Citations in Virginia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Virginia.
Statistics for Virginia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Virginia
A resident with Type 2 Diabetes Mellitus did not receive ordered blood glucose checks or Novolog insulin administration on multiple occasions, with no documentation to indicate the medication was given, refused, or held. The DON could not provide evidence explaining the omissions, and facility policy required such checks and documentation prior to medication administration.
A resident with moderate cognitive impairment and physical limitations was repeatedly observed with their call bell out of reach, both while in bed and in a wheelchair. Despite facility policy and staff acknowledgment that call bells should always be accessible, the device was found on the floor or on the opposite side of the bed, making it difficult for the resident to access assistance when needed.
A resident with multiple pressure ulcers and complex medical conditions did not receive proper wound care when a nurse and an LPN failed to follow infection control procedures, including not cleaning scissors before use and not performing hand hygiene between glove changes and wound care steps, contrary to facility policy and standard clinical guidelines.
Facility staff did not provide written notification to a resident before moving them to a different room for medical management, despite the resident being cognitively intact and the facility's policy requiring such notification. Only verbal notification was given, and documentation was incorrectly completed by a social worker.
Staff failed to accurately document a wound's location for one resident, recording it on the wrong foot in clinical records, and did not document scheduled oxycodone administration on the MAR for another resident, despite recording it on the NARC log. Both residents had complex medical histories, and these documentation errors were confirmed by facility leadership.
A resident with diabetes, neuropathy, and muscle weakness, who was moderately cognitively impaired and dependent on staff for ADLs, did not receive necessary nail care. The resident reported discomfort and stated they had requested nail trimming multiple times without results, leading them to chew their own nails. Observations confirmed the resident's nails were long and unclean, and staff interviews showed inconsistent provision of nail care despite facility policy assigning this responsibility to CNAs and nurses.
Staff failed to adhere to infection control protocols during wound care for two residents, including not cleaning scissors between uses, not performing hand hygiene between glove changes, and improper handling of a multiuse Dakins Solution bottle by an LPN, which was placed on unclean surfaces and returned to the treatment cart without sanitization.
Facility staff did not ensure that three resident rooms were kept clean, safe, and functional, as evidenced by persistent dust and debris in air conditioning units, missing or soiled bathroom fixtures, uncleaned furniture, broken overbed tables, and a toilet bowl with a large smear of feces that remained unaddressed over multiple days.
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.
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.
Failure to Administer Insulin and Document Blood Glucose Checks as Ordered
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for one resident diagnosed with multiple conditions, including Type 2 Diabetes Mellitus. The resident had medical provider orders for Novolog insulin to be administered subcutaneously before meals and at bedtime, with specific dosing instructions based on a sliding scale and blood glucose checks. Review of the medication administration record (MAR) for August revealed that there was no documentation of blood glucose checks or administration, refusal, or holding of Novolog on several specified dates and times. The resident's care plan included interventions to administer medications as ordered and to monitor for signs and symptoms of hypoglycemia. During an interview, the DON was unable to provide evidence explaining the lack of documentation or administration of Novolog on the identified dates. The facility's policy required staff to check the MAR for orders and ensure any necessary tests, such as vital signs or blood glucose checks, were completed prior to medication administration. No further information or documentation was provided to the survey team to account for the missed treatments prior to the survey exit.
Call Bell Not Accessible to Resident with Cognitive and Physical Impairments
Penalty
Summary
Facility staff failed to ensure that a resident's call bell was accessible, as observed on multiple occasions. The resident, who has diagnoses including idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness, was found with the call bell on the floor or out of reach while in bed or seated in a wheelchair. The resident's most recent assessment indicated moderate cognitive impairment. During interviews, the resident acknowledged difficulty accessing the call bell, stating they could reach it only with effort if necessary. The DON confirmed that call bells are required to be within reach of residents at all times, regardless of their location in bed or in a chair. Facility documentation, including Mosby's Textbook for Long-Term Care Assistants, also specifies that call lights must always be kept within the person's reach. Despite these requirements, repeated observations showed the call bell was not accessible to the resident, and no additional information was provided by facility leadership prior to the survey exit.
Failure to Follow Infection Control Procedures During Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide appropriate care and treatment to promote healing of pressure ulcers for one resident with multiple complex medical conditions, including type 2 diabetes mellitus, gangrene, and acute osteomyelitis. The resident was assessed as moderately cognitively impaired and had one stage 1 pressure ulcer and three unstageable pressure ulcers. During a wound care and dressing change, a registered nurse, assisted by an LPN, did not follow proper infection control procedures. Specifically, the nurse used bandage scissors that were not cleaned prior to use, failed to perform hand hygiene between glove changes, and did not change gloves or perform hand hygiene between cleaning the wound and applying the treatment dressing. Facility policies and standard clinical references provided clear instructions for hand hygiene before and after glove use, after contact with potentially contaminated materials, and before and after dressing changes. The infection preventionist confirmed that the observed practices did not meet facility expectations or policy requirements. The failure to adhere to infection control protocols during wound care was observed and discussed with facility leadership.
