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 The Laurels Of Bon Air during CMS and state inspections, most recent first.
Staff failed to administer and/or accurately document multiple medications as ordered for three residents. One resident did not have two scheduled morning doses of Calcium Carbonate documented on the MAR. Another resident with a new order for Ciprofloxacin for a UTI had two scheduled doses on the start date left blank on the MAR, despite the drug being available in the emergency backup supply. A third resident on scheduled Lorazepam for anxiety had conflicting records between the MAR and the narcotic sign-out sheet, with several doses charted as given on the MAR but not recorded on the narcotic log, and one scheduled dose missing entirely from the narcotic record. An LPN confirmed that if a medication is not documented, it is considered not administered, and described the expected process for narcotic handling and documentation.
Staff failed to maintain complete and accurate MAR documentation for two residents receiving Morphine and Lorazepam. For one resident, multiple PRN doses of Morphine and Lorazepam recorded on the narcotic sign-out sheet were not documented on the MAR. For another resident, there were multiple discrepancies where Morphine and Lorazepam doses were charted as given on the MAR without corresponding entries on the narcotic sign-out sheet, and instances where the MAR simultaneously indicated a resident was sleeping and that a dose was administered. An LPN reported that the standard process is to sign out narcotics in the narcotic book and then document administration on the MAR, but this process was not consistently followed.
The facility failed to provide timely care for three residents, leading to significant deficiencies. A resident did not receive ceftriaxone, insulin, or blood sugar monitoring upon admission, resulting in confusion and a hospital transfer. Another resident experienced a delay in receiving Coumadin, increasing the risk of blood clots after heart surgery. A third resident did not have timely blood glucose monitoring or insulin administration, despite a diabetes diagnosis.
A resident with a history of heart valve replacement and atrial fibrillation did not receive a physician-ordered PT/INR test for anticoagulant monitoring. The test was scheduled but not completed due to a lapse in the facility's process for verifying lab orders. An LPN responsible for checking lab test completion was unable to confirm the test on the due date, leading to the oversight.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in care. A resident's Foley catheter was improperly managed, increasing infection risk. Another resident's anticoagulant use was not monitored, and safety measures like a fall mat and bed positioning were ignored. Additionally, care plans for bed positioning and enabler bar discussions were not followed for two other residents. Staff interviews confirmed these lapses, indicating non-compliance with care planning policies.
A resident with severe cognitive impairment experienced a fall in the facility, resulting in minor injuries. Although the physician was notified, the responsible party was not informed as required by the facility's policy. Interviews with LPNs revealed inconsistencies in the notification process, highlighting a deficiency in adhering to the Fall Management policy.
A facility staff member failed to accurately code a resident's discharge as planned on the MDS assessment, despite documentation indicating it was planned. The MDS coordinator admitted to the coding error, which was identified during a survey. The administrator and DON were informed of the issue.
A resident with COPD and chronic hypoxic respiratory failure did not receive oxygen as per the baseline care plan, which specified continuous oxygen at two liters per minute. Observations showed incorrect oxygen rates, and the resident was unaware of how to adjust the flowmeter. An LPN confirmed the care plan's purpose and the need to follow physician's orders, but the facility staff failed to adhere to these guidelines.
The facility failed to update the care plans for two residents to include the use of side rails, despite observations confirming their use. Clinical records initially indicated the use of beds against the wall without side rails. Interviews with LPNs confirmed that the care plans should have been revised to reflect the current use of side rails.
Two residents in a facility experienced deficiencies in care. One resident received pain medications not aligned with physician orders, with Acetaminophen given for higher pain levels and Tramadol for lower levels than prescribed. Another resident with Type 2 Diabetes had incomplete blood glucose monitoring, as required checks were not documented in the eMAR. These issues were noted by facility staff, including an LPN, and reported to the administration.
The facility staff failed to provide appropriate care for two residents, leading to deficiencies in wound care management. One resident did not receive treatment for toe wounds as per the physician's plan, while another resident's surgical incisions were not regularly assessed or managed. An LPN acknowledged the absence of treatment orders and assessments, indicating lapses in the facility's care processes.
