Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glasgow Hills Of Journey during CMS and state inspections, most recent first.
Expired Infectious Medical Waste Permit: The facility's Infectious Medical Waste Program permit was posted in the building but had expired. The administrator confirmed the lapse and said the invoice had been sent to corporate for payment but had not yet been paid at the time of the survey.
A resident filed a grievance about a missing pajama set, and the grievance form stated the item was being replaced, but the pajamas were still not replaced when the resident and SW were interviewed later. The facility did not make prompt efforts to resolve the grievance as documented in its grievance policy.
Incorrect Diagnosis on Care Plan: A resident’s care plan included hemiplegia/hemiparesis despite the diagnosis list and MDS showing no such diagnosis or impairments. The DON confirmed the care plan diagnosis was incorrect.
Two residents did not receive care in accordance with physician orders: one did not receive the full prescribed course of an antibiotic for a UTI, and another was administered hydrocodone-acetaminophen for pain levels below the ordered threshold, including when pain was documented as minimal or absent. The DON confirmed these deviations from prescribed care.
Surveyors found a dirty floor fan blowing toward the food prep area and multiple open, undated food items in a unit refrigerator. The dietary manager confirmed the fan was used to manage heat and that food items should have been dated, indicating a failure to maintain safe and sanitary food storage and preparation.
Surveyors identified that the facility failed to ensure accurate and complete medical records for multiple residents, including incorrect medication diagnoses and repeated misidentification of a resident's gender in psychiatric notes. The DON confirmed these documentation errors during the survey.
A resident who requires set-up assistance and cueing to use utensils during meals was observed feeding himself with his hands and dropping food, without staff providing the necessary supervision or prompts. Staff and therapy interviews confirmed the resident can use utensils with proper support, but this was not provided, resulting in a lack of dignity during mealtimes.
A resident with severe cognitive impairment and a documented lack of capacity was issued and signed Medicare non-coverage forms, rather than having the legal representative sign as required. Staff interviews confirmed the facility's process should have involved the legal representative, but an oversight led to the resident signing the forms.
A bathroom shared by residents was found to have a toilet seat in poor repair with worn plastic coating and discoloration, as well as missing baseboard trim, resulting in an environment that was not clean or homelike.
Surveyors identified that two residents had inaccurate MDS assessments: one resident with a tracheostomy was not documented as such on the MDS, and another resident's history of a fall prior to admission was not correctly recorded. These inaccuracies were confirmed by facility leadership.
A resident with a new seizure diagnosis was prescribed Divalproex Sodium, but the facility did not complete an updated PASARR to reflect this change. The Social Worker confirmed that the PASARR did not capture the new seizure disorder.
Two residents did not have care plans that accurately reflected their needs: one had a care plan that misstated cognitive status based on BIMS scores, and another's care plan failed to address the need for constant supervision and cueing during meals, despite staff and therapy observations confirming this requirement.
Surveyors found that the facility did not update care plans for two residents to reflect one resident's refusal of a catheter privacy cover and another resident's changes in Seroquel and Hydroxyzine dosages. The care plans did not accurately document the residents' current choices or medication regimens, as confirmed by the DON.
A resident was observed feeding himself with his hands and dropping food during meals, while staff interviews and a speech therapist confirmed he could use utensils if provided with constant supervision and cueing. However, his care plan only indicated set-up assistance, failing to reflect his true needs.
A resident with COPD and a respiratory disorder was observed receiving supplemental oxygen at a flow rate of four liters per minute via nasal cannula, despite a physician's order for two liters per minute as needed for shortness of breath. Staff confirmed the oxygen was set higher than ordered, and the resident denied making any adjustments.
A resident with a tracheostomy and PEG tube, as well as a history of ESBL, received care from an LPN who wore gloves but did not don a gown during high-contact procedures, contrary to the facility's Enhanced Barrier Precautions policy. The DON confirmed that gowns were required for such care activities.
A resident received multiple doses of PRN Ativan without appropriate documentation of behaviors or non-pharmacologic interventions, and the medication was administered for reasons not consistent with regulatory requirements. The physician's order lacked a specific time limit, and pharmacy recommendations to update the order were not promptly followed.
