Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodmont Center during CMS and state inspections, most recent first.
Unsanitary Dumpster Area: The facility failed to keep the exterior dumpster area sanitary. During an observation with the dietary manager, debris was found scattered behind the dumpsters, including a black egg crate, latex gloves, napkins, and batteries. The dietary manager stated kitchen staff oversee the area and had been sent out after the dumpster was emptied, but the area was still not maintained in a clean condition. The facility policy stated the Dining Services Director coordinates with the Director of Maintenance to keep the dumpster area free of rubbish or other debris.
The facility failed to ensure required QAPI committee members attended two reviewed meetings. Sign-in sheets did not show the administrator present at one quarterly meeting and did not show the MD present at another, and the administrator stated the MD was absent during a provider transition while she was not the administrator during the earlier meeting. The facility policy identified the QAA committee as including the administrator, DON, and MD.
Staff failed to consistently develop and implement comprehensive care plans for multiple residents, resulting in undocumented or omitted interventions for pain management, catheter care, fluid restriction, transfers, activities, dialysis communication, mobility, and bathing. Cognitively intact and impaired residents with pain did not have non-pharmacological interventions documented as required. Residents with indwelling catheters and ESRD lacked complete intake/output, catheter care, and fluid restriction monitoring despite physician orders and care plan directives. Other residents who required maximal assist or mechanical lifts for transfers were not consistently documented as being transferred, and one resident reported not being offered to get out of bed daily. A resident who valued voting and religious practice was not assisted to vote and had to request chaplain visits, while another on dialysis lacked consistent dialysis communication documentation. One resident with an OT-ordered hand splint had no corresponding care plan entry, and another dependent resident received fewer showers than the twice-weekly schedule specified in the care plan and described by staff. Staff interviews confirmed that care plans are intended to guide care, that missing documentation means care was not provided, and that the interdisciplinary team is responsible for updating and implementing care plans.
Staff failed to consistently provide and document ADL care, including bathing, transfers, and grooming, for several dependent residents. One resident who required assistance with bathing received far fewer showers than the twice-weekly schedule, despite being in the facility most days. Another cognitively intact resident who depended on a mechanical lift was rarely transferred out of bed over several months, while documentation often showed "not applicable" or no transfer entries. A third resident needing maximal assist for transfers had numerous days across all shifts with missing transfer documentation, which a CNA acknowledged meant the care likely did not occur. A dependent resident with advanced MS and keloids was observed with significant facial hair and reported waiting for a family member to bring an electric shaver, while therapy notes and staff interviews showed ongoing distress and lack of grooming assistance. Another severely cognitively impaired, fully dependent resident was observed in bed throughout multiple survey observations and was not transferred to a wheelchair, with the assigned CNA citing time constraints and a mistaken belief that therapy had said the resident did not need to get up.
Facility staff failed to follow professional standards for food storage, preparation, and sanitation in the kitchen and on a resident hallway. Surveyors observed dirty food-contact equipment, improperly stored dry goods, and wet pans stacked and dripping in clean storage areas. Hot foods were held and served below the facility’s stated minimum of 135°F. Expired milk cartons were placed on breakfast trays and in the milk supply on a hallway, with both dietary and nursing staff not identifying the out-of-date product. In the kitchen, a pizza cutter that had fallen to the floor and other utensils, trays, and dome lids were inadequately sanitized, with submersion times far below the one-minute contact time required by the sanitizer manufacturer, and some items not fully submerged. A dietary staff member also used a soiled utility cart and contaminated gloves to handle both dirty and clean dishware without cleaning the cart between uses, contrary to facility policy.
Failure to Inform and Assist Residents With Voting: A cognitively intact resident was not informed about voting rights or the voting process, despite care plan documentation noting that voting was important to her. Staff reported there was no formal process for offering voting assistance, and multiple cognitively intact residents stated they were not informed about the election or assisted with in-person or absentee voting. Facility policy required staff to provide voting assistance and make residents aware of voting opportunities.
Failure to respond to Resident Council concerns. Six cognitively intact residents reported that staff attended Council meetings but did not consistently address concerns or follow up with them. Minutes showed unresolved issues with delayed call bell response, staff using earbuds or phones during direct care, a late weekend lunch, and staff not being courteous. Residents also reported that call bell delays and staff phone/earbud use were still ongoing, and the record lacked evidence of investigation or response to the concerns raised.
Failure to complete required pre-employment screening: The facility did not follow its hiring and abuse-prevention policies for 22 of 25 employee records reviewed. Missing items included sworn statements, criminal background checks, license verification, and reference checks for multiple hires, including administrators, RNs, LPNs, CNAs, housekeeping, dietary, maintenance, and other staff. The Scheduling and Payroll Manager and Senior Scheduling Manager stated these checks should be completed before a candidate starts work, and the facility policy required screening for abuse history and verification of credentials.
Failure to send required transfer paperwork and bed hold notices: The facility did not document that required clinical information was sent with residents transferred to the hospital, and it also failed to provide bed hold notices and care plan goal summaries for other residents. One resident had CHF, GERD, spinal stenosis, and HTN; another had ESRD, hemodialysis, and DM and was sent out after becoming lethargic and hard to arouse. Staff gave conflicting accounts about whether nursing or admissions was responsible for the transfer paperwork and bed hold notifications.
A resident with advanced MS, MDD, and chronic respiratory failure did not receive preferred chaplain visits as part of her activity plan. She stated she had to ask for more visits, while the care plan noted her religious preference and the Activities Director described limited room-based chaplain engagement and routine one-to-one activities. Recreation records showed only occasional spiritual support visits and mostly independent TV/resting activities.
Staff failed to carry out ordered mobility-support interventions for two residents. One resident with stroke-related impairment was discharged from OT with a recommendation for restorative nursing/functional maintenance, but there was no evidence the exercises were provided or documented. Another resident with one-sided weakness had an OT order for a left-hand splint, yet the resident was observed without the splint and the TAR had no documentation showing it was applied.
Failure to monitor an ordered fluid restriction for a resident with ESRD, hemodialysis, and DM. The resident’s care plan identified renal risk and hemodialysis-related concerns, but the MAR-TAR had no evidence of fluid restriction monitoring. The physician order specified a 1500 ml daily fluid restriction divided between dietary and nursing, yet the meal ticket showed liquids served with breakfast, and staff gave conflicting statements about who was responsible for tracking the restriction.
A facility failed to complete a full pain management process for two residents receiving PRN analgesics. One resident with lower back pain and another resident with chronic pain had physician orders for PRN pain meds, but the eMAR and nursing notes did not show non-pharmacologic interventions before multiple administrations. The Unit Manager confirmed that staff were expected to assess pain, document pain location and severity, and attempt non-pharmacologic measures first, but this was not evidenced in the records.
A facility failed to provide documented dialysis care and services for one resident with ESRD, including missing hemodialysis site monitoring and no evidence of an ordered snack bag or early meal tray before dialysis. The resident also did not have the dialysis communication book available when requested. For another resident receiving HD, the facility did not complete the dialysis communication forms for multiple treatments, despite orders and care plan directions requiring the communication book to be sent to and reviewed from the dialysis center.
The facility failed to ensure CNAs completed the required annual training hours. Record review showed one CNA completed 3.44 of 12 required hours and another completed 7.90 of 12 required hours during their annual training periods. The DON stated training included in-services, an online training program, and competency skill fairs, and that a staff training coordinator would track staff training.
A facility failed to ensure three residents were free from unnecessary medications. One resident received PRN acetaminophen and oxycodone without defined pain-level parameters or documented non-pharmacological interventions, another resident received PRN Dilaudid without documented pain-scale parameters or attempted non-pharmacologic measures, and a third resident on apixaban had no evidence of anticoagulation monitoring on the MAR-TAR. An LPN stated that anticoagulation monitoring should include assessment for bruising, bleeding, tarry stools, and blood in urine.
Medication error rate exceeded the allowed threshold when surveyors observed three errors in 27 medication opportunities, resulting in an 11.11% error rate. An LPN was observed crushing medications for a resident with severe cognitive impairment and diagnoses including seizures and sub-arachnoid hemorrhage, even though the resident had orders for divalproex delayed release, sertraline capsules, and gabapentin, and another LPN stated that coated, capsule, and extended-release medications should not be crushed.
Food was repeatedly served cold and not palatable for multiple residents, based on resident interviews and a Resident Council meeting. Residents reported that meals were always cold, not hot, had no taste, and in some cases were too cold to enjoy or eat. The DON and Dining Services Director were aware of ongoing temperature concerns, and the Dining Services Director stated that broken equipment and disposable dishware made it impossible to keep food hot.
