood sugar. This was confirmed through clinical record review and staff interviews, where it was acknowledged that the order required immediate physician notification prior to insulin administration. Another resident experienced repeated delays in the administration of multiple scheduled medications, including gabapentin, furosemide, Novolog, tiotropium bromide, sennosides-docusate sodium, MiraLAX, and clopidogrel bisulfate. These medications, scheduled for administration at 9:00 a.m., were consistently given several hours late over multiple days. Staff interviews confirmed that medications should be administered within one hour before or after the scheduled time, and that late administration is considered a medication error. Facility policy also required medications to be administered within 60 minutes of the scheduled time. A third resident was affected by unclear and unclarified medication orders, as well as late administration of medications. The resident had orders for modafinil at two different times, but the order was not clarified, leading to confusion among staff and issues with pharmacy supply. Additionally, other medications for this resident, such as acarbose and metoprolol, were administered outside the prescribed time frames. Staff interviews and policy reviews confirmed that medications were not administered as ordered and that orders requiring clarification were not addressed in a timely manner.
Failure to Provide Required ADL Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically turning and repositioning, for a dependent resident with a history of diabetes mellitus, cerebrovascular accident (CVA) with hemiplegia and hemiparesis, and vascular dementia. The resident was assessed as severely cognitively impaired and totally dependent on staff for all ADL needs, including bed mobility. The care plan required two staff members to assist with repositioning and turning in bed as necessary. A review of the ADL documentation for November and December revealed multiple dates and shifts with missing entries for turning and positioning. Interviews with CNAs confirmed that if the care was not documented, it was not performed. This was corroborated by staff statements indicating that blanks in the documentation meant the required care was not provided. The deficiency was brought to the attention of administrative and nursing leadership, with no further information provided prior to the survey exit.
Failure to Administer Medications and Coordinate Care as Ordered
Penalty
Summary
Facility staff failed to administer physician-ordered medications and treatments in a timely and accurate manner for multiple residents. In one instance, a resident with a urinary tract infection did not receive an ordered intravenous antibiotic until four days after the order was written, despite the medication being available in the facility's Omnicell system. Documentation showed that pharmacy alerts regarding allergies and drug interactions delayed administration, but staff did not follow up promptly with the provider or pharmacy to resolve the issue. Additionally, the same resident did not have a blood glucose recheck performed at the time specified by the provider, with the check occurring nearly two hours late. Another resident did not receive multiple scheduled medications, including insulin, gabapentin, and trazodone, on specific dates, even though these medications were available in the facility's Omnicell. Staff interviews confirmed that nurses should have checked the Omnicell and administered the medications as ordered. In a separate case, a resident scheduled for a colonoscopy did not receive the required bowel preparation medications, which were available in house stock, resulting in the procedure being canceled and delayed. Documentation and staff interviews indicated that the medication was not located or administered as required, and the provider was not notified in a timely manner. Additional deficiencies included failure to provide required PICC/midline dressing changes for a resident, with no documentation to support that the care was provided as ordered. Another resident did not have a gastrointestinal appointment scheduled as ordered by the physician, and there was no evidence in the medical record or from the physician's office that the appointment was made. These failures were identified through clinical record review, staff interviews, and review of facility policies, with no further information or corrective actions provided prior to the survey exit.
Failure to Provide and Document Foley Catheter Care
Penalty
Summary
Facility staff failed to provide Foley catheter care as ordered for a resident diagnosed with neuromuscular dysfunction of the bladder. The physician's order required catheter care every shift and as needed, which was documented in the resident's treatment administration records (TARs) from September through November. However, review of the TARs revealed multiple instances where catheter care was not documented as provided, with blank spaces noted on specific dates and shifts. An interview with an LPN confirmed that catheter care should be performed at least once per shift and documented on the TAR. The facility's policy also required routine hygiene and documentation of catheter care, including the date and time care was given. Despite these requirements, the records did not show evidence that catheter care was consistently provided or documented for the resident during the identified periods.
