Citations in Virginia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Virginia.
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Latest Citations in Virginia
A resident with hypotension related to ESRD had a comprehensive care plan directing staff to administer Midodrine as ordered and to monitor vital signs as ordered and as clinically indicated, but staff did not implement the care-planned intervention to give Midodrine per the physician’s orders. An LPN acknowledged that the care plan is meant to guide staff in meeting residents’ individual needs, and facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident.
Staff failed to clarify PRN orders and consistently monitor blood pressure for a resident receiving Midodrine via PEG tube for orthostatic hypotension and Clonidine for HTN, both ordered every eight hours with specific SBP parameters. Clinical record review showed no evidence that blood pressure was taken every eight hours to determine the need for these PRN medications. An LPN stated that blood pressure should be checked before administering such medications, and a regional clinical leader acknowledged that PRN Midodrine had been cited previously and that PRN Clonidine orders were unusual and required clarification.
Staff failed to follow physician-ordered blood pressure parameters for Midodrine administration for a resident with hypotension related to ESRD and dialysis dependence. The order required Midodrine 10 mg via PEG tube every 8 hours only when SBP was under 100 mmHg, but the MAR showed the medication was given multiple times when SBP readings were above 100 mmHg. An LPN confirmed that the medication should have been held based on the documented blood pressures, despite the care plan and facility policy requiring adherence to ordered parameters and monitoring of vital signs.
A resident with Alzheimer's disease, severe cognitive impairment (BIMS 0), muscle weakness, and documented total-assist/dependent status for transfers was being moved from a wheelchair to a bed by a single CNA. Despite MDS and therapy documentation indicating the need for full assistance and hands-on support, the CNA attempted the transfer alone. During the transfer, the resident became combative and resisted care, the CNA tripped over the leg rest, and both fell, causing the resident to sustain a facial laceration, a closed nasal bone fracture, and a closed nondisplaced C2 fracture, as confirmed by ED records and nursing notes. The DON and rehab director later acknowledged that the resident required continuous hands-on assistance and/or a second staff member for such transfers.
Two residents were affected when staff failed to provide required notifications of changes in condition and room assignments. One resident with multiple comorbidities and moderate cognitive impairment repeatedly reported feeling ill and awaiting test results for suspected flu and UTI, while documentation later showed negative COVID/flu results and a yeast infection diagnosis that were not promptly communicated to the resident, despite orders for multiple labs and provider involvement. Another resident with severe cognitive impairment and Alzheimer's disease experienced five separate room changes documented in the clinical census, and the DON and Administrator acknowledged that the resident's representative was not notified prior to these moves, contrary to facility expectations.
Facility staff failed to ensure that a resident’s discharge needs were met when the resident, who was non–weight bearing, required supervision for transfers, and lived alone in a multi-level home with the only bathroom up 13 stairs, was discharged home without confirmed delivery of a recommended 3-in-1 bedside commode. Admission and therapy assessments documented substantial assistance needs for toileting and transfers, frequent incontinence, severe pain, and inability to negotiate stairs, and social services had identified the home’s stairs and lack of support as major barriers. Therapy recommended DME including an elevated toilet seat/3-in-1 commode, and the social services assistant placed the DME order late in the afternoon before discharge; the DME vendor accepted the order but only attempted to reach the resident around midday on the discharge date and did not complete delivery. Home health records later showed multiple unsuccessful attempts to contact the resident and documented that the resident reported falling at home on the day of discharge and being admitted to another facility, while interviews confirmed that social services was responsible for arranging DME and that there was no evidence the bedside commode was in place before the resident left.
Staff failed to honor a resident’s right to dignity and respect when a social worker discussed the resident’s morbid obesity, weight gain, and food intake with the roommate’s mother, despite the resident being cognitively intact and care planned for obesity and weight loss goals. The resident reported feeling humiliated by the disclosure and by statements that the roommate might be moved if food continued to be brought, and the roommate’s mother and the LTC ombudsman both confirmed that personal information about the resident’s weight was shared and that the conversation was upsetting.
Staff failed to follow written menus and individual meal tickets for several residents, including one with stroke and heart failure on a fluid‑restricted diet who received a biscuit instead of the ordered cornbread, another with a tracheostomy and diabetes on a mechanical advanced/chopped diet who was served an unchopped pork loin and a biscuit instead of the ordered dinner roll, and a resident with dysphagia and cerebral palsy who did not receive the cornbread portion listed on the meal ticket despite expressing a desire for more food to gain weight. The Dietary Manager reported that ordered bread items were unavailable due to missed food deliveries and that substitutions were not updated in the menu/meal ticket software.