Incomplete Infection Surveillance Tracking: The facility failed to maintain a complete IPC tracking program because the infection logs reviewed only tracked infections requiring antibiotics and did not include viral infections or symptom-based tracking for infections not requiring antibiotics. The DON/IP stated she had not been keeping any other tracking log, although resident symptoms were reviewed when reported by staff, and the market clinical lead said a separate line listing was available but no additional logs were provided.
Facility staff failed to provide or offer scheduled showers or bed baths to a cognitively intact resident who required partial/moderate assistance with bathing. Although the shower schedule listed bathing on specific weekdays during the day shift, ADL documentation over multiple days showed entries coded as not applicable or not attempted, with some shifts left blank, and no evidence that bathing was provided or offered. A CNA who routinely cared for the resident confirmed the scheduled shower days and, upon review of the ADL records, acknowledged not knowing why the resident did not receive showers or bed baths and that there was no documentation that these were offered.
A resident with DM, Parkinson’s disease, dementia, adult FTT, severe cognitive impairment, and dependence for bed mobility and transfers was care planned as at risk for falls, with interventions including bed rails as an enabler and two-staff assistance for repositioning in bed. An agency CNA who had been at the facility about a week provided care without ensuring the low air loss mattress was in static mode, and the resident subsequently fell from bed and complained of left knee pain. Imaging showed a possible subtle distal femoral fracture. The DON described the resident as a one-person assist who held onto the bedrail and was alert but confused, and the facility’s falls policy required individualized interventions based on risk factors, which were not properly implemented in this instance.
Failure to assist a resident with shaving facial hair affected her dignity. The resident, who had advanced MS and was dependent for ADLs, said she was waiting for an electric shaver because she could not use facility razors due to keloids. Therapy notes showed she refused OOB care and ROM because she was unshaven, and the care plan did not address facial hair.
Unclear PRN pain medication orders led to a deficiency for two residents. One resident with lower back pain and another resident with chronic pain had orders for acetaminophen, oxycodone, and Dilaudid written for mild, moderate, or severe pain without defining the numeric pain ranges. The DON said staff follow facility policy, and the Unit Manager stated nurses assess pain on a 0 to 10 scale but could not define the ranges for mild, moderate, and severe pain.
Missing Indwelling Catheter Care and Urinary Output Documentation: Two residents with indwelling urinary catheters had missing TAR documentation for urinary output and catheter care across multiple shifts. One resident had orders to monitor intake/output and report low UO, but several shifts had no recorded output; the other resident, with ESRD, HD, and DM, had orders for catheter care every shift and output recording, yet the TAR showed multiple missed entries. An LPN stated that if it is not documented on the TAR, the care was not done.
Facility staff failed to store respiratory equipment in a sanitary manner for two residents. One resident with COPD had an incentive spirometer left uncovered on the bedside table, and another resident with sleep apnea had a CPAP mask left uncovered when not in use. An LPN stated both items should be placed in a plastic bag to keep them clean, and the facility policy for the spirometer required placement in a treatment bag.
Incomplete COVID-19 Immunization Documentation and Administration: The facility failed to document vaccine administration for three residents after consent forms were signed. Records showed pending or outdated COVID-19 immunization status, while the DON stated residents were screened and vaccines were offered if eligible, with doses grouped for cost purposes. However, the charts did not evidence that the COVID-19 vaccine was actually given after consent was obtained.
The facility failed to complete annual performance evaluations for five of five CNA records reviewed. During staff interview and record review, the DON could not locate evidence that CNAs #6, #8, #9, #10, and #11 had received the required yearly performance review, as required by facility policy.
Facility staff failed to follow care plans requiring a two-person assist for a resident with a below-the-knee amputation, resulting in a fall and serious injury. Additionally, after two separate falls involving another resident, staff did not update care plans or implement new interventions to prevent future incidents. Documentation and investigation procedures were not followed as required by facility policy.
Facility staff did not consistently implement or document comprehensive care plans for three residents, resulting in unmet care needs such as inadequate assistance with bed mobility leading to a fall and fracture, missed incontinence and wound care, lack of contracture management, and improper handling of a urinary catheter. Staff interviews and documentation reviews confirmed that care plans and physician orders were not followed as required.
Facility staff did not review or revise the comprehensive care plans for multiple residents after documented falls, despite clinical records and staff interviews confirming that care plans should be updated following such incidents. The care plans remained unchanged after each fall, contrary to facility policy and standard practice, as confirmed by staff and documentation review.
Staff failed to provide and document required ADL care for two residents, including incontinence care for a dependent, cognitively impaired resident and twice-daily oral hygiene for another resident needing assistance. Documentation was incomplete or incorrectly marked as 'not applicable,' and staff interviews confirmed that care was not provided as required.
Staff failed to maintain sanitary food service practices, including using a dirty floor fan that blew air onto clean dishware, not covering facial hair during food preparation, and not changing gloves between tasks such as handling food and touching unclean surfaces. Management acknowledged these lapses did not meet facility policy.
Facility staff did not ensure privacy for a resident with an indwelling catheter, as the catheter collection bag was repeatedly left uncovered and visible to anyone entering the room. The resident, who was alert with some forgetfulness and had a diagnosis of urinary retention, reported being bothered by the lack of privacy. This action was inconsistent with the facility's policy to treat residents with dignity and respect.
A resident was found lying in bed with the call bell on the floor and out of reach, and reported that staff only respond when the call bell is accessible. An LPN confirmed the call bell should be within reach and acknowledged it was not at the time of observation. The issue was reported to administrative staff, with no further information provided before survey exit.
Facility staff did not notify a resident's responsible party when a physician-ordered IV antibiotic for a serious foot infection was unavailable for administration. Although the nurse practitioner was informed and the pharmacy was contacted, there was no documentation that the responsible party was notified, as required by facility policy.
Staff did not maintain a clean and comfortable environment for a resident, as fall mats and floors in the resident's room were observed to have spilled liquids, debris, and dirt. Environmental services staff confirmed the cleaning protocols were not followed, resulting in unsanitary conditions despite facility policy requiring a clean and homelike environment.
Facility staff did not document or resolve a written grievance submitted by a resident's responsible party concerning wound care and other care issues. Despite being told the concerns were under review, the responsible party received no follow-up or resolution, and the grievance was not found in facility records. The resident was severely cognitively impaired and dependent on staff for ADLs, with a family member as their health care representative. Staff interviews confirmed a lack of documentation and uncertainty about the grievance process for this incident.
Facility staff did not submit a required admission MDS assessment within the federally mandated timeframe for a resident. The assessment was marked as in progress without a documented completion or submission date, and the MDS coordinator confirmed that some assessments had fallen behind due to staffing issues.
Facility staff did not develop a baseline care plan for oral hygiene for one resident and failed to implement ordered wound care for another, despite both needs being identified in their baseline care plans. Interviews and record reviews confirmed that required care planning and interventions were not completed or documented as per facility policy.
The facility did not ensure that a resident received proper care for pressure ulcers and failed to implement adequate preventive measures, resulting in the development or worsening of pressure ulcers.
A resident with an indwelling catheter for urinary retention was observed with their catheter collection bag lying on the floor, despite care plan interventions and physician orders requiring the bag to be kept off the floor. This failure to maintain proper catheter care was identified during a survey and reported to facility administration.
Staff failed to maintain an accurate medical record for a resident by documenting a progress note after the resident had expired and was no longer in the facility. The note, which described an advanced care planning discussion with the responsible party and DON, was not properly identified as a late entry, resulting in an inaccurate record.
Inaccurate MDS coding was identified for a resident whose records documented a Foley/indwelling catheter, including the care plan, hospital discharge paperwork, physician notes, and TAR entries for catheter care. However, the Medicare 5-day and discharge return anticipated assessments coded the catheter as "no," while the MDS coordinator later stated it should have been coded "yes" based on the documentation.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain one of one dumpster area in a sanitary manner. During an observation of the dumpster area behind the facility with the dietary manager, debris was seen scattered behind the dumpsters, including a black egg crate, latex gloves, napkins, and batteries. The dietary manager stated that kitchen staff oversee maintaining the area and that staff had been sent out to clean the area after the dumpster was emptied that morning, but staff had not done a good job. Review of the facility's Dispose of Garbage and Refuse Policy showed that the Dining Services Director coordinates with the Director of Maintenance to ensure the exterior dumpster area is maintained free of rubbish or other debris.
