Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vierra Falls Church during CMS and state inspections, most recent first.
A facility failed to follow several residents’ care plans by not completing ordered wound care as documented, not ensuring ordered CBC/CMP/BMP and other labs were obtained, documenting delayed IV antibiotic administration, and not recording required midline measurements. The records showed staff calls to the lab when it did not arrive, but no evidence that the ordered testing was completed for multiple residents, and one resident’s wound vac was temporarily replaced with wet-to-dry dressings until supplies became available.
A resident with a surgical wound infection and right knee replacement did not receive ordered IV antibiotics as scheduled. MAR audits showed Vancomycin and Cefepime doses were often documented hours late, and some Vancomycin doses were left blank at the scheduled time. An RN stated meds are documented on the MAR and are normally given within 1 hour before or after the ordered time, consistent with facility policy.
Failure to provide foot wound care: A resident had a painful right great toe wound noted by podiatry, but the record showed no further treatment for nearly two weeks before a physician order was entered for daily wound care. The wound care NP later documented the toe as a partial-thickness abrasion. RN staff stated that podiatry-reported foot wounds should be reported to the MD and wound care NP, and the facility policy required the LPN/RN to notify the physician when treatment orders were absent.
Staff failed to provide and document ordered nephrostomy and catheter care for three residents. One resident with bilateral nephrostomy tubes had missed dressing changes, missed bag emptying, and limited site cleansing documentation. Another resident with a Foley catheter had missed shift checks of the anchor, catheter placement/function, and catheter care. A third resident with an indwelling catheter had blank TAR entries for urinary output and catheter care, despite physician orders for shift-based monitoring and care.
Improper Food Cooling and Thawing Practices: Kitchen staff failed to store and prepare food in a sanitary manner. An uncovered pan of cooked bacon and sausage was left cooling in the walk-in refrigerator, and a container of sliced pork was found thawing in water without running water or temperature monitoring; the dietary manager later stated the meat should have been thawing under running cold water and that cooled food should be covered to prevent contamination.
A resident with a BIMS score of 15/15 had Blu Emu, a topical pain reliever, kept at the bedside, but the clinical record did not show a physician order or a medication self-administration assessment. The resident said her sister helped apply the cream, and an LPN stated staff should notify the NP or MD and complete a self-administration evaluation when a resident wants to keep a medication at the bedside.
A resident fell in the room while attempting to self-toilet, and the record did not show that the MD or RP was notified. The resident was a new admit with diagnoses including malignant neoplasm of the mouth, dysphagia, difficulty walking, and HTN, and had a PEG tube with most calories coming from enteral feeding. Staff interviews and the facility’s fall policy confirmed that provider and family notification was expected after a fall.
Grievance Not Fully Addressed: A resident’s representative raised concerns about the resident’s phone, podiatry appt, and nursing care, but the grievance record focused on bowel regimen refusal and bedbound behavior instead. The summary listed the grievance as resolved by the former DON, yet it did not show that the phone or podiatry concerns were addressed, despite the facility’s grievance policy requiring prompt efforts toward resolution.
Incomplete Baseline Care Plan for PEG Tube Care: A resident with a PEG tube, dysphagia, and a diagnosis of mouth cancer had physician orders for enteral tube site care, but the initial baseline care plan did not include a care plan focus, goal, or interventions for PEG tube care. Interviews with the DON, MDS Coordinator, and Unit Manager confirmed that PEG/enteral feeding care should have been included in the baseline care plan, and the facility policy required the baseline care plan to contain the minimum healthcare information needed to care for the resident.
Improper Crushing of Extended-Release Medication: An LPN crushed Toprol XL ER 50 mg for a resident who could not swallow pills whole, despite the medication being ordered as an extended-release tablet and the pharmacist stating it should not be crushed. The resident’s care plan directed meds to be crushed in applesauce/pudding, but staff did not follow the manufacturer’s do-not-crush instructions or professional standards for administering ER medication.
Failure to provide ordered pressure injury care occurred for a resident with a stage IV right hip wound and a stage II sacral pressure injury. The resident’s wound vac was not functioning, and staff documented switching to wet-to-dry dressings because a wound vac canister was unavailable, even though the MD order did not include a wet-to-dry dressing when the wound vac stopped working. An LPN stated wet-to-dry dressings were used when the resident refused the wound vac or when it was not working.
Failure to Document Scheduled Enteral Feeding Administration: A resident with a PEG tube, dysphagia, and cancer of the mouth had an order for Nutren 2.0 via pump with automatic flushes, but the MAR did not show the scheduled enteral feeding was administered at the ordered time. Interviews with LPNs, the central supply coordinator, RN, and the dietician described routine stocking and documentation practices, and the dietician stated there were no known shortages of enteral feeding or syringes.
Staff failed to measure and document PICC/midline catheter length and arm circumference for two residents receiving IV therapy. An LPN and RN stated they changed dressings, checked for redness, swelling, and infiltration, and used SASH flushing, but did not measure catheter ports or the arm unless specifically ordered. Care plans for the residents included monitoring and measurement expectations, but the TAR and orders did not show the required documentation.
Pain medication was not administered as ordered for a resident with a PEG tube, oral cancer, dysphagia, and pain-related diagnoses. MAR and audit records showed one scheduled dose was not documented as given and another dose of Lyrica and acetaminophen was administered hours late, while staff stated pain meds should be given within an hour of the scheduled time and documented if late.
A facility failed to obtain physician-ordered labs for three residents. One resident with diabetes and anemia did not have ordered CBC and BMP testing completed, and two other residents with serious conditions had ordered CBC, BMP, CMP, and UA C&S labs that were not shown as collected or resulted before they were sent to the ER. Notes showed the lab person did not come to the unit, staff called the lab center, and the records lacked evidence of completed follow-up on the ordered tests.
Kitchen sanitation, food dating, temperature checks, and tray-line contamination: Surveyors observed a dirty can opener, multiple opened food items in dry storage, the walk-in freezer, and a refrigerator that were not dated or had unreadable dates, and tray-line staff served hot foods without checking temps after placing them on the steam table. Staff also repeatedly touched spaghetti and plate surfaces with gloved hands while assembling trays, and the DM acknowledged the improper practices.