Failure to Provide and Document Prescribed Oxygen Therapy
Penalty
Summary
Facility staff failed to provide prescribed respiratory care and services for two residents with chronic respiratory conditions. For one resident with chronic obstructive pulmonary disease, staff did not administer continuous oxygen as ordered by the physician on multiple shifts, as evidenced by blank documentation on the treatment administration record (TAR) for several dates. Interviews with nursing staff confirmed that oxygen administration should be documented on the TAR, and the facility's policy requires recording the date and time of oxygen setup or adjustment in the medical record. For another resident with chronic respiratory failure and hypoxia, staff did not document the administration of oxygen therapy as ordered on several shifts throughout the month. The resident's care plan and physician orders specified continuous oxygen, but the TAR showed missing documentation for multiple day, evening, and night shifts. Nursing staff confirmed that if documentation is missing, there is no evidence that oxygen was administered. Facility policy also requires documentation of the rate, route, and rationale for oxygen administration.
Failure to Document Physician Response to Pharmacist Recommendations
Penalty
Summary
Facility staff failed to document a physician's response to pharmacist recommendations made during the monthly Medication Regimen Review (MRR) for one resident. Specifically, recommendations from the pharmacist regarding the prolonged use of antibiotics (Fluconazole and Ketoconazole) and a suggested dose reduction for Protonix were not addressed or documented by the physician. The facility's policy requires that recommendations from the pharmacist be acted upon and documented by staff or the prescriber, with either acceptance and action or a documented explanation for disagreement. The resident involved had multiple diagnoses, including diabetes mellitus, congestive heart failure, seizures, and chronic respiratory failure with hypoxia, and was not cognitively impaired according to the most recent assessment. Despite the facility's established process for reviewing and responding to MRR recommendations, there was no evidence in the clinical record or facility documentation that the physician responded to the pharmacist's recommendations for this resident on two separate occasions.
Failure to Honor Resident Dietary Allergies and Preferences
Penalty
Summary
Facility staff failed to honor dietary allergies and preferences for two residents, resulting in the provision of inappropriate food items. One resident, who was cognitively intact and had multiple diagnoses including diabetes, heart failure, and morbid obesity, reported allergies to several foods and a need for a gluten-free diet, as well as adherence to Jewish dietary guidelines. Despite these documented needs and preferences, the resident was served chicken noodle soup containing gluten, and her meal ticket did not reflect her gluten intolerance or religious dietary requirements. The resident stated that staff did not understand her needs and required her to provide proof of her gluten intolerance, and staff interviews confirmed that her preferences were not being met. Another resident, who was moderately cognitively impaired and had chronic medical conditions, had a documented dislike of eggs. Despite this, the resident was served eggs for breakfast, as observed by surveyors. The resident expressed dissatisfaction with the food provided, and the dietary director acknowledged that serving eggs did not honor the resident's stated preferences. The resident's care plan and dietary orders did not indicate any allergies but did specify food preferences that were not followed. Interviews with dietary staff revealed that the process for identifying and accommodating food allergies and preferences involved resident interviews and electronic documentation, with meal tickets intended to reflect these needs. However, in both cases, the system failed to ensure that residents' dietary restrictions and preferences were honored, resulting in the provision of inappropriate meals. The facility's policy recognizes residents' rights to make personal dietary choices and to receive reasonable accommodations for individual, religious, cultural, and ethnic preferences, but these were not upheld in the observed incidents.
Failure to Provide Snacks Between Meals and at Bedtime
Penalty
Summary
Facility staff failed to provide snacks during the day and at bedtime for two residents, both of whom were moderately cognitively impaired and had significant medical conditions, including Parkinson's Disease, convulsions, chronic kidney disease, hereditary and idiopathic neuropathy, and arthritis. Observations conducted on multiple units at various times revealed that snacks such as milk, applesauce, ice cream, crackers, yogurt, and peanut butter were not available, with only a minimal amount of milk and yogurt found on one occasion. The facility census at the time was 120 residents. Interviews with the affected residents confirmed that they did not receive snacks during the day or at bedtime, and that nothing was provided between meals. Multiple CNAs corroborated this, stating that there were no snacks available for residents on day, evening, or night shifts, except for some peanut butter and jelly or cheese sandwiches sent for diabetic residents. One CNA demonstrated the lack of available snacks by showing an almost empty jar of peanut butter and noting the absence of crackers. The Director of Dietary Services stated that snacks such as PBJ and grilled cheese sandwiches were offered at any time, but also acknowledged that there were no established par levels for nourishment items like milk, applesauce, or crackers, and was unaware of any issue prior to the survey. The facility's policy on between meal and bedtime snacks indicated the purpose was to provide adequate nutrition, but no further information was provided prior to the survey exit.