QAPI Committee Missing Required Members at Meetings
Penalty
Summary
The facility failed to ensure attendance of the required members at two of nine reviewed QAPI meetings. Review of the QAPI meeting sign-in sheets did not show the administrator present at the Q4 2025 meeting and did not show the medical director present at the Q1 2026 meeting. During an interview on 4/24/2026, the administrator stated she was not the administrator at the facility during the Q4 2025 meeting and would look for documentation of the former administrator’s attendance, and stated the medical director did not attend the Q1 2026 meeting because the facility was transitioning between providers at that time. The facility policy stated that the QAA committee functions under the authority of the administrator and governing body and is composed of the administrator, DON, and medical director.
Failure to Develop and Implement Comprehensive Care Plans Across Multiple Care Areas
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for multiple residents across pain management, catheter care, fluid restriction, transfers, activities, dialysis communication, mobility, and bathing. For two residents with pain, staff did not follow care plan directions for non-pharmacological interventions. One cognitively intact resident with frequent severe back pain received PRN acetaminophen and oxycodone, but nursing progress notes from early April showed no documentation of non-pharmacological pain interventions in numerous opportunities, despite the care plan requiring evaluation of pain characteristics and use of such measures. Another resident with chronic pain and moderate cognitive impairment received PRN hydromorphone for moderate to severe pain, but the eMAR and nursing notes lacked evidence of non-pharmacological interventions at multiple documented administration times, contrary to the pain-focused care plan. For residents with urinary catheters and renal conditions, staff did not consistently implement care plan interventions or related physician orders. One resident with an indwelling catheter and an order for daily intake and output monitoring, with instructions to report urinary output below a specified amount, had multiple shifts with no recorded urinary output on the TAR, despite a care plan directive to monitor catheter output for odor, color, consistency, and amount. Another resident with ESRD and a neurogenic bladder had a care plan requiring catheter care twice daily and recording of output, and physician orders for catheter care every shift and regular emptying of the drainage bag; the TAR showed missing documentation of catheter care and output on several day and night shifts. The same ESRD resident also had physician orders for a specific daily fluid restriction total, divided between dietary and nursing-provided fluids, but there was no evidence on the MAR/TAR of fluid restriction monitoring, and the care plan for impaired renal function did not include fluid restriction monitoring as an intervention. Staff also failed to implement care plans related to transfers, activities, dialysis communication, mobility, and bathing. One resident requiring maximal assistance of one to two staff for transfers had numerous missing entries in ADL documentation for transfers across multiple dates and shifts, with a CNA stating that if care was not documented, it did not happen. Another resident, cognitively intact and dependent for mobility, had a care plan stating it was important to engage in meaningful routines, including voting and religious activities; the resident reported no one approached her about voting in a recent election and that she had to ask to see the chaplain more often, despite care plan interventions noting the importance of voting and religious engagement. A resident with a left-hand splint ordered by OT had no corresponding care plan update addressing limited range of motion or the splint, and the same resident on hemodialysis had a care plan intervention to send and review a dialysis communication book each treatment, but dialysis communication records were missing for several dialysis dates. Additional failures involved assistance out of bed and bathing frequency. One cognitively intact resident, dependent on staff for transfers and requiring a total mechanical lift with two-person assist, reported not getting out of bed every day and only being offered to get up when enough staff were available; ADL documentation over several months showed the resident was transferred out of bed only a small number of times, with many days marked as not applicable or not attempted, even though staff interviews indicated residents should be offered to get out of bed daily and refusals documented and reported. Another resident, severely impaired for decision-making and dependent for ADLs, had a care plan stating it was important to choose between a shower or bed bath and that extensive assistance for bathing would be provided, with showers scheduled twice weekly. ADL records showed this resident received only one shower in one month and five showers in the following month, despite the stated expectation of twice-weekly showers, and staff confirmed showers were scheduled twice weekly and refusals should be documented and reported. Throughout the report, multiple LPNs, a CNA, and the MDS Coordinator acknowledged that the purpose of the care plan is to guide and assist staff in providing appropriate care and that the interdisciplinary team is responsible for implementing and updating care plans. They also confirmed that missing documentation indicates care was not provided and that specific interventions, such as fluid restriction monitoring, dialysis communication, and daily transfer offers, should be reflected in and carried out according to the care plans. The Administrator and DON were notified of each set of findings, and no additional information was provided prior to exit.
Failure to Provide and Document Required ADL Care for Multiple Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, including bathing, transfers, and grooming, to multiple dependent residents as documented in clinical records, observations, and interviews. One resident who was severely cognitively impaired and required partial/moderate assistance for showering was care planned to receive assistance with bathing and to choose between a shower or bed bath. ADL documentation over two separate months showed this resident received only one shower in one month and five showers in the following month, despite facility staff stating that showers are scheduled twice weekly and refusals are to be documented and reported. Census records showed the resident was out of the facility on only one day during this period, and the facility’s ADL policy required necessary care and services to maintain grooming and personal hygiene. Another resident, cognitively intact and dependent on staff for transfers using a total mechanical lift, reported not getting out of bed every day and stated staff only offered to get them up when enough staff were available. Observations over multiple days showed this resident in bed, and ADL documentation over three months reflected very limited transfers out of bed, with many days coded as not applicable or not attempted due to medical condition or safety concerns. Staff interviews indicated that not applicable should only be used when a resident is not in the building or is not allowed to get out of bed, and that all residents should be offered to get out of bed daily with refusals documented and reported to the physician and responsible party. A third resident, cognitively intact and requiring maximal assistance for mobility, transfers, bathing, dressing, and hygiene per MDS and care plan, had numerous dates across all three shifts with missing ADL transfer documentation. A CNA confirmed that transfers are documented in the electronic record and that if there is no documentation, it means the care did not occur. Another resident, dependent on staff for transfers, mobility, and requiring maximum assistance with hygiene and bathing, was observed with a large amount of facial hair and reported waiting for a family member to bring an electric shaver due to keloids and an inability to use facility razors. Therapy notes documented the resident’s repeated statements about waiting for a shaver, her distress about her appearance, and her refusal to participate in certain therapy activities because of her unshaven face, while a CNA described her as totally dependent and stated she believed the resident was waiting for someone to come and shave her and that the resident refused a lot. A fifth resident, severely cognitively impaired and completely dependent on staff for transfers from bed to wheelchair, was observed lying in bed multiple times over two survey days and was never seen out of bed during surveyor presence. The resident’s representative expressed concerns about whether staff were assisting the resident out of bed. The CNA assigned to the resident on one of those days stated the resident was completely dependent for all ADLs and admitted she did not transfer the resident out of bed because she arrived late to the unit as a float CNA, had other residents to care for, and believed, based on what she said a therapy staff member told her, that the resident did not need to get up that day. The therapy assistant later stated she had not instructed any CNA that the resident did not need to get out of bed and explained that it was beneficial for the resident to be up in the wheelchair as much as tolerated each day and that he had previously been up much of the time each day before his most recent readmission. Across these five residents, the survey findings showed failures to provide scheduled showers, to consistently offer and perform transfers out of bed, to document transfers as required, and to assist with grooming needs such as shaving, despite care plan directives, MDS assessments indicating dependence for ADLs, and facility policy requiring provision of necessary ADL care to maintain grooming and personal hygiene. Staff interviews repeatedly confirmed that care should be offered and documented, that refusals should be recorded and reported, and that lack of documentation indicates care was not provided, yet the records and observations did not support that these ADL services were consistently delivered.
