Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Virginia Beach Healthcare And Rehab Center during CMS and state inspections, most recent first.
A cognitively intact resident with quadriplegia, PTSD, and total dependence on staff for care reported that staff ignored her call light, turned it off without helping, refused to enter her room, and left her in an unsafe position in bed. She stated that staff talked about her outside the room, police had to respond after she called for help, and she felt fear and anxiety because of the treatment. The DON acknowledged awareness that police were called and that an allegation of neglect had been made.
Failure to Protect Resident During Abuse and Neglect Allegation A resident with quadriplegia, PTSD, and total dependence on staff for care reported ongoing night-shift neglect, including call lights being turned off, delayed response to care needs, and staff refusing to provide care. She showed surveyors photos and videos of staff leaving her in bed improperly, turning off her call light, and police responding after she called for help. The DON knew police had been called and was aware of the neglect allegation, but the facility did not protect the resident from the alleged perpetrators, report the allegation, or complete a thorough investigation, and the resident remained fearful and refused to allow her door to be closed.
Limited Snack Availability on Multiple Units: Staff failed to ensure snacks were available on four of four units. During tour observations, one unit had only a few cups of applesauce, another had no snacks available, and two others had only applesauce or said residents would need to check with the kitchen for anything more substantial. The dietary manager stated that sandwiches were sent only for diabetics with orders, and cookies, crackers, or fruit were not sent for all residents.
Failure to develop a care plan for hemorrhoids treated with a rectal hydrocortisone order. A resident with multiple chronic conditions had an order for hydrocortisone 2.5% cream to be inserted rectally BID, but the care plan did not address this internal treatment. Survey review also noted the order lacked a clear dose or quantity, and references indicated hydrocortisone is intended for external use only. The resident was later found unresponsive, CPR was started, and the resident expired in the hospital.
A resident with multiple chronic conditions had a physician order for hydrocortisone cream written without a specific dose or quantity and with a rectal route, yet the medication was administered twice. The record also showed no care plan for internal hemorrhoid treatment, while reference material stated the cream is to be applied externally and never taken internally. Later that morning, the resident was found unresponsive, a Code Blue was called, CPR was started, and the resident was transferred to the hospital and later expired.
A resident with BIMS 15/15 and total ADL assistance needs was found with strong body odor, dry peeling feet, and long discolored toenails. The resident said showers were painful because of lift transfers and reported only occasional bed baths; a CNA said he refused showers and did not accept daily bed baths, and an LPN said he was care planned for shower refusal.
Failure to provide appropriate foot care for a resident with stiff man syndrome and total ADL assistance. The resident was observed with extremely dry, peeling skin and long, thick, discolored mycotic toenails, and stated that no one had applied lotion or trimmed his nails since a prior podiatry visit. An LPN said the resident could not be placed on the podiatry list without a MD order.
A medication cart was found unlocked and unattended in a resident-accessible area, with no authorized staff present. The assigned LPN had left the building to make a phone call, leaving the cart unsecured, which was acknowledged as a mistake by both the LPN and the Unit Manager. Facility policy requires medication carts to be locked when not under direct observation by authorized personnel.
Two residents with cognitive impairments eloped from the facility, and staff failed to report these incidents to the State Survey Agency within the required timeframe. One resident was found in the parking lot 16 hours after elopement, while the other was discovered by family members. Both residents had care plans indicating a risk for elopement, but the facility did not adhere to its policy of immediate reporting.
Two residents at the facility eloped despite being identified as at risk for elopement. One resident, with a history of suicidal ideations and dementia, left the facility at night and was found in the parking lot. The incident was reported to the state agency 16 hours later. Another resident, with depression, was found by family in the parking lot, expressing a desire to leave against medical advice. Both residents had wander guards, but the facility's measures were insufficient to prevent their unsupervised departure.
A resident with contracted fingers developed a pressure sore from fingernails pressing into the palm, which became infected and led to cellulitis. The facility staff failed to apply the necessary palm guard, and the resident's diet was insufficient, contributing to significant weight loss and malnutrition. The pressure sore was only identified after infection, requiring hospitalization for intravenous antibiotics.
The facility failed to maintain a sanitary and homelike environment, with issues such as leaking ceilings, debris, and pest infestations observed across all units. Residents reported dissatisfaction with cleanliness, maintenance, and food quality, citing lukewarm meals and laundry delays. Specific rooms had additional deficiencies like stained ceiling tiles and black spots on walls, causing resident concern. The administration did not provide comments or a plan to address these issues.
The facility staff failed to provide food that is palatable, attractive, and at an appetizing temperature due to the use of Styrofoam containers while the dishwasher was inoperable. Residents across all units complained about receiving cold food, as meals sat on carts for extended periods before being served. The Resident Council documented ongoing concerns about food quality, portion sizes, and meal variety, which were not addressed by the administration.
The facility experienced multi-system failures, including inadequate laundry services, unsanitary kitchen conditions, and failure to prevent resident-to-resident abuse. These issues persisted for months, affecting resident care and quality of life. The administration was aware of these problems but failed to resolve them, leading to the administrator's departure and the Regional President of Operations stepping in as Acting Administrator.
The facility's assessment was not tailored to its specific needs, lacking details on essential components such as compliance processes, contracts, and health information technology. It also failed to evaluate the physical environment, with issues like inoperable washing machines. The Acting Administrator recognized the need for more detailed information to accurately reflect the facility's operations.
The facility failed to maintain a sanitary environment, with mold, pests, and unsanitary conditions observed throughout. Residents reported symptoms consistent with mold exposure, and maintenance issues were prevalent, including broken washing machines and an inoperable dishwasher. The facility's infection control practices were inadequate, leading to potential health risks for residents.
The facility failed to maintain a sanitary and safe environment, with issues such as a damp mildew smell, unsanitary shower rooms, and unclean ice machines. Observations included live roaches near an ice machine, black substances in shower areas, and strong urine odors. The maintenance schedule for ice machines was not followed, and cleaning logs were blank.
The facility failed to address grievances raised by the Resident Group, as residents reported that their concerns were not acted upon despite being communicated multiple times. Issues included improper medication administration, inadequate linen changes, unprofessional staff, insufficient meal variety, and insufficient staffing levels. The Activity's Director confirmed that grievances were presented to department heads, but no feedback was provided to the residents.
A facility failed to protect residents from abuse and neglect, as a resident with mild cognitive impairment and a language barrier repeatedly abused three other residents. Despite complaints and staff witnessing the abuse, the facility did not report the incidents to the state agency, did not fully investigate, and failed to protect the victims. The facility's documentation was incomplete and inaccurate, and their policies on abuse were not implemented.
The facility failed to implement its abuse policies, resulting in repeated abuse and neglect of residents. A resident with mild cognitive impairment abused two others, and the facility did not report the incidents to the state agency or protect the victims. The administrator's documentation was incomplete and contained errors, leading to a lack of investigation and protection for the residents involved.
A resident with mild cognitive impairment and a language barrier repeatedly abused her roommates in an LTC facility. Despite complaints and witnessed incidents, the facility failed to protect the victims, report the abuse to the state agency, or fully investigate the incidents. The administrator's incomplete and erroneous documentation contributed to the lack of investigation by Adult Protective Services.
A facility failed to prevent and report abuse by a resident against others, including two known residents and an unknown third. Despite complaints, the facility did not act until abuse was witnessed, and documentation was incomplete and incorrect. The facility did not follow its abuse policy, leaving residents unprotected.
The facility failed to provide comprehensive care plans for two residents, leading to significant deficiencies. One resident with contractures did not have an individualized care plan for palm guards, resulting in a pressure sore and infection. Another resident exhibited aggressive behaviors and abused three other residents, but the facility did not conduct behavior monitoring or obtain a timely psychiatric consult. The facility's failure to implement its abuse policy and protect residents from a known abuser was evident, as allegations were not reported to the state agency, and no additional supervision was provided.
Two residents in an LTC facility experienced deficiencies in care due to staff failing to follow professional standards. One resident did not receive the full duration of cardiac monitoring as ordered, while another missed six doses of prescribed antibiotics. Frequent staff turnover and reliance on agency nurses contributed to these issues.
Two residents in an LTC facility did not receive adequate ADL care, including hygiene and showers, due to staff turnover and reliance on agency staff. One resident with severe cognitive impairment had long, dirty fingernails and only two baths in 30 days, while another cognitively intact resident reported not receiving scheduled baths, impacting her comfort and pain management. The facility's DON and Administrator acknowledged the deficiencies, citing leadership changes and staffing challenges.