Failure to Provide Adequate Supplies for Resident Care
Penalty
Summary
Facility staff failed to provide necessary supplies, including urinals, gloves, and cup tops, for two residents with significant medical needs. One resident, admitted with Parkinson's Disease, convulsions, and chronic kidney disease, was assessed as moderately cognitively impaired and required substantial assistance with toileting due to frequent incontinence. Observations of supply closets revealed inconsistent availability of urinals and gloves, with periods where these items were missing or in short supply. Staff interviews confirmed recurring shortages of essential supplies such as urinals, gloves, adult briefs, towels, washcloths, and sheets, with staff sometimes needing to retrieve gloves from other resident rooms or carry them in their pockets due to lack of availability. Another resident, also moderately cognitively impaired and diagnosed with hereditary and idiopathic neuropathy, arthritis, and chronic kidney disease, required peri-area cleaning with each incontinence episode. This resident reported that their size of briefs was not always available. Staff interviews across multiple shifts consistently indicated shortages of gloves, urinals, and other personal care items, with some staff noting that these shortages persisted over weekends and during night shifts. Additionally, staff reported having to provide residents with bottled water due to the absence of lids for water cups. The central supply supervisor, who had recently assumed the role, described the supply ordering and stocking process, noting that orders are typically placed weekly and that rush orders can be made if items run out. However, the process did not prevent periods of supply shortages, especially when the supervisor was not present. No facility policy regarding supply management was provided, and administrative staff were made aware of the findings during the survey.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
Facility staff failed to provide dignity and respect to two residents, as evidenced by multiple documented incidents and staff interviews. For one resident, a grievance was filed by the resident's sister, stating that an agency RN was rude and abrasive after the family waited for hours for assistance. The RN reportedly responded dismissively, saying, 'I am busy too.' Resident council meeting minutes over several months also documented ongoing concerns about staff attitudes and customer service issues. Staff interviews confirmed that agency staff, including CNAs, have been observed responding rudely to residents, such as refusing requests or speaking in a curt manner. The facility's own policy requires residents to be treated with dignity and respect at all times, but these standards were not met. Another resident, who was cognitively intact and had multiple medical conditions including diabetes, CHF, and chronic respiratory failure, reported that a CNA used profanity and was verbally aggressive when asked about her behavior. The resident stated she did not feel treated with dignity or respect. Additional staff interviews corroborated that some staff, particularly agency staff, have been short or used a hard tone of voice with residents. One CNA stated that residents were not being treated with dignity. The facility's policy emphasizes respectful communication and addressing residents by their preferred names, but these practices were not consistently followed.
Failure to Provide Written Notice and Obtain Consent for Room Change
Penalty
Summary
Facility staff failed to provide a written notice of a room change and did not ensure resident consent to a new roommate assignment prior to moving a resident from a private room to a semi-private room. The resident, who was documented as cognitively intact and their own responsible party, was resistant to the move and had previously notified the ombudsman to mediate the situation. Despite the resident's refusal and ongoing discussions, staff proceeded with the room change, packing the resident's belongings and moving them to the new room without documented written notice or evidence of consent to the new roommate. Progress notes and staff interviews confirmed that the resident was not agreeable to the move, expressed distress during the process, and that staff could not confirm the resident had met the new roommate prior to the move. The facility's policy required advance notice and explanation for room changes unless medically necessary, but the clinical record did not show that these requirements were met. The deficiency was identified through review of clinical records, staff interviews, and facility policy documentation.