Food Storage, Sanitation, and Temperature Control Deficiencies in Dietary Services
Penalty
Summary
Facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and on one resident hallway. During a kitchen observation, surveyors noted multiple soiled or improperly cleaned food-contact items, including a cutting board with dried red debris, ladles with yellow debris and a noodle attached, baking sheets with thick white debris, and a cake mixer guard and stand with white debris and the electrical cord stored inside the mixing bowl. Clean dish storage was also deficient: steam pans were stacked while still wet, and baking sheets on a rack were dripping water onto the floor. In the refrigerator, an unlabelled, undated 2‑quart container with a thick yellow substance identified by the dietary manager as butter was found. In dry storage, an open, undated bag of potato chips was not closed after opening, a blue bag of parboiled rice was left open inside a 25‑lb box, and a container of chicken base was found with the lid off on a cart. These conditions were inconsistent with the facility’s written policies requiring utensils and food-contact surfaces to be clean and sanitized after each use and dry goods to be properly sealed and date marked. Hot food holding and service temperatures were also not maintained according to professional standards and facility policy. Immediately prior to lunch tray preparation, surveyors measured five hot food items below the facility’s stated acceptable serving temperature of 135°F: mashed potatoes at 123.5°F, puréed peas at 133.3°F, gravy at 134.4°F, puréed burger at 110.0°F, and ground beef hamburger at 127.0°F. Despite these readings, staff proceeded to serve the lunch meal with the temperatures as recorded. The facility’s Dining Services policy specified that all foods would be held at appropriate temperatures greater than 135°F for hot holding, but this was not followed during the observed meal service. On a resident hallway, staff distributed expired milk and failed to ensure proper sanitization of utensils and warewashing. During breakfast tray distribution, 12 individual milk cartons on resident trays and in the ready-to-distribute supply were observed with an expiration date of the previous day. A CNA reported that dietary staff place milk in an ice-filled container on the tray cart and CNAs add milk to trays per resident request, and that dietary staff are responsible for checking expiration dates, while nursing staff are responsible for double-checking before serving. The Dining Services Director later confirmed that she and dietary aides are responsible for checking milk dates and acknowledged that expired milk had been placed in the hallway milk bucket and not identified by dietary or nursing staff. Surveyors also observed improper sanitization of a pizza cutter and other utensils and equipment at the three-compartment sink. After a pizza cutter fell to the floor, a dietary district manager briefly dipped it in the wash, rinse, and sanitizer sinks, leaving it in the sanitizer for less than three seconds before returning it for use in lunch service, contrary to the Dining Services Director’s statement that utensils should be immersed in sanitizer for at least 60 seconds. Additional observations showed a dietary staff member washing plastic tongs and submerging them in sanitizer for only 2–3 seconds before placing them in a drying rack. Later, corporate and facility dietary staff washed trays and dome covers, with observed sanitizer contact times ranging from approximately 3.38 to 40.83 seconds, and some dome covers not fully submerged in the sanitizer solution. Manufacturer instructions for the Oasis 146 Multi‑Quat sanitizer required exposure of food-contact surfaces to the sanitizing solution for at least one minute. Further, staff did not maintain separation between soiled and clean items and did not follow glove-use and cart-cleaning practices described in facility policy. A dietary staff member collected used plates and dome covers from meal carts onto a black utility cart while wearing one glove, picked up a plastic juice cup from the floor with the gloved hand, and then moved all items to the sink area. Without cleaning the cart, the staff member then used the same cart to receive washed dome lids from the sanitizer sink and stacked them on the visibly wet and debris-contaminated cart surface before transporting them to a storage rack in the kitchen. The dietary manager later stated that carts were supposed to be cleaned daily and after dirty items were placed on them, and that dishes had to go into sanitizer and then air dry, but she also stated there was no required time they had to sit in the sanitizer, which conflicted with the manufacturer’s instructions and the facility’s manual warewashing policy.
Failure to Inform and Assist Residents With Voting
Penalty
Summary
The facility failed to assist residents to exercise their right to vote and failed to inform a cognitively intact resident about her voting rights and the voting process. Resident #43 had a Quarterly MDS completed on 3/19/26 with a BIMS score of 13/15, indicating she was not cognitively impaired for making daily decisions. During an interview on 4/22/26, she stated that no one came to her about voting on Tuesday. Her comprehensive care plan dated 3/31/26 documented that it was important for her to vote while in the facility. The Activities Director stated that residents get absentee ballots in the mail and that she did not do voting for Tuesday, while the Social Services Director stated she only helps residents with voter registration or absentee ballots if they request it and does not always offer this assistance to all eligible residents. At a Resident Council meeting, six cognitively intact residents said none remembered being informed about the state election the previous day or being encouraged or assisted to vote in person or by absentee ballot. The facility policy required staff to provide assistance with voting activities, coordinate absentee ballots, and ensure patients were made aware of voting opportunities through announcements and other written communications.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to respond to concerns raised in Resident Council meetings for five of six months reviewed, including October through December 2025 and January through February 2026. During the 4/22/26 Resident Council meeting, six cognitively intact residents who regularly attended the meetings reported that staff attended at their request but did not always respond to the concerns they expressed, and that it was rare for staff to follow up with them about how concerns were addressed. Review of the Resident Council minutes showed unresolved concerns about delayed call bell response times, staff wearing earbuds or using phones while providing direct care, lunch being served as late as 3:00 p.m. on a weekend, and staff not being courteous in interactions with residents. The residents also reported during the 4/22/26 meeting that call bell response times were still delayed and that staff members were still wearing earbuds and conducting phone conversations while providing direct care. On 4/24/26, the Administrator stated that concerns raised in Resident Council should be recorded on a grievance form, investigated, documented, and followed up, with staff or the Council informed of progress toward resolution the next month. The facility policy stated that all grievances and concerns would be investigated, documented, and followed up on, but the record reviewed did not provide evidence of investigation and/or response to the concerns raised during the five months of meetings.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
The facility failed to follow its policies for screening potential employees to prevent abuse, neglect, and theft for 22 of 25 employee records reviewed. The missing pre-employment documentation included sworn statements, criminal background checks, license verification, and reference checks for multiple employees in a variety of positions, including administrators, RNs, LPNs, CNAs, a scheduler, a receptionist, maintenance staff, housekeepers, floor technician, cooks, a dietary aide, and a bookkeeper. Specific examples included an administrator hired without a sworn statement, license verification, or reference checks; an LPN hired without a sworn statement, criminal background check, or reference checks; and another LPN hired without license verification or reference checks. During interview, the Scheduling and Payroll Manager and the Senior Scheduling Manager stated that sworn statements should be completed at interview, submitted for Virginia State Police criminal background checks the same day, and verified before a candidate starts work. They also stated that reference checks are the Scheduler's responsibility and should be completed immediately after interview, and that the recruiter is responsible for verifying nursing licenses through the Virginia Board of Nursing. The Administrator and DON were notified of the concerns, and the facility policies reviewed stated that the center will screen potential employees for a history of abuse, neglect, or mistreating patients and will verify credentials, licenses, certificates, and request criminal background checks where applicable.
Failure to Send Required Transfer Documentation and Bed Hold Notices
Penalty
Summary
The facility failed to provide required clinical documentation and related notices when residents were transferred or discharged to the hospital. For Resident #7, who had diagnoses including CHF, GERD, spinal stenosis, and HTN and was cognitively intact with a BIMS score of 15, the record showed a hospital transfer on 1/27/26, but there was no evidence that clinical documents were sent with the resident. The facility’s discharge-transfer policy stated that transfer paperwork, medication information, advance directive documents, and the Bed Hold Notice of Policy & Authorization form were to be sent with the resident during hospital transfers. For Resident #2, who had ESRD, hemodialysis, and DM and was also cognitively intact with a BIMS score of 15, the record showed transfer to the hospital on 2/5/26 after a change in condition with altered mental status. Nursing documentation noted the resident was lethargic and hard to arouse, and the PCP responded to send the resident to the ER for evaluation. However, the record did not show evidence that clinical documents were sent to the hospital for this transfer. For Resident #1 and Resident #91, the facility failed to provide a written bed hold notice to the resident at the time of discharge to the hospital and failed to provide a summary of care plan goals to the receiving hospital. Interviews with nursing and admissions staff showed conflicting statements about who was responsible for sending bed hold notices and clinical information, with staff identifying both nursing and admissions as responsible at different times. The record review did not reveal evidence that the required bed hold notice or care plan goal summary had been provided for either resident.
Failure to Provide Preferred Spiritual Activities
Penalty
Summary
The facility failed to provide a resident with preferred activities by not ensuring regular visits with the chaplain as requested. The resident was admitted with diagnoses including advanced multiple sclerosis, major depressive disorder, and chronic respiratory failure. During interview, the resident stated that a chaplain comes to see her sometimes, but that she has to ask someone if she wants to see him more. Her comprehensive care plan documented that it was important for her to have opportunities to engage in daily routines meaningful to her preferences and noted that she is religious. The Activities Director stated that she sees residents at least two times a week and provides one-to-one activities for residents who do not leave their rooms, including this resident Monday through Friday. She also stated that the chaplain comes to the resident's room on the second Friday of every month. Review of the April recreation calendar showed one-to-one room visits with the chaplain offered only once during the month. Review of the resident's recreation participation records showed limited cultural or spiritual support individual engagement room visits in January, February, and March, with daily independent engagement documented as resting, thinking, watching nature, and watching or listening to TV or movies. The facility's recreation services policy stated that residents should be invited and encouraged to assist in planning recreation programming and be offered activities of preference and interest, including structured and individual programs.