A resident with dementia and a language barrier was not provided timely psychiatric care or a comprehensive care plan, resulting in aggressive behaviors and abuse towards other residents. The facility failed to monitor the resident's behavior, implement effective communication strategies, or follow its abuse policy, leaving other residents unprotected.
The facility staff failed to administer significant medications to several residents, leading to multiple deficiencies. A resident missed a dose of Lisinopril due to the absence of a nurse, while another experienced missed doses of multiple medications due to not being in the room. A serious drug interaction was not addressed for another resident, and critical medications were not procured or administered for a fourth resident. Additionally, a resident's antibiotic treatment was compromised due to missed doses. These deficiencies highlight significant lapses in medication administration and documentation.
The facility staff failed to manage medications properly on two units. On Unit 3, an LPN had expired Humalog and Fiasp insulin pens, and undated Toujeo pens. On Unit 4, the B cart had undated over-the-counter medications, including Senna and Ferrous Sulfate. The LPNs acknowledged the expectation to date medications upon opening, and the DON confirmed this during a debriefing.
The facility's pest control program was ineffective, as evidenced by the presence of roaches, fruit flies, and large flies throughout the facility. Dead roaches were found in the kitchen, and live roaches were observed near the ice machine, which also had standing water and a dripping drainage pipe. Despite monthly pest control services, pests remained visible, and the Administrator was informed of these issues.
The facility did not maintain an effective training program for all new and existing staff, as evidenced by incomplete training transcripts. During a final interview, the facility's leadership did not express any concerns about this deficiency.
The facility staff failed to ensure that all staff members completed the required training on residents' rights and facility responsibilities. A review of training transcripts showed incomplete education among staff, which was confirmed during staff interviews. In a final interview, the facility's leadership did not express any concerns about these findings.
The facility staff did not ensure that all staff members completed the required training for the Quality Assurance and Performance Improvement (QAPI) program. A review of training transcripts showed incomplete training, and during a final interview, no concerns were raised by the facility's leadership.
The facility failed to ensure all staff completed required Compliance and Ethics training, as revealed by a review of training transcripts. During a final interview, the Administrator, Interim Administrator, DON, and regional Nurse Consultants had no comments or concerns.
The facility failed to ensure all CNAs completed the mandatory twelve hours of education annually, which is essential for addressing their areas of weakness and the special needs of residents. This deficiency was identified through a review of Staff Education and Relias training transcripts. During a final interview, the facility's leadership did not express any concerns about this issue.
The facility staff did not complete the required training for behavioral health care, as revealed by a review of Staff Education and Relias training transcripts. During a final interview, the Administrator, Interim Administrator, DON, and two regional Nurse Consultants did not express any concerns about the incomplete training.
A resident was allowed to self-administer trazodone without an assessment to determine clinical appropriateness. The resident reported keeping the medication by his bedside, but now faces difficulty obtaining it. Facility staff confirmed that residents must be screened for safety and cognitive ability and have a lock box for medication storage, but no such screening was documented. The facility's policy requires physician authorization and adherence to procedures for self-administration.
Two residents experienced non-functioning clocks in their rooms, impacting their ability to know the correct time. Despite complaints, staff failed to address the issue, with one resident's clock stuck at 11:50 and another's at 4:50. The Regional Nurse Consultant confirmed the importance of accurate clocks for resident orientation, and facility leadership acknowledged the deficiency.
The facility failed to accurately complete the PASARR for two residents, not coding a resident with a serious mental illness despite diagnoses of PTSD, anxiety disorder, OCD, and major depressive disorder. The resident was on psychotropic medications and had a care plan addressing depression. Interviews revealed the PASARR was not coded for serious mental illness due to a lack of recent treatment, despite ongoing medication and positive depression screenings. No concerns were raised by the administration during a final interview.
A resident with an ileostomy experienced a deficiency in discharge planning due to the facility's failure to address skin issues and align with the resident's discharge goals. Despite the resident's and family's preference for discharge back to an ICF, improper care of the ileostomy led to skin irritation, preventing the transition. The facility did not facilitate the discharge even after the resident's skin healed, resulting in the resident remaining in LTC unnecessarily.
A resident with an ileostomy experienced improper care due to the use of an incorrect size ostomy wafer, which exposed too much skin and was cut too large. The resident's sister reported delays in changing the colostomy bag, leading to skin irritation. An LPN confirmed the incorrect wafer size during an observation. The resident's physician's orders specified a 1 3/4 cm wafer and regular bag checks, which were not followed, resulting in a deficiency.
A resident experienced significant weight loss and malnutrition due to insufficient meal portions and lack of adherence to dietary orders. The facility failed to monitor the resident's weight as recommended, and nutritional supplements were not consistently provided. Additionally, the resident developed a pressure sore that progressed to cellulitis, requiring hospitalization, due to improper management of contractures and lack of prescribed palm guard application.
The facility failed to staff an RN for at least 8 consecutive hours a day, 7 days a week, potentially affecting all residents. A review of the nursing schedule revealed no RN coverage for 8 consecutive hours on two specific days. This deficiency was confirmed by a Corporate Nurse Consultant, who acknowledged the lack of coverage on those dates.
A resident with depression, anxiety, and a history of trauma did not receive adequate mental health and psychosocial services in a facility. The resident experienced multiple falls, hospitalization, and behavioral issues, yet the facility failed to reinstitute long-standing medication therapy and provide consistent psychiatric evaluations. Erratic medication management and insufficient staff training further contributed to the deficiency.
A resident with a language barrier and mild cognitive impairment exhibited aggressive behaviors towards other residents, which were not adequately addressed by the facility. The social worker failed to provide necessary services, and the facility did not implement a comprehensive care plan or timely psychiatric consultation. The incidents were not properly documented or reported, resulting in multiple instances of abuse.
The facility failed to administer medications as ordered for two residents, including essential drugs for atrial fibrillation and dementia, and did not document the reasons for missed doses. Additionally, the facility lacked a proper system for managing controlled drugs, with inconsistencies in narcotic disposal processes. Another resident did not receive prescribed antibiotics due to unavailability, highlighting issues with pharmacy coordination and medication access.
A kitchen staff member was observed preparing food with a beard guard that only partially covered his facial hair, contrary to the facility's policy requiring full coverage. The cook stated that the provided beard guards did not fit properly. A corporate employee confirmed the expectation of full facial hair coverage.
The facility failed to maintain essential equipment, with a non-functional dishwasher and two broken washing machines impacting operations. The dishwasher had been down for weeks, and although a new one arrived, it was not installed until the survey. Laundry services were also affected, with only one working washer for 180 beds, leading to linen shortages and delays.
A resident with multiple diagnoses, including Parkinson's and COPD, did not receive medications as ordered due to staffing issues. The resident's medication administration record showed missed doses, and an LPN confirmed that inadequate staffing contributed to this failure, which did not meet professional standards.
A resident with chronic conditions requiring extensive assistance for ADLs did not have consistent documentation for incontinence care and grooming. Interviews revealed care frequency depended on staffing, and the resident reported delays in care. Despite these issues being communicated to facility leadership, no additional information was provided before the survey exit.
A resident with multiple health conditions, including dementia and COPD, did not receive consistent urinary catheter care as required by physician orders. Documentation was missing for several shifts, and an LPN confirmed that care was not provided if not documented. Facility leadership was informed of these findings.
Abuse and Neglect Allegation Involving Ignored Call Light and Unsafe Care
Penalty
Summary
Facility staff failed to protect a resident from abuse and neglect when the resident reported that staff ignored her call light, turned it off from the nurses’ station before entering the room, refused to provide care, and left her in an unsafe position in bed. The resident was cognitively intact with a BIMS score of 15 and was totally dependent on staff for all aspects of care due to quadriplegia from a gunshot wound to the neck. She also had epilepsy, neuromuscular dysfunction of the bladder, a suprapubic catheter, autonomic dysreflexia, and PTSD. The resident stated that on the night shift she was repeatedly ignored, that staff stood outside her room and talked about her loudly enough for her to hear, and that staff told her they would not take care of her or that two people were needed to go into her room. She reported that the situation became so severe that she called the non-emergency police number for help, and police responded to the facility. She also showed a picture of how she was left in bed with her legs hanging over the side and her torso still on the bed, and she showed videos in which staff turned off the call light without attending to her needs and then left without providing care. The resident stated that she informed the DON and Unit Manager after calling the police and that the events caused fear and anxiety because she was a former victim of domestic violence and had PTSD. She said she no longer felt she could trust the people responsible for her care and that she was afraid to have her door shut because staff might not hear her if she screamed. The clinical record showed the trauma-informed screening was not completed until after the resident raised the allegations, and there were no progress notes from psychiatric services. The DON acknowledged awareness that the police were called and that an allegation of neglect had been made.