Surveyors found that the facility did not consistently implement or document care plans for several residents, including the use of non-pharmacological interventions before administering PRN Ativan and adhering to restricted limb precautions for those with dialysis access. Despite physician orders and care plan directives, blood pressure was repeatedly taken in restricted limbs, and non-pharmacological interventions were not documented prior to medication use.
Three residents experienced failures in following physician orders or appropriate documentation for restricted limb precautions, resulting in blood pressure measurements being taken on restricted limbs despite existing orders or lack of proper orders, as confirmed by the DON.
A resident's privacy curtain was found to have multiple large stains that had been present for several days. The issue was confirmed by the resident's roommate and acknowledged by a NA, who described the process for reporting such concerns to housekeeping for cleaning.
A resident experienced verbal abuse when a laundry staff member was argumentative and rude regarding laundry services. The incident was verified as abuse, indicating a failure to protect the resident from verbal mistreatment as required by facility policy.
A resident reported to hospital staff and surveyors that she was subjected to severe physical and verbal abuse by facility staff, including waterboarding, being thrown on the floor, forced cold showers, and derogatory remarks. Despite receiving this information, facility leadership acknowledged that the allegations were not reported to the appropriate agencies as required by policy.
A facility did not complete or document an investigation or required five-day follow-up after an alleged verbal abuse incident was reported by a resident's family member. Leadership confirmed that the necessary documentation was missing, despite facility policy requiring thorough investigation records.
A resident with a dialysis fistula in the left arm had blood pressure measurements taken in the restricted limb on multiple occasions, despite a physician's order to monitor the fistula and no order specifying blood pressure restrictions. The DON confirmed the absence of an order regarding the restricted limb.
A resident's medical record lacked accurate and complete documentation of a skin concern. While a Nursing Assistant Skin Inspection and Shower sheet noted a skin issue on the buttocks, this was not reflected in the physician's orders, care plan, or weekly skin assessments, which only documented a skin tear on the hand. The DON and a Corporate RN could not find any other record of the buttocks skin concern and believed it may have been documented in error.
The facility did not ensure that the most recent survey results were available for residents, family members, and legal representatives. The survey documentation in the lobby lacked the November 2023 results. The DON and ADON confirmed the absence of the latest survey in the public access binder, with the ADON noting the Administrator could email the results from outside the office.
The facility failed to perform required hourly and 15-minute checks for residents with fall risks and behavioral concerns, leading to multiple incidents of falls and a compromising situation involving a resident. Staff interviews revealed discrepancies in the documentation of these checks, and the DON acknowledged the oversight, which could have contributed to the incidents.
A facility failed to report a verbal abuse allegation involving a resident to State Authorities. A family member reported that staff were argumentative and unhelpful in calming the resident, which was overheard during a phone call. Despite documentation of the grievance, the facility did not complete a reportable form or conduct an investigation as required by their policy. The DON acknowledged the oversight and confirmed the lack of documentation of communication with the family.
The facility placed several residents on 15-minute monitoring checks due to sexual behavior or interactions without a clear policy or order for discontinuation. Interviews with the DON revealed that these checks were to continue for 90 days without formal guidance, affecting residents' quality of life.
The facility failed to administer medications on time for several residents, with delays ranging from over an hour to nearly three hours, and did not conduct required 15-minute monitoring or neuro checks as ordered. These deficiencies were acknowledged by the DON, with missing documentation and no nursing notes explaining the delays.
The facility did not ensure a safe environment, as a medication room door was left open and unattended, and an electrical box at the nurse's station was found with an unlocked padlock. These issues were observed by an LPN and reported to the Administrator.
The facility failed to accurately post daily staff information, not reflecting 13 callouts over two weeks. The Administrator confirmed the postings were not updated, potentially affecting a limited number of residents with a census of 99.
The facility failed to maintain a comfortable environment, as observed when residents were seen with blankets due to low temperatures. The ambient temperature was 61 degrees, while the thermostat was set to 69 degrees. A maintenance assistant adjusted it to 74 degrees, indicating a recurring issue with temperature control.
Two residents in a LTC facility, one with capacity and the other with moderate cognitive impairment, were involved in a consensual relationship. Despite their consent, the facility intervened by separating them and placing them on 15-minute checks, citing inappropriate behavior. Interviews revealed that the residents were not informed they could not have a relationship, and they expressed their desire to be together. The facility continued monitoring them, and they were not observed together during the survey.