Failure to Provide Ordered Restorative Services and Splint Use
Penalty
Summary
Facility staff failed to implement interventions to maintain residents’ mobility and range of motion for two residents. For one resident, the occupational therapist discharged the resident after skilled therapy for stroke-related upper and lower extremity impairment and documented that restorative nursing/functional maintenance program services were recommended to maintain current level of function and prevent decline in mobility. The resident was cognitively intact, used a wheelchair, and stated they were not receiving therapy services and that staff were not assisting with exercises or ROM exercises. Review of the clinical record did not show restorative nursing services after the therapy discharge, and the DON stated there was no evidence to provide that the discharge recommendations had been implemented. For the second resident, staff failed to apply a left-hand splint as ordered. The resident had documented one-sided upper and lower extremity impairment and an OT order for services to address upper extremity strength and tone and to assess the need for a resting hand splint or palmar guard for the left hand. During observation, the resident was in a wheelchair and not wearing a splint. Nursing staff stated splint use would be documented on the TAR, but there was no TAR documentation showing the splint was applied. Interviews with CNA, LPN, rehab, and administrative staff showed that restorative nursing tasks and splint use were expected to be carried out and documented, but the record did not contain evidence that these interventions were provided for the two residents. The rehab director stated that therapy had recommended restorative exercises for the first resident to maintain progress and prevent decline, and that therapy maintained documentation for splint trials for the second resident, but the survey record still lacked documentation of the ordered splint use and restorative services.
Failure to Monitor Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor fluid intake for Resident #2, who was admitted with diagnoses including ESRD, hemodialysis, and diabetes mellitus. The resident’s most recent MDS indicated a BIMS score of 15 out of 15, showing no cognitive impairment, and the resident was dependent for mobility, transfers, bathing, dressing, and hygiene. The comprehensive care plan identified the resident as at risk for impaired renal function and complications related to hemodialysis, but the interventions listed only medication monitoring and did not include evidence of fluid restriction monitoring. The physician orders dated 4/3/26 included a daily fluid restriction total of 1500 ml, with amounts assigned to dietary and nursing. However, there was no evidence on the April 2026 MAR-TAR for fluid restriction monitoring. A review of the 4/23/26 breakfast meal ticket showed liquids provided with the meal, including syrup, coffee or hot tea, milk, and fruit juice. The dietary manager stated dietary does not give residents any liquids, only nursing, while an LPN stated evidence of fluid restriction should be on the MAR and that the dietician divides it between nursing and dietary.
Failure to Document and Attempt Non-Pharmacologic Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to implement a complete pain management program for two residents who had physician-ordered PRN pain medications. For one resident with lower back pain, a quarterly MDS showed a BIMS score of 15/15 and frequent pain rated 8/10. The resident had orders for PRN acetaminophen for mild pain and PRN oxycodone for moderate to severe pain, and the care plan identified pain-related comfort concerns with an intervention to evaluate pain characteristics. Review of the eMAR and nursing progress notes for this resident showed that PRN acetaminophen was administered in 12 of 23 opportunities and oxycodone in 13 of 46 opportunities, but the record did not evidence non-pharmacological interventions in 13 of 46 opportunities. During interview, the Unit Manager stated that nurses were to assess pain, obtain the location and severity, and attempt non-pharmacological intervention before giving PRN pain medication, and she agreed that this was not documented for the resident. For the second resident, who had chronic pain and a significant change MDS with a BIMS score of 10/15 and occasional pain rated 5/10, the physician ordered PRN Dilaudid for severe and moderate-to-severe pain. The care plan directed staff to offer non-pharmacologic interventions prior to PRN pain medication administration and to use a pain scale. Review of the eMAR and nursing progress notes failed to show non-pharmacological interventions for multiple documented medication administrations, and the Unit Manager agreed that these interventions were not attempted for the listed dates and times.
Dialysis Care and Communication Deficiencies
Penalty
Summary
The facility failed to provide evidence of dialysis care and services for a resident with ESRD, hemodialysis, and DM. The resident’s care plan and physician orders directed dialysis three times weekly and required monitoring of the hemodialysis site for signs and symptoms of complications every shift. However, the treatment administration record did not show monitoring of the hemodialysis site on day shift for two dates, and there was no evidence that a snack bag or early meal tray was provided when the resident went to dialysis. The resident stated she did not take a snack bag or meal to dialysis, and the dialysis communication book could not be located when requested. The dietary manager stated the kitchen prepares snack bags or trays for dialysis residents when nursing notifies dietary, and then said the resident may not be getting them. An LPN stated the resident should be receiving an early meal tray or snack bag and that it should also be documented on the MAR like other dialysis residents; when asked whether there was evidence it was provided without documentation, the LPN stated there was no evidence of it being provided. The administrator and DON were informed of the findings. The facility also failed to implement a complete dialysis communication program for another resident receiving dialysis. The resident’s orders identified dialysis days, chair time, pickup time, and transport information, and the care plan directed that a communication book be sent to dialysis and reviewed upon return. Review of the dialysis communication record did not show completed communication forms for multiple dialysis appointments. Staff interviews stated that the communication form should be completed before each dialysis trip, placed in the communication book, sent with the resident, and reviewed when the resident returned.
Failure to Ensure CNAs Completed Required Annual Training Hours
Penalty
Summary
The facility failed to ensure CNAs completed the required annual training hours. Record review on 04/23/2026 showed CNA #9 completed 3.44 hours of the required 12 hours during the annual training period from 07/29/2024 through 07/29/2025, and CNA #10 completed 7.90 hours of the required 12 hours during the annual training period from 01/17/2025 through 01/17/2026. During an interview on 04/24/2026, the DON stated that staff training consisted of in-services, an online training program, and competency skill fairs throughout the year, and that a staff training coordinator would track staff training. The Administrator and DON were informed of the findings on 04/24/2026.
Unnecessary Medications and Incomplete Monitoring
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary drugs by not following ordered parameters and monitoring for PRN pain medications and anticoagulation therapy. For one resident with lower back pain and intact cognition, the record showed PRN acetaminophen and oxycodone orders for mild to moderate/severe pain, but the eMAR documented repeated administrations without defined numeric pain-level parameters and without documented non-pharmacological interventions. The Unit Manager reviewed the record and agreed that non-pharmacologic interventions were not attempted and that, without defined pain-level parameters, the resident may have received unnecessary pain medication. For a second resident with chronic pain and moderate cognitive impairment, the physician ordered PRN Dilaudid for moderate to severe pain. The eMAR showed multiple administrations of Dilaudid under two separate PRN orders during April 2026. The Unit Manager stated that nurses should assess pain location, severity on a 0 to 10 scale, and attempt non-pharmacological intervention before giving pain medication, and that these elements should be documented in the eMAR and nurse's note. After reviewing the eMAR and progress notes, the Unit Manager agreed that non-pharmacologic interventions were not attempted and that there were no defined pain-level parameters for the medication orders. For a third resident with CHF, GERD, spinal stenosis, and HTN, the physician ordered apixaban twice daily for coagulation. Review of the February, March, and April MAR-TAR showed no evidence of anticoagulation monitoring. An LPN stated that monitoring for a resident on anticoagulation should include assessment for bruising, bleeding, tarry stools, and blood in urine, and that this evidence should be found on the MAR-TAR. The facility's Medication Administration Guidelines policy stated that residents should be observed for medication actions/reactions and that adverse consequences should be reported to the prescriber and/or attending physician.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent. During medication administration observation, four residents were observed and three errors were identified out of 27 opportunities, resulting in an 11.11 percent medication error rate. The report states these errors had the potential to increase or decrease the effectiveness of the medications. During observation, an LPN was seen crushing medications for a resident with diagnoses including acute respiratory failure with hypoxia, epileptic seizures, encephalopathy, and non-traumatic sub-arachnoid hemorrhage. The resident’s MDS showed severe cognitive impairment, and the care plan addressed gastrointestinal symptoms or complications related to constipation, diarrhea, and a history of emesis. The resident had orders for divalproex sodium delayed release sprinkle capsules, sertraline capsules, and gabapentin, and the LPN stated the resident’s pills were crushed so he could swallow them easier. Another LPN stated that not all medications can be crushed, including coated, capsule, and extended-release medications. The facility’s medication administration policy stated that long-acting, extended-release, or enteric-coated dosage forms should generally not be crushed and that the need for crushing medications should be indicated on the resident’s orders and MAR.