A resident's toenails were not trimmed, extending over an inch past the toes, despite no medical conditions preventing staff from doing so. The resident's daughter raised concerns, and staff interviews revealed confusion about responsibilities for toenail care. The facility's policy required nails to be neatly trimmed, but this was not followed.
The facility failed to secure portable oxygen tanks and implement fall prevention measures for three residents. Unsecured oxygen tanks were found in a shared room, posing a safety risk. Additionally, fall prevention measures, such as placing a fall mat and positioning beds against walls, were not implemented as required by care plans. Staff interviews confirmed these deficiencies, and there was no updated evaluation to justify the removal of these safety measures.
A resident's Foley catheter bag was repeatedly observed dragging on the floor while she was in her wheelchair, despite facility policies and care plans indicating it should be secured properly. Interviews with LPNs confirmed awareness of the issue and the associated risks, but the deficiency persisted.
A resident with a colostomy did not receive appropriate care due to the absence of physician's orders and inadequate documentation of colostomy care. An LPN confirmed the need for such orders to guide care, and the facility lacked a policy on colostomy management. The administrative staff was informed of these deficiencies.
A resident in a long-term care facility did not receive oxygen at the physician-prescribed rate of two liters per minute. Observations showed the oxygen flow was set incorrectly on two occasions, and the resident, who was cognitively intact, did not adjust the flowmeter. An LPN confirmed that nurses should ensure the correct oxygen rate, but the facility lacked a policy on oxygen administration. The issue was reported to the facility's administration.
The facility failed to ensure current evaluations and consents were in place before implementing side rails for three residents. Observations revealed side rails in use without proper documentation or care planning. Interviews with LPNs confirmed the necessity of reassessment and updated consent, which were not conducted according to facility policy.
The facility failed to ensure timely review and implementation of pharmacy recommendations for three residents. Despite the facility's policy requiring prompt review and documentation, the Director of Nursing admitted that some reviews were missing and could not confirm if they had been reviewed. This issue affected multiple medication regimen reviews over several months.
A resident was prescribed Eliquis for atrial fibrillation, but the facility failed to conduct consistent monitoring for signs of bleeding as required by their policy. An LPN admitted that monitoring should be documented daily, but was unable to identify signs of bleeding. The lack of documentation in the MAR and TAR from the order date to the survey date confirmed the deficiency.
A facility failed to maintain a complete and accurate medical record for a resident transferred to the emergency room. The record lacked documentation of the reason for the transfer, despite standard procedures requiring an SBAR assessment and a change in condition assessment. The nurse responsible for the transfer was no longer employed, and the facility's policy on medical records was not adhered to.
A CNA in an LTC facility failed to follow contact precaution protocols by not wearing an isolation gown and neglecting hand hygiene after assisting a resident. Despite the facility's policy requiring hand washing after removing PPE, the CNA did not wash her hands before entering another resident's room. Interviews with staff confirmed the breach in protocol.
Medication Administration and Documentation Errors for Multiple Residents
Penalty
Summary
Facility staff failed to administer medications according to physician orders and to accurately document administration for three residents. For one resident, a standing order for Calcium Carbonate 500 mg by mouth each morning, in place since 3/22/2025, was listed on the December 2025 MAR, but there was no documentation of administration on 12/5/2025 and 12/26/2025; the MAR boxes for those dates were left blank. During interview, an LPN confirmed that nurses evidence medication administration by checking off the MAR and acknowledged that if it is not documented, it is considered not done. For another resident with an order dated 12/18/2025 for Ciprofloxacin HCL 500 mg by mouth every 12 hours for 7 days for a UTI, the December MAR showed the order starting 12/19/2025, but the 9:00 a.m. and 9:00 p.m. doses on that date were left blank, despite Ciprofloxacin being available in the emergency backup box. For a third resident admitted for respite care, staff failed to administer and/or accurately document Lorazepam Oral Concentrate per a physician order dated 12/4/2025 for 2 mg/mL, 0.25 mL by mouth every 2 hours for anxiety. The December MAR showed the medication as given at 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. on 12/4/2025, and at 4:00 a.m. and 6:00 a.m. on 12/5/2025. However, the narcotic sign-out sheet documented only two doses on 12/4/2025 at 5:30 p.m. and 7:00 p.m., with no entries for the other scheduled times. On 12/5/2025, the narcotic sheet showed doses at 12:00 a.m., 2:00 a.m., and what appears to be 6:00 a.m., with no documented 4:00 a.m. dose. The resident’s comprehensive care plan noted the resident was at risk for adverse reactions and side effects from antianxiety medications and included an intervention to administer antianxiety medications per orders. The LPN described the process for narcotic administration as removing the drug from the narcotic box, signing it out in the narcotic book, and then documenting the dose on the MAR, highlighting the discrepancy between the two records.