Improper Dumpster Storage and Coverage: Surveyors observed three dumpsters outside the kitchen back door with lids open and trash piled above the top of the containers, and two of the three dumpsters lacked drain plugs. A DA and the DM both confirmed the conditions and stated they did not know. The facility policy required outside refuse containers to have tightly fitting lids or covers and to be kept covered when not being loaded.
A resident admitted with a lumbar burst fracture and a dehisced post-laminectomy back wound had wound care managed by contracted NPs. Initial assessments documented a full-thickness surgical wound without infection, and treatment orders were implemented, but staff did not document ongoing wound progression in progress notes. On a later visit, an NP documented that the wound had widened and that spinal surgical hardware was visible, yet still described the wound as stable and did not notify the attending physician or neurosurgeon, despite the care plan requiring reporting of abnormalities and signs of infection. The DON later stated that the exposed hardware should have been escalated, and a QIO review found that the surgeon did not appear to have been contacted when the hardware first became exposed. The resident was eventually sent from a scheduled surgical follow-up appointment to the hospital for a wound infection and started on antibiotics.
Two residents did not receive showers as scheduled and required by their care plans and facility policy. One resident, with moderate cognitive impairment and dependent on staff for bathing, was scheduled for twice-weekly showers but reported missing multiple consecutive showers, while CNA documentation showed conflicting entries for bed baths, showers, and even a tub bath despite the facility not having a tub. Another cognitively intact resident, needing partial to moderate assistance with bathing and care planned to receive a sponge bath if a full shower was not tolerated, had documentation of only one bathing event over an entire month, with no additional records produced upon request. The DON stated that all residents were to receive two showers per week per the CNA schedule and that CNAs were expected to document accurately, but the records did not support that this occurred.
A resident admitted with an unstable lumbar burst fracture and a surgical back wound had wound assessments documented in the EMR, including changes from full-thickness dehiscence to stability and later exposed surgical hardware. A contracted NP obtained wound photographs over several visits that showed initial improvement and later deterioration, with increased redness and wound width, but these images were never uploaded into the EMR. The DON confirmed the absence of the photographs in the clinical record, despite a facility policy requiring complete, accurate, and timely documentation of all assessments and observations to provide a clear picture of a resident’s progress.
Failure to Offer Advance Directive Information: A resident with significantly impaired cognition did not receive advance directive information after admission. The EMR and social services assessment showed no advance directive and that information was not offered, and the ADM stated no family could be found and the resident was not in a state to sign. Facility policy states the resident or resident representative is to be provided easy-to-understand information about the right to refuse treatment and to formulate an advance directive.
A resident with severe cognitive impairment was sent to the ER after copious pus was found at the G-tube site, and the RR was notified. However, the facility had no evidence that a written transfer/discharge notice with appeal rights was provided to the resident or RR, and the Administrator stated he was unaware of the requirement for the notice and appeal process.
Care plan omitted comfort care for a resident receiving palliative care. Review of the resident’s MDS showed severe cognitive impairment and diagnoses including hypertensive heart disease, hypertensive CKD stage four, and palliative care, but the comprehensive care plan did not include comfort care. An LPN, the MDSC, and the DON all stated comfort care should be included so staff know the resident’s needs, and the DON confirmed comfort measures were not listed as care needs.
A resident admitted with dysphagia, Parkinson's disease, and tube feeding dependence was not weighed weekly for the first four weeks after admission as required by policy. The RD completed a nutrition assessment without obtaining an updated weight, and the DON acknowledged the resident missed two weeks of weighing. The resident's chart showed admission weight, moderate cognitive impairment, and an underweight BMI, while the care plan and RD note identified malnutrition risk and called for weight monitoring per protocol.
Oxygen concentrator filters were not maintained in accordance with manufacturer guidance for two residents receiving O2 therapy. An LPN observed grey debris buildup on the external filters in both rooms and confirmed it should not be there. The DON stated Maintenance was responsible for cleaning the filters and that they "know" when to do it, while the facility policy required following manufacturer recommendations for filter cleaning and servicing.
Failure to document a provider response to a consulting pharmacist’s medication regimen review recommendation for a resident with schizophrenia and intact cognition. The resident was receiving risperidone, mirtazapine, and fluoxetine, and the pharmacist recommended considering a GDR and possible dose changes or discontinuation of some psychotropic meds. The EMR showed no provider response, and the DON confirmed there was no evidence of follow-up in the chart.
The facility failed to offer two residents, including one with moderate cognitive impairment and one with severe cognitive impairment, the opportunity to receive pneumococcal vaccination in line with current CDC guidance. Records showed one resident was overdue for the pneumococcal vaccine and the other had prior PCV13 and PPSV23 doses, yet both MDS assessments indicated their pneumococcal vaccines were not up to date. The DON stated they were not familiar with the CDC’s current pneumococcal vaccine recommendations, despite the facility policy requiring immunization offers based on current CDC guidelines.
A resident in an LTC facility was administered ten times the prescribed dose of IV Acyclovir due to a misunderstanding by an LPN. The LPN misinterpreted the pharmacist's instructions and failed to verify the medication order, resulting in the resident's hospitalization for acute kidney injury and acyclovir-induced nephrotoxicity. The resident, who had a history of encephalopathy and HSV encephalitis, was critically affected and later passed away after the family chose comfort measures.
A resident with a PICC line was not provided with proper infection control measures as an LPN administered IV medication without wearing a gown, despite orders for enhanced barrier precautions. Facility staff confirmed the protocol requires gown and glove use for such procedures, aligning with CDC guidelines to prevent MDRO transmission.
