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)
Some of the Latest Corrective Actions taken by Facilities in Virginia
Latest Citations in Virginia
Facility staff did not consistently deliver resident mail and newspapers in a timely manner, particularly on Fridays and weekends. Multiple residents reported delays, and staff interviews confirmed that late-arriving mail was sometimes not distributed until Monday due to unclear procedures and limited access to mailboxes.
Staff failed to properly store and label medications, including storing new insulin pens in medication carts instead of the refrigerator and not dating an opened eye drop bottle. Multiple staff confirmed knowledge of correct procedures, but these were not followed, as observed on three medication carts.
Surveyors found that staff failed to store and prepare food in a sanitary manner, including unlabeled and undated dry goods, expired milk in the refrigerator, improper sanitizer concentration in the 3-compartment sink, and wet, nested pans stored as ready to use. The dietary manager confirmed these practices were not in line with facility policy.
Facility staff did not implement a comprehensive infection surveillance system, as only residents treated with antibiotics were tracked and no proactive monitoring of infection signs or symptoms was conducted. The infection preventionist confirmed that surveillance was only done retrospectively and could not provide evidence of ongoing monitoring, despite policy requirements. The administrator and DON were made aware of these findings.
Facility staff did not consistently implement an antibiotic stewardship program, resulting in multiple residents being prescribed antibiotics without meeting McGeer criteria and incomplete documentation. In two cases, antibiotics were given without proper assessment or communication among staff, and one resident was not tested for COVID-19 despite symptoms and an active order. The facility's policy for antimicrobial stewardship was not followed, and oversight was lacking.
Facility staff did not provide or document COVID-19 vaccine education or offers to three eligible residents, as required by policy. Clinical records lacked evidence of vaccination status, education, or offers, and the infection preventionist confirmed that immunization discussions had not occurred.
Facility staff did not provide required education or offer influenza and pneumococcal immunizations to two residents, as evidenced by missing documentation in clinical records and confirmation from the infection preventionist. Physician orders and facility policy required these actions, but neither education nor vaccine offers were made, and responsible family members were not contacted for consent or information.
Facility staff did not maintain a complete clinical record for a resident with significant cognitive impairment, failing to include pharmacy recommendations and the provider's response regarding psychotropic medication management. Despite requests from surveyors, the missing documentation was not provided before the survey ended.
A resident with advanced dementia and mental health diagnoses received increased doses and additional psychotropic medications without adequate documentation or consistent behavior monitoring. Facility staff did not initiate timely medication monitoring, failed to document non-pharmacological interventions, and did not attempt gradual dose reductions as required by policy, resulting in unnecessary use of psychotropic medications.
A resident admitted with a PICC and a suprapubic catheter did not have these devices or their care needs included in the baseline care plan. The plan only addressed toileting assistance and contact precautions, omitting specific instructions for the PICC and catheter, despite facility policy requiring such information based on admission assessments.
Failure to Ensure Timely Resident Mail Delivery
Penalty
Summary
Facility staff failed to ensure timely delivery of resident mail, including newspapers, across all three nursing units. During a group interview, multiple residents reported not receiving mail on Fridays or weekends, with one resident specifically stating that his Friday newspaper was not delivered until Monday. These concerns were echoed by several residents, indicating a pattern of delayed mail distribution affecting the entire facility. Interviews with the activities director and activity assistant revealed inconsistencies in the mail delivery process. The activities director acknowledged that late-arriving Friday mail was sometimes not distributed until Monday, especially when part-time staff were unaware of mail locations. The activity assistant further explained that access to mail was limited due to locked mailboxes and lack of keys, resulting in sporadic mail delivery and occasional delays over weekends. The facility's leadership was informed of these issues, and a request for the mail policy was made, but no additional information was provided before the survey concluded.