The facility failed to report disciplinary actions against two LPNs to the Virginia Board of Nursing. One LPN had discrepancies in narcotic administration, while another failed to administer medications as ordered to multiple residents. Despite knowledge of these incidents, the facility did not report them to the nursing board.
The facility failed to ensure clear and accurate documentation in skin assessments, with 12 forms missing or having unidentifiable resident names, and lacking dates or shifts. The DON confirmed these deficiencies, noting all forms were signed by the Assistant DON.
Expired Infectious Medical Waste Permit
Penalty
Summary
The facility failed to comply with applicable state laws, regulations, and codes because its Bureau for Public Health, Office of Environmental Health Services, Infectious Medical Waste Program permit was expired. The permit was posted on the wall in the facility and had been issued on one date and expired on another date. During the survey, the administrator confirmed that the permit had expired and stated that she had submitted the invoice to corporate for payment, but it had not yet been paid. Later the same day, the administrator stated that she had just paid the invoice to renew the facility's Infectious Medical Waste Program permit and provided the receipt showing the invoice had been paid.
Failure to Resolve Resident Grievance About Missing Pajamas
Penalty
Summary
The facility failed to make prompt efforts to resolve a resident grievance involving missing pajamas. A review of the Resident and Family Grievances policy stated that the facility will make prompt efforts to resolve grievances. Resident #40 filed a grievance on 02/05/26 stating that a pajama set was missing, and the grievance form documented that the pajamas were being replaced with a resolution date of 02/10/26. However, during an interview on 05/11/26, Resident #40 stated the pajama set had not been replaced, and the Social Worker confirmed during an interview at 1:10 PM on 05/11/26 that the pajamas had not been replaced.
Incorrect Diagnosis on Care Plan
Penalty
Summary
The facility failed to develop a care plan for Resident #40 based on accurate diagnoses. During record review, the resident’s care plan included a focus stating the resident had hemiplegia/hemiparesis, with a date initiated of 04/07/26. However, the diagnosis list showed no diagnosis of hemiplegia or hemiparesis, and the MDS confirmed there were no impairments on either side. During interview, the DON confirmed the diagnosis on the care plan was incorrect and that Resident #40 did not have hemiplegia/hemiparesis.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with physician orders and professional standards of practice for two residents. For one resident, a physician ordered a seven-day course of Cipro 500 mg twice daily for a urinary tract infection, totaling 14 doses. Documentation showed that only 13 doses were administered, with one dose missed due to the medication not being available as noted in the nursing record. The Director of Nursing confirmed there was no documentation that the full course was given as ordered. For another resident, physician orders specified the use of acetaminophen for general discomfort and hydrocodone-acetaminophen for pain rated 6 to 10 on the pain scale. Review of the medication administration record revealed that hydrocodone-acetaminophen was administered on ten occasions when the resident's pain level was below the ordered threshold, including instances where the pain level was documented as 0, 3, 4, or 5. The Director of Nursing confirmed that the medication was given outside the parameters set by the physician's order.
Unsanitary Food Storage and Preparation Practices Identified
Penalty
Summary
During an initial tour of the kitchen and pantries, surveyors observed a cyclone floor fan covered in dust and not clean, positioned on the floor and blowing toward the food preparation area. The dietary manager acknowledged the presence of the dirty fan and indicated it was being used to manage heat. Additionally, in the dementia unit refrigerator, two open bottles of ranch dressing, a small open carton of vitamin D milk, and a small open bag of fiesta shredded cheese were found without any dates indicating when they were opened. The dietary manager confirmed that all items should have been dated. These observations demonstrate that the facility failed to store and prepare food in a safe and sanitary manner, as required by professional standards, potentially affecting more than an isolated number of residents.
Inaccurate Medical Records and Documentation Errors Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by inaccurate medication diagnoses and documentation errors. For one resident, a physician's order for Apixaban incorrectly listed the diagnosis as pleural effusion instead of pulmonary embolism. Another resident was prescribed Escitalopram Oxalate (Lexapro) for dementia, although the medication was intended for anxiety, and the diagnosis listed in the order was not appropriate for the medication being administered. These discrepancies were confirmed by the Director of Nursing during interviews. Additionally, a review of psychiatric evaluation notes for a third resident revealed that the psychiatrist repeatedly referred to a female resident as a male in the documentation, despite the resident's correct gender being noted elsewhere in the record. These errors in resident-identifiable information and medical record documentation were identified during the survey process and confirmed by facility staff.