Failure to Protect Resident During Abuse and Neglect Allegation
Penalty
Summary
The facility failed to implement its abuse and neglect policy, failed to protect a resident during an allegation of abuse and neglect, failed to report the allegation, and failed to conduct a thorough investigation. The resident was admitted with diagnoses including quadriplegia from a gunshot wound to the neck, epilepsy, neuromuscular bladder dysfunction, a suprapubic catheter, autonomic dysreflexia, and PTSD. Her most recent MDS coded her as cognitively intact with a BIMS score of 15 and totally dependent on staff for all care due to quadriplegia, while using a motorized wheelchair with mouth control. The resident stated that she had ongoing problems on the night shift, including being ignored and neglected, having her call bell turned off before staff entered her room, hearing staff talk about her outside her room, and being called names. She reported that on one early morning she called the non-emergency police number because the situation had become so bad that she needed help. She showed surveyors a photo and videos depicting staff leaving her in bed with her legs hanging over the side, turning off her call light, delaying care after responding to the light, and refusing to provide care while stating they would not come into the room alone. She also showed a video of police arriving after she called for assistance. The DON stated she was aware that police had been called and confirmed awareness of the resident’s allegation of neglect, but the facility had no evidence that it implemented measures to protect the resident from the alleged perpetrators, reported the allegation to regulatory agencies, or investigated the allegation. The resident continued to have the same caregivers assigned to her and, out of fear, refused to allow staff to close her door and reported feeling fearful, which was identified as psychosocial harm.
Limited Snack Availability on Multiple Units
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests because staff failed to ensure snacks were available on four of four units. During the initial tour of unit 1, a CNA opened the pantry refrigerator and showed only a plastic bag containing 6 small individual cups of applesauce, stating that this was the only snack available for the entire unit. On unit 2, a CNA stated that snacks were not available. On unit 3, an LPN stated that only a few containers of applesauce were available and that residents wanting something more substantial, such as a sandwich, would have to see if the kitchen could accommodate them; she added that they usually could get something if a diabetic needed it. On unit 4, an LPN stated there were no snacks available in general, but diabetic residents could go to the kitchen to get something, and she said that on off shifts they would have to check all the units. She also stated that applesauce was always available for med pass. The dietary manager stated that sandwiches were sent to the unit in the evening after dinner for diabetics with orders, but cookies, crackers, or fruit were not sent to the units for all residents and snacks were only sent for diabetics. The Administrator was informed of the concern during the end of day meeting, and no further information was provided.
Failure to Develop Care Plan for Rectal Hemorrhoid Treatment
Penalty
Summary
Facility staff failed to develop a comprehensive plan of care for hemorrhoids treated with an internal rectal medication for one resident. The resident was admitted with multiple diagnoses including breast cancer, osteoporosis with femur fracture and surgical repair, beta thalassemia, chronic kidney disease stage 4, irritable bowel syndrome, atrial fibrillation, arteriosclerotic cardiovascular disease, chronic heart failure, hypertension, rheumatoid arthritis, thrombocytopenia, PTSD, panic disorder, and depression. The resident’s only admission MDS showed the resident was cognitively independent and her own responsible party. The clinical record contained a physician order for hydrocortisone external cream 2.5% with instructions to insert 1 application rectally twice per day for hemorrhoids, ordered on 4-10-26 and administered twice on 4-11-26. The record also showed the resident was discharged and expired on 4-12-26. Review of the care plan revealed no plan of care had been developed for the internal treatment of hemorrhoids. The report noted that the order did not specify a dosage or quantity, stating it was unknown what “insert 1 application rectally” meant because no standard dose measurement was directed. References reviewed by surveyors indicated hydrocortisone is to be applied in a thin layer externally and never taken internally. Nursing and physician progress notes and hospital records showed the resident was found unresponsive without a palpable pulse on 4-12-26 at approximately 7:05 AM, a Code Blue and CPR were initiated, emergency responders transported the resident to the hospital, and the resident later expired there.
Unclear hydrocortisone order was administered without clarification
Penalty
Summary
The facility failed to clarify a physician’s order for hydrocortisone external cream 2.5% that was written as “insert 1 application rectally 2 times per day for hemorrhoids,” even though the order did not specify a dosage or quantity and included a rectal route. The medication was administered twice on 4-11-26. Review of references noted that hydrocortisone cream is to be applied in a thin layer externally and never taken internally, and the record showed no care plan for internal treatment of hemorrhoids that would require specific nursing knowledge of rectal insertion. The resident involved was admitted with multiple diagnoses including breast cancer, osteoporosis with femur fracture and surgical repair, beta thalassemia, chronic kidney disease stage 4, irritable bowel syndrome, atrial fibrillation, arteriosclerotic cardiovascular disease, chronic heart failure, hypertension, rheumatoid arthritis, thrombocytopenia, PTSD, panic disorder, and depression. The resident’s MDS indicated cognitive independence and that she was her own responsible party. On 4-12-26, the resident’s vital signs were documented as stable earlier in the morning, and later that morning she was found unresponsive without a palpable pulse, prompting a Code Blue, CPR, and transfer to the hospital, where she later expired.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
Facility staff failed to provide necessary services to maintain good grooming and personal hygiene for one resident. The resident was admitted with diagnoses including unspecified severe protein-calorie malnutrition, right hip pain, myalgia, stiff man syndrome, abnormal coagulation profile, and hypertension. The most recent MDS, with an ARD of 2/24/26, coded the resident with a BIMS score of 15 out of 15 and indicated the resident required physical assistance from staff for all aspects of ADL care. During observation on 5/6/26, a surveyor smelled a strong body odor coming from the resident’s room and observed the resident lying in bed with exposed feet. The resident’s feet were extremely dry with peeling dead skin and long, thick, discolored, mycotic toenails. The resident stated he did not like showering because it hurt to transfer in the lift and onto the shower stretcher, and said CNAs gave him a bed bath only a couple of times a month. A CNA stated the resident always refused showers and did not allow daily bed baths, and an LPN stated the resident was care planned for refusal of showers. The care plan documented refusals of medications, weights, showers, and bed baths at times, with interventions including education, provider notification, safety measures, psych referral as needed, and redirection.
Failure to Provide Appropriate Foot Care
Penalty
Summary
Provide appropriate foot care was not ensured for one resident in the survey sample. The resident was admitted with diagnoses including unspecified severe protein-calorie malnutrition, right hip pain, myalgia, stiff man syndrome, abnormal coagulation profile, and hypertension. The most recent MDS coded the resident with a BIMS score of 15 out of 15 and indicated the resident required physical assistance from staff for all aspects of ADL care. On observation, the resident’s feet were extremely dry with peeling dry/dead skin and long, thick, discolored, mycotic toenails. During interview, the resident stated he does not walk because of stiff man syndrome, that it hurts to move and transfer, that he had seen the podiatrist but it had been a long time, and that no one puts lotion on his skin or has tried to cut his toenails since the podiatrist visited a long time ago. An LPN stated she could not place the resident on the podiatry list until she had a doctor’s order and would obtain the order when the doctor or NP made rounds. The Administrator was informed of the concern and no further information was provided.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
Facility staff failed to ensure that a medication cart was kept locked or under the direct observation of authorized staff in an area accessible to residents. During an observation tour, a medication cart was found unlocked outside the nursing station with no authorized staff in sight. The Unit Manager was unaware of the nurse assigned to the cart's whereabouts. Shortly after, the assigned LPN returned from outside the building, stating she had been making a phone call and acknowledged that leaving the cart unlocked and unattended was a mistake. The facility's policy requires that only licensed nurses, pharmacy personnel, or those lawfully authorized to administer medications have access to medications, and that medication carts must be locked when not attended by authorized personnel. Interviews with the Unit Manager and the LPN confirmed that the cart was left unattended and unlocked, contrary to facility policy. No further comments or concerns were voiced by facility leadership during the final interview.