Improper Medication Storage and Labeling on Medication Carts
Penalty
Summary
Facility staff failed to properly label and store medications on three of five medication carts inspected. Observations revealed that new insulin pens were being stored in medication carts instead of in the refrigerator as required by the manufacturer's label instructions. Additionally, an eye drop bottle was found without an opened date, and staff confirmed that opened medications are supposed to be dated. Multiple staff interviews confirmed awareness of the correct procedures for insulin pen and eye drop storage and labeling, but these procedures were not consistently followed during the inspection. A review of facility documentation indicated that safe and secure storage of medications includes proper temperature controls. Despite this, unopened insulin pens were found outside the refrigerator, and opened medications lacked appropriate dating. The facility's administration and nursing leadership were informed of these findings during the end-of-day meeting.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Facility staff failed to store and prepare food in a sanitary manner in the main kitchen. During an inspection of the kitchen, surveyors observed four 8-quart containers of dry cereal not in their original packaging and lacking labels indicating the date opened or a discard date. Additionally, two partially used packages of gravy mix and an opened package of corn meal were found without date labels. Eighty-four cartons of whole milk were stored in the walk-in refrigerator with expiration dates that had passed. The 3-compartment sink was in use with pots and pans soaking, but the sanitizer concentration was measured at 100 ppm, below the facility's policy requirement of 200-400 ppm, and there was no supply of sanitizer connected to the sink pump at the time of observation. Further inspection revealed that prep and service pans identified as ready to use were stored nested and wet, including three 8-quart plastic containers and a large stainless pan with standing water on the rim. The dietary manager confirmed that all food items were supposed to be labeled with the date opened and a discard date, expired milk was to be discarded, and pans were not to be stored nested and wet. Facility policies reviewed documented requirements for proper food labeling, sanitizer concentration, and air drying of pans and dishes before stacking or nesting. These findings were confirmed in interviews with the dietary manager and reviewed with facility leadership.
Failure to Implement Infection Surveillance in Infection Control Program
Penalty
Summary
Facility staff failed to implement an effective infection prevention and control program, as evidenced by the lack of a comprehensive infection surveillance system across all three nursing units. The infection preventionist (IP) was responsible for the program but only tracked residents who were treated with antibiotics, using an Antibiotic Use Tracking Sheet. No logs were completed for the current month, and the IP confirmed that surveillance was conducted retrospectively at the end of each month, rather than proactively. Residents who developed signs or symptoms of infection were not tracked unless they were prescribed antibiotics. During interviews, the IP acknowledged that the purpose of infection surveillance is to identify symptoms and trends to prevent the spread of infection, but admitted that no proactive tracking or documentation was in place. The IP stated that she reviewed the 24-hour report daily but could not provide evidence of infection surveillance. Review of the facility's policy confirmed that the IP was responsible for conducting surveillance of staff and residents for infections, but this was not being carried out as required. The administrator and DON were informed of these findings, and no additional information was provided.
Failure to Implement and Adhere to Antibiotic Stewardship Program
Penalty
Summary
Facility staff failed to implement an effective, facility-wide antibiotic stewardship program, as evidenced by interviews, clinical record reviews, and documentation. The Infection Preventionist (IP) described a process using McGeer criteria to determine the need for antibiotics, but acknowledged that antibiotics were sometimes prescribed even when residents did not meet these criteria, often at the discretion of the physician. Tracking forms revealed that, over several months, a significant number of residents were prescribed antibiotics without meeting McGeer criteria, and documentation was often incomplete regarding whether criteria were met prior to initiating treatment. For one resident, antibiotics were prescribed for urinary symptoms, and later, duplicate antibiotic therapy was initiated without documented discussion of this with the medical provider. The resident subsequently received additional antibiotics for a positive urinalysis without documented symptoms, and the IP's event report indicated that McGeer criteria were not met. There was no evidence that the IP or other staff discussed the lack of criteria with the prescribing provider. Another resident was prescribed antibiotics for acute bronchitis based on symptoms of cough and congestion, but there were no preceding notes documenting symptoms, and the IP's event report again indicated that McGeer criteria were not met. Additionally, despite an active order to test for COVID-19 as needed, there was no documentation that the resident was tested after developing respiratory symptoms. The facility's policy required collaborative oversight of antimicrobial stewardship, but the process was not consistently followed, and there was a lack of communication among staff and providers regarding adherence to established criteria.
Failure to Educate and Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
Facility staff failed to provide education and offer the COVID-19 vaccine to three residents selected for immunization review. Clinical record reviews for these residents showed no documentation of COVID-19 vaccination status, education regarding the benefits and risks of the vaccine, or evidence that the vaccine had been offered. The infection preventionist (IP) confirmed during interview that she had not discussed immunization with the residents and that information from the state immunization portal was not entered into the clinical record. The IP also stated that she tracks immunization status using the state portal and records it in the electronic health record, but did not document education or offers of vaccination as required by facility policy. The facility's policy requires that vaccination history, education, and consents or refusals be documented in the health record, and that the IP is responsible for ensuring this process. For the three residents in question, there was no evidence in their records of any COVID-19 vaccine education or offer, despite at least two being eligible or overdue for vaccination according to the state immunization system. The deficiency was confirmed through staff interviews, record reviews, and review of facility policy.