Failure to Assist Resident with Eating to Maintain Dignity
Penalty
Summary
Staff failed to provide necessary assistance to a resident during mealtimes, resulting in the resident feeding himself with his fingers and dropping food on his clothes and the floor. Observations during two separate noontime meals showed the resident eating with his hands, struggling with certain foods, and leaving a mess in the dining area. No staff were observed prompting or assisting the resident to use utensils during these meals. Interviews with nurse aides and the speech therapist confirmed that the resident is capable of using utensils but requires constant supervision and cueing to do so effectively. The resident's care plan indicated that he requires set-up assistance with eating, but this intervention was not observed being implemented. The deficiency was confirmed with the Director of Nursing.
Failure to Obtain Proper Signatures for Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) forms were issued and signed in a timely manner by the appropriate individual for one resident reviewed for beneficiary protection notification. Record review showed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 06 and a physician determination of incapacity, signed the forms instead of the legal representative. The resident's emergency contact was listed as an Adult Protective Services (APS) worker and health care proxy. Staff interviews confirmed that the facility's process was to have the legal representative sign for residents lacking capacity, but in this case, the forms were signed by the resident due to an oversight.
Unclean and Unhomelike Resident Bathroom Environment
Penalty
Summary
During a facility tour with the Dementia Unit Director, surveyors observed that the bathroom shared between two resident rooms had a toilet seat in poor repair. The seat appeared dirty, but the director clarified that the discoloration was due to the plastic coating being worn off, and acknowledged having previously reported the issue to maintenance. Additionally, the same bathroom was found to have missing baseboard trim along the wall toward one of the rooms. These conditions resulted in the environment not being maintained in a clean and homelike manner as required.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. One resident, who had a tracheostomy tube placed prior to admission and was observed with a speaking valve, was not identified as having a tracheostomy on her MDS assessment with an assessment reference date of 05/22/25, despite medical records confirming the presence of the tracheostomy at admission. The Director of Nursing later confirmed the inaccuracy of this MDS assessment. Another resident's admission assessment indicated a history of a fall within the last 31-180 days prior to admission, but the corresponding MDS section J1700 B inaccurately documented that the resident had not fallen in the previous two to six months. The Nursing Home Administrator confirmed this MDS was also inaccurate.
Failure to Update PASARR for New Seizure Disorder
Penalty
Summary
The facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident who developed a newly evident or possible serious disorder. Record review showed that the resident had a physician's order for Divalproex Sodium, prescribed for seizures, but the most recent PASARR did not indicate a seizure disorder. During staff interview, the facility Social Worker confirmed that a new PASARR had not been completed to reflect the resident's seizure diagnosis.
Failure to Develop Comprehensive and Accurate Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the needs and status of two residents. For one resident with impaired cognitive function and a history of dementia, the care plan incorrectly documented the resident's cognitive status by stating a BIMS score greater than 12, when in fact all assessments consistently showed a BIMS score of 3, indicating severe cognitive impairment. This error was confirmed by the Director of Nursing, who acknowledged that the resident had never had a BIMS score of 12 during their stay, and that the care plan was inaccurate from its initial development and subsequent revision. For another resident, repeated observations during mealtimes showed the individual feeding himself with his hands, dropping food on his clothes and the floor, and having difficulty using utensils. Staff interviews confirmed that the resident required constant supervision and cueing to use utensils, and that he performed well with one-on-one assistance. However, the care plan only indicated that the resident required set-up assistance with eating, without addressing the need for ongoing supervision and cueing. This discrepancy between the resident's observed needs and the documented care plan was confirmed by both nurse aides and the speech therapist.
Failure to Revise Care Plans for Resident Preferences and Medication Changes
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents to accurately reflect their choices and changes in medication dosages. For one resident with a suprapubic catheter, the care plan did not document the resident's refusal to have a privacy cover placed on the urine collection bag, despite the resident and the DON confirming this preference during interviews. The care plan interventions listed several catheter-related tasks and precautions but did not initially include the resident's choice regarding the privacy cover. For another resident, the care plan was not updated to reflect changes in prescribed medications. Physician orders showed multiple changes in the dosage and administration schedule for Seroquel (Quetiapine Fumarate) and Hydroxyzine (Vistaril), including a switch from as-needed to scheduled dosing. However, the care plan continued to reference outdated medication regimens and did not reflect the current orders. The DON confirmed that the care plan was not revised to match the updated medication orders.