Failure to Honor Resident's Right to Refuse Room Change
Penalty
Summary
Facility staff failed to honor a resident's right to refuse a room change, resulting in the involuntary relocation of a cognitively intact resident from a private to a semi-private room. The resident, who was his own responsible party and had no documented behaviors or clinical need for a private room, was actively involved in discharge planning to return to the community. Despite the resident's clear and repeated refusals to move, as documented in progress notes and staff interviews, the facility proceeded with the room change. On the day of the move, multiple staff members, including the social worker, director of admissions, and a CNA, entered the resident's room to assist with packing and moving. The resident became visibly upset, yelling at staff and demanding they leave his belongings alone. Despite his protests and physical resistance, staff continued to pack and relocate him to the new room. Staff interviews confirmed that the resident had not agreed to the move and that the facility's rationale was based on payer status and the need to use the private room for another resident, although documentation did not support an immediate clinical need for the private room. Facility policy states that residents have the right to refuse room changes if the move is solely for staff convenience or involves relocation between skilled and non-skilled units. In this case, the move was not supported by a documented clinical need or isolation requirement for another resident, and available room options were not fully explored or offered to the resident. The facility's actions were inconsistent with their own policy and the resident's rights, as evidenced by the lack of documentation supporting the necessity of the move and the resident's clear refusal.
Failure to Notify Physician and Responsible Parties of Significant Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify the physician, nurse practitioner, and/or resident representative in a timely manner regarding significant changes in condition or care for multiple residents. In one instance, a resident with a urinary tract infection had an order for Ertapenem, but due to pharmacy alerts about a possible allergy and drug interaction, the medication was not available for four days. During this period, nurses documented waiting for the pharmacy and did not promptly notify the physician or nurse practitioner about the delay, despite facility policy and staff statements indicating that such notifications should occur immediately when medication is unavailable or when alerts are received. In another case, the same resident experienced a critically high blood glucose reading, requiring multiple administrations of insulin as ordered by the nurse practitioner. However, there was no documentation that the resident's representative was notified of the high blood sugar or the additional insulin orders, contrary to facility policy and staff expectations that representatives should be informed of such significant changes. A separate incident involved a resident with severe cognitive impairment who exhibited combative and aggressive behavior, including refusal of care, spitting, kicking, and biting staff. Despite these significant behavioral changes and refusal of care, there was no evidence that the physician or responsible party was notified, nor was there an investigation into the incident. Staff interviews confirmed that such notifications should have occurred, and the facility's policy requires prompt notification of significant changes in a resident's condition or behavior.
Failure to Maintain Clean, Homelike Environment and Provide Adequate Linens
Penalty
Summary
Facility staff failed to provide a safe, clean, and homelike environment for three residents, as evidenced by multiple observations and interviews. In one case, a resident's room had peeling wallpaper and visible spackled drywall behind the bed, which the resident and maintenance director acknowledged was due to ongoing renovations. The maintenance director confirmed that the current state of the room did not meet clean and homelike standards, and the facility's policy requires such an environment. Another resident's room also had peeling wallpaper on three walls, and the resident reported that it had been in that condition for some time. Additionally, there was a consistent lack of clean linens, towels, and washcloths available for residents. Staff interviews confirmed that there were frequent shortages of linens, making it difficult to provide basic care such as bathing and incontinence care. Residents reported having to wait until late morning for linens, and staff stated that they often ran out of supplies. A third resident reported that for several days there had been no linen available in the morning, forcing them to use a pillowcase for personal hygiene. Observations confirmed the lack of necessary linens and supplies on multiple units. Staff interviews further corroborated the ongoing issue with linen shortages, which directly impacted the ability to provide care. The facility's own policy emphasizes the importance of providing clean bed and bath linens in good condition as part of a homelike environment.