Failure to Educate and Offer Flu and Pneumococcal Vaccines to Residents
Penalty
Summary
Facility staff failed to provide education and offer influenza and pneumococcal immunizations to two residents, as required by physician orders and facility policy. Clinical record reviews for both residents showed no documentation of immunization status, education, or offers of the vaccines in the preventative health care tab. Physician orders for both residents specified that high dose flu vaccines should be offered annually and pneumococcal vaccines administered unless contraindicated, but there was no evidence these actions were taken. The infection preventionist (IP) confirmed during interviews that she had not provided education or offered the pneumonia vaccine to one resident, who was past due for both pneumococcal and influenza immunizations according to the state immunization information system. For the second resident, the IP stated she was waiting for the resident's confusion to clear before asking about immunizations, despite the family being responsible for care decisions. The family had not been contacted regarding immunization education or consent, even though they were involved in other care decisions. Facility policy required documentation of historical vaccinations, tracking of immunizations, and ensuring timely administration and documentation of consents or refusals. The CDC's Adult Immunization Standards emphasize the importance of assessing immunization status, providing education, making clear recommendations, and documenting vaccines. The facility failed to meet these standards for the two residents reviewed.
Incomplete Clinical Record for Pharmacy Recommendations
Penalty
Summary
Facility staff failed to maintain a complete clinical record for one resident, specifically omitting documentation of pharmacy recommendations and the provider's response. The resident in question had significant cognitive impairments and was unable to answer questions appropriately during the surveyor's visit. Clinical record review showed that the resident was on multiple psychotropic medications, with changes to dosages and the addition of new medications over time. On a specific date, the pharmacist made recommendations regarding the resident's medications, but this recommendation and any response from the provider were not found in the clinical record. Despite requests from the surveyor to the facility administrator and follow-up by the DON and corporate staff, the requested documentation was not provided before the survey concluded.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary psychotropic medications and chemical restraints. The resident, who had a history of generalized anxiety disorder, major depressive disorder, and advanced dementia, was observed to be confused and unable to answer questions appropriately. Upon review, it was found that the resident's psychotropic medication doses were increased and new medications were added without adequate supporting documentation or clear evidence of behaviors warranting such changes. There was also a lack of consistent and detailed monitoring of the resident's behaviors and the effectiveness of non-pharmacological interventions. The clinical records and medication administration records revealed that behavior monitoring for psychotropic medication use was not initiated upon admission and was delayed for several months. Documentation of behaviors was sporadic and inconsistent between nursing and CNA records, with many instances lacking detail or correlation. Additionally, there was no documentation from the psychiatric nurse practitioner for the dates when medication increases were ordered, and progress notes often did not align with the reported behaviors or medication changes. The facility's own policy required initiation of behavior monitoring and documentation of non-medication interventions, which was not followed. Interviews with the medical director and psychiatric nurse practitioner indicated that decisions regarding medication increases were based on staff reports of behaviors, but these reports were not substantiated in the resident's clinical record. There was also no evidence that gradual dose reductions were attempted or considered, as required by facility policy. The lack of supporting documentation, inadequate monitoring, and failure to attempt dose reductions led to the resident receiving unnecessary psychotropic medications.
Failure to Include PICC and Suprapubic Catheter Care in Baseline Care Plan
Penalty
Summary
Facility staff failed to include essential initial care needs for a resident who was admitted with a peripherally inserted central catheter (PICC) and a suprapubic urinary catheter. The resident's baseline care plan, created within 48 hours of admission, did not mention the presence of the PICC or the suprapubic catheter, nor did it address specific care needs related to these devices. The baseline care plan only referenced toileting assistance for bowel/bladder needs and contact precautions for infection control, omitting any mention of the urinary catheter and PICC care requirements. Interviews with the registered nurse unit manager and the director of nursing confirmed that the resident was admitted with both a PICC and a suprapubic catheter, and that these were not included in the baseline care plan. The facility's policy requires that the baseline care plan include the minimum health care information necessary to care for a resident, based on admission orders and assessments. The omission was identified during a review of the clinical record, staff interviews, and facility documentation, with no additional information provided by facility leadership prior to the end of the survey.