Care Plan Failed to Reflect Resident's Actual Eating Assistance Needs
Penalty
Summary
Staff failed to ensure that a resident's care plan accurately reflected the level and type of assistance needed for eating. Observations during two consecutive noontime meals showed the resident feeding himself with his fingers, dropping food on his clothes, and leaving food scattered around his dining area. No staff were observed prompting the resident to use utensils during these meals. Interviews with nurse aides and the speech therapist confirmed that the resident is capable of using utensils but requires constant supervision and cueing to do so effectively. The current care plan only indicated that the resident required set-up assistance with eating, without specifying the need for ongoing supervision and cueing. This discrepancy between the care plan and the resident's actual needs was confirmed by the Director of Nursing.
Oxygen Flow Rate Not Set per Physician Order
Penalty
Summary
The facility failed to ensure that a resident's supplemental oxygen therapy was administered according to the physician's orders. The resident, who had a history of COPD and respiratory disorder, was observed on multiple occasions to be receiving oxygen at a flow rate of four liters per minute via nasal cannula, despite a physician's order specifying two liters per minute as needed for shortness of breath. Staff confirmed that the oxygen flow rate was set higher than ordered, and the resident denied adjusting the oxygen rate themselves. This discrepancy between the ordered and administered oxygen flow rate was observed over several days and was confirmed by staff during the survey.
Failure to Follow Enhanced Barrier Precautions During Indwelling Device Care
Penalty
Summary
The facility failed to maintain compliance with its own infection prevention and control program by not following Enhanced Barrier Precautions (EBP) for a resident with indwelling medical devices. According to the facility's EBP policy, staff are required to wear both gloves and a gown when performing high-contact care activities, such as tracheostomy care and feeding tube care, for residents with indwelling devices or a history of multidrug-resistant organisms. The policy was in effect at the time of the incident and was clearly posted outside the resident's room, specifying the use of gloves and gowns for these activities. During observation, an LPN provided care to a resident with a tracheostomy and a PEG tube, both of which are considered indwelling medical devices. The LPN changed the inner cannula of the tracheostomy and the dressing on the PEG tube, wearing gloves but not a gown as required by the facility's policy. The Director of Nursing confirmed that gowns were required for these procedures. No additional information or mitigating factors were provided during the survey process.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of PRN Ativan without appropriate justification or documentation. The resident had a physician's order for Ativan 0.5mg every 12 hours as needed, but the order lacked a specified time limit. Although the pharmacy recommended discontinuing the PRN Ativan or reordering it with a specific duration, the physician did not update the order until several weeks later. During this period, the medication was administered for reasons not consistent with treating a medical symptom, such as the resident attempting to get up unassisted, which does not meet the regulatory requirements for psychotropic medication use. Additionally, the documentation for 29 doses of PRN Ativan administered over several weeks failed to include specific behaviors or non-pharmacologic interventions attempted prior to medication administration. The only behavior documented was 'increased agitation,' as stated in the physician's order, without further detail or evidence of alternative interventions. This lack of detailed documentation and failure to use the least restrictive alternatives contributed to the deficiency identified during the survey.
Failure to Implement Care Plans for Non-Pharmacological Interventions and Restricted Limb Precautions
Penalty
Summary
The facility failed to develop and implement complete care plans that addressed all the needs of several residents, specifically regarding non-pharmacological interventions for behavioral symptoms and restricted limb precautions for those with dialysis access. For one resident with a physician's order for PRN Ativan due to behaviors such as resisting care, physical aggression, and agitation, the care plan included non-pharmacological interventions. However, documentation showed that 29 doses of Ativan were administered without recording the specific behaviors that prompted use or the non-pharmacological interventions attempted prior to medication administration. Additionally, multiple residents with physician's orders to avoid blood pressure measurements or blood draws in limbs with dialysis fistulas or shunts had care plans that were either not implemented or not developed to reflect these restrictions. Despite clear orders and care plan interventions, blood pressure readings were repeatedly documented as being taken in the restricted limbs for these residents over an extended period. In one case, the care plan did not include the necessary intervention at all, and in others, the intervention was listed but not followed in practice. These deficiencies were identified through record reviews and staff interviews, which confirmed that the care plans were either incomplete or not followed as required. The Director of Nursing acknowledged the failures in documentation and care plan implementation when notified during the survey process.