Multiple residents did not receive beverages with their lunch meals as listed on menus, meal tickets, or physician orders. Cognitively intact and impaired residents with conditions such as dysphagia, cerebral palsy, malnutrition, stroke, renal failure, heart failure, tracheostomy, diabetes, and PVD were served full meals without the hot coffee, tea, milk, or measured fluid-restricted beverages specified for them. In some cases, a resident verbally requested the missing beverage from an LPN, who did not return with it, while CNAs relied on bedside water pitchers instead of following the meal ticket. The Dietary Manager reported that beverages had been removed from trays due to spills and sent separately, and also noted a software error listing milk at lunch, but was unaware that residents were not consistently receiving the required 8 oz and 6 oz beverages with meals.
Staff failed to post required enhanced barrier precaution (EHB) signage for a resident with a tracheostomy and feeding tube who had an active physician order for EHB every shift and documented cognitive impairment. During multiple days of surveyor observation, no EHB sign was present on the resident’s door or wall, even though EHB signs were posted for other residents throughout the facility. A CNA and an RN confirmed that residents with trachs, feeding tubes, PICC lines, or dialysis should be on EHB precautions and that staff had been in-serviced to follow posted signs for high-contact care activities. The RN acknowledged that the resident should have been on EHB precautions and attributed the missing signage to the resident’s recent room change, during which new signage was not put up.
Failure to Implement Care Plan for Midodrine Administration
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plan for one of six sampled residents, Resident #5, related to the administration of the medication Midodrine for hypotension associated with end stage renal disease (ESRD). The comprehensive care plan dated 11/3/2025 identified a focus of hypotension related to ESRD and included interventions to give medications as ordered and to monitor vital signs as ordered and as clinically indicated. Surveyors determined that staff did not follow the care-planned intervention to administer Midodrine per the physician’s orders. In an interview, LPN #4 stated that the care plan is intended to guide staff on how to care for residents and their individual needs. The facility’s written policy on comprehensive, person-centered care plans states that a comprehensive care plan with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs is to be developed and implemented for each resident. Administrative staff, including the administrator, director of nursing, and regional director of operations, were informed of these findings during the survey, and no additional information was provided by the facility prior to survey exit.
Failure to Clarify PRN Blood Pressure Medication Orders and Monitor Blood Pressure
Penalty
Summary
Facility staff failed to clarify and appropriately implement physician orders for as-needed blood pressure medications for one resident. The resident had a physician order for Midodrine 10 mg via PEG tube every eight hours as needed for orthostatic hypotension, to be given when systolic blood pressure (SBP) was under 100 mmHg, and a separate order for Clonidine to be given by mouth every eight hours as needed for hypertension, to be given when SBP was over 170 mmHg. Review of the clinical record did not show that the resident’s blood pressure was being taken every eight hours to determine whether either of these PRN medications was needed. During an interview, an LPN stated that when a medication requires a blood pressure check, the nurse should take the blood pressure and then administer or hold the medication according to the physician’s order. In another interview, the regional director of clinical services reported that the facility had previously been cited regarding Midodrine orders and had addressed this with physicians by changing such orders from PRN to scheduled doses with hold parameters, and also stated that it was unusual to have a PRN order for Clonidine and that these orders needed clarification. Administrative staff, including the administrator, DON, and regional director of operations, were informed of these findings, and no additional information was provided before survey exit.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Facility staff failed to administer Midodrine according to physician orders for one resident with hypotension related to end stage renal disease and dependence on dialysis. The physician’s order, dated 11/4/2025, specified Midodrine 10 mg via PEG tube every 8 hours to be given only when the resident’s systolic blood pressure (SBP) was under 100 mmHg. The comprehensive care plan documented the resident’s hypotension and directed staff to give medications as ordered and monitor vital signs as ordered and as clinically indicated. The facility’s medication administration policy required staff to validate physician-ordered parameters prior to medication administration. Despite these orders and policies, the January 2026 MAR showed that Midodrine was administered on multiple occasions when the resident’s SBP was above 100 mmHg. Specifically, the drug was given when blood pressures were recorded as 126/80, 122/76, 126/86, 148/80, 125/78, and 117/83. During an interview, an LPN stated that when a medication has blood pressure parameters, the nurse should take the blood pressure and then administer or hold the medication based on the physician’s order, and acknowledged that the Midodrine should not have been administered under the documented blood pressure readings. Administrative staff were informed of these findings, and no additional information was provided prior to survey exit.