Failure to Follow Care Plans for Wounds, Labs, Antibiotics, and Midline Monitoring
Penalty
Summary
The facility failed to implement comprehensive care plans for multiple residents by not carrying out ordered treatments, laboratory monitoring, and line care as documented in the clinical record. For one resident with a Stage IV right hip pressure injury and a Stage II sacral pressure injury present on admission, the care plan directed staff to administer treatments as ordered and monitor effectiveness, and the physician ordered a specific wound regimen for the right hip wound when the wound vac stopped working. Progress notes showed the wound vac was changed to wet-to-dry dressing when the vac was beeping and the canister was unavailable, then wet-to-dry dressing was continued the next day until a new canister arrived and the wound vac was reapplied. The record also showed the resident had a fall risk care plan with an order for CBC, CMP, and UA C&S on 3/23/2026, but the only note documented that the lab person did not come and a call was placed to the lab center; the record did not show further follow-up or that the ordered labs were obtained before the resident went to the ER on 3/25/2026. A second resident with a traumatic subdural hemorrhage had a care plan that included labs and radiology tests as ordered, with a physician order for CBC and BMP every Wednesday and Sunday night shift. The progress notes documented that the lab person did not come to the unit and that staff called the lab center, but the record did not show further follow-up or evidence that the ordered labs were collected or resulted before the resident went to the ER on 3/24/2026. Staff interviews indicated that routine labs were expected to be drawn by the lab service and that if labs were not completed, the lab would be contacted to come in, but the clinical record did not show completion of the ordered testing. For another resident with a right total knee arthroplasty surgical wound infection status post incision and drainage, the care plan directed staff to administer antibiotics as ordered. The physician ordered vancomycin twice daily and cefepime three times daily for wound infection, but the MAR audit showed delayed administration times for multiple doses, including doses documented hours after the scheduled times. For a resident with diabetes and anemia, the care plan included labs/radiology tests as ordered, and the physician ordered CBC and BMP every Wednesday and Sunday night shift, but the clinical record did not evidence that the ordered lab tests were completed. For a resident with a midline IV and indwelling catheter, the care plan required weekly measurement of arm circumference and catheter length, and the physician ordered observation of the midline insertion site and surrounding areas, but the TAR did not evidence documentation of the required measurements.
Failure to Administer IV Antibiotics per Physician Orders
Penalty
Summary
Facility staff failed to administer Vancomycin and Cefepime according to physician orders for one resident with a right total knee arthroplasty surgical wound infection status post incision and drainage. The resident was admitted with diagnoses including infection following a procedure, presence of a right artificial knee joint, aftercare following joint replacement, osteoarthritis, and depression, and had a BIMS score of 15 indicating cognitive intactness. The physician ordered Vancomycin 500 mg IV twice daily for 6 weeks, later changed to 500 mg IV twice daily at 0600 and 1800, and Cefepime 2 grams IV three times daily for 6 weeks. The medication administration records and audit reports showed multiple doses of Vancomycin and Cefepime were documented as given several hours after the scheduled times, and several Vancomycin doses were left blank on the MAR at the scheduled administration time. RN #1 stated that nurses document medication administration on the MAR and that medications are administered within one hour before or after the scheduled time unless otherwise ordered. The facility policy also stated medications and treatments are to be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician.
Failure to Provide Foot Wound Care
Penalty
Summary
Facility staff failed to provide treatment for Resident #9’s right great toe wound from 2/7/26 through 2/19/26. A podiatry note dated 2/6/26 documented a painful right great toe with a superficial wound to the lateral border secondary to an ingrown toenail, and the podiatrist performed a partial slant back for relief, cleansed the site with soap and water, applied bacitracin, covered it with a bandaid, and told the facility wound nurse that the resident would be added to her list. A review of the clinical record did not reveal any further treatment of the right great toe until a physician order dated 2/18/26 directed cleansing the toe with wound cleanser, patting it dry, applying silver alginate, and covering it with a bordered dressing daily and as needed. A wound care NP note dated 2/19/26 documented the wound as a partial-thickness abrasion on the right great toe measuring 0.5 cm by 0.5 cm by 0.1 cm. During interview, RN #1 stated that when a podiatrist reports a foot wound treated in the office, the nurse should immediately report it to the physician and wound care NP, who would determine whether to continue current treatment or initiate a new one, and that wound treatments are evidenced by signatures on the treatment administration record. The facility policy stated that in the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders.
Failure to Provide Ordered Catheter and Nephrostomy Care
Penalty
Summary
Facility staff failed to provide ordered care for three residents with urinary drainage devices. For one resident with bilateral nephrostomy tubes and a BIMS score of 15/15, the record showed physician orders for daily dressing changes and for emptying both nephrostomy bags every shift and as needed, but the chart contained blank treatment records for multiple shifts and dates. The record also failed to show documentation that both nephrostomy tube sites were cleansed, except for one nurse note documenting cleansing of the right tube site. For another resident with an indwelling Foley catheter, physician orders required the catheter anchor to be checked every shift, the catheter to be checked for placement and function every shift, and catheter care every shift using soap and water or a cleansing cloth. The treatment administration record contained blank entries on multiple shifts in January and March 2026 showing that the anchor was not checked, the catheter was not checked for placement and function, and catheter care was not documented as provided on those shifts. For a third resident with an indwelling catheter and diagnoses including BPH and bladder cancer, the physician ordered urinary output to be measured every shift, catheter placement and function to be checked every shift, and catheter care every shift. The June and July 2026 treatment records contained blank entries for urinary output and catheter care on several shifts, and the care plan directed staff to monitor and document intake and output. An RN stated that urinary catheter treatments should be provided per physician orders and documented on the treatment administration record.
Improper Food Cooling and Thawing Practices
Penalty
Summary
The facility failed to prepare and store food in a sanitary manner in the kitchen. During an observation with the dietary manager, a baking sheet in the walk-in refrigerator contained cooked bacon and sausage that was left uncovered while cooling. The dietary manager stated the food had been placed in the refrigerator to cool and that they had been told by the local health department to leave it uncovered. The same observation identified an approximately two-gallon plastic container of sliced pork in water that was not being thawed with running water and had no temperature monitoring in place. When the dietary manager checked the temperature, it read 72 degrees. The dietary manager stated the meat should have been thawing under running cold water. Facility policy required food to be stored, prepared, distributed, and served in accordance with professional food safety standards, including proper storage to prevent contamination and proper thawing, cooking, cooling, holding, and reheating.