Failure to Follow Physician Orders for Restricted Limb Precautions
Penalty
Summary
The facility failed to follow physician's orders regarding restricted limb precautions for three residents. For one resident with a physician's order not to take blood pressure (B/P) on the left arm due to a dialysis fistula, documentation showed that B/P was repeatedly taken on the restricted limb on numerous occasions over several months. Another resident had a physician's order not to take B/P on the right arm every shift, but records indicated that B/P was taken on the right arm multiple times after the order was in place. In both cases, the Director of Nursing (DON) confirmed that the physician's orders were not followed. A third resident's record did not contain a physician's order regarding restricted limb precautions, yet documentation showed that B/P was taken on a restricted limb on several occasions. The DON confirmed that there was no physician's order in place for this resident regarding restricted limb precautions. These findings were based on record reviews and staff interviews during the survey process.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Staff failed to maintain a homelike environment for a resident whose privacy curtain was observed to have several large, red stains and a brown stain. The stained curtain had been present for at least a couple of days, as confirmed by the resident's roommate. During an interview, a nurse aide acknowledged the condition of the curtain and stated that the process for addressing such issues involves notifying housekeeping to change and clean the curtains when stains are noticed. This deficiency was identified through observation and interviews with both staff and residents, and it affected one of five residents reviewed for environmental concerns in a facility with a census of 107.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident reported that a laundry staff member was argumentative and rude to her regarding her laundry. The incident was investigated and the allegation of verbal abuse was verified. The facility's policy on abuse, neglect, and exploitation states that protections must be in place to prevent all forms of abuse, but in this instance, the resident was not protected from verbal abuse by a staff member.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse involving one resident, as required by their policy and regulatory guidelines. According to a hospital discharge plan, the resident reported to hospital staff that facility staff had subjected her to waterboarding for 36 hours, thrown her on the floor, and forced her to endure weekly hour-long cold showers, including having water poured on her face and in her ear. Additionally, the resident reported to surveyors that she had informed unidentified staff that she could not tolerate being in the facility any longer, and that staff had verbally abused her by calling her derogatory names and making statements suggesting she should die. Despite receiving this information from the hospital, the DON, Corporate Nurse, and Administrator acknowledged during interviews that the incident was not reported to the appropriate agencies as required. Review of the facility's abuse policy confirmed that all alleged violations must be reported immediately, but not later than two hours after the allegation is made, particularly if the events involve abuse or result in serious bodily injury. The failure to report these allegations was confirmed through record review and staff interviews, and the incident involved one of six residents reviewed in a facility with a census of 107.
Failure to Investigate and Document Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to complete an investigation and five-day follow-up for an alleged incident of verbal abuse involving a resident. Record review showed that an incident report was filed after a resident's daughter reported hearing a staff member being argumentative with the resident during a phone call. There was no documentation of an investigation or a five-day follow-up attached to the incident report. Interviews with the DON and the Regional President of Clinical Services confirmed that the required follow-up and investigation documentation were not available. Review of the facility's Abuse, Neglect and Exploitation policy indicated that complete and thorough documentation of investigations is required, but this was not done in this case.
Failure to Follow Professional Standards for Dialysis Care
Penalty
Summary
The facility failed to maintain professional standards of care for a resident receiving dialysis services. Record review for a resident revealed that, although there was a physician's order to check the thrill and bruit of the left arm fistula every shift, there was no physician's order specifying that blood pressure should not be taken in the restricted limb. Despite this, blood pressure measurements were repeatedly taken in the limb with the dialysis fistula on multiple occasions over a period of several weeks. The Director of Nursing confirmed that there was no physician's order regarding the restricted limb at the time of review.
Incomplete and Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident's skin assessment. During a record review, it was found that the physician's orders, care plan, weekly skin assessments, and progress notes did not indicate any skin concerns for the resident, except for a documented skin tear on the right hand. However, a Nursing Assistant Skin Inspection and Shower sheet indicated a skin concern on the bilateral buttocks, which was not reflected elsewhere in the resident's medical record. The Director of Nursing and a Corporate RN confirmed that there was no other documentation of this skin issue and believed the entry may have been made in error for the wrong resident, as all other weekly skin observations before and after the date in question showed no indication of skin concerns.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were accessible to residents, family members, and legal representatives. During an observation on April 22, 2024, it was noted that the survey documentation available in the lobby did not include the most recent survey results from November 2023. An interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the latest survey was missing from the survey binder intended for public access. The ADON admitted that he could not locate the current survey results within the facility and mentioned that the Administrator could email the survey results from outside the office.