Incomplete and Inaccurate Documentation of Narcotic Administration on MARs
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents by not consistently documenting the administration of narcotic medications on the medication administration record (MAR) and by documenting administrations that were not supported by the narcotic sign-out sheets. For one resident, a physician order dated 12/4/2025 directed Morphine Sulfate Oral Solution 100 mg/5 mL, 0.5 mL by mouth every 4 hours as needed for shortness of breath or discomfort. The December MAR showed only one dose given on 12/5/2025 at 9:33 a.m., while the narcotic sign-out sheet, which is not part of the clinical record, showed additional doses given on 12/4/2025 at 5:00 p.m. and 9:00 p.m. and on 12/5/2025 at 9:00 a.m., with only the 12/5/2025 9:00 a.m. dose reflected in the clinical record. For the same resident, a physician order dated 12/4/2025 for Lorazepam 0.5 mg, one tablet by mouth every 4 hours as needed for anxiety, restlessness, or agitation for 14 days, was present on the December MAR, but there was no documentation on the MAR that the medication had been administered, despite the narcotic sign-out sheet showing doses given on 12/4/2025 at 5:00 p.m. and 9:00 p.m. and on 12/5/2025 at 1:00 a.m. For a second resident, staff inconsistently documented Morphine and Lorazepam administrations between the MAR and the narcotic sign-out sheet. A physician order dated 12/4/2025 for Morphine Sulfate Solution 20 mg/mL, 0.5 mL by mouth every 2 hours for pain, was recorded on the December MAR with administrations documented on 12/4/2025 at 4:00 p.m., 8:00 p.m., and 10:00 p.m.; however, the narcotic sign-out sheet only showed a dose at 6:00 p.m. that day. Additional MAR entries on 12/5/2025 at 6:00 a.m. and on 12/6/2025 at 2:00 a.m. were not supported by corresponding entries on the narcotic sign-out sheet, and on 12/6/2025 at 6:00 a.m. the MAR indicated both that the resident was sleeping and that the dose was administered. For the same resident, a physician order dated 12/4/2025 for Lorazepam Oral Concentrate 2 mg/mL, 0.25 mL by mouth every 2 hours for anxiety, was documented on the December MAR. On 12/6/2025 at 2:00 a.m., the MAR showed administration of Lorazepam without a matching entry on the narcotic sign-out sheet, and at 6:00 a.m. the MAR documented the resident was sleeping and the medication was not given, while the narcotic sign-out sheet documented that the dose was administered. An LPN stated that the process for administering a narcotic is to remove it from the narcotic box, sign it out in the narcotic book, and then document the dose on the MAR.
Delayed Medication Administration and Monitoring
Penalty
Summary
The facility staff failed to provide timely and accurate care for three residents, leading to significant deficiencies in their treatment. For Resident #4, the staff did not verify and transcribe the physician's orders upon admission, resulting in a delay in administering ceftriaxone, insulin, and blood sugar monitoring. The resident was admitted with bacterial meningitis and diabetes, and the lack of timely medication administration led to confusion and concern from the resident's husband, who eventually requested a transfer to a hospital. Resident #11 experienced a delay in receiving Coumadin, a critical medication for managing her atrial fibrillation and preventing blood clots following heart valve replacement surgery. The facility did not have an order for Coumadin until approximately 48 hours after admission, increasing the resident's risk of developing a blood clot. The attending physician acknowledged the delay and the associated risks due to the resident's recent heart surgery. For Resident #9, the facility staff failed to initiate blood glucose monitoring and insulin administration in a timely manner. The resident, admitted with a diagnosis of diabetes, did not have orders for glucose monitoring or insulin administration until two days after admission. The attending physician noted that residents receiving insulin should have their blood glucose levels checked multiple times a day, highlighting the deficiency in care provided to this resident.