Failure to Develop Comprehensive Care Plan for PICC/Midline
Penalty
Summary
Facility staff failed to develop a comprehensive care plan addressing the care and management of a peripherally inserted central catheter (PICC) or midline for one resident. The resident was admitted with multiple diagnoses, including diabetes mellitus, congestive heart failure, seizures, and chronic respiratory failure with hypoxia. Despite these complex medical needs, the resident's care plan, dated 1/18/25, did not include any interventions or focus related to the presence or care of a PICC or midline catheter. The care plan only addressed risks related to weight loss, malnutrition, and hydration, with no mention of the PICC/midline. Clinical documentation confirmed that the resident had a PICC line, which was removed on 3/10/25, and the resident was aware of the procedure. Interviews with the resident and staff confirmed the presence and subsequent removal of the PICC line, and staff acknowledged that special needs such as a midline should be included in the care plan. No facility policy regarding care planning was provided, and the deficiency was acknowledged by administrative and clinical leadership.
Failure to Provide Prescribed Medications Due to Pharmacy Service Lapse
Penalty
Summary
Facility staff failed to provide necessary pharmacy services for one resident by not obtaining and administering prescribed medications. The resident had physician's orders for Verapamil and Prazosin to be given at bedtime for hypertension, as documented in both the clinical record and the medication administration record (MAR). However, review of the MAR showed that these medications were not administered on a specific date, with blank spaces indicating missed doses. Staff interviews revealed that when medications are unavailable, nurses are expected to check the Omnicell, contact the pharmacy, and notify the provider for alternative orders or to place the medication on hold. In this case, the medications were not available in the Omnicell, and there was no evidence that further steps were taken to obtain or administer the medications as ordered. The facility's policy requires medications to be administered according to prescriber orders, but this was not followed for the resident in question.
Delay in Providing Ordered Radiology Services
Penalty
Summary
Facility staff failed to provide timely radiology services as ordered for one resident with multiple complex medical conditions, including diabetes mellitus, cerebrovascular accident with hemiplegia, and vascular dementia. The resident was severely cognitively impaired and fully dependent on staff for activities of daily living, including bed mobility. A physician's order was placed for a one-time chest x-ray due to a productive cough. Documentation shows that staff attempted to schedule the x-ray after hours but were unable to do so and deferred the task to the next shift. The x-ray order was subsequently placed the following day, and the imaging was completed and resulted the day after the initial order. Staff interviews indicated that the expected timeframe for obtaining and receiving x-ray results is typically within 24 hours. The facility's policy states that radiological and diagnostic services are to be provided to meet residents' needs, either on-site or through contracted providers. No additional information or documentation was provided by facility administration regarding the delay or actions taken to ensure timely completion of the ordered radiology service.
Failure to Document Blood Sugar Reading in Clinical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident by not documenting the numerical blood sugar reading after a physician-ordered recheck. The physician's order required a blood glucose recheck at 2:00 a.m., and the medication administration record indicated the recheck was performed at 3:59 a.m. However, a review of the clinical record, including the medication administration record, nurses' notes, and blood sugar summary, did not reveal the actual blood sugar value obtained during the recheck. The nurse responsible for the recheck confirmed that the blood sugar number should have been documented but could not recall the specific resident or event. Additionally, the facility did not have a policy regarding the maintenance of a complete and accurate clinical record. Administrative staff, including the administrator and director of nursing, were informed of the concern, and no further information was provided prior to the survey exit.
Failure to Implement and Document Incontinence Care Plans
Penalty
Summary
Facility staff failed to implement comprehensive care plans for incontinence care for three residents. Each resident had a documented care plan specifying the need for substantial or maximal assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene as needed for incontinent episodes. Despite these documented interventions, reviews of the activities of daily living (ADL) records revealed multiple instances of missing documentation for 'bowel and bladder elimination' across various dates and shifts for all three residents. The residents involved had significant medical histories, including end stage renal disease, HIV, cancer, malnutrition, colitis, diabetes mellitus, hemiplegia, hemiparesis, rhabdomyolysis, and spondylosis. All were assessed as not cognitively impaired and required maximal or dependent assistance for mobility, transfers, bathing, dressing, and toileting. The care plans were tailored to their physical limitations and incontinence needs, yet the required interventions were not consistently documented as provided. During interviews, an LPN confirmed that if interventions listed on the care plan are not evidenced, the care plan was not implemented. The administrator, DON, and regional director of clinical operations were made aware of these concerns, but no further information was provided prior to the survey exit.