Failure to Report Resident Elopements Timely
Penalty
Summary
The facility staff failed to prevent the elopement of two residents, which was not reported to the State Survey Agency within the required timeframe. Resident #217, who had a history of suicidal ideations and unspecified dementia, eloped from the facility and was found in the parking lot. The incident was not reported until 16 hours later, despite the requirement to report such events within 2 hours. The resident's care plan indicated a risk for elopement, with interventions including checking the wander guard function and conducting elopement risk assessments. Similarly, Resident #223, diagnosed with depression, was found by family members in the parking lot after eloping. The facility staff did not complete a Facility Synopsis of the event, and the incident was not reported to the State Survey Agency. The resident's care plan also identified a risk for elopement, with similar interventions as Resident #217. The facility's policy mandates immediate reporting of such incidents, but this was not adhered to in both cases.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide necessary supervision to prevent elopement for two residents, leading to deficiencies in care. Resident #217, who had a history of suicidal ideations and dementia, eloped from the facility late at night and was found in the parking lot. Despite having a wander guard, the resident managed to leave the building, and the incident was not reported to the state agency until 16 hours later. The resident's care plan identified them as at risk for elopement, but the interventions in place were insufficient to prevent the incident. Resident #223 also eloped from the facility, as observed by their family in the parking lot. This resident had a history of depression and was assessed as at risk for elopement. Despite wearing a wander guard, the resident left the facility, expressing a desire to leave against medical advice. The facility staff attempted to persuade the resident to stay, but the resident's wander guard was removed upon discharge. The incident was not properly documented in a facility synopsis, although an elopement incident report was completed. Both residents were identified as at risk for elopement through the facility's Elopement Risk Tool Assessment, yet the measures in place failed to prevent their unsupervised departure. The facility's policy required regular checks of wander guard function and placement, but these measures were not effective in preventing the elopements. The incidents highlight a deficiency in the facility's ability to adequately supervise and protect residents at risk of elopement.
Failure to Prevent and Treat Pressure Ulcer Leads to Hospitalization
Penalty
Summary
The facility staff failed to prevent, assess, identify, and treat an avoidable pressure ulcer for a resident with contracted fingers of the left hand. The resident developed a pressure sore injury from his fingernails pressing into his palm, which became infected and resulted in cellulitis. This infection led to the resident being hospitalized for treatment with intravenous antibiotics for 10 days. The facility staff were unaware of the wound prior to the infection and had not been applying the resident's hand splint (palm guard) to prevent the wound. The resident, who had a history of stroke with left hemiplegia, dementia, contractures, and other medical conditions, was suffering from significant weight loss and malnutrition, which increased his debility and inability to heal. Despite being at risk for skin breakdown due to immobility and contractures, the facility staff did not consistently use palm guards to protect the resident's skin. The pressure sore injury was only identified after it became infected, requiring hospitalization. The resident's diet was also insufficient in quantity and did not meet the ordered caloric intake, contributing to his malnutrition. The facility's failure to conduct regular skin assessments and monitor the resident's nutritional status contributed to the development and progression of the pressure sore. The resident's care plan did not include specific instructions for the use of palm guards, and staff were unaware of the need for these devices. Additionally, the facility did not administer antibiotics promptly after the cellulitis was identified, further delaying treatment and contributing to the resident's hospitalization.
Unsanitary Conditions and Maintenance Failures in LTC Facility
Penalty
Summary
The facility failed to maintain a sanitary, comfortable, and homelike environment across all units and some common areas, leading to a substandard quality of life for residents. Observations included water leaking from the ceiling in the lobby, debris and dark spots in corridors, and unsanitary conditions in resident rooms, such as soiled floors, clogged toilets, and strong odors. Residents expressed dissatisfaction with the cleanliness and maintenance of their living spaces, reporting issues like unanswered call bells, uncleaned rooms, and pest infestations. The facility's administration did not provide comments or concerns when these issues were presented. The facility also failed to provide sanitary conditions in the kitchen and common areas, with dead roaches found in the dry storage area and live roaches near the ice machine. The ice machine area was unsanitary, with standing water and a black slimy substance. Residents complained about lukewarm or cold food due to an inoperable dishwasher and the use of Styrofoam containers. Additionally, there was a shortage of linens and delays in laundry services due to broken washing machines, which the director of housekeeping acknowledged. Specific units and rooms were observed with additional deficiencies, such as wet and stained ceiling tiles, cobwebs, and black spots on walls. Residents expressed frustration and concern over these conditions, with one resident fearing for their health due to the black spots. Maintenance staff attempted to address some issues, such as replacing ceiling tiles and cleaning walls, but the underlying problems persisted. The facility's administration was informed of these findings but did not provide further information or a plan to address the deficiencies.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility staff failed to serve food that is palatable, attractive, and at an appetizing temperature for residents across all four units. This deficiency was primarily due to the use of Styrofoam takeout containers for food service, necessitated by an inoperable dishwasher from August 9, 2024, to October 10, 2024. Residents consistently complained about receiving cold food, as the meals sat on carts in the hallways for 10 to 20 minutes before being served by CNAs. Despite food temperatures being within safe ranges during a kitchen inspection, the delay in distribution led to lukewarm or cold meals, which residents found unappetizing. The Resident Council documented ongoing food-related concerns that were not addressed by the administration. Complaints included watery oatmeal, insufficient portions, incorrect meal tickets, and a lack of alternative meal options. Residents also expressed dissatisfaction with the quality and variety of food, noting issues such as overcooked chicken, uncooked potatoes, and a lack of fresh fruits and vegetables. These issues persisted over several months, as evidenced by Resident Council meeting notes from April to September 2024, indicating a pattern of neglect in addressing dietary concerns.
Multi-System Failures in Facility Operations and Resident Care
Penalty
Summary
The facility experienced a multi-system failure affecting various aspects of resident care and facility operations. Deficiencies were identified in environmental services, sanitary conditions, infection control practices, medication storage and administration, and resident abuse prevention. Specifically, the facility had inadequate laundry services with only one working washing machine for several months, leading to a shortage of clean linens and gowns for residents. Staff members were observed apologizing for using the last gowns during incontinence care rounds, and interviews confirmed ongoing issues with laundry services. Additionally, the kitchen was found to have unsanitary conditions, including rodent activity, roaches, and an unsanitary ice machine, which raised concerns among residents about the food quality. The facility also failed to protect residents from abuse, as there were incidents of resident-to-resident abuse that were not adequately addressed. The survey team reviewed maintenance and pest control logs, as well as Resident Council minutes and grievance logs, which indicated that the administration was aware of these issues for several months without resolution. The facility's administrator, who had been employed for four weeks, acknowledged the laundry issues and stated that incorrect parts had been ordered for the washing machines. However, the problems persisted, and the administrator was no longer employed at the facility by the end of the survey. The Regional President of Operations assumed the role of Acting Administrator and was informed of the survey findings.
Facility Assessment Lacks Specificity and Detail
Penalty
Summary
The facility failed to create a facility-specific assessment to determine the necessary resources for resident care during both regular operations and emergencies. The assessment, which was 22 pages long, was based on a template and lacked specific details relevant to the facility. It was not reviewed by the Quality Assurance Process Improvement (QAPI) Committee, as indicated by the blank review date. The assessment did not include essential components such as a compliance hotline, grievance process, Resident Council, Family Council, or QAPI. Additionally, it failed to list contracts, memoranda of understanding, or agreements with third parties, and did not describe the process for overseeing services to meet resident needs. The assessment also inadequately addressed health information technology resources, merely stating the use of PointClickCare for electronic health records without detailing secure information transfer processes. There were concerns about residents not receiving timely access to their medical records. Furthermore, the assessment did not evaluate the physical environment necessary for resident care, as evidenced by the inoperability of washing machines for at least two months. The Acting Administrator acknowledged the need for more detailed information in the assessment to accurately reflect the facility's operations.