Failure to Assess Bedside Self-Administration of Topical Pain Reliever
Penalty
Summary
The facility failed to assess a resident for medication self-administration for one of 26 residents in the survey sample. Resident #17 had a quarterly MDS with an ARD of 5/27/26 showing a BIMS score of 15 out of 15, indicating the resident was cognitively intact for making daily decisions. On 7/7/26, the resident was observed lying in bed with a plastic jar of Blu Emu, approximately one-quarter empty, on the bedside table. The resident stated she had kept the cream in her room for some time and that her sister helped apply it. A review of the resident’s clinical record did not reveal a physician’s order for Blu Emu and did not reveal a medication self-administration assessment. An interview with an LPN on 7/7/26 confirmed that if a resident wants to keep a medication at the bedside, nursing staff should notify the NP or physician and complete a medication self-administration evaluation. The LPN stated she had administered medications to the resident earlier that morning but did not see the Blu Emu because the overbed table had a lot of items on it. The facility policy stated that a resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely.
Failure to Notify Provider and Family After Resident Fall
Penalty
Summary
The facility failed to notify the medical provider and the responsible party of a change in condition for Resident #8 after the resident fell in the room while attempting to self-toilet. The fall was not witnessed, and the late entry documented that the resident was a new admit, had no evident reason for the fall, and had no immediate findings such as pain, skin issues, or other new injuries beyond those present on admission. Resident #8’s clinical record showed diagnoses including malignant neoplasm of the mouth, dysphagia, difficulty walking, and hypertension. The most recent MDS indicated the resident had a PEG tube and received 51% or more of calories from enteral feeding, and the BIMS score was 15, indicating the resident was intact for daily decision-making. The record review did not show that the medical provider was notified of the fall. During interviews, LPN #7 stated that after a resident falls, the doctor and family members should be notified, and the DON stated the nurse should call the doctor or NP on call and the RP after assessing the resident. LPN #8 also stated that the MD and family should be notified after a fall. The facility’s Fall Prevention Program policy stated that when any resident experiences a fall, the facility will notify the physician and family. Despite this, the record did not evidence notification of the provider or RP for Resident #8’s fall.
Grievance Not Fully Addressed
Penalty
Summary
The facility failed to promptly and fully resolve a grievance for Resident #9 involving the resident representative’s concerns about the resident’s phone and podiatry appointment. A grievance summary dated 3/23/26 documented that the resident’s son reported concerns about the phone, podiatry appointment, and nursing care, but the investigation and findings focused on the resident refusing bowel regimen medications, requesting an enema and then refusing it, and declining daily to get out of bed. The grievance summary listed the grievance as resolved on 3/31/26 and stated it was resolved by the former DON, but the record did not show that the concerns about the phone or podiatry appointment were addressed. During interview, the DOSS, who was also the Grievance Official, reviewed the summary and stated the former DON resolved the grievance even though it did not document resolution of the phone and podiatry concerns. The facility policy required prompt efforts to resolve grievances and defined prompt efforts as acknowledgment of the complaint and actively working toward resolution.
Incomplete Baseline Care Plan for PEG Tube Care
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident with a PEG tube. The resident’s most recent MDS showed a PEG tube and that 51% or more of calories were received from enteral feeding. The resident also had a BIMS score of 15 and diagnoses including malignant neoplasm of the mouth, dysphagia, difficulty walking, and hypertension. Physician orders directed enteral tube site care every shift, including cleansing the site with soap and water, patting dry, and placing a dry dressing around the site. Review of the initial baseline care plan dated 4/20/2026 showed no care plan focus, goal, or interventions for the resident’s PEG tube. During interviews, the DON stated that baseline care plans should include nursing needs, medical devices, nutrition, and fluid restrictions, and that enteral feeding should be included. The MDS Coordinator stated that nursing initiates the care plan on admission and that anything pertaining to the resident should be on the care plan, including enteral feeding and PEG care. The Unit Manager also stated that enteral feeding and PEG tube care should be included in the baseline care plan. The facility policy stated that the baseline care plan must include the minimum healthcare information necessary to properly care for a resident.
Improper Crushing of Extended-Release Medication
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration when staff crushed Toprol XL extended-release 50 mg for Resident #25 during a medication pass observation. On 7/7/2026 at approximately 9:18 AM, an LPN was observed removing a Metoprolol succinate ER tablet from the packaging and crushing it along with the resident’s other scheduled medications. The LPN stated that the resident was unable to swallow pills whole and required all medications to be crushed and given in applesauce. The physician order for the resident documented Toprol XL Oral Tablet Extended Release 24 Hour 50 mg, one tablet by mouth daily for hypertension, and the care plan included special instructions that medications were to be crushed in applesauce/pudding. During interviews, another LPN stated that extended-release medications should not be crushed and that the nurse would normally contact the nurse practitioner to change the medication to one that could be crushed or to a liquid form. The pharmacist also stated that Toprol XL extended release should not be crushed because it was designed to be released over 24 hours and crushing defeated that purpose. The facility policy stated medications are to be administered in accordance with professional standards of practice and manufacturer specifications, and that medications with do-not-crush instructions should not be crushed.
Failure to Follow Ordered Pressure Injury Treatment
Penalty
Summary
Failure to provide pressure injury treatment per the physician’s order occurred for one resident with a stage IV right hip pressure injury and a stage II sacral pressure injury that were both present on admission. The resident’s care plan documented the stage IV right hip wound, stage II sacral pressure injury, risk for further skin breakdown related to immobility, decreased mobility, comorbidities, and stool incontinence, and noted that the resident had refused turning/offloading and proper wound care and had declined the wound vac. The physician’s order for the right hip wound directed cleansing with normal saline, application of vashe-moistened gauze, Aquacel Ag rope, Drawtex, and bordered foam, with use every 24 hours as needed if the wound vac stopped working and every day shift. The record showed that the wound vac was not functioning and was beeping, and staff documented changing the wound vac therapy to a wet-to-dry dressing because a wound vac canister was unavailable. Subsequent notes documented that the wound vac was not in use and wet-to-dry dressings were applied, followed by completion of a wet-to-dry dressing to the stage 4 right hip wound. The physician orders did not evidence an order for a wet-to-dry dressing when the wound vac was not working, although an LPN stated that wet-to-dry dressings were used when the resident refused the wound vac or when it was not working.