Food Served at Cold, Unappetizing Temperatures
Penalty
Summary
Food was not served at a palatable temperature for six residents in the survey sample, including residents who were interviewed and reported that meals were consistently cold. Resident interviews documented complaints that the food was always cold, not hot, tasted bad, or was too cold to enjoy or eat. One resident stated that the cold temperature sometimes prevented him from eating or enjoying his meal, and another said the food had no taste and remained cold even when eaten in the dining room. During a Resident Council meeting, six cognitively intact residents who regularly attended were unanimous in reporting that the facility food was frequently served cold, even when it came directly from the steam table tray line in the kitchen to residents seated in the dining room. The Dining Services Director acknowledged ongoing concerns about food temperatures and stated that the dishwasher had been broken for a few weeks, making it impossible to keep food hot when served on disposable dishware; she also reported that the hot plate warmer had been broken before the dishwasher malfunctioned. The facility policy required food to be palatable, attractive, and served at a safe and appetizing temperature.
Incomplete Infection Surveillance Tracking
Penalty
Summary
The facility failed to implement a complete infection control tracking program. During review of the infection tracking logs from 4/1/2025 to the present, the logs documented only infections requiring antibiotic coverage and did not include viral infections or symptom tracking for infections that did not require antibiotics. The facility staff therefore did not maintain a complete line listing of infection surveillance information as described in the facility’s infection control policies. On 4/24/2026, the DON/IP and the market clinical lead specialist were interviewed. The DON/IP stated she had been in the IP role since the end of January 2026 or beginning of February 2026 and had not been keeping any type of tracking log other than the ones provided, although resident symptoms were reviewed when reported by staff. The market clinical lead specialist stated there was a separate line listing available to staff so the IP could track signs and symptoms to check for trends and that they would check to see if any were in the files, but no additional tracking logs were provided prior to exit.
Failure to Provide Scheduled Showers/Bed Baths and ADL Support
Penalty
Summary
Facility staff failed to ensure that a resident did not lose the ability to perform activities of daily living (ADLs) by not providing or offering showers or bed baths as scheduled. The resident was admitted with diagnoses including muscle weakness and, on the most recent MDS admission assessment with an ARD of 03/19/2026, scored 15/15 on the BIMS, indicating intact cognition for daily decision-making. Section GG of the MDS coded the resident as requiring partial/moderate assistance for showering/bathing. The facility’s 200 Wing Shower List showed the resident was scheduled for showers on Mondays and Thursdays during the 7:00 a.m. – 3:00 p.m. shift. However, review of the ADL documentation for March and April 2026 revealed multiple dates on which showering/bathing was coded as not applicable or not attempted, and there was no documentation that the resident received or was offered a shower or bed bath on those days. Specifically, the March 2026 ADL sheet showed that on 03/06/2026 the day shift was coded “09” (not applicable – not attempted and the resident did not perform this activity prior to the current illness), the evening shift “88” (not attempted due to medical condition or safety concerns), and the night shift “09.” On 03/23/2026, the day shift entry was left blank, and the evening and night shifts were both coded “09.” The April 2026 ADL sheet showed that on 04/13/2026 the day shift was coded “98,” the evening shift “88,” and the night shift “09,” and on 04/20/2026 all three shifts were coded “09.” During an interview on 04/23/2026, CNA #5, who provided care and showers to the resident and confirmed the scheduled Monday/Thursday shower days, stated she did not know why the resident did not receive showers or bed baths on the identified dates and acknowledged the resident should have been offered them. Upon review of the ADL sheets, CNA #5 confirmed there was no evidence that showers or bed baths were offered on those dates.
Failure to Ensure Safe Bed Environment Resulting in Resident Fall and Injury
Penalty
Summary
Facility staff failed to provide a safe environment and adequate supervision for a resident with significant cognitive and functional impairments, resulting in a fall from bed. The resident had diagnoses including DM, Parkinson’s disease, dementia, and adult FTT, and was assessed on the most recent MDS as severely cognitively impaired with a BIMS score of 04/15. The MDS Section GG documented that the resident was dependent for bed mobility, transfers, hygiene, and bathing, and required supervision for eating. The comprehensive care plan identified the resident as at risk for falls due to Parkinson’s disease, dementia, poor safety awareness, and general weakness, and included interventions such as use of bed rails as an enabler and requiring two staff to assist with repositioning/turning in bed. Despite these identified risks and interventions, the resident experienced a fall from bed. On the date of the incident, a CNA reported that the resident fell out of bed, after which the resident complained of left knee pain. The resident was unable to verbalize what occurred other than stating she fell out of bed. Subsequent evaluation and imaging showed a possible subtle distal femoral fracture of the left knee. A root cause analysis documented that the CNA, an agency staff member who had been working at the facility for about a week, failed to ensure that the low air loss mattress was placed in static mode prior to providing care. The DON stated that the resident was considered a one-person assist who would hold onto the bedrail and was described as alert but confused. The facility’s Falls Management policy required implementation and documentation of patient-centered interventions according to individual risk factors and adjustment of interventions as the patient’s condition changed, but the failure to properly set the mattress contributed to the unsafe environment and the resulting fall.
Failure to Assist with Grooming and Facial Hair Removal
Penalty
Summary
The facility failed to promote dignity for one resident by not assisting her with shaving facial hair. The resident was admitted with diagnoses including advanced multiple sclerosis, depression, gout, and hypertension. Her quarterly MDS showed a BIMS score of 13 out of 15, indicating she was not cognitively impaired for daily decisions, and she required dependent assistance for transfers, mobility, hygiene, and bathing. During interview, she stated she was waiting for her brother to bring an electric shaver because she could not use the facility razors due to keloids, and she said she just had to wait when asked how this made her feel. The clinical record included a photo of the resident without facial hair, but later therapy notes documented that she refused out-of-bed care and therapy because she was unshaven, stating, "you aren't the one that has to do this looking like a man." The care plan addressed total assistance with personal hygiene and grooming, but it did not address facial hair. A CNA stated the resident was totally dependent and allowed staff to take care of her totally, and when asked about the facial hair, said she was waiting for someone to come and do it for her and refused a lot.
Unclear PRN pain medication orders
Penalty
Summary
The facility failed to follow professional standards of practice for pain medication administration for two residents. For one resident with lower back pain and a quarterly MDS showing frequent pain rated 8 out of 10, the physician orders for PRN acetaminophen and oxycodone were written using terms such as mild, moderate, and severe pain, but the numeric pain ranges for those terms were not clarified. The resident was cognitively intact with a BIMS score of 15 out of 15, and the eMAR showed acetaminophen was given in 12 of 23 opportunities and oxycodone in 13 of 46 opportunities. For another resident with chronic pain and a significant change MDS showing moderate cognitive impairment with a BIMS score of 10 out of 15, the physician orders for PRN Dilaudid were also written for pain described as moderate to severe without defining the numeric pain range. The orders included Dilaudid 2 mg tablets given as 1.5 tablets every 8 hours PRN and later every 6 hours PRN. The eMAR documented multiple administrations of Dilaudid under both orders during April 2026. During interview, the DON stated nurses follow facility policies as the standard of practice. The Unit Manager stated that when administering PRN pain medications, nurses assess pain location and severity using a 0 to 10 scale and attempt non-pharmacological intervention before giving medication. She also stated she could not define the numeric range for mild, moderate, and severe pain and said the physician should be contacted to clarify the numeric range for pain medication administration. After reviewing the orders, she stated the order for the resident’s pain medication should have been clarified to define the numeric range for moderate pain.
Missing Indwelling Catheter Care and Urinary Output Documentation
Penalty
Summary
The facility failed to provide care and services for indwelling urinary catheters for two residents. For one resident, who had an order to keep the patient hydrated, obtain intake and output daily, and report urinary output less than 1200 mL daily, the April 2026 TAR showed no recorded urinary output on multiple shifts between 4/9/26 and 4/17/26, including day, evening, and night shifts on several dates. The resident was observed sitting up in the room on 4/21/26 and 4/22/26 with the catheter tubing visible. The care plan stated the resident required an indwelling catheter and that output was to be monitored for odor, color, consistency, and amount. An LPN/unit manager stated that urinary output documentation is used to monitor kidney function and hydration status and that if nothing is recorded for a shift, there is no way to determine the total 24-hour output. For the second resident, who was admitted with diagnoses including ESRD, hemodialysis, and DM, the MDS showed a BIMS score of 15 out of 15 and dependence for mobility, transfers, bathing, dressing, and hygiene. The care plan directed catheter care twice daily and PRN and to record output, while physician orders required emptying the drainage bag at least every eight hours, when half to two-thirds full, and every shift, and performing indwelling catheter care every shift. The TAR showed missing documentation for urinary output on multiple day and night shifts and missing documentation for catheter care on several day and night shifts. An LPN stated that documentation on the TAR is where urinary output and catheter care are evidenced and that if there is no documentation, the care was not done.