Failure to Provide Written Notification of Room Change
Penalty
Summary
Facility staff failed to provide written notification of a room change to a resident prior to moving the resident to another room. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including malignant neoplasm of the frontal lobe and cervical spondylosis with radiculopathy, was moved to a different room for medical management. The clinical record showed that the resident's Power of Attorney was notified and gave consent for the change on the same day the move occurred, but there was no evidence that the resident received written notification prior to the move. A Room Change Notification form was completed by a social worker, who later admitted to marking that the resident and responsible party received a copy of the notification in error. The facility's policy required proper documentation and timely notification for internal room transfers, but in this instance, only verbal notification was provided. The deficiency was confirmed through staff interviews, clinical record review, and facility document review, with no additional information provided to the survey team before the exit conference.
Incomplete and Inaccurate Clinical Record Documentation for Two Residents
Penalty
Summary
Facility staff failed to ensure complete and accurate clinical records for two of ten sampled residents. For one resident, staff incorrectly documented the location of a foot wound, recording it as being on the left foot in the skin assessment, treatment administration record, and wound assessment report, when the wound was actually on the right foot. Medical provider notes and orders referenced both feet inconsistently, but the wound nurse and DON later confirmed the documentation error. The facility was unable to provide a policy for accurate documentation when requested by surveyors. For another resident, staff failed to document the administration of scheduled oxycodone on the medication administration record (MAR) for multiple dates and times, despite the medication being administered and recorded on the controlled drug administration record (NARC log). The resident had multiple diagnoses, including chronic pain and moderate cognitive impairment. The facility's policy required documentation of medication administration on the MAR, but this was not followed for the identified dates.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) care, specifically nail care, to a dependent resident diagnosed with idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness. The resident was assessed as moderately cognitively impaired and required assistance with ADLs according to their care plan. During multiple interviews, the resident reported that their long, jagged fingernails with brownish debris underneath were bothersome and stated that they had asked staff to trim their nails but this was not done. The resident indicated they resorted to chewing their nails due to lack of assistance. Observations confirmed the resident's nails were untrimmed, and staff interviews revealed inconsistencies regarding who was responsible for providing nail care and the frequency with which it was performed. While CNAs and nurses were identified as responsible for nail care, staff who worked with the resident that week had not provided the service. Facility policy required nursing staff to provide care according to current standards, but documentation and interviews indicated this standard was not met for the resident in question.
Failure to Follow Infection Control Procedures During Wound Care and Medication Handling
Penalty
Summary
Facility staff failed to follow established infection control procedures for two residents during wound care and medication handling. For one resident with multiple pressure ulcers, diabetes, gangrene, and osteomyelitis, a registered nurse did not clean scissors before use during a dressing change and failed to perform hand hygiene between glove changes and before applying wound treatments, despite facility policy requiring hand hygiene before and after glove use and after contact with potentially contaminated materials. The infection preventionist confirmed that scissors should be cleaned after each use and hand hygiene should be performed with each glove change, which was not done during the observed dressing change. In a separate incident, another staff member did not maintain infection control measures when handling a multiuse bottle of Dakins Solution. The LPN placed the bottle directly on an unclean overbed table and later on a fabric chair cushion in a resident's room without sanitizing the bottle before returning it to the treatment cart. The infection preventionist stated that the solution should have been stored in a zip lock bag in the treatment cart, and the observed handling did not meet infection control expectations.
Failure to Maintain Sanitary and Safe Resident Rooms
Penalty
Summary
Facility staff failed to maintain a safe, functional, sanitary, and comfortable environment in three sampled resident rooms. In one room, the air conditioning/heating wall unit (p-tac) contained a large amount of thick dust and debris, including torn paper or wrapper, and the bathroom ceiling light cover was missing, leaving the bulb exposed. The bathroom vent was rusted and covered in dust, the bathroom door was soiled around the doorknob and edges, and a nightstand had multiple areas of a dried, light-brown substance. These conditions remained unchanged upon re-inspection the following day. In another room, the p-tac unit was observed with thick dust, debris, food crumbs, and two dead bugs in the grates. The window curtains had fallen down in the middle, with several sharp-ended curtain hooks left in the windowsill, and the curtains had multiple dark stains. The overbed table's leg supports were soiled with a white substance, and two broken overbed tables were in use, one of which could not be raised or lowered and had non-functional wheels, while the other had an unstable tabletop. The p-tac unit remained uncleaned upon follow-up, though the curtains had been re-hung. In a third room, the bathroom toilet bowl had a large, brown smear of feces on the outside, approximately the size of an average woman's hand. This unsanitary condition was observed repeatedly over two days, with no change despite multiple observations and staff being made aware. Facility policy required daily cleaning and spot cleaning of all necessary areas, but staff interviews revealed that rooms were not cleaned every day, and the observed deficiencies persisted throughout the survey period.
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.
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.
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