Neglect in Performing Required Resident Checks
Penalty
Summary
The facility failed to ensure residents were free from neglect, as evidenced by the lack of adherence to physician orders for hourly checks for fall prevention. Residents #13, #90, and #100 had orders for hourly checks due to their history of falls, but the facility did not consistently perform these checks. This failure resulted in multiple incidents where residents were found on the floor, indicating potential neglect. For instance, Resident #13 was found on the floor with signs of pain after missing several hourly checks, and Resident #90 experienced multiple falls, including one where he was found with his wheelchair flipped backward. Additionally, Resident #2, who was on 15-minute checks due to a previous altercation, was found in a compromising situation with another resident, indicating that the checks were not performed as required. Staff interviews revealed that the checks were not conducted within the specified time frames, with one nurse aide admitting to not having checked on the residents for about an hour. The documentation of the 15-minute checks was found to be inaccurate, as staff statements contradicted the recorded check times. The Director of Nursing (DON) acknowledged the failure to complete the required checks, which could have contributed to the residents' falls and the incident involving Resident #2. The facility's neglect in performing these checks as ordered by physicians highlights a significant deficiency in ensuring resident safety and preventing potential harm.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the appropriate State Authorities. The incident was documented in a grievance form initiated by the family member of a resident, who reported that the evening staff was argumentative and unhelpful in calming the resident. The family member overheard this interaction while on the phone with the resident. Despite the grievance being documented, the facility's administration, including the Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON), did not complete a reportable form or conduct an investigation as required by their Abuse Prevention Program policy. During interviews, the DON acknowledged the oversight and confirmed that no documentation existed to show that the ADON had communicated with the family representative about the issue. The facility's policy on verbal abuse, which includes harassment, mocking, and intimidating behavior, was not followed, as the incident was not reported to the proper authorities. The DON admitted that the process of reporting and investigating the incident should have been initiated, indicating a lapse in adhering to the facility's abuse prevention protocols.
Deficiency in Resident Monitoring Practices
Penalty
Summary
The facility failed to ensure that all residents attained or maintained the highest practicable physical, mental, and psychosocial well-being by placing seven residents on 15-minute monitoring checks without a specified duration or time frame for discontinuation. This practice was applied to residents who exhibited sexual behavior or interactions, such as being found in bed with another resident, having altercations, or making inappropriate comments. The monitoring checks were implemented without a clear policy or order to guide their duration, leading to an indefinite continuation of these checks. Interviews with the Director of Nursing (DON) revealed that the decision to continue the 15-minute checks for 90 days was made without a formal order or policy in place. The residents involved included those residing in the memory unit and those with capacity, indicating a lack of individualized assessment and planning. The absence of a facility policy for such monitoring practices was noted, and no policy was provided by the close of the survey, highlighting a deficiency in the facility's approach to managing resident behavior and ensuring their quality of life.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered by the physician for multiple residents, resulting in significant delays. For instance, Resident #33 experienced repeated delays in receiving critical medications such as Eliquis, Norvasc, Lantus, Novolog, and Bactrim DS, with delays ranging from over an hour to nearly three hours. These delays were not documented, and there was no indication that the attending physician was notified. Similar issues were observed with Resident #31, who received medications like Novolog insulin, Acidophilus, Albuterol Inhalation, and others significantly later than scheduled, with no nursing notes explaining the delays. Additionally, the facility failed to conduct required 15-minute monitoring for several residents, as evidenced by missing data and incomplete monitoring sheets. For Resident #62, there were multiple instances where monitoring data was missing for extended periods, such as from 7:15 PM to 11:45 PM on one occasion. Similar deficiencies were noted for Residents #37 and #60, where monitoring sheets lacked necessary documentation, including nurse signatures and specific time entries. Furthermore, the facility did not perform neuro checks as ordered for Resident #90 following an unwitnessed fall. The neuro check record was missing documentation for several required time intervals on the day of the fall. The Director of Nursing acknowledged that the neuro checks were not completed according to the physician's orders, and no facility neuro check policy was provided during the survey.