Failure to Provide Adequate Supervision During Dependent Transfer Resulting in Fall With Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and safe transfer assistance for Resident #98, resulting in a fall with injury during a wheelchair-to-bed transfer. Resident #98 had diagnoses including Alzheimer's disease, essential hypertension, major depressive disorder, and muscle weakness, and was assessed on the MDS as severely cognitively impaired with a BIMS score of 0/15. The MDS Section GG dated 8/15/23 coded the resident as dependent for chair/bed-to-chair transfers, meaning the helper did all of the effort or that assistance of two or more helpers was required. An occupational therapy treatment note dated 8/25/23 documented that the resident required total assist for stand-pivot transfers to a wheelchair. Despite these documented needs, a single CNA attempted to transfer the resident from a wheelchair to the bed. During the transfer, the CNA and the resident lost their balance and both fell to the floor. Post-fall documentation and the CNA’s statement indicated that the resident became combative, resisted care, pushed against the CNA, and the CNA then tripped over the leg rest, leading to the resident falling face forward to the ground. Nursing notes documented that the resident was found on her left side on the floor with blood present and a laceration to the middle of the forehead, was assisted back to bed with a two-person assist, and was sent to the emergency department. Hospital records and subsequent nursing documentation confirmed diagnoses of a facial laceration, a closed fracture of the nasal bone, and a closed nondisplaced fracture of the second cervical vertebra. The DON and Director of Rehabilitation both stated that, given the resident’s dependent/total assist status for transfers, the CNA should have maintained hands-on assistance at all times and/or had assistance from another staff member during the transfer.
Failure to Notify Residents and Representatives of Test Results and Room Changes
Penalty
Summary
Facility staff failed to promptly notify a cognitively impaired resident of diagnostic test results related to ongoing symptoms. The resident, who had diabetes, atrial fibrillation, and renal insufficiency, reported on multiple occasions that she felt unwell, with nausea, lack of appetite, and suspected flu and UTI, and stated she was awaiting test results. Orders dated 1/19/26 included in-house COVID and flu tests, CBC, BMP, urinalysis, and urine culture and sensitivity. On 1/20/26, 1/22/26, and 1/23/26, the resident continued to report feeling ill and not having been informed of her test results or what could be done for her symptoms. An LPN later confirmed she had not been informed of any test results and needed to consult the unit manager to determine whether tests were completed and what the results were. Documentation showed a late entry nurses' note entered on 1/23/26 for 1/19/26, stating that the resident had been assessed per provider order for COVID-19 and influenza swabs, that results were negative, and that the provider was notified of the negative results. The NP stated it was the responsibility of direct care nurses, not the NP, to notify the resident or representative of test results. The NP also stated she added an addendum to her 1/19/26 progress note on 1/23/26 to document that the nurse had notified her of the test results on 1/19/26. The resident later reported that, after the 1/23/26 conversation, a nurse informed her that she had a yeast infection, would be started on medication, and that she did not have COVID-19 or the flu, indicating a delay in communicating test findings and diagnosis to the resident. Facility staff also failed to notify a resident representative of multiple room changes for a severely cognitively impaired resident with Alzheimer's disease and prostate cancer. The DON reported that this resident had five room changes and that the resident representative was not notified of any of them. Clinical census documentation confirmed room changes on five separate occasions, with moves between different units and room numbers. During a final interview, the Administrator stated that a resident or resident representative needs to be notified prior to a room change, confirming that required notification did not occur in these instances.