Inadequate Infection Control and Sanitation in LTC Facility
Penalty
Summary
The facility staff failed to maintain a safe, sanitary, and comfortable environment, leading to the transmission of communicable diseases and infections across all resident living units and communal spaces. Observations revealed the presence of wet mold on floors, walls, ceiling tiles, and other areas, as well as unsanitary conditions in shower rooms, laundry facilities, and the main kitchen. The ice machines were not kept clean, with one machine found to have standing water and live cockroaches around it, and mold growing underneath. The maintenance director admitted to inadequate cleaning schedules and lack of documentation for the ice machines. Residents reported symptoms such as headaches, sore throats, asthma, and other respiratory issues, which were consistent with exposure to mold and damp environments. Interviews with residents revealed ongoing issues with mold and mildew in their rooms, with maintenance staff merely painting over affected areas instead of addressing the root cause. The maintenance director discovered non-operational blowers in the ceiling, which could have prevented the condensation and mold growth, but no testing had been conducted to determine the extent of mold presence. The facility also faced issues with pest control, as fruit flies, large flies, and cockroaches were noted throughout the building. Laundry services were inadequate due to broken washing machines, leading to a shortage of linens and delayed return of personal clothing. The kitchen was found to be unsanitary, with dead cockroaches, food debris, and an inoperable dishwasher, resulting in the use of Styrofoam containers for meals. These conditions contributed to residents receiving lukewarm or cold food, further impacting their quality of life.
Unsanitary Conditions and Maintenance Failures
Penalty
Summary
The facility staff failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed significant issues, including a damp mildew smell, wet ceiling tiles, unsanitary shower rooms, and unclean ice machines. Specifically, the ice machine located in a closet across from the dining room had standing water on the floor, a rubber mat with live roaches, and a drainage pipe dripping onto the floor. The area emitted a damp and mildew odor, and the ice machine filter date was illegible with no documentation of a cleaning schedule or inspection. The maintenance person stated that ice machines were wiped down monthly, sanitized quarterly, and filters changed every six months, but the policy for ice machine cleaning was not followed as evidenced by blank cleaning logs. Further observations in various shower rooms across different units revealed unsanitary conditions. These included wet washcloths left on floors, dirty and stained floors, black substances in grout lines and shower areas, and strong urine odors. Broken toilet paper holders, rust stains, and personal items without names were also noted. The administrator was informed of these concerns during an end-of-day meeting, but no further information was provided.
Failure to Address Resident Group Grievances
Penalty
Summary
The facility staff failed to adequately address grievances raised by the Resident Group, as evidenced by the lack of response or action taken on multiple issues voiced by the residents. During a Resident Group meeting, it was unanimously agreed by the attendees that their grievances were not being acted upon, despite being communicated multiple times. The group's President noted that the Activity's Director (AD) facilitated the meetings and ensured that grievances were communicated to the relevant departments, but no feedback or resolution was ever provided to the residents. A review of six months of Resident Group meeting minutes revealed numerous unresolved concerns, including improper medication administration, inadequate linen changes, unprofessional nursing staff, insufficient meal variety and portions, lack of resident shopping trips, unclean rooms, and insufficient staffing levels. The AD confirmed that grievances were presented to department heads during morning meetings but admitted to not receiving any feedback to relay back to the residents. The facility's administrative staff, including the Administrator and Director of Nursing, did not provide any comments or express concerns when interviewed about these issues.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by the repeated willful abuse of three residents by another resident. The facility did not report the abuse to the state agency, did not fully investigate the incidents, and failed to protect the victims during the investigation. The abuse involved physical and verbal aggression, including kicking, hitting, and spitting, and was witnessed by staff but not adequately addressed. Resident #68, who was cognitively intact, reported being abused by her roommate, Resident #521, who had mild cognitive impairment and a language barrier. Despite repeated complaints, the facility staff did not take action until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to another room, where she continued to exhibit aggressive behavior towards her new roommate, Resident #20, and later towards an unknown resident. The facility's documentation and reporting of the incidents were incomplete and inaccurate. The Administrator's report contained errors and was not submitted correctly to the state agency, resulting in no investigation by Adult Protective Services. The facility's policies on abuse were not implemented, and there was no added staff supervision for the known abuser, leading to further incidents of abuse.
Failure to Implement Abuse Policies and Protect Residents
Penalty
Summary
The facility failed to implement its abuse policies, resulting in repeated willful abuse and neglect of residents. The staff did not report the abuse to the state agency, failed to fully investigate the incidents, and did not protect the victims during the investigation. This involved four known residents, with one resident being the perpetrator of abuse against two others. The facility's documentation and interviews revealed that the abuse was not reported to the state agency, and the facility did not follow its own policies for investigating and protecting residents from abuse. Resident #68, who was cognitively intact, reported being physically and verbally abused by her roommate, Resident #521, who had mild cognitive impairment and a language barrier. Despite repeated complaints to the staff, no action was taken until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to a room with Resident #20, who also experienced abuse. The facility's records showed that Resident #521 continued to exhibit aggressive behavior, including hitting and spitting on Resident #20, and threatening another unknown resident after being moved to a third room. The facility's administrator failed to complete the Facility Reported Incident (FRI) documentation properly, resulting in the state agency not receiving the report. The administrator's synopsis contained errors, such as incorrect BIMS scores, and implied that the victim was responsible for triggering the abuse. The facility did not conduct a thorough investigation or provide adequate protection for the residents involved. Additionally, there was no added staff supervision for Resident #521 to prevent further abuse, and no police report was filed despite the suspicion of a crime.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, and failed to protect the victims during the investigation. This involved four residents, including two victims and one perpetrator. The abuse was perpetrated by a resident with mild cognitive impairment and a language barrier, who was involved in multiple incidents of physical and verbal abuse against her roommates. Despite repeated complaints from the victims, the facility staff did not take timely or adequate action to protect the residents or report the incidents to the appropriate authorities. Resident #68, who was cognitively intact, reported being physically and verbally abused by her roommate, Resident #521. Despite her complaints to the staff, no action was taken until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to another room, where she continued her aggressive behavior towards her new roommate, Resident #20. Resident #20, also cognitively intact, reported being yelled at, spit on, and physically assaulted by Resident #521. The staff witnessed the abuse but failed to document the full extent of the injuries or report the incident to the state agency. The facility's administrator failed to complete the Facility Reported Incident (FRI) documentation correctly, resulting in the state agency not receiving the report. The administrator's synopsis contained errors, including an incorrect assessment of Resident #521's cognitive status, which contributed to the lack of investigation by Adult Protective Services. The facility's policies on abuse were not implemented, and there was no added staff supervision for Resident #521 to prevent further abuse. The facility's failure to protect residents from a known abuser and to report and investigate the incidents fully resulted in a deficiency in their care standards.
Failure to Prevent and Report Resident Abuse
Penalty
Summary
The facility staff failed to prevent repeated willful abuse and neglect, failed to fully investigate the abuse, failed to report the abuse to the state agency, and failed to protect the victims during the investigation. The incidents involved four residents, with Resident #521 being the perpetrator of abuse against Residents #68, #20, and an unknown third resident. Despite repeated complaints from Resident #68 about being abused by Resident #521, the facility staff did not take action until the abuse was witnessed by the Assistant Director of Nursing. Resident #521 was then moved to a room with Resident #20, where further abuse occurred. The facility's documentation and reporting of these incidents were inadequate. The Administrator's synopsis of the abuse was incomplete, unsigned, and contained errors, such as incorrectly stating Resident #521's cognitive status. The report to the state agency was not received due to an incorrect fax number, and the facility did not conduct a thorough investigation or provide adequate protection for the residents involved. The facility's policy on abuse was not implemented, and there was no added staff supervision for Resident #521 to prevent further abuse. The facility's failure to report and investigate the abuse incidents properly resulted in a lack of protection for the residents. The Administrator's response to the situation was insufficient, and the facility did not follow its own policies for handling abuse allegations. The lack of a comprehensive investigation and failure to report the incidents to the appropriate authorities left the residents vulnerable to further abuse.