Failure to Document Scheduled Enteral Feeding Administration
Penalty
Summary
Scheduled enteral feeding was not documented as administered for one resident who had a PEG tube and received 51% or more of calories from enteral feeding. The resident’s most recent MDS assessed a BIMS score of 15, indicating intact decision-making, and documented diagnoses including malignant neoplasm of the mouth, dysphagia, difficulty walking, and hypertension. The physician’s order directed Nutren 2.0 via pump at 60 mL/hr for 20 hours with automatic flushes at 50 mL/hr for 20 hours, but the April MAR did not show administration of the enteral feeding on 4/23/2026 at 4:00 PM. Facility interviews described how enteral feeding supplies were stocked in the medical supply room, with additional supplies kept downstairs and substitutions obtained by calling the physician if needed. The dietician stated the resident had been admitted on a bolus feeding and was changed to Nutren for higher calories and weight gain, and also stated they were not aware of any shortages of enteral feeding or syringes. The nurse interviews stated enteral feeding should be documented on the MAR and that medications are administered within an hour before or after the scheduled time. No policy was provided.
Failure to Measure and Document PICC/Midline Line Position and Arm Circumference
Penalty
Summary
The facility failed to provide care and services for PICC/midline lines for two residents, including failure to assess and document catheter length and arm circumference as outlined in the care plans and referenced standards. For Resident #18, who was admitted with diagnoses including benign prostatic hypertrophy, bladder cancer, and UTI, the MDS and admission assessment coded the resident as cognitively intact with a BIMS score of 14 out of 15 and identified a midline IV access. The physician order directed staff to observe the midline insertion site and surrounding areas and monitor for infiltration, bruising, pain, and signs and symptoms of infection. Resident #18’s comprehensive care plan directed weekly measurement of the arm circumference 3 inches above the insertion site and the length of the catheter from the insertion site to the tip, with documentation and notification of the MD if swelling or migration was noted. Review of the TAR failed to show documentation of these measurements. During interview, LPN #9 stated that during weekly dressing changes she looked for redness, swelling, and whether the line was intact, but she had never measured the PICC line or the arm circumference and had never seen the care plan intervention before. The facility policy on care and maintenance of central venous catheters also did not evidence documentation related to measuring catheter length. For Resident #19, the MDS admission assessment showed the resident was receiving IV medications, and physician orders directed weekly and PRN dressing changes, weekly needless cap changes, and assessment each shift for infiltration, bruising, swelling, pain, and signs or symptoms of infection. The care plan identified the resident as having a PICC line for antibiotic/IV treatment for a leg infection. Interviews with LPN #9 and RN #1 confirmed that staff changed dressings, assessed the site, and used the SASH protocol, but did not measure the PICC catheter ports or the arm circumference unless an order specifically required it. The physician orders for this resident also did not evidence an order to measure the exposed catheter ports or arm circumference.
Pain Medication Not Given as Ordered
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who had a PEG tube, dysphagia, malignant neoplasm of the mouth, difficulty walking, and hypertension, and who was assessed with a BIMS score of 15. The resident had physician orders for pregabalin/Lyrica and acetaminophen administered via G-tube for pain, including scheduled doses for neuropathic pain and pain control. Facility records showed the pain medication ordered for the resident was not administered as scheduled on one occasion, with the MAR lacking evidence that the 9:00 AM dose was not given and a progress note stating that pain medications had not been delivered from the pharmacy. The medication audit also showed that Lyrica oral solution and acetaminophen were not administered at the ordered 8:00 AM time on another date and were instead given at 11:32 AM, about three and a half hours late. Staff interviews indicated the expectation was to administer pain medication within one hour before or after the scheduled time and to document late administration in the MAR and progress notes.
Missed Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for three residents. For one resident with diagnoses including diabetes, aftercare following joint replacement surgery, and anemia, the physician ordered CBC and BMP testing every Wednesday and Sunday for routine labs, but the clinical record did not show that the ordered tests were completed. The resident’s care plan included labs and radiology tests as ordered by the physician, and the attending physician later reviewed the record and stated the lab tests were not done per the order, noting the resident should have had blood drawn on the specified dates. For another resident, the physician ordered CBC, CMP, and UA C&S as one-time labs after a fall-related care plan entry noted continued monitoring of labs ordered. The progress notes documented that the lab person did not come to the unit and that staff called the lab center, where they were told the lab person would come later that day. The record did not show that the CBC and CMP were collected or resulted before the resident was sent to the emergency room, and there was no further documentation showing follow-up on the ordered labs. For a third resident with traumatic subdural hemorrhage and a care plan calling for labs and radiology tests as ordered, the physician ordered CBC and BMP every Wednesday and Sunday for subarachnoid hemorrhage. The progress notes again documented that the lab person did not come to the unit and that staff called the lab center and were told someone would come later. The record did not show that the CBC and BMP were collected or resulted before the resident was sent to the emergency room, and staff interviews reflected that routine labs were expected to be drawn by the lab service, with missed labs to be followed up the same day.