Failure to Ensure DME Delivery Prior to Discharge for Dependent Resident Living Alone
Penalty
Summary
Facility staff failed to ensure that all discharge needs were met for a resident who was discharged home without confirmed delivery of essential durable medical equipment (DME), specifically a bedside commode, despite the resident’s inability to negotiate stairs and the bathroom being located on the second floor of a multi-level home. The resident’s admission MDS documented partial/moderate assistance needs for bathing, upper body dressing, and standing from sitting, and substantial/maximal assistance for toileting and lower body dressing. Toilet transfers and walking were not attempted due to medical or safety concerns, and the resident was frequently incontinent of bowel and bladder, had frequent severe pain, and had a recent fall and major surgery prior to admission. The social services admission assessment identified significant barriers to a safe discharge, including that the resident lived alone, had 13 steps to reach the bathroom level, had no supervision, and no family supports, and it documented that social services would arrange home health and any needed equipment at discharge. A safe transition meeting documented that the resident’s goal was to return home alone and again identified barriers such as living alone and the 13 steps to the second-floor bathroom. Therapy discharge documentation later specified that the resident required supervision or touching assistance for toilet transfers and recommended home health services and multiple environmental and equipment modifications, including an elevated toilet seat/3-in-1 commode, shower bench, grab bars, assistance with ADLs, and a Lifeline for safety. PT documentation indicated the resident required supervision for all bed mobility and transfers and remained non–weight bearing on the right leg, unable to go up or down stairs at discharge. Progress notes showed that the resident repeatedly appealed Medicare non-coverage decisions, stating they were not ready for discharge, were unable to put weight on one leg, and that the other leg had become weak, but the appeals were ultimately denied and liability began prior to discharge. On the day before discharge, a late-entry social services note documented that the writer attempted to order oxygen and a bedside commode due to the resident’s bathroom being on the second floor and the resident’s inability to walk or climb stairs, and that the resident did not qualify for oxygen. A nurse practitioner note on the day of discharge stated the resident was in stable condition for discharge home with home health and skilled nursing, and referenced coordinating DME with social work. The facility’s internal DME chat log showed the social worker created the order for a 3-in-1 bedside commode in the late afternoon the day before discharge, with the DME provider accepting the order that evening and marking it pending further review. The DME company attempted to contact the resident around midday on the day of discharge and later documented awaiting a callback to discuss financial obligation and delivery, with the order ultimately canceled nearly two months later. A faxed email chain from the home health agency showed that staff were unable to reach the resident on the day of discharge and subsequent attempts, and later documented that when they finally spoke with the resident several days after discharge, the resident reported having fallen at home on the day of discharge and going to the emergency room, then refusing return to the original facility and being admitted to another facility. Interviews with the social services assistant and rehab director confirmed that therapy had recommended a bedside commode, that social services was responsible for arranging DME, that the resident was non–weight bearing and unable to manage stairs at discharge, and that there was no evidence the bedside commode had been delivered to the home prior to discharge.
Failure to Protect Resident Dignity and Privacy When Discussing Weight and Food
Penalty
Summary
Facility staff failed to treat a cognitively intact resident with dignity and respect by disclosing her personal health and weight information to her roommate’s mother. The resident, who had diagnoses including morbid obesity due to excess calories and a BMI of 73.4, had a care plan noting her obesity, history of weight fluctuations, and desire to lose 100 pounds while on a special diet. The resident reported that the facility social worker called her roommate’s mother and told her to stop bringing the resident food, stated that the resident had gained 20 pounds, and said that if the food deliveries did not stop, the roommate would be moved. The resident stated this was none of the roommate’s business, that she felt stepped on, humiliated, and never received an apology. The roommate’s mother confirmed that the social worker called her about bringing food to the resident and discussed the resident’s weight gain, which she felt was the resident’s personal information and should not have been shared. She stated she only brought the resident iced tea, hot coffee, fresh fruits, and salads. The local LTC ombudsman reported that the resident called her crying and very upset that the social worker had contacted the roommate’s mother, and further stated that the roommate’s mother was upset that the social worker said her daughter would be moved if she continued to bring food to the resident, which the mother perceived as retaliation. The facility’s written policy, “Your Rights and Protections as a Nursing Home Resident,” stated that residents have the right to be treated with dignity and respect, which was not followed in this instance.
Failure to Follow Menus and Meal Tickets for Diet Orders and Portions
Penalty
Summary
Facility staff failed to serve meals according to the written menu and individual meal tickets for multiple residents. One resident with stroke, renal failure, and heart failure, who had moderately impaired cognition and required setup assistance for eating, was observed at lunch receiving roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The resident’s menu and personal meal ticket specified that cornbread, not a biscuit, should be served, and the meal ticket also documented a regular diet with a fluid restriction of 1200 milliliters per day and one 8‑ounce beverage. The Dietary Manager later stated that cornbread was not available because the food delivery did not occur as scheduled and that the substitute item was not updated on the menu or meal tickets due to software difficulties. Another resident with tracheostomy, diabetes, peripheral vascular disease, and heart failure, who had intact cognition and required setup assistance with eating, was ordered a mechanical advanced/chopped diabetic diet. The meal ticket for this resident specified chopped roasted pork loin, diced beets, mashed potatoes, a dinner roll, margarine, apple crisp, 2% milk, and hot coffee or tea. During observation of the lunch meal, the resident was served a whole slice of roasted pork with gravy instead of chopped pork, and a biscuit instead of the dinner roll listed on the ticket. The Dietary Manager acknowledged that the pork loin not being chopped was an error and again reported that dinner rolls were unavailable due to a missed food delivery and that the substitute item was not reflected on the menu or meal tickets. A third resident with dysphagia, mechanically altered PO intake, and cerebral palsy, who had intact cognition and was able to use utensils to eat once the meal was placed before him, reported wanting more food to gain weight and stated he was not receiving extra portions despite asking. Observation of this resident’s lunch tray showed roasted pork loin, pork gravy, diced Harvard beets, creamy mashed potatoes, a biscuit, and apple crisp. The resident’s meal ticket listed the same items but included cornbread, which was not present on the tray. The resident commented that the tray “comes like that sometimes” but reiterated his desire to gain weight. The Dietary Manager later stated there was no cornbread mix available, so a biscuit was served instead.