Failure to Provide Comprehensive Care Plans and Protect Residents from Abuse
Penalty
Summary
The facility staff failed to provide a comprehensive care plan for two residents, leading to significant deficiencies in their care. Resident #73, who had contractures with splints and palm guards required to prevent further contracture and maintain skin integrity, did not have an individualized care plan for the palm guards. This oversight resulted in a pressure sore injury from the resident's fingernails pressing into his palm, which became infected and led to cellulitis. The infection necessitated hospitalization for treatment with IV antibiotics. The facility staff were unaware of the wound prior to the infection and had not been applying the resident's hand splint consistently, which contributed to the injury. Resident #521 exhibited aggressive behaviors and signs of distress that were not assessed or care planned by the facility staff. The resident, who had a language barrier and mild cognitive impairment, abused three other residents in the facility. The staff failed to obtain a timely psychiatric consult, conduct behavior monitoring, or provide a comprehensive care plan for emotion regulation. This lack of intervention resulted in the willful abuse of other residents, including physical aggression and intimidation. Despite repeated complaints from the victims, the facility staff did not take adequate measures to protect the residents or investigate the allegations of abuse. The facility's failure to implement its abuse policy and protect residents from a known abuser was evident in the handling of Resident #521's case. The allegations of abuse were not reported to the state agency, and the facility did not provide additional staff supervision to prevent further incidents. The psychiatric evaluation for Resident #521 was delayed, and no psychosocial or behavioral services were provided despite the resident's aggressive behavior. The facility's inaction and lack of a comprehensive care plan for Resident #521 contributed to the continuation of abusive behavior and the failure to protect other residents from harm.
Deficiencies in Cardiac Monitoring and Antibiotic Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of nursing practice for two residents, leading to deficiencies in care. For one resident, the staff did not apply a cardiac monitor for the required duration to diagnose the cause of repeated syncopal episodes. The resident, who had multiple diagnoses including chronic kidney disease and dementia, was supposed to have the cardiac monitor patch changed every seven days for a total of 30 days. However, the monitor was discontinued 14 days early without any documented reason, and the physicians were unaware of this early discontinuation. In another case, the facility staff failed to administer antibiotics as ordered for a resident with septic arthritis of the knee. The resident was prescribed oral Amoxicillin to be taken three times a day for 14 days. However, six doses were missed during the treatment period, including four consecutive doses. There was no documentation that the missed doses were communicated to the Infectious Disease Physician, nor were the missed doses compensated for by extending the treatment period. The report highlights issues with continuity of care due to frequent staff turnover and reliance on agency nurses. The facility had experienced significant staff changes, including four Directors of Nursing in less than a year, which contributed to the lack of adherence to physician orders and professional standards. The facility's failure to ensure proper medication administration and monitoring as prescribed resulted in deficiencies in the care provided to the residents.
Inadequate ADL Care and Hygiene for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care, including hygiene and showers, to two residents, resulting in deficiencies. Resident #89, who has severe cognitive impairment and requires extensive assistance, was observed with long, dirty fingernails and had only received two baths in 30 days. Despite the facility's policy of providing at least two baths per week, the resident's care plan did not include a bathing schedule, and staff were unaware of her hygiene needs. Interviews with staff revealed a lack of familiarity with the resident and inconsistent care due to high staff turnover and reliance on agency staff. Resident #68, who is cognitively intact and requires assistance for hygiene, reported not receiving the scheduled twice-weekly baths. The resident expressed concerns about staff shortages and the impact on her comfort and pain management. Bathing records confirmed that she had only received one bath in the past month, despite her requests and the facility's policy. Staff interviews indicated a lack of communication and coordination between shifts, contributing to the oversight in her care. The facility's Director of Nursing (DON) and Administrator, both relatively new to their positions, acknowledged the deficiencies and attributed them to frequent changes in leadership and staffing challenges. The surveyors highlighted the impact of these issues on the continuity of care, as evidenced by the inadequate ADL support provided to the residents. The facility did not provide any additional information or corrective actions at the time of the survey.
Failure to Address Behavioral Health Needs Leads to Resident Abuse
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with non-Alzheimer's type dementia and a language barrier, leading to multiple incidents of abuse against other residents. The resident, who spoke only Spanish, was not given a timely psychiatric consultation, and there was no comprehensive care plan addressing her emotional regulation or responses to stressors. This lack of intervention resulted in aggressive behaviors, including physical and verbal abuse towards other residents. The facility's staff did not adequately monitor the resident's behavior or implement a care plan to address her needs. Despite the resident's known language barrier and previous diagnosis of depression or bipolar disorder, no effective communication strategies or behavioral interventions were put in place. The resident's aggressive actions were not reported to the state agency, and the facility's abuse policy was not followed, leaving other residents unprotected. The facility's documentation and response to the incidents were insufficient. The psychiatric consultation was delayed, and the resident's care plan lacked focus on her dementia, language barrier, and behaviors. The facility's failure to address these issues resulted in repeated abuse incidents, with no added staff supervision or investigation into the allegations. The facility's administrator and corporate staff were unable to provide further information or documentation regarding the incidents.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to ensure that significant medications were administered to several residents, leading to multiple deficiencies. Resident #47 did not receive a scheduled dose of Lisinopril due to the absence of a nurse on the unit, resulting in severe pain and physical symptoms. Despite the medication being available, the facility staff could not explain the missed administration. Similarly, Resident #57 experienced missed doses of multiple medications, including Eliquis, Flomax, Gabapentin, and Amlodipine, due to the resident not being in the room during medication rounds. The facility's policy required nurses to return to administer missed medications, but this was not adhered to, and there was no documentation explaining the missed doses. Resident #424's case involved a failure to notify the physician or seek clarification regarding a serious drug interaction flagged by the pharmacy. The resident was prescribed Levofloxacin, which had a potential severe interaction with Citalopram, but the facility staff did not address the pharmacy's alerts. Additionally, Resident #372 did not receive several critical medications, including anti-seizure medication, insulin, and analgesics, for multiple days. The facility staff did not procure or administer these medications as ordered, leading to missed doses without any documented explanation. Resident #161's antibiotic treatment was compromised due to six missed doses, including four consecutive doses, during the prescribed course. The facility staff did not extend the antibiotic treatment to cover the missed doses, and there was no documentation explaining the omissions. The Regional Nurse Consultant emphasized the importance of completing antibiotic courses to prevent bacterial resistance, but the facility failed to ensure adherence to the prescribed regimen. These deficiencies highlight significant lapses in medication administration and documentation within the facility.
Medication Management Deficiencies in Facility Units
Penalty
Summary
The facility staff failed to adhere to proper medication management protocols on two of the four facility units, as observed during a survey. On Unit 3, an LPN was found with an opened multi-dose Humalog (insulin lispro) KwikPen and a Fiasp (insulin aspart) injection pen, both of which were past their 28-day discard date according to the manufacturer's guidelines. Additionally, two Toujeo (insulin glargine) injection pens were found opened and undated, contrary to the facility's training and competency requirements that mandate dating medications upon opening. On Unit 4, the B cart inspection revealed four bottles of over-the-counter medications that were opened and undated, including Senna, Ferrous Sulfate, Naproxen, and Chewable aspirin. The LPN on duty acknowledged that all medications should be dated when opened, and the Director of Nursing confirmed this expectation during the end-of-day debriefing. The facility's administration and nursing consultants were informed of these findings, but no further comments or concerns were raised by them at the time of the survey exit.
Ineffective Pest Control Program Leads to Roach and Fly Infestation
Penalty
Summary
The facility staff failed to maintain an effective pest control program, resulting in the presence of pests within the facility. During a kitchen inspection, two dead roaches were found in the dry storage area and one near the 3-compartment sink. Additionally, an inspection of the ice machine area revealed standing water on the floor, live roaches crawling around and under a rubber mat, and a dripping drainage pipe. The area also contained a black slimy substance and wet paper trash, emitting a smell of dampness and mildew. Throughout the survey, fruit flies and large flies were observed on all units and in common areas. Despite having monthly pest control services, the program was deemed ineffective as pests remained visible. The Administrator was informed of these concerns during the end-of-day meeting, but no further information was provided.
Failure to Maintain Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the deficiency.
Deficiency in Staff Education on Resident Rights
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on residents' rights and the facility's responsibilities. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training concerning the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified during a review of facility documents and staff interviews. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the information presented.
Incomplete QAPI Training for Facility Staff
Penalty
Summary
The facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement (QAPI) program. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training for QAPI. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the incomplete training.
Non-compliance in Staff Training on Ethics
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on Compliance and Ethics. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training for Compliance and Ethics. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, they had no comments or concerns regarding the information presented.
Deficiency in CNA Education Compliance
Penalty
Summary
The facility staff failed to ensure that all Certified Nurses Aides (CNAs) completed the mandatory twelve hours of education each year. This education is crucial as it addresses each CNA's areas of weakness as determined in their performance reviews, the facility assessment, and the special needs of residents as determined by the facility staff. A review of the Staff Education and Relias training transcripts revealed this deficiency. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding this information.