Failure to Conduct Physician-Ordered PT/INR Test
Penalty
Summary
The facility staff failed to obtain a physician-ordered PT/INR blood test for a resident on the specified date. The resident, who had a history of heart valve replacement and atrial fibrillation, was on Warfarin, a blood thinner, with a daily dosage based on INR levels. The physician's order, dated earlier in the month, required a PT/INR test for anticoagulant monitoring to be conducted on a specific date. However, a review of the resident's clinical record showed no evidence that the test was completed as ordered. During an interview, an LPN, who was a unit manager, explained that night shift nurses were responsible for ensuring laboratory orders were entered correctly, and she performed a secondary check each morning to confirm completion of lab tests. On the day the PT/INR test was due, the LPN stated that circumstances prevented her from verifying the test's completion, resulting in the test not being conducted. The facility's policy on Anticoagulant Therapy emphasized confirming the testing schedule with the physician and ordering labs per the physician's order, which was not adhered to in this instance.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility staff failed to implement comprehensive care plans for several residents, leading to deficiencies in care. For Resident #97, the staff did not follow the care plan regarding the management of a Foley catheter. Despite the care plan's directive to ensure the drainage bag was secured properly, observations revealed the catheter bag was often dragging on the floor, posing risks of urinary tract infections and urethral trauma. Interviews with LPNs confirmed that the care plan was not being followed, and the facility's policy on care planning was not adhered to. Resident #22's care plan was not implemented in several areas, including monitoring for anticoagulant medication use, placing a fall mat by the bed, and positioning the bed against the wall for safety. The staff failed to document consistent monitoring of the anticoagulant medication, which is crucial due to the risk of bleeding. Additionally, the fall mat was not placed as ordered, and the bed was not positioned against the wall, contrary to the facility's safety assessment. Interviews with staff confirmed these lapses, and there was no updated assessment to justify the removal of these interventions. For Resident #19, the care plan to maintain the bed against the wall was not followed, as the bed was observed to be away from the wall. Similarly, for Resident #86, the facility did not implement the care plan to discuss and record the risks and benefits of using bilateral enabler bars with the resident and family. The clinical record lacked an updated assessment and informed consent for the use of side rails, indicating a failure to follow the care plan. These deficiencies highlight a pattern of non-compliance with care planning policies, as confirmed by interviews with administrative staff.
Failure to Notify Responsible Party of Resident Fall
Penalty
Summary
The facility staff failed to notify the responsible party of a fall involving a resident, identified as Resident #323, on April 2, 2024. The resident, who was severely impaired in making daily decisions as indicated by a BIMS score of 4 out of 15, was found lying on her right side near the toilet, attempting to transfer herself to the bathroom. The resident sustained a skin tear to her left shin and a small skin tear and bruising to her right rib. Although the physician was notified of the fall, there was no evidence in the progress notes that the responsible party was informed, as required by the facility's policy. Interviews with several LPNs revealed inconsistencies in the notification process. LPN #1 stated that responsible parties were notified at the same time as physicians unless the incident occurred in the middle of the night and was not emergent. LPN #3 did not recall the specific fall incident or the progress note, while LPN #4 confirmed that responsible parties were notified and documentation was made in the progress notes. The facility's Fall Management policy, dated September 22, 2023, mandates that both the attending physician and the responsible party be notified of falls, with documentation in the medical record. The deficiency was brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional clinical coordinator, but no further information was provided before the survey exit.