Failure to Provide and Document Incontinence Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically incontinence care, for three dependent residents. Each resident had significant medical conditions, including end stage renal disease, HIV, cancer, malnutrition, colitis, diabetes mellitus, hemiplegia, hemiparesis, rhabdomyolysis, and spondylosis. Their most recent MDS assessments indicated that they required maximal or total assistance for mobility, transfers, bathing, dressing, and toileting, with care plans specifying the need for frequent checking and changing of briefs and provision of toileting hygiene as needed for incontinent episodes. Review of the ADL records for these residents revealed multiple instances of missing documentation for 'bowel and bladder elimination' across various dates and shifts. The documentation gaps spanned several months and included both day, evening, and night shifts. The care plans for each resident clearly outlined the need for substantial or maximal assistance with toileting and incontinence care, yet the records did not consistently reflect that this care was provided or documented as required. Interviews with CNAs revealed a lack of awareness regarding specific time frames for providing incontinence care, and both CNAs stated that care was documented on the ADL forms. However, the missing documentation suggests that either the care was not provided or not properly recorded. Facility administrative staff, including the administrator, DON, and regional director of clinical operations, were made aware of these concerns during the survey process. No additional information was provided prior to the survey exit.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for several residents, leading to deficiencies in care. For one resident with a diagnosis of C-diff, staff did not adhere to contact precautions as outlined in the care plan. Observations revealed that staff entered the resident's room without the required personal protective equipment (PPE) such as gowns and gloves, and did not follow proper hand hygiene protocols. Interviews with staff confirmed a lack of compliance with the care plan's requirements for infection control measures. Another resident with end-stage renal disease and a dialysis AV fistula did not receive the necessary monitoring as per the care plan. The facility's records showed that assessments of the dialysis fistula for function were not documented on multiple occasions. This lack of documentation indicates that the required checks for thrill and bruit, as well as signs of infection, were not consistently performed, which is a critical component of the resident's care plan. Additional deficiencies were noted in the care of residents with colostomies and those requiring incontinence care. For a resident with a colostomy, the care plan specified that colostomy care should be provided every shift, yet records showed multiple instances where this care was not documented. Similarly, residents dependent on staff for toileting hygiene did not receive the necessary incontinence care as outlined in their care plans. These failures to implement the care plans highlight significant lapses in the facility's adherence to established protocols for resident care.
Failure to Maintain Transmission-Based Precautions
Penalty
Summary
The facility staff failed to maintain proper transmission-based precautions for three residents diagnosed with infectious diseases. For Resident #5, who was diagnosed with Clostridium difficile (C-diff), a staff member entered the resident's room without wearing the required personal protective equipment (PPE) such as a gown and gloves. The staff member also failed to wash their hands with soap and water after exiting the room, which is crucial for preventing the spread of C-diff. The facility's policy and the signage on the resident's door clearly outlined the necessary precautions, but these were not followed. Similarly, for Resident #8, who was also diagnosed with C-diff, a staff member entered the room without the appropriate PPE and used alcohol-based hand sanitizer instead of washing hands with soap and water, which is ineffective against C-diff spores. Additionally, another staff member was observed wearing the same gown and gloves outside the resident's room, which could lead to cross-contamination. The facility's policies and the physician's orders required strict adherence to contact precautions, but these were not consistently implemented. For Resident #10, who was diagnosed with COVID-19, a staff member entered the room wearing only a surgical mask, without donning a gown, gloves, or eye protection as required by droplet precautions. The facility's policy and CDC guidelines specified the use of an N95 mask, gown, gloves, and eye protection for residents with confirmed COVID-19. The lack of adherence to these precautions was observed despite clear signage and available PPE, indicating a failure to follow established infection control protocols.