Improper Storage of Respiratory Equipment
Penalty
Summary
Facility staff failed to provide respiratory care and services for two residents by not storing respiratory equipment in a sanitary manner when not in use. One resident with diagnoses including COPD had an incentive spirometer ordered to be used as often as tolerated and was observed twice with the spirometer left uncovered on the bedside table. The resident was alert, oriented x3, and able to communicate verbally. The facility policy for incentive spirometers stated that after treatment the spirometer should be placed in a treatment bag with the patient's name, and an LPN stated it should be placed in a plastic bag to keep it clean. A second resident with diagnoses including sleep apnea had a CPAP order and was cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included CPAP/BiPAP therapy and interventions to educate and encourage use of the therapy. The resident's CPAP mask was observed twice uncovered on the bedside table when not in use. An LPN stated the CPAP mask should be placed in a plastic bag to keep it clean.
Incomplete COVID-19 Immunization Documentation and Administration
Penalty
Summary
The facility failed to implement a complete immunization program for three residents by not documenting administration of the COVID-19 vaccine after consent was obtained. For Resident #12, the clinical record showed 2025-2026 COVID-19 Nuvaxovid listed as pending immunization, and a Patient Informed Consent or Declination COVID-19 Vaccine 2025-2026 form documented consent signed on 4/2/26, but the record did not show the vaccine was administered afterward. For Resident #43, the record similarly showed 2025-2026 COVID-19 Nuvaxovid as pending immunization, with consent signed on 4/2/26 and no evidence of vaccine administration after consent. For Resident #36, the clinical record showed the last COVID-19 vaccine was administered on 8/28/2023, and a Patient Informed Consent or Declination COVID-19 Vaccine 2024-2025 form documented consent signed on 2/6/26, but the record did not evidence administration after that consent. During interview, the DON/ Infection Preventionist stated residents were screened for vaccinations and offered them if eligible, and that the facility tried to have five residents at a time for cost purposes. The DON stated that after consent was obtained, the vaccine was obtained from the pharmacy, an order was entered, and the vaccine was given; however, the records for these three residents did not show that occurred.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for five of five CNA records reviewed, including CNAs #6, #8, #9, #10, and #11. During staff interview and document review, no evidence could be located showing that these nurse aides had received the required performance review within the past 12 months. On 04/23/2026, the most recent performance evaluations were requested from the DON, and on 04/24/2026 at approximately 8:00 a.m., the DON stated that the evaluations for CNAs #6, #8, #9, #10, and #11 could not be located. The facility policy, Nurse Aide Training and Certification, stated that the service location must complete a performance review of every nurse aide at least once every 12 months. The Administrator and DON were informed of the findings on 04/24/2026 at approximately 12:32 p.m., and no further information was provided prior to exit.
Failure to Implement Fall Prevention Interventions and Inadequate Post-Fall Response
Penalty
Summary
Facility staff failed to implement required interventions for fall prevention for two residents, resulting in deficiencies related to accident hazards and supervision. In one case, a resident with a right below-the-knee amputation and multiple comorbidities, including heart failure, diabetes, and muscle weakness, was assessed as requiring a two-person assist for all activities of daily living (ADLs), including bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to the resident rolling off the bed and sustaining a right distal femoral fracture. Documentation confirmed that the care plan and CNA Kardex both specified a two-person assist, but this was not followed. Additionally, there was no evidence of a thorough investigation into the fall with serious injury, as required by facility policy. Staff interviews revealed inconsistent communication and understanding of care requirements for new admissions and readmissions. While some staff stated that care plans and Kardexes are used to inform CNAs of resident needs, the involved CNA did not follow the two-person assist directive. Witness statements and interviews indicated that the incident was not properly documented in the risk management system, and the required accident report was not completed. The facility's fall management policy mandates assessment, documentation, and implementation of individualized interventions, but these steps were not adequately performed in this case. In a separate incident, another resident experienced two falls within a four-month period. After each fall, there was no evidence in the clinical record or care plan that staff addressed or implemented new interventions to prevent future falls. Interviews with staff confirmed that interventions such as increased monitoring and toileting should be implemented post-fall, but the records did not reflect any such actions. The lack of follow-up and failure to update care plans or implement preventive measures contributed to the ongoing risk of falls for this resident.
Failure to Implement and Document Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for three residents, resulting in unmet care needs and adverse outcomes. For one resident with a right below-knee amputation, the care plan and CNA Kardex specified a two-person assist for bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to a fall from bed and a fracture of the distal right femur. Documentation and staff interviews confirmed that the care plan was in effect at the time of the incident and should have been followed. Another resident, assessed as severely cognitively impaired and fully dependent for ADLs, did not receive incontinence care and wound treatments as outlined in their care plan and physician orders. Multiple dates showed missing or inappropriate documentation for incontinence care, with staff confirming that such care should always be documented for a resident who is always incontinent. Additionally, wound care treatments were not administered or documented on several dates, and there was no evidence of resident refusal. The care plan also failed to address contracture management, despite the resident having a diagnosis and orders for splints and braces, as well as therapy recommendations for contracture prevention. A third resident with an indwelling urinary catheter had a care plan intervention to keep the catheter bag off the floor. However, observation revealed the catheter collection bag lying flat on the floor next to the bed. Staff interviews confirmed that the care plan should be implemented for resident safety. In all cases, the facility's own policies required timely development and implementation of individualized, measurable care plans, but these were not consistently followed or documented.
Failure to Review and Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following documented falls. For one resident, after a fall was observed and documented by nursing staff, there was no evidence that the care plan, which had been created months prior, was reviewed or updated to address the incident. Interviews with staff confirmed that care plans are expected to be updated after such events, but this was not done in these cases. Another resident experienced multiple falls, each documented in the clinical record, but the care plan remained unchanged after each event. Staff interviews reiterated the expectation that care plans should be updated after falls, but documentation did not support that this occurred. The facility's own policy requires care plans to be reviewed and revised after assessments and as needed to reflect changes in the resident's condition or response to care. Additional residents also experienced falls, with clinical records and fall investigations documenting the incidents and subsequent assessments, but without evidence of care plan review or revision. In each case, staff interviews confirmed the expectation for care plan updates following such events, and facility policies supported this requirement. Despite this, the care plans did not reflect the necessary reviews or changes after the falls, as confirmed by both documentation review and staff statements.
Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide required activities of daily living (ADL) care for two residents who were dependent on staff assistance. For one resident with severe cognitive impairment and total incontinence of bowel and bladder, documentation showed multiple instances across several months where incontinence care was not provided or not documented as provided on various shifts. The resident's care plan specified the need for incontinence care to maintain dignity and prevent complications, yet ADL records were either left blank or marked as 'not applicable' on days when care should have been given. Staff interviews confirmed that such documentation was inappropriate for a resident who was always incontinent and dependent on staff. For another resident, who was cognitively intact but required set-up or clean-up assistance with oral hygiene, the facility failed to provide oral care twice daily as required. Review of the ADL tracking sheets for this resident revealed missed oral hygiene care on several consecutive days, with documentation either left blank, marked as 'not applicable,' or coded without explanation for why care was not provided. Staff interviews confirmed that the resident did not receive oral hygiene care as required during these periods. Facility policy required that ADL care, including hygiene and elimination, be documented accurately and reflect the care provided by nursing staff. The deficiencies were identified through clinical record review, staff interviews, and examination of facility documentation, which consistently failed to show evidence of required care being provided or properly documented for these dependent residents.
Sanitary Food Service Deficiencies in Kitchen Operations
Penalty
Summary
Facility staff failed to maintain sanitary food service practices in the kitchen, as observed during multiple site visits. A floor fan was found on the dish room floor, blowing air across clean plate bases and covers, with visible debris and grease on the fan guard. The dietary manager acknowledged the fan was dirty and removed it after the observation. Additionally, a kitchen aide was seen plating pureed cake and assembling dinner trays without a cover over his mustache and facial hair, contrary to facility policy requiring facial hair to be restrained. The aide confirmed that his mustache should have been covered during food preparation. Further observations revealed a cook wearing gloves while performing multiple tasks, including opening and closing the walk-in refrigerator, wiping hands on a dirty apron, handling resident sandwiches, stacking dinner plates, and plating food, without changing gloves between tasks. The dietary manager confirmed that gloves should be changed between tasks to maintain sanitation. Interviews with dietary management staff indicated awareness of these issues and acknowledged that the observed practices were not sanitary and did not align with facility policy.