Inaccurate MDS Assessment Due to Coding Error
Penalty
Summary
The facility staff failed to maintain an accurate Minimum Data Set (MDS) assessment for a resident in the survey sample. Specifically, the staff incorrectly coded the resident's discharge as unplanned on the MDS assessment, despite documentation indicating it was a planned discharge. The error was identified in Section A0310 of the resident's discharge MDS assessment, which was dated with an Assessment Reference Date (ARD) of 4/5/24. A nurse's note from 4/6/24 confirmed the resident was discharged home, contradicting the unplanned discharge coding. During an interview, the MDS coordinator acknowledged the mistake, attributing it to a coding error, and stated that she follows the CMS Resident Assessment Instrument (RAI) manual when completing MDS assessments. The administrator and director of nursing were informed of the issue, but no further information was provided before the survey exit.
Failure to Implement Baseline Care Plan for Oxygen Administration
Penalty
Summary
The facility staff failed to implement the baseline care plan for a resident, identified as Resident #76, who was admitted with a potential for difficulty breathing and risk for respiratory complications related to COPD exacerbation and chronic hypoxic respiratory failure. The baseline care plan, dated 6/11/24, required the application of oxygen per physician's orders, which specified continuous oxygen at two liters per minute. However, observations on 6/24/24 and 6/25/24 revealed that the resident was receiving oxygen at incorrect rates, between three and a half to four liters per minute and between one and a half to two liters per minute, respectively. The resident, who was cognitively intact, stated he did not know how to adjust his oxygen concentrator flowmeter. Interviews with facility staff, including an LPN, indicated that the purpose of the care plan is to guide staff in providing appropriate care, and that nurses should administer oxygen per physician's orders, checking the rate whenever they are in the resident's room. The LPN confirmed that the oxygen flowmeter should be set to the two-liter line as per the physician's order. The facility's policy on care planning mandates that every resident should have a person-centered plan of care developed and implemented. Despite this policy, the facility staff did not adhere to the prescribed oxygen administration for Resident #76, leading to the deficiency noted in the survey.
Failure to Update Care Plans for Side Rail Use
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plans for two residents, specifically regarding the use of side rails. For Resident #22, the clinical record indicated a Physical Device Evaluation dated 12/18/22, which specified the use of a bed against the wall for safety awareness, with no mention of side rails. However, observations on multiple occasions revealed that quarter-length side rails were in use on both sides of the resident's bed. The comprehensive care plan did not reflect this change, and interviews with LPNs confirmed that the care plan should have been updated to include the use of side rails. Similarly, for Resident #19, the Physical Device Evaluation dated 7/19/22 also documented the use of a bed against the wall, with no options for side rails checked. Observations showed that quarter-length side rails were in use while the resident was in bed. The comprehensive care plan for this resident also lacked documentation of the side rails, and interviews with LPNs reiterated that the care plan should have been revised. The facility's care planning policy requires that residents' needs be assessed and care plans be developed, reviewed, and revised based on interdisciplinary assessments, which was not adhered to in these cases.
Deficiencies in Pain Management and Blood Glucose Monitoring
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for two residents, leading to deficiencies in pain management and blood glucose monitoring. For Resident #26, the staff did not follow the physician's orders for administering Tramadol and Acetaminophen based on specified pain levels. The resident, who was cognitively intact, reported managing their pain with these medications as needed. However, the electronic medication administration record (eMAR) showed that Acetaminophen was administered for pain levels higher than the prescribed range, and Tramadol was given for pain levels lower than the prescribed range. This discrepancy indicates a failure to clarify and adhere to the physician's orders, as confirmed by an LPN who stated that any deviation from the prescribed pain parameters should have been clarified with the physician. For Resident #323, the facility staff failed to properly transcribe and monitor blood glucose levels. The resident, who was severely impaired in making daily decisions, had a diagnosis of Type 2 Diabetes Mellitus and was on Glipizide. The physician's orders required blood sugar checks twice a day, but the eMAR did not document any blood glucose results prior to a reading on April 4, 2024. An LPN explained that blood glucose checks should populate on the eMAR and be documented during medication passes, but acknowledged that the order may not have been entered correctly, leading to a lack of recorded glucose levels. Both deficiencies were brought to the attention of the facility's administrative staff, including the administrator, director of nursing, and regional clinical coordinator. The report highlights the need for clear communication and adherence to physician orders to ensure proper care and monitoring of residents' health conditions.