Kitchen sanitation, food dating, temperature checks, and tray-line contamination
Penalty
Summary
The facility failed to ensure kitchen equipment used in food handling was clean when not in use. During the initial kitchen inspection, an accumulation of a dark substance was observed on the inside of the can opener device, and in interview, staff confirmed it was dirty and needed to be cleaned. The facility also failed to ensure food in dry storage, the walk-in freezer, and the refrigerator in the cooking area was properly dated and not expired. Surveyors observed an opened and undated 16-ounce container of roasted chicken base in the refrigerator, an opened box of individually wrapped soft baked cookies with no open date, three 5-pound boxes of Krusteaz Homestyle Cornbread mix with no opened date, an open package of food in the walk-in freezer with no open date and an unreadable label, and a 6-pound can of red peppers with an unreadable stamped date. The Dietary Manager confirmed several of these items should have been marked with the date opened. During lunch tray preparation, staff placed meat sauce and broccoli on the steam table and served them without checking their temperatures after placement. Staff also touched spaghetti hanging off the sides of plates with gloved hands multiple times and placed the palm of the same gloved hand on plate surfaces several times while assembling trays. In interview after tray line, the Dietary Manager stated staff should not have touched the spaghetti or plate surfaces and acknowledged she did not know temperatures were supposed to be checked after food was placed on the steam table before serving.
Improper Dumpster Storage and Coverage
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed three trash dumpsters outside the kitchen back door with lids open and trash piled higher than the top of the dumpsters. Two of the three dumpsters did not have drain plugs, leaving openings at the bottom edges. During interviews, Dietary Aide 1 stated, "I didn't know," when shown the dumpsters, and the Dietary Manager also observed the same conditions and confirmed the findings, stating, "I didn't know." Review of the facility policy titled "Disposal of Garbage and Refuse" required refuse containers and dumpsters kept outside the facility to have tightly fitting lids, doors, or covers and to be kept covered when not being loaded.
Failure to Escalate Change in Surgical Wound With Exposed Spinal Hardware
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a contracted wound NP recognized and escalated a significant change in a resident’s surgical back wound, which had exposed spinal hardware and possible infection. The resident was admitted with an unstable burst fracture of the first lumbar vertebra and had undergone a T10–L4 laminectomy, resulting in a surgical wound on the back that was dehisced on admission. The admission MDS showed the resident was cognitively intact, dependent on staff for all ADLs, and had a surgical wound. The care plan directed staff to monitor and document the wound’s location, size, and treatment, and to report abnormalities, failure to heal, and signs and symptoms of infection to the physician. Initial wound assessments by NP1 documented the wound as a full-thickness surgical dehiscence present on admission, with measurements recorded and no signs of infection noted. On a subsequent assessment, NP1 documented that the wound remained stable, with some slough present and moderate serosanguineous exudate, and the treatment plan was adjusted to cleansing with Vashe, application of Hydrofera Blue, and coverage with an ABD dressing three times per week. The Treatment Administration Record showed that clinical staff completed the ordered wound care, but there was a lack of progress notes documenting the wound’s appearance over time, which would have shown the progression or deterioration of the wound. On a later visit, NP2 assessed the wound and documented that it was stable, with measurements indicating a wider wound, 80% granulation tissue, 20% slough, and moderate serosanguineous exudate. NP2 also documented that there was exposed tissue including the spinal surgical hardware, and repeated this finding in a Skin and Wound Note. Despite this significant change, there was no indication that NP2 notified the resident’s physician or neurosurgeon, as required by the care plan. The DON stated that the exposure of spinal hardware should have been escalated and that the surgeon should have been alerted, and also noted that the former wound nurse (an LPN) should have questioned NP2 about the exposed hardware and did not, and that floor nurses should have documented the wound’s appearance after each dressing change. The resident had a follow-up appointment scheduled with the neurosurgeon, and NP2 documented that the resident was not seen again because of the upcoming appointment, with plans to follow up after that visit. At the neurosurgeon’s appointment, the resident was transferred to the emergency room due to a wound infection and was treated with antibiotics. A QIO review later noted that by the time NP2 documented visible surgical hardware, the surgeon did not appear to have been contacted sooner despite the new exposure of underlying hardware, and stated that such findings should prompt immediate contact with the surgeon and consideration of possible hospitalization. Interviews with NP1, the DON, the medical director’s NP, and the resident’s physician confirmed that the exposed spinal hardware and worsening wound should have triggered immediate notification of the surgeon, but this did not occur, resulting in a delay in further assessment and treatment.
Failure to Provide and Accurately Document Scheduled Showers for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and accurately document showers according to its own shower schedule and residents’ care plans for two residents. One resident was admitted with arthritis, muscle weakness, and lack of coordination, had a BIMS score of 10 indicating moderate cognitive impairment, and was care planned as dependent on staff for bathing/showering twice weekly and as necessary, with a preference to choose between a shower or sponge bath. The facility’s shower assignment schedule listed this resident to receive showers on Mondays and Thursdays on day shift. Despite this, the resident and a family member reported that the resident did not receive scheduled showers, missing multiple consecutive showers, and the resident stated on multiple occasions that no one came to offer or provide a shower. Record review for this resident showed inconsistencies and inaccuracies in CNA documentation of showers and baths. The Plan of Care response history indicated showers were due on specific dates, but CNAs documented some showers as non-applicable and entered multiple bathing events (bed baths, showers, and a tub bath) on various dates and times. One CNA later stated she had not provided the bed bath she documented and believed she had charted on the wrong resident. Another CNA documented a tub bath even though the facility did not have a tub bath, as confirmed by the ADON. These discrepancies showed that the documented bathing did not reliably reflect actual care provided and that the resident’s scheduled showers were not ensured according to the facility’s shower schedule and care plan. The second resident was admitted with muscle weakness, had a BIMS score of 15 indicating intact cognition, and required partial to moderate assistance with bathing. The care plan directed that the resident should receive a sponge bath if a full shower or bath could not be tolerated. Facility documentation for this resident showed only one shower/bath or sponge bath for an entire month, and when the surveyor requested all bathing/shower records for the resident’s stay, no additional records were produced. The DON stated that all residents were to receive two showers per week per the CNA book schedule and that CNAs were expected to follow the schedule and document correctly, but the records for this resident did not demonstrate that showers or sponge baths were provided as required by the facility’s policy and schedule.