Failure to Provide Privacy for Catheter Collection Bag
Penalty
Summary
Facility staff failed to promote the dignity of a resident with urinary retention who had an indwelling catheter. On two separate occasions, surveyors observed the resident's catheter collection bag hanging uncovered on the lower portion of the bed, with the contents clearly visible. The resident was alert with some forgetfulness, as documented in the facility's clinical admission assessment. The physician's order specified the use of an indwelling catheter with straight drainage due to urinary retention. During an interview, the resident expressed discomfort and stated that it bothered him that anyone entering the room could see the urine in the collection bag. The facility's policy on resident rights requires that each resident be treated with respect and dignity, and that care be provided in a manner that promotes or enhances quality of life. Despite this policy, the lack of privacy for the catheter collection bag was not addressed prior to the survey exit.
Failure to Maintain Call Bell Within Resident's Reach
Penalty
Summary
Facility staff failed to accommodate the needs of a resident by not ensuring the call bell was within the resident's reach. The resident was observed lying in bed with the call bell on the floor, out of reach, and reported that staff only respond to the call bell when it is accessible. During an interview, an LPN confirmed that the call bell should be placed next to or clipped on the resident when in bed, and acknowledged that the call bell was not within reach at the time of observation. The issue was brought to the attention of the administrator and interim director of nursing, but no additional information was provided before the survey exit. The deficiency was identified through direct observation, resident interview, and staff interview, specifically noting the failure to maintain the call bell within reach for the resident while in bed.
Failure to Notify Responsible Party of Unavailable Medication
Penalty
Summary
Facility staff failed to notify the responsible party when a physician-ordered medication, Daptomycin, was not available for administration to a resident with a left foot infection and gangrene. The resident was alert with some forgetfulness, and the medication was ordered to be given intravenously every other day for 23 days. On the scheduled administration date, the medication was not available, and the nurse's note indicated that the pharmacy would deliver it during the next run and that the nurse practitioner was aware. However, there was no documentation that the responsible party was informed of the missed dose. Staff interviews confirmed that the facility's procedure requires notifying the responsible party when a medication is unavailable, and this notification should be documented in the progress notes. Review of the clinical record and facility documentation did not show evidence that the responsible party was notified as required. The facility's policy also mandates immediate notification of the patient's representative when there is a need to alter treatment significantly, such as when a medication is not available.
Failure to Maintain Clean and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to maintain a clean and comfortable environment for one resident, as evidenced by observations of the resident's room. During two separate visits, surveyors noted that the fall mats on both sides of the resident's bed had visible evidence of spilled liquids, causing the surveyor's shoes to stick to the mats. Additionally, there were bits of paper on both sides of the bed and dirt and debris behind the bed and nightstand. These conditions were present despite the facility's stated cleaning protocols. Interviews with the director of environmental services and another environmental services staff member confirmed that all resident rooms are supposed to be cleaned daily, including lifting and cleaning fall mats. However, both staff members acknowledged that the fall mats in this resident's room were in need of cleaning at the time of observation. The facility's own policy requires a safe, clean, and comfortable environment for residents, but this standard was not met for the resident in question.
Failure to Document and Resolve Family Grievance Regarding Resident Care
Penalty
Summary
Facility staff failed to demonstrate efforts to resolve a written grievance submitted by a resident's responsible party in November 2024. The grievance, which was related to wound care procedures and other care concerns, was sent to the former administrator. Although the responsible party was informed that the administration was investigating the concerns, there was no documented follow-up or resolution provided to the responsible party. Review of facility grievance records from January 2024 onward did not show any documentation of the November 2024 grievance, and staff interviews revealed uncertainty about whether an official grievance was completed or properly tracked. The resident involved was assessed as being severely impaired in making daily decisions and was dependent on staff for activities of daily living, with a family member designated as the responsible party and health care representative. Interviews with current and former administrative staff indicated a lack of clear documentation and follow-up regarding the grievance, and the facility's grievance log did not reflect the reported concern. The facility's policy required the administrator to oversee and track grievances through to their conclusion, but this process was not followed in this instance.
Failure to Submit Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to submit a required Minimum Data Set (MDS) admission assessment within the federally mandated timeframe for one resident. Clinical record review showed that the resident was admitted on a specific date, but the admission MDS assessment, while marked as in progress, did not have a documented completion or submission date within the required 14 days. This omission was confirmed through review of the resident's facesheet and MDS records. During an interview, the MDS coordinator, an LPN, acknowledged that the admission MDS was completed and submitted before the fourteenth day, but also stated that some MDS assessments had fallen behind due to staffing issues. The deficiency was brought to the attention of the administrator and acting DON, and no further information was provided prior to the survey exit.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans for two residents within 48 hours of admission, as required by facility policy. For one resident, who was admitted with muscle weakness and was cognitively intact, the baseline care plan did not address oral hygiene needs. The MDS coordinator confirmed that a baseline care plan for this resident was not developed, despite the facility's policy mandating a person-centered care plan be created within 48 hours of admission. For another resident, staff failed to implement the baseline care plan intervention for pressure injury treatment as ordered by the physician. The baseline care plan identified the resident as being at risk for skin breakdown and included an intervention to provide wound treatment as ordered. However, review of the electronic treatment administration record did not show evidence that the wound care was completed on a specified date, and there was no documentation of treatment refusal. Staff interviews confirmed that wound care should have been provided and documented according to the care plan.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents at risk for pressure ulcers did not consistently receive necessary interventions such as regular repositioning, skin assessments, or timely wound care. As a result, some residents developed new pressure ulcers or experienced worsening of existing wounds due to inadequate preventive and treatment practices.
Failure to Maintain Proper Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate care and services for an indwelling catheter for one resident. Specifically, the staff did not keep the resident's catheter collection bag off the floor, as observed during the survey. The collection bag was found lying flat on the floor next to the resident's bed, contrary to the care plan intervention that required the catheter to be kept off the floor. The resident had a diagnosis of urinary retention and was alert with some forgetfulness at the time of admission. The physician's order specified the use of a 16FR indwelling catheter with a 10cc balloon to bedside straight drainage for urinary retention. The comprehensive care plan, initiated upon admission, included an intervention to keep the catheter off the floor. Despite these documented requirements, the deficiency was observed and brought to the attention of administrative staff, with no additional information provided prior to the survey team's exit.
Failure to Maintain Accurate Medical Record Documentation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident. The clinical record for this resident documented a discharge date, but a progress note was entered with a date after the resident had already expired and was no longer in the facility. The note described an advanced care planning discussion with the resident's responsible party and the DON, referencing the resident's ongoing decline, multiple hospitalizations, and poor prognosis. However, the nurse practitioner who authored the note confirmed in an interview that the entry was made after the resident's death and should have been documented as a late entry, which it was not. The administrator reviewed the progress note and confirmed that the resident was not present in the facility on the date indicated in the documentation, acknowledging the inaccuracy of the medical record. Facility policy requires that documentation be completed at the time of service or during the shift in which care occurred, and that any late entries be clearly indicated as such. The failure to properly document the timing and nature of the entry resulted in an incomplete and inaccurate medical record for the resident.
Inaccurate MDS Coding for Indwelling Catheter
Penalty
Summary
The facility failed to provide an accurate MDS assessment for one resident, who was admitted with diagnoses including muscle wasting/atrophy, a sacral pressure ulcer, and atrial fibrillation. The most recent Medicare 5-day MDS assessment coded the resident as having a BIMS score of 15 out of 15 and indicated no cognitive impairment, while Section GG reflected extensive assistance needs for bathing, transfers, dressing, and toileting, with supervision for eating. The deficiency involved Section H, Bladder and Bowel, where the MDS coded indwelling catheter as "yes" even though the Medicare 5-day assessment and the 10/27/25 discharge return anticipated assessment coded indwelling catheter as "no." The resident’s care plan documented that the resident had a Foley catheter, hospital discharge and physician records identified a urethral catheter/Foley catheter, and the TAR showed indwelling catheter care was provided. During interview, the resident stated the catheter had been in place for several weeks, and the MDS coordinator acknowledged the catheter should have been coded "yes" on the MDS because it was documented in the care plan, hospital discharge summary, and physician note.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fredericksburg Health And Rehab | 4.3 mi | ★★★★★ | 3 | 0 |
| Carriage Hill Health & Rehab Center | 5.4 mi | ★★★★★ | 2 | 0 |
| Falls Run Nursing And Rehabilitation | 5.5 mi | ★★★★★ | 0 | 0 |
| Berea Health & Rehab Center | 5.6 mi | ★★★★★ | 14 | 0 |
| Heritage Hall King George | 13.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.