Deficiencies in Wound Care Management for Two Residents
Penalty
Summary
The facility staff failed to provide appropriate care and treatment for two residents, leading to deficiencies in maintaining their highest level of well-being. For Resident #104, the staff did not initiate or implement treatment for toe wounds identified by a wound care physician. Despite a documented treatment plan involving Xeroform gauze dressings, there were no physician's orders or evidence of treatment implementation in the resident's clinical record. An LPN acknowledged the absence of orders and treatments, indicating a lapse in the facility's process for entering and executing treatment plans. For Resident #133, the facility staff did not assess or provide care for two surgical incisions on the resident's leg. The resident expressed concern about the incisions, which were closed with staples, and reported no staff assessments or plans for staple removal. The admission nursing assessment noted the presence of staples, but the clinical record lacked evidence of regular assessments or a removal plan. An LPN admitted to seeing the incisions only once and was unsure about the care plan, highlighting a deficiency in the facility's wound care management.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility staff failed to provide appropriate foot care for a resident, identified as Resident #27, by not trimming the resident's toenails. During an observation, the resident was found with toenails extending greater than one inch past the tip of the toes. The resident's daughter expressed concerns about the length of the toenails. A review of the resident's clinical record showed no documentation of conditions like diabetes or vascular insufficiency that would prevent staff from trimming the toenails, nor were there any orders for foot care or a podiatry consultation. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities regarding toenail care. An LPN stated that CNAs are responsible for trimming toenails for residents without specific medical conditions, but the CNA interviewed stated she was not allowed to cut toenails. The Director of Nursing mentioned that nurses could trim toenails if they felt comfortable, and residents could be sent to a podiatrist if necessary. However, there was uncertainty about when the podiatrist would visit the facility. The facility's policy on personal hygiene indicated that nails should be kept neatly trimmed, but this was not adhered to in the case of Resident #27.
Failure to Secure Oxygen Tanks and Implement Fall Prevention Measures
Penalty
Summary
The facility staff failed to provide a safe environment for three residents by not securing portable oxygen tanks and not implementing fall prevention measures. For two residents, portable oxygen tanks were observed unsecured in their shared room, contrary to the facility's policy requiring tanks to be secured in a storage rack or rolling cart. Interviews with staff confirmed that unsecured tanks pose a safety risk, and the facility's policy mandates securing each tank individually. For another resident, the facility staff did not implement the physician-ordered fall prevention measure of placing a fall mat on the right side of the bed. Additionally, the bed was not positioned against the wall as assessed necessary for safety. The facility's comprehensive care plan indicated the need for these interventions, but they were not followed. Interviews revealed that staff were instructed not to place beds against walls, and there was no updated evaluation to justify the removal of this safety measure. Similarly, another resident's bed was not positioned against the wall as required by the comprehensive care plan and side rail evaluation. The facility had removed the intervention of placing beds against walls without updating assessments or documenting the change in care plans. This lack of individualized reassessment left the safety measure unimplemented, contrary to the facility's policy on fall management, which requires ongoing evaluation and implementation of interventions based on resident needs.
Foley Catheter Bag Not Maintained Properly
Penalty
Summary
The facility staff failed to maintain a Foley catheter in a sanitary manner for a resident, identified as Resident #97. On multiple occasions, the resident was observed with the Foley catheter bag dragging on the floor while she was in her wheelchair. This was first noted on 6/25/24 at 10:21 AM, and again at 10:32 AM and 10:37 AM, with the catheter bag either laying on the floor or dragging behind the wheelchair. The tubing was fully stretched from the bag to the resident, indicating improper securing of the catheter bag. Interviews with LPNs revealed awareness of the issue, with LPN #5 acknowledging that the Foley bag should not be on the floor due to risks of urinary tract infections and urethral trauma. LPN #7 mentioned the resident's preference for having the tubing in her pant leg, which complicates keeping the Foley off the floor. The resident's care plan, dated 2/12/24, indicated a risk for urinary tract infection and catheter-related trauma, with an intervention to ensure the drainage bag is secured properly. The facility's policy also stated that the collection bag and tubing should be kept off the floor. Despite these guidelines, the deficiency was observed, and administrative staff were informed of the findings on 6/27/24.