Failure to Incorporate Wound Photographs Into Resident’s EMR
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation in the electronic medical record (EMR) for one resident with a surgical back wound. The resident was admitted with an unstable burst fracture of the first lumbar vertebra and had a surgical wound documented on the admission MDS, with a BIMS score of 15 indicating intact cognition and an upper body impairment. Wound Assessment Reports in the EMR documented a full-thickness surgical dehiscence on one date, a stable wound on a later date, and then a stable wound with exposed surgical hardware on a subsequent date. However, photographs taken of the wound by a contracted wound management nurse practitioner (NP1) on multiple visits, which visually demonstrated improvement between the first two assessments and a decline by the third, were not uploaded or incorporated into the resident’s EMR. During interviews, NP1 confirmed visits with the resident on two of the documented assessment dates and presented wound photographs showing the wound’s progression and later deterioration, including increased redness around the wound and increased wound width on the later date. NP1 stated she did not know why these images were not incorporated into the clinical record. The DON acknowledged that the photographs of the resident’s wound were not uploaded into the clinical record and stated that having such images would provide critical information on the wound’s status and healing. Review of the facility’s “Documentation in Medical Record” policy indicated that each resident’s medical record must contain an accurate representation of the resident’s experiences and enough information to provide a picture of the resident’s progress through complete, accurate, and timely documentation, and that licensed staff and interdisciplinary team members are to document all assessments and observations in the medical record.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to offer advanced directive information for one of five residents reviewed for advanced directives, Resident 13. Review of the electronic medical record showed the resident was admitted to the facility on [DATE], and the admission MDS with an ARD of 06/30/25 documented a BIMS score of 7 out of 15, indicating significantly impaired cognition. The resident’s undated Social Services History & Initial Assessment, under Advanced Care Planning, indicated the resident did not have an advance directive and that information about advance directives was not offered. During interview on 04/21/26 at 3:34 PM, the Administrator reviewed the document and stated that no family could be found, the resident was not in a state to sign, and the facility did not offer the advanced directives information. The facility policy titled SS024: Residents' Rights Regarding Treatment and Advanced Directives, dated 08/15/2022, states that the facility will provide the resident or the resident’s representative information, in an easy-to-understand manner, about the right to refuse medical or surgical treatment and to formulate an advanced directive.
Failure to Provide Written Emergency Transfer Notice With Appeal Rights
Penalty
Summary
The facility failed to ensure that Resident 9 and the resident representative were provided a written emergency transfer notice that included appeal rights when the resident was sent to the hospital. Resident 9 was admitted on 03/27/26 and had an MDS assessment with a BIMS score of 0 out of 15, indicating severe cognitive impairment. On 04/08/26, an SBAR note documented a change in condition when the resident was found with copious amounts of pus from the G-tube site, and both the medical provider and the resident representative were notified. The medical provider ordered the resident to be transported immediately to the emergency room for evaluation and treatment. Record review found no evidence that the resident and/or the resident representative were given a written emergency transfer notice with appeal rights related to the transfer/discharge. During interview, the Administrator stated he was unaware of the requirement for a transfer/discharge notice along with the appeal requirements. The facility policy stated that the transfer or discharge notice would be provided to the resident and resident representative in a language and manner they could understand and would include the right to appeal the transfer or discharge to the State, the State entity contact information, how to obtain an appeal form, and how to obtain assistance in completing and submitting the appeal hearing request.
Care plan omitted comfort care for a resident receiving palliative care
Penalty
Summary
The facility failed to revise the comprehensive care plan to include comfort care for Resident R110. Review of the quarterly MDS with an ARD of 09/20/25 showed the resident had a BIMS unable to perform, indicating severe cognitive impairment, and listed diagnoses including hypertensive heart disease, hypertensive chronic kidney disease stage four, and palliative care. The resident’s comprehensive care plan, initiated on 03/14/25, did not include comfort care. During interviews, an LPN stated that a resident receiving comfort care should be included on the care plan so staff know the care needed. The MDSC also stated comfort care should be included on the care plan so staff know the resident’s needs. The DON confirmed that comfort measures were not listed as care needs on R110’s care plan and stated the care plan lets all nursing staff know how to properly take care of a resident; the DON also stated that not including comfort care could lead to staff providing cares that may cause unnecessary cares being provided. The facility policy titled Comprehensive Care Plans stated that a comprehensive person-centered care plan should be developed and implemented for each resident and include measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
Failure to Complete Required Admission and Weekly Weights
Penalty
Summary
The facility failed to follow its weight monitoring policy for one resident who was admitted with dysphagia, Parkinson's disease, and dependence on enteral tube feeding for total nutrition support. The resident's admission record showed a weight of 105 pounds, and the MDS documented moderate cognitive impairment with a BIMS score of 11 out of 15. The record did not contain evidence that the resident was weighed each week for four weeks after admission, and the resident was not weighed again before the RD completed the nutritional assessment on 04/20/26, when the resident's current body weight was documented as 104.8 pounds and the BMI was underweight. The RD noted on admission that the resident was at risk for malnutrition related to dependence on enteral feeding, dysphagia, and low BMI, and recommended that the resident's weight be done per facility protocol. The care plan also identified risk for malnutrition and included weight monitoring per facility protocol and/or interdisciplinary team recommendation. During interviews, the RD stated she was unaware of the facility's weight policy and acknowledged she had not obtained another weight before completing her assessment. An LPN stated new admissions are weighed daily for three days then weekly for four weeks, but could not explain why this resident had not been weighed since admission. The DON acknowledged the resident's weights had not been done per facility policy and stated the resident missed two weeks of being weighed.