Failure to Provide Ordered and Menu-Listed Beverages With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages as listed on menus, as ordered, or per resident preferences during meals for multiple residents. For one resident with dysphagia, mechanically altered PO intake, and cerebral palsy, the lunch meal ticket specified hot coffee or hot tea, but no beverage was served with the meal. The resident, who had intact cognitive abilities and could use utensils to bring food and liquid to the mouth, reported not receiving anything to drink with lunch and indicated he would drink from his personal water bottle instead. Facility leadership later acknowledged that the meal ticket should have been followed and that beverages should have been available. Another cognitively intact resident with a diagnosis including moderate protein calorie malnutrition reported poor service from nursing and dietary staff. At lunch, the resident’s meal ticket listed hot tea or coffee, but no beverage was present on the tray other than what was already on the bedside table. The resident was heard asking an LPN for his tea or coffee; the LPN shrugged, left the room, and did not return with a beverage. The Dietary Manager later stated that the residents should have received their beverages. Two additional residents did not receive beverages in accordance with the menu and their personalized meal tickets. One resident with stroke, renal failure, and heart failure, and with moderately impaired cognition, had a lunch meal served without any fluids, despite the menu specifying an 8 oz and a 6 oz beverage at lunch and the resident’s ticket allowing one 8 oz beverage due to a 1200 ml/day fluid restriction. The following day, this resident again received a lunch meal with no fluids served. Another resident with tracheostomy, diabetes, PVD, and heart failure, and intact cognition, was served lunch meals on two consecutive days without any fluids, even though the menu called for an 8 oz and a 6 oz beverage and the meal ticket specified 2% milk (8 oz) and hot coffee or tea (6 oz). The Dietary Manager explained that beverages had been removed from trays due to spilling and were being sent separately, and that he was unaware residents were not consistently receiving beverages as planned. Across these cases, surveyors observed that residents did not receive beverages as listed on the menu or meal tickets, or as ordered, during lunch meals. Staff interviews confirmed that meal tickets should have been followed and that beverages were expected to be provided with meals. The Dietary Manager acknowledged that drinks were being sent separately from trays due to spill concerns and that there was an error in the menu software offering milk at lunch, while also stating that no concerns had been raised to him about residents not receiving beverages according to the menu, preferences, and physician orders.
Failure to Post Enhanced Barrier Precaution Signage for Resident With Tracheostomy
Penalty
Summary
Facility staff failed to implement the ordered enhanced barrier precautions (EHB) for a resident with a tracheostomy. The resident, admitted with diagnoses including tracheostomy status and a feeding tube, had a physician’s order for "Enhanced Precaution r/t Trach every shift" active since 11/04/25. The discharge MDS documented short-term memory loss and moderately impaired cognitive abilities for daily decision-making. During surveyor rounds from 1/12/26 through 1/14/26, no EHB signage was observed on the door or wall of the resident’s room, despite the active order and the presence of a tracheostomy and enteral feeding at the bedside. Staff interviews confirmed that EHB precautions were required for residents with tracheostomies, feeding tubes, PICC lines, or dialysis, and that staff had been in-serviced on following posted EHB signs for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care, and wound care. A CNA described the need to follow EHB signage for such residents, and an RN acknowledged that the resident with a tracheostomy should have been on EHB precautions and that signage should have been posted, explaining that the resident had been moved to another room the previous day and no new signage was put up. Throughout the survey, EHB signs were observed on all floors for other residents, but not for this resident, and facility leadership did not provide additional information to refute the absence of signage.
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