Failure to Provide Colostomy Care
Penalty
Summary
The facility staff failed to provide appropriate colostomy care and services for a resident, identified as Resident #127, who was admitted with a colostomy. Upon review of the resident's clinical records, it was found that there were no physician's orders regarding the colostomy care, which is essential for guiding the nursing staff in providing necessary care. The records showed minimal documentation of colostomy care, with only two notes indicating that the colostomy bag was changed and emptied on specific dates. This lack of consistent documentation and absence of physician's orders highlights a deficiency in the facility's care for the resident's colostomy needs. During an interview, an LPN confirmed that there should be physician's orders for colostomy care, which typically include daily checks of the stoma site, routine colostomy care every shift, and instructions on when to change the colostomy wafer and bag. The facility's administrative staff, including the administrator and the director of nursing, were informed of this concern. Additionally, the facility did not provide a policy regarding colostomy care, further indicating a gap in their procedures for managing residents with colostomies.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for a resident, identified as Resident #76, by not administering oxygen at the physician-prescribed rate of two liters per minute. The resident, who was cognitively intact, had a physician's order for continuous oxygen at this rate. However, observations revealed discrepancies in the oxygen flow rate being administered. On one occasion, the oxygen was set between three and a half and four liters per minute, and on another occasion, it was set between one and a half and two liters per minute. The resident stated that he did not know how to adjust the oxygen concentrator flowmeter and did not make any adjustments himself. Interviews with facility staff, including an LPN, indicated that nurses are responsible for administering oxygen according to physician orders and should verify the oxygen rate whenever they are in the resident's room. The LPN confirmed that the flowmeter should be set to the two-liter line as per the physician's order. Despite this, the facility did not provide a policy regarding oxygen administration, and the manufacturer's instructions for the oxygen concentrator were not followed, as the flowmeter ball was not centered on the prescribed line. The facility's administrative staff, including the administrator and the director of nursing, were informed of the issue, but no further information was provided before the survey exit.
Failure to Obtain Consent and Evaluation for Side Rail Use
Penalty
Summary
The facility staff failed to ensure that a current evaluation and consent, including risks and benefits, were in place prior to implementing side rails for three residents. For Resident #22, side rails were observed in use without a completed evaluation and consent indicating their necessity. The clinical record and informed consent forms did not reflect the use of side rails, and the comprehensive care plan lacked documentation of their use. Interviews with LPNs confirmed that there should have been a reassessment and updated consent before implementing side rails, and the use of side rails should have been included in the care plan. Similarly, for Resident #19, side rails were observed in use without a current evaluation and consent. The Physical Device Evaluation and Siderail Informed Consent forms did not indicate the need for side rails, and there was no updated documentation to justify their use. The comprehensive care plan also failed to include the use of side rails. Interviews with LPNs reiterated the necessity of a current evaluation and consent, as well as the inclusion of side rails in the care plan. For Resident #86, side rails were observed without an assessment or updated informed consent. The Siderail Informed Consent form indicated no rails were in use, and the comprehensive care plan mentioned the use of enabler bars but did not follow through with the necessary documentation and consent for side rails. Interviews with LPNs confirmed the lack of adherence to the care plan and the need for reassessment and updated consent. The facility's policy on Restraint Management was not followed, as it requires a current, signed restraint consent and a comprehensive care plan for the use of side rails.