Oxygen concentrator filters not maintained
Penalty
Summary
The facility failed to ensure oxygen concentrators were maintained in accordance with manufacturer specifications for two residents receiving oxygen therapy. On 04/20/2026, R38 was observed in his room receiving oxygen via nasal cannula, and the oxygen concentrator in his room had a build-up of grey debris on the external surface of the filter. Later that same day, R87 was observed lying in bed in her room, and her oxygen concentrator had a solid layer of grey debris across the entire external surface of the filter. During interview, LPN 3 observed the filters in both rooms and confirmed there was a build-up of grey debris on the filters and that there should not be. When asked who was responsible for maintenance of the oxygen concentrator filters, LPN 3 stated he did not know. The DON stated that Maintenance was responsible for cleaning the oxygen concentrator filters and, when asked if there was a schedule for cleaning them, stated, "They know." The facility policy required staff to follow manufacturer recommendations for cleaning filters and servicing the device, and the manufacturer’s service manual stated the air filter should be inspected periodically and cleaned as needed by the user.
Failure to Document Provider Response to Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that the provider responded in a timely manner to the consulting pharmacist’s recommendation for one resident reviewed for unnecessary medications. The resident had an admission diagnosis of schizophrenia unspecified, and the quarterly MDS showed a BIMS score of 14 out of 15 with no behavioral symptoms, no physical behavioral issues toward others, no verbal behaviors toward others, and no behavioral symptoms toward self. The resident’s EMR pharmacy review dated 02/18/26 showed orders for risperidone 3 mg, mirtazapine 7.5 mg at bedtime, and fluoxetine 40 mg daily. The consulting pharmacist recommended, if clinically appropriate, considering a gradual dose reduction and perhaps discontinuing risperidone and mirtazapine, or considering risperidone 2.5 mg at bedtime and mirtazapine 15 mg at bedtime. The pharmacy review form did not show a provider response to the recommendation. During interview, the consulting pharmacist stated that after a resident has been admitted on psychotropic medications for six months, it is his practice to consider a GDR. The DON stated that pharmacist recommendations go to the unit managers for follow-up with the provider and confirmed there was no evidence in the EMR that the provider responded. The physician stated he would prefer the psychiatrist to receive recommendations regarding psychiatric medications, but in this case the recommendation had been made to him, and he believed it may have been rerouted in the wrong direction. The facility policy required staff to act upon medication regimen review irregularities and to follow up on non-urgent irregularities within 30 days of receiving the recommendation.
Failure to Offer Pneumococcal Vaccinations in Accordance With CDC Guidance
Penalty
Summary
The facility failed to offer two residents, R25 and R51, or their representatives, the opportunity to receive flu and/or pneumococcal vaccinations in accordance with nationally recognized standards. A review of the facility’s Patient Vaccination View/Audit showed R25 was overdue for the pneumococcal vaccine, and the resident’s EMR indicated admission on 03/23/23 and a quarterly MDS with a BIMS score of 9 out of 15, showing moderate cognitive impairment; the assessment also indicated the pneumococcal vaccine was not up to date. For R51, the vaccination audit showed prior receipt of PCV13 on 07/23/15 and PPSV23 on 10/18/16, while the EMR showed admission on 10/29/24 and a quarterly MDS with a BIMS score of 3 out of 15, showing severe cognitive impairment; that assessment also indicated the pneumococcal vaccine was not up to date. During interview, the Infection Preventionist and DON stated they were not familiar with the CDC’s current recommendations for pneumococcal vaccines. Review of the CDC PneumoRecs VaxAdvisor guidance indicated that one dose of PCV15, PCV20, or PCV21 is recommended, and that pneumococcal vaccination is complete with PCV20 or PCV21, or after PCV15 given at least 1 year after the last PPSV23 dose. The facility policy titled Pneumococcal Vaccine stated that residents and staff are to be offered immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.
Medication Error Leads to Resident Overdose
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medication, resulting in a significant medication error. A resident was prescribed 500 mg of intravenous Acyclovir every 12 hours for encephalitis. However, the staff administered ten times the prescribed dose, giving the resident 5 grams of Acyclovir instead of the intended 500 mg. This error was discovered after the resident exhibited symptoms of shortness of breath and altered mental status, leading to their transfer to the hospital for evaluation. The error occurred due to a misunderstanding by the LPN who administered the medication. The LPN misinterpreted the instructions from the pharmacist and believed that ten vials of Acyclovir, each containing 50 mg/mL, were needed to achieve the prescribed dose. The LPN failed to verify the medication order with the provider, nurse supervisor, or Director of Nursing, leading to the administration of an overdose. The pharmacist's instructions were misunderstood, and the LPN did not recognize the discrepancy between the vial's concentration and the prescribed dose. The resident, an 88-year-old female with a history of encephalopathy and HSV encephalitis, was critically affected by the overdose. She was admitted to the hospital with acute kidney injury and acyclovir-induced nephrotoxicity. The hospital records confirmed that the overdose led to the resident's altered mental status and respiratory distress. Despite efforts to manage the overdose, the resident's condition deteriorated, and the family eventually elected for comfort measures, leading to the resident's passing.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to implement proper infection control practices for a resident who required enhanced barrier precautions. Specifically, a licensed practical nurse (LPN) was observed administering intravenous (IV) medication to a resident with a peripherally inserted central catheter (PICC) line without wearing a gown, despite a physician's order for enhanced barrier precautions. The resident was receiving Unasyn for empyema, and a sign on the resident's door clearly indicated the need for enhanced barrier precautions, including the use of gloves and a gown during high-contact resident care activities. Interviews with facility staff confirmed that the protocol for residents with IV lines includes wearing gloves and a gown to protect the resident. The facility's policy and the Centers for Disease Control and Prevention guidelines both emphasize the importance of enhanced barrier precautions to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. The deficiency was brought to the attention of the facility's administrative staff, including the Administrator and the Director of Nursing.
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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.
Illustrative
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Nursing homes near Falls Church
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arleigh Burke Pavilion | 1.1 mi | ★★★★★ | 0 | 0 |
| Cherrydale Health & Rehabilitation Center | 3.2 mi | ★★★★★ | 7 | 0 |
| The Jefferson | 3.2 mi | ★★★★★ | 43 | 3 |
| August Healthcare At Iliff | 3.3 mi | ★★★★★ | 5 | 0 |
| Sibley Mem Hosp Renaissance | 3.5 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 October 2026) and official state health department websites.