Failure to Maintain a Safe Environment
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, as observed during a survey. In the medication room, the door was found propped open and unattended, which was witnessed by an LPN who attributed the action to a pharmacy technician. Additionally, at the west nurse's station, an electrical box was found with an unlocked padlock, which was subsequently locked by the LPN after it was pointed out. These observations were reported to the Administrator, but no comments were made regarding the incidents.
Inaccurate Staff Posting Records
Penalty
Summary
The facility failed to meet the requirements for daily staff posting by not accurately reflecting the actual number of staff who worked and the hours they worked. This deficiency was identified during a review of facility documents and staff interviews, which revealed discrepancies in the staff postings over a two-week period. Specifically, the staff posting sheets did not account for 13 callouts that occurred during this time frame. The Administrator confirmed that the staff postings had not been updated to reflect these callouts, indicating a failure to maintain accurate staffing records. This oversight had the potential to affect a limited number of residents, with the facility census at 99.
Temperature Control Deficiency
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents. During an observation, residents were seen sitting at the nurses' station with blankets, indicating discomfort due to low temperatures. The ambient temperature at chair level was measured at 61 degrees, while the wall thermostat was set to 69 degrees. Maintenance Assistant #6 adjusted the thermostat to 74 degrees and mentioned that he frequently had to increase the thermostat setting, suggesting a recurring issue with maintaining appropriate temperatures.
Failure to Support Resident Self-Determination in Relationship
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice, specifically in the case of two residents. Resident #95, a paraplegic male with capacity, and Resident #99, a female with moderate cognitive impairment due to a stroke, were involved in a consensual relationship. Despite both residents expressing consent and desire for the relationship, the facility intervened by separating them and placing them on 15-minute checks. Nursing notes indicated that the residents were educated on inappropriate behavior, and staff were notified of the incident. The residents had been observed spending time together, including eating meals and attending activities, but were told by staff that their relationship was against facility rules. Interviews with the residents revealed that neither had been informed they could not have a relationship with each other. Resident #95 expressed feeling as though he was doing something wrong, while Resident #99 asserted her right to have a relationship with anyone she chooses. Despite the residents' statements, the facility continued to monitor them closely, with the DON and Administrator deciding to maintain the 15-minute checks for 90 days. During the survey, the residents were not observed together, indicating a lack of support for their self-determination and choice.
Failure to Report Disciplinary Actions to Nursing Board
Penalty
Summary
The facility failed to report disciplinary actions against two LPNs to the Virginia Board of Nursing. The first incident involved an LPN who was found to have discrepancies in the administration of narcotics, specifically Morphine and Neurontin, to a resident. The narcotic count was off, and the LPN was unable to account for the missing medication. Despite the facility's knowledge of the incident, it was not reported to the nursing board, and the administrator could not provide a reportable number when questioned. The second incident involved another LPN who failed to administer medications as ordered to multiple residents. This included not performing an acu-check and administering insulin to a resident, and failing to administer antibiotics and controlled medications to others. These discrepancies were discovered during a review of the medication cart. Similar to the first incident, the facility did not report these actions to the nursing board, and no complaint was filed against the LPN.
Deficient Documentation in Skin Assessments
Penalty
Summary
The facility failed to ensure that all handwritten skin assessments were clear, accurate, and contained sufficient information to accurately identify the resident. During a review of medical records related to skin assessments conducted following a sexual behavior allegation involving another resident, it was found that 12 forms were either missing the resident's name or had unidentifiable names. Specifically, six forms had unidentifiable names, and six forms had no names at all. Additionally, none of the forms included a date or shift, which are essential for proper documentation. The Director of Nursing (DON) confirmed these deficiencies upon review and noted that all 12 pages were signed by the Assistant Director of Nursing.
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.
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What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Glasgow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery General Elderly Care | 5.4 mi | ★★★★★ | 14 | 0 |
| Montgomery General Hospital | 5.4 mi | ★★★★★ | 0 | 0 |
| Marmet Center | 7.7 mi | ★★★★★ | 19 | 0 |
| Charleston Healthcare Center | 12.5 mi | ★★★★★ | 14 | 0 |
| Meadowbrook Acres | 14.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.