Failure to Review and Implement Pharmacy Recommendations
Penalty
Summary
The facility staff failed to ensure that pharmacy recommendations were reviewed and implemented in a timely manner for three residents. For Resident #26, the facility did not provide evidence of pharmacy recommendations being reviewed and implemented for the medication regimen reviews conducted on three separate dates. The Director of Nursing admitted that some reviews were missing and could not confirm if they had been reviewed, despite the facility's policy requiring timely review and documentation of pharmacy recommendations. Similarly, for Resident #75, the facility staff did not provide evidence of pharmacy recommendations being reviewed and implemented for the medication regimen reviews conducted on three specific dates. The Director of Nursing acknowledged that the pharmacist completed the reviews and emailed them, but some were missing, and she could not confirm if they had been reviewed. The facility's policy outlines a process for ensuring timely review and response to pharmacy recommendations, which was not followed. For Resident #29, the facility staff failed to provide evidence of pharmacy recommendations being reviewed and implemented for multiple medication regimen reviews over several months. The Director of Nursing stated that the reviews were completed and emailed, but some were missing, and she was unsure if they had been reviewed. The facility's policy requires the attending physician to review and document pharmacy recommendations within a specified timeframe, which was not adhered to in these cases.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medication by not conducting consistent ongoing monitoring for the use of an anticoagulant medication, Eliquis, prescribed for atrial fibrillation. The physician's order for Eliquis was dated February 25, 2024, but there were no orders for consistent monitoring of the medication's use. The comprehensive care plan included interventions to observe for signs of complications related to anticoagulant use, such as abnormal bleeding or bruising, but there was no evidence of ongoing monitoring documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) from the date of the order through the date of the survey. During an interview, an LPN acknowledged that monitoring should be done daily and documented, but was unable to identify signs of bleeding associated with anticoagulant use. The facility's policy on anticoagulant therapy required monitoring for signs and symptoms of bleeding and immediate notification of a physician if such signs were noted. Despite this policy, the facility failed to provide evidence of compliance with these monitoring requirements, as confirmed by the Administrator, Director of Nursing, and Regional Clinical Coordinator during the survey.
Incomplete Medical Record for Resident Transfer
Penalty
Summary
The facility staff failed to maintain a complete and accurate medical record for one resident, identified as Resident #323, during a survey. The deficiency was identified through a clinical record review, staff interviews, and facility document review. Specifically, the medical record lacked documentation regarding the reason for the resident's transfer to the emergency room on the specified date. The progress notes indicated that the resident left via ambulance and was later admitted to the ICU, but there was no documentation of a change in condition or the reason for the transfer. Interviews with facility staff revealed that the nurse responsible for the transfer no longer worked at the facility and could not be interviewed. An LPN explained that standard procedure involved completing an SBAR assessment, a transfer note, and a change in condition assessment to document the reason for a hospital transfer. However, this documentation was missing for Resident #323. The facility's policy on Medical Records Management emphasized the need for complete and accurate medical records, but this standard was not met in this instance.
Infection Control Breach in Contact Precaution Protocol
Penalty
Summary
The facility staff failed to adhere to infection control procedures for a resident under contact precautions. On a specific date, a CNA entered the resident's room, which had a sign indicating the need for contact precautions, without wearing an isolation gown. The CNA assisted the resident into a wheelchair and pushed them into the bathroom. After removing her gloves, the CNA left the room without washing her hands and proceeded to enter another resident's room. Interviews with facility staff, including another CNA and an LPN, confirmed that the proper protocol for contact precautions was not followed. The facility's hand hygiene policy requires hand washing after removing personal protective equipment, which was not adhered to in this instance. The CNA involved stated it was her first day at the facility and could not recall if she had washed her hands after removing her gloves.
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What surveyors actually found near you
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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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Nursing homes near Bon Air
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaufont Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Southampton Rehabilitation And Healthcare Center | 3.3 mi | ★★★★★ | 4 | 1 |
| The Laurels Of Willow Creek | 3.4 mi | ★★★★★ | 0 | 0 |
| Forest Hill Health & Rehabilitation | 4.8 mi | ★★★★★ | 0 | 0 |
| Sitter And Barfoot Veterans Care Center | 5.1 mi | ★★★★★ | 0 | 0 |
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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.