Incomplete Behavioral Health Training for Facility Staff
Penalty
Summary
The facility staff failed to ensure that all staff members were educated on behavioral health care and services. A review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed the required training for behavioral health care. During a final interview with the Administrator, Interim Administrator, Director of Nursing, and two regional Nurse Consultants, no comments or concerns were voiced regarding the incomplete training.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility staff failed to determine the clinical appropriateness for a resident to self-administer the psychotropic medication, trazodone, which is used to treat insomnia. The resident was allowed to self-administer the medication without an assessment to ensure it was safe and appropriate for him to do so. During an interview, the resident mentioned that he used to keep the medication by his bedside and take it at his discretion, but now he has to request it, which he finds difficult. The clinical record review showed that the resident had an order for unsupervised self-administration of trazodone from September 9 to September 16, 2024, without any documented screening for safety or cognitive ability. Interviews with facility staff, including an LPN and the Clinical Nurse Consultant, revealed that residents must be screened for safety and cognitive ability and have a lock box for medication storage to self-administer medications. However, no such screening was documented for the resident in question. The facility's Medication Administration Policy states that residents are permitted to self-administer medications only when specifically authorized by the attending physician and in accordance with established procedures. The deficiency was discussed with the Administrator, but no further information was provided.
Failure to Maintain Accurate Clocks in Resident Rooms
Penalty
Summary
The facility staff failed to reasonably accommodate the needs and preferences of two residents by not ensuring the clocks in their rooms were functioning correctly. Resident #161, who was admitted with diagnoses including Primary Osteoarthritis of the Knee and Heart Failure, was observed to be alert and oriented with a BIMS score of 14, indicating no cognitive impairment. Despite being aware of the incorrect time displayed on the clock in her room, which had been stuck at 11:50, the resident's repeated complaints to staff members went unaddressed. The CNA acknowledged the issue, stating that maintenance was needed to replace the battery, but despite submitting work orders, the clock remained unfixed. Similarly, Resident #107, who had severe cognitive impairment with a BIMS score of 6, also experienced a non-functioning clock in his room, which was stuck at 4:50. This resident, admitted with conditions such as Metabolic Encephalopathy and Chronic Kidney Disease, expressed his inability to determine the time due to the faulty clock. Staff members, including those picking up food trays and delivering ice, failed to address the issue despite being informed by the resident. The Regional Nurse Consultant confirmed the importance of having accurate clocks for resident orientation and acknowledged that staff should have corrected the issue. During a debriefing, facility leadership, including the Facility Administrator and Regional President of Operations, were informed of the findings, and they agreed that clocks in residents' rooms should be accurate. No further information was provided regarding corrective actions or follow-up measures taken to address the deficiency.
Failure to Accurately Complete PASARR for Residents with Mental Illness
Penalty
Summary
The facility staff failed to accurately complete the Preadmission Screening and Resident Review (PASARR) for two residents, specifically failing to code a resident with a current serious mental illness. One resident, who was originally admitted to the facility and later readmitted after a hospital stay, had diagnoses including PTSD, anxiety disorder, OCD, personality hysterical, and major depressive disorder with severe psychotic symptoms. Despite these diagnoses and ongoing treatment with psychotropic medications, the resident's PASARR assessment did not reflect a current serious mental illness. The resident's care plan acknowledged signs of depression and risk for adverse reactions, with interventions including medication administration and referral to psychiatric services. Interviews with facility staff and family members revealed discrepancies in the PASARR coding. The Social Worker indicated that the PASARR was not coded for a serious mental illness because the resident had not been treated for a mental health disorder in two years, despite recent positive screenings for depression and ongoing medication for depression and anxiety. A family member confirmed the resident's long history of mental health issues, which had significantly impacted her life. During a final interview with the facility's administration and nursing staff, no comments or concerns were raised regarding the deficiency.
Failure in Discharge Planning for Resident with Ileostomy
Penalty
Summary
The facility staff failed to maintain an ongoing discharge planning process that aligned with the resident's and their representative's goals, resulting in a deficiency for one resident. The resident, who was admitted to the facility after surgery for colon cancer, required rehabilitation services and surgical wound care that the Intermediate Care Facility (ICF) could not provide. Despite the resident's and their family's preference for discharge back to the ICF, the facility did not adequately address the resident's skin issues related to the ileostomy, which were exacerbated by improper care, such as using the wrong size stoma wafer and not providing frequent enough ileostomy care. This lack of proper care led to skin irritation, preventing the resident from transitioning back to the community. The discharge planner noted that the resident's medical record indicated a plan to transfer back to the ICF once the surgical wound healed. However, the resident's last day of covered rehabilitation services was in May, and the wound was not healed at that time, leading to a change in the resident's discharge status to long-term care. Despite the resident's skin healing approximately two months prior to the survey, the facility had not taken steps to facilitate the resident's discharge back to the ICF, as desired by the resident and their family. The facility's failure to focus on the resident's discharge goals and needs resulted in the resident remaining in long-term care unnecessarily.
Incorrect Ostomy Appliance Size and Care Deficiency
Penalty
Summary
The facility's staff failed to apply the correct size ostomy appliance and did not provide care to an ostomy according to the physician's order for one resident. The resident, who has an ileostomy, was observed to have the wrong size wafer applied, which exposed too much skin and was cut too large. This was confirmed during an observation by an LPN, who noted that the wafer needed to be cut smaller. The resident's sister also reported that the staff used the incorrect size wafer and that it took up to six hours for the staff to change the resident's colostomy bag when it was full, causing skin irritation. The resident, who was admitted to the facility with diagnoses including ileostomy status and malignant neoplasm of the sigmoid colon, was coded as having severe memory and decision-making impairments. The physician's orders specified the use of a 1 3/4 cm wafer and outlined specific care instructions, including checking and emptying the colostomy bag every four hours. However, these orders were not followed, leading to the deficiency. The facility's corporate nurse consultant confirmed the correct wafer size and indicated that the nursing staff had been educated on this matter.
Inadequate Nutrition and Monitoring Leads to Resident's Decline
Penalty
Summary
The facility failed to provide adequate nutrition and hydration to a resident, leading to significant weight loss and malnutrition. The resident, who had severe cognitive impairment and required extensive assistance with eating, was observed receiving insufficient meal portions that did not meet the dietary orders. The meals lacked several components, including fortified pudding and pureed cookies, and were not in the quantity specified by the tray ticket. The kitchen staff admitted to running out of certain items and substituting others without proper authorization. The resident's weight was not monitored as recommended, with significant weight loss documented over several months. Despite a weight gain during a hospital stay, the resident continued to lose weight upon returning to the facility. The Registered Dietician's recommendations for weekly weight checks and dietary adjustments were not followed, and the resident's malnutrition risk was not adequately addressed. The facility also failed to provide the prescribed nutritional supplements consistently, with orders for Pro-stat liquid being discontinued after only three days. Additionally, the resident developed a pressure sore on the left hand, which progressed to cellulitis and required hospitalization. The facility did not apply the prescribed palm guard consistently, contributing to the development of the wound. The resident's contractures and pressure sore were not managed effectively, as evidenced by the lack of proper splint application and monitoring. The facility's inaction and failure to adhere to dietary and medical orders resulted in the resident's declining health and need for hospitalization.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which could potentially affect all residents. A review of the nursing schedule from November 19, 2024, through December 5, 2024, revealed that there was no RN coverage for at least 8 consecutive hours on November 30, 2024, and December 1, 2024. This deficiency was confirmed by the Corporate Nurse Consultant (CNC) #2 on December 3, 2024, who acknowledged the lack of RN coverage on the specified dates. A final interview with CNC #2 on December 4, 2024, reiterated that RN coverage should have been provided on those dates.