Failure to Provide Incontinence Care
Penalty
Summary
The facility staff failed to provide incontinence care for three residents, identified as Residents #2, #5, and #6, who were part of a survey sample. Resident #2 was severely cognitively impaired and dependent on staff for toileting hygiene. The clinical records indicated that there were shifts where no incontinence care was provided, despite the care plan specifying the need for peri-care after each incontinent episode and encouraging toileting during the night. Interviews with staff revealed that CNAs were expected to check on residents every two hours and provide care as needed, but this was not consistently documented or performed. Resident #5, who was cognitively intact but dependent on staff for toileting hygiene, also did not receive incontinence care during certain shifts as documented in the facility's records. The facility's policy required staff to provide timely peri-care and apply barrier creams to maintain skin integrity, but these actions were not consistently carried out. Staff interviews confirmed the expectation to document incontinence care and educate residents if they refused care, yet gaps in care provision were noted. Similarly, Resident #6, who was dependent on staff for toileting hygiene, experienced lapses in incontinence care. The care plan for this resident included encouraging toileting after meals and providing peri-care after each incontinent episode. However, documentation showed that care was not provided during some shifts. The facility's policy emphasized the importance of managing incontinence to prevent infections and maintain skin health, but the staff did not adhere to these guidelines consistently, leading to the identified deficiencies.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility staff failed to provide necessary colostomy care for a resident, identified as Resident #4, on multiple occasions. The clinical record review and electronic treatment administration records (eTARs) revealed that colostomy care was not documented as provided during several shifts in March, April, and May 2024. The resident's comprehensive care plan required colostomy care every shift and as needed, but the records did not show evidence of this care being administered on the specified dates. Interviews with facility staff, including a CNA and an LPN, indicated that while CNAs were responsible for emptying and burping colostomy bags, nurses were supposed to change the bags and document the care in the medical record. The facility's policy stated that colostomy and ileostomy care should be provided by a licensed nurse as ordered by the physician. Despite this policy, the lack of documentation in the eTARs suggests that the required care was not consistently provided or recorded. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, assistant director of nursing, and regional director of clinical services, but no further information was provided before the survey exit.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility staff failed to provide feeding assistance to Resident #2 on March 23, 2024. Resident #2 was identified as severely cognitively impaired and required partial/moderate assistance for eating, as indicated in the most recent Minimum Data Set (MDS) assessment. The clinical record review revealed that on the specified date, Resident #2 did not receive feeding assistance and did not eat, despite having a physician's order for a mechanically soft diet with thin liquids. The care plan highlighted the resident's risk for nutritional problems due to poor oral intake and the need to maintain stable weight. Interviews with facility staff, including a CNA and an LPN, provided insights into the situation. The CNA mentioned that feeding assistance requirements are communicated during shift reports, and any refusal to eat is reported to the nurse. The LPN stated that Resident #2 did not have eating issues during her care but acknowledged the family's concerns about the resident's food intake. She also noted that Resident #2 was a slow eater and required ample time for meals, which she communicated to the staff. The administrative staff, including the administrator and the regional director of clinical services, were informed of these concerns, but no further information was provided before the survey exit.
Failure to Monitor Dialysis AV Fistula
Penalty
Summary
The facility staff failed to provide complete dialysis care and services for a resident with end-stage renal disease who required monitoring of their dialysis AV fistula. The physician's orders specified that the dialysis fistula should be assessed daily for thrill and bruit, as well as for signs and symptoms of infection, every shift. However, the electronic treatment administration records did not show evidence of these assessments being conducted on several specified dates. This lack of documentation indicates that the required monitoring was not performed as per the physician's orders. The facility's policy on Hemodialysis Access Care outlines the necessity of preventing infection and maintaining the patency of the catheter by checking for signs of infection and ensuring the patency of the site at regular intervals. Despite this policy, the staff did not document the presence of bruit and thrill, signs of infection, or the condition of the dressing for the resident's AV fistula on the specified dates. Interviews with facility staff confirmed that the monitoring should have been documented in the clinical record, but it was not, leading to the deficiency finding.
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.
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What surveyors actually found near you
We read the 237 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster-canterbury Of Richmond | 0.8 mi | ★★★★★ | 0 | 0 |
| Vcu Health Children's Services At Brook Road | 1.5 mi | ★★★★★ | 0 | 0 |
| Lakeside Health & Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Glenburnie Rehab & Nursing Center | 2.1 mi | ★★★★★ | 14 | 0 |
| The Virginia Home | 3.2 mi | ★★★★★ | 0 | 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.