Inadequate Mental Health and Psychosocial Services for Resident
Penalty
Summary
The facility failed to provide adequate mental health and psychosocial services to a resident diagnosed with depression and anxiety, who also had a history of trauma and post-traumatic stress disorder. The resident, who had multiple medical conditions including cardiovascular disease, chronic kidney disease, and chronic obstructive pulmonary disease, experienced several falls, a hospitalization for a hip fracture and head injury, and exhibited behavioral issues upon returning to the facility. Despite these challenges, the facility did not reinstitute the resident's long-standing medication therapy for depression and anxiety after hospitalization, nor did they provide sufficient psychiatric evaluations or psychosocial treatments. The resident's clinical record revealed a lack of consistent psychiatric care, with only two psychiatric evaluations conducted from admission until the time of the survey. The facility's management of the resident's psychoactive medications was erratic, with rapid changes in medication regimens that could have contributed to the resident's psychological distress. The facility also failed to conduct necessary assessments, such as a CT scan following the resident's head injury, to determine the cause of the resident's distress. Additionally, the care plan lacked specific interventions for the resident's psychiatric needs, and non-pharmacological interventions were not specified or implemented. Interviews with facility staff indicated a lack of training in psychiatric and behavioral health care, and care planning meetings were not interdisciplinary, involving only the discharge planner and activities director, neither of whom were trained in healthcare. The facility's failure to provide adequate mental health services and appropriate medication management, coupled with insufficient staff training and care planning, contributed to the deficiency identified by surveyors.
Failure to Address Language Barrier and Aggression in Resident
Penalty
Summary
The facility failed to provide necessary medically-related social services to a resident who was strictly Spanish-speaking and exhibited signs of frustration and aggression. This resident, identified as Resident #521, was involved in multiple incidents of aggression and abuse towards other residents, which were not adequately assessed or addressed by the facility's social worker. Despite the resident's language barrier and signs of distress, there was no comprehensive care plan developed to address these issues, nor was there timely intervention from medical social work or psychiatric consultation. Resident #521, who had a mild cognitive impairment and spoke only Spanish, was involved in aggressive incidents with at least three other residents. The facility staff failed to monitor the resident's behavior, obtain a timely psychiatric consult, or provide a comprehensive care plan for emotion regulation. The resident's aggressive behaviors, including physical abuse and intimidation, were not properly documented or reported to the state agency, and the facility's abuse policy was not implemented to protect other residents from further harm. The facility's social worker was only involved with Resident #521 on three occasions, none of which addressed the resident's aggressive behaviors or language barrier. The social worker was not informed of the ongoing issues, resulting in a lack of documentation and intervention. The facility's failure to address the resident's needs and protect other residents from abuse highlights significant deficiencies in the provision of social services and adherence to abuse prevention policies.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility staff failed to procure routine medications as ordered by the physician for two residents, leading to deficiencies in medication administration and documentation. For one resident, the staff did not sign off on the administration of 9 a.m. medications on a specific date, nor did they document why the medications were not given. The medications included essential drugs such as aspirin for atrial fibrillation and Namenda for dementia. The Director of Nursing (DON) acknowledged that the lack of documentation gives the appearance that nothing was done, highlighting a failure to adhere to the facility's Medication Administration Policy. Additionally, the facility staff did not establish a proper system for the receipt and disposition of controlled drugs, as evidenced by the presence of too many count narcotics in an unlocked file cabinet. Interviews with nurses across different units revealed inconsistencies in the process for disposing of narcotic medications. The DON demonstrated the current process for narcotic destruction, which involves locking medications in a safe until another nurse is available to witness and countersign the disposal form. Another resident did not receive oral antibiotics as per physician's orders due to the medication not being available. The resident was admitted with conditions including osteoarthritis and septic arthritis of the knee. The medication, Amoxicillin, was missed six times during the treatment course, including four consecutive doses. The Regional Nurse Consultant stated that the pharmacy should have ensured the medication was available, and the nurses should have checked the Omnicell for an available supply. The facility's acting administrator and other staff were informed of these findings during the end-of-day debriefing.
Improper Beard Guard Use by Kitchen Staff
Penalty
Summary
The facility staff failed to ensure food was prepared in accordance with professional standards for food service safety. During the preparation of the evening meal, a staff member identified as the cook was observed with a beard guard that only partially covered his facial hair. When questioned, the cook stated that the facility only provided beard guards that did not fit properly. The facility policy requires all Dining Services employees to wear approved attire, including properly restrained facial hair. A corporate employee confirmed the expectation that facial hair should be fully covered, aligning with the facility's policy. The Administrator was informed of this issue during an end-of-day meeting, but no further information was provided.
Failure to Maintain Essential Equipment in Safe Operating Condition
Penalty
Summary
The facility staff failed to maintain essential equipment in safe operating condition, specifically the dishwasher and two washing machines. During a kitchen inspection, it was observed that the kitchen staff were using Styrofoam takeout containers for food service due to the dishwasher being non-functional for several weeks. Despite the arrival of a new dishwasher, it had not been installed until the survey was conducted. Interviews with staff revealed uncertainty about the timeline of the dishwasher's downtime, with documentation showing the dishwasher was purchased in early August and arrived at the facility in late September. Additionally, the facility faced issues with laundry services due to two out of three washing machines being broken. The director of housekeeping reported a shortage of linens and delays in laundry processing, as they were operating with only one functional washing machine for 180 beds. The broken washers had been out of service since the end of September, and by the close of the survey, they had not been repaired or replaced. The administrator was informed of these concerns during the survey, but no further information was provided.
Medication Administration Deficiency Due to Staffing Issues
Penalty
Summary
The facility staff failed to meet professional standards by not administering medications as ordered for one resident. This resident, who was admitted with multiple diagnoses including sepsis, dementia, cardiomyopathy, Parkinson's, and COPD, was cognitively intact but required total dependence for most activities of daily living. The comprehensive care plan indicated the need for cardiac medications as ordered. However, a review of the medication administration record for December revealed that the 9:00 PM doses of several medications, including Atorvastatin, Sinemet, Zaleplon, and Xalatan, were missed on December 31st. An interview with an LPN revealed that staffing issues contributed to the failure to administer medications as ordered. The LPN stated that there were times when there was inadequate staffing, with no nurse scheduled for a unit or minimal CNAs available, which was not sufficient to meet the residents' needs. The LPN confirmed that not administering medications as ordered did not align with professional standards. The facility's administrative and clinical leadership were made aware of these findings, but no further information was provided before the survey exit.
Deficiency in ADL Care Documentation and Provision
Penalty
Summary
The facility staff failed to provide evidence of activities of daily living (ADL) care, specifically incontinence care and feeding assistance, for one resident. This resident was admitted with chronic kidney disease, vascular dementia, and stroke with hemiplegia, and was assessed as requiring extensive assistance for various ADLs. The comprehensive care plan highlighted the resident's risk for weight loss or malnutrition, necessitating specific interventions such as recording meal intake and providing supplements. However, documentation for bladder elimination and grooming was missing on multiple occasions across March, April, and May 2024. Interviews with facility staff revealed inconsistencies in the provision of incontinence care, with a certified nursing assistant indicating that care frequency depended on staffing and resident needs. The resident reported not always being kept dry and experiencing long waits for care, although noting some improvement. Despite these findings being communicated to the facility's administrative and clinical leadership, no further information was provided before the survey exit.
Failure to Provide Consistent Catheter Care
Penalty
Summary
The facility staff failed to provide appropriate urinary catheter care for a resident, identified as Resident #4, who was admitted with multiple diagnoses including sepsis, dementia, cardiomyopathy, Parkinson's, and COPD. The resident was assessed as cognitively intact and required total dependence for various activities of daily living, including hygiene and toileting. The physician orders specified that Foley catheter care should be provided every shift, with documentation of output and monitoring for signs of infection. However, a review of the treatment administration record (TAR) for December 2023 and January 2024 revealed multiple instances of missing documentation across various shifts, indicating that the required catheter care was not consistently provided. During an interview, an LPN confirmed that if there was no documentation of Foley catheter care on the TAR, it was not provided. The facility's administrative and clinical leadership, including the administrator, assistant administrator, director of nursing, and regional directors of clinical services, were informed of these findings. No additional information was provided before the survey exit, indicating a lack of evidence to demonstrate that the required catheter care was consistently administered to the resident.
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What surveyors actually found near you
We read the 180 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Virginia Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Health & Rehab Center, Llc | 0.1 mi | ★★★★★ | 0 | 0 |
| Bay Pointe Rehabilitation And Nursing | 0.2 mi | ★★★★★ | 0 | 0 |
| Westminster-canterbury On Chesapeake Bay | 4.1 mi | ★★★★★ | 0 | 0 |
| Rosemont Health & Rehab Center, Llc | 4.7 mi | ★★★★★ | 0 | 0 |
| Birchwood Park Rehabilitation | 4.9 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.