Citations in Virginia s

Penalty

Fine: $14,300

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to implement necessary interventions, care, and services to prevent the development of pressure ulcers in a resident identified as being at risk. The resident, who had multiple comorbidities including end stage renal disease, diabetes, heart failure, dementia, and a history of sacral pressure ulcers, was re-admitted to the facility with intact skin. Despite being at risk, as indicated by a Braden Scale score of 17 and a history of previous pressure injuries, the resident did not have a care plan addressing pressure ulcer prevention, and no specific interventions were documented to prevent pressure-related injuries. Weekly skin assessments, as required by facility policy, were not consistently performed between the resident's re-admission and the discovery of two advanced-stage pressure injuries. The facility only identified the injuries during a facility-wide skin sweep, which was initiated after it was recognized that weekly skin reviews were not being completed. Documentation also showed inconsistent or missing records for turning and repositioning, which are critical interventions for pressure ulcer prevention, especially for residents with limited mobility and incontinence. Interviews with facility staff, including the Wound Care Nurse and DON, confirmed that preventive measures such as air mattresses and regular repositioning were only implemented after the wounds were discovered, rather than proactively based on the resident's risk profile. The care plan lacked interventions for pressure ulcer prevention and did not address the resident's refusal of care or changes in condition. Facility policies required systematic risk assessment, care planning, and intervention for at-risk residents, but these were not followed, resulting in the resident developing two advanced pressure injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide care and services to promote the highest level of wellbeing for three residents by not following physician orders and facility policies. For one resident with diabetes, acute/chronic respiratory failure, and a tracheostomy, staff did not perform or document blood sugar checks as ordered before meals and at bedtime on multiple occasions. The resident was cognitively intact and dependent for most activities of daily living. Staff interviews confirmed that if blood sugar checks are not documented, there is no evidence they were performed, and review of the facility's policy indicated that a physician's order must be verified for such procedures. Two other residents, both with significant medical histories including cerebrovascular accident, atrial fibrillation, NSTEMI, diabetes, CHF, subdural hemorrhage, and tracheostomy, experienced falls resulting in head injuries and bleeding. In both cases, the facility failed to initiate and document neurological checks post-fall as required by facility policy and standard clinical practice. Staff interviews revealed that neuro checks should be started immediately after a fall, especially when the resident is on anticoagulants or has sustained a head injury, and should be documented on a paper flowsheet. However, administrative staff confirmed that there was no evidence of neuro checks being performed for either resident after their respective falls. Facility documentation and staff interviews consistently indicated that the required monitoring and documentation were not completed for these residents. The facility's own policies on obtaining fingerstick glucose levels and managing falls and fall risks were not followed, and there was no evidence provided to show that the necessary assessments and interventions were carried out as ordered or per policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to develop a baseline care plan addressing diabetes and blood sugar monitoring for a newly admitted resident diagnosed with diabetes, acute/chronic respiratory failure, and a tracheostomy. Upon admission, the resident was assessed as not cognitively impaired and was dependent on staff for mobility, transfers, dressing, hygiene, toileting, and eating setup. The baseline care plan created at admission focused only on discharge planning and equipment needs, without including any interventions or monitoring related to the resident's diabetes or blood sugar levels. A physician's order for blood sugar checks before meals and at bedtime was present, but there was no evidence that the baseline care plan incorporated these orders or addressed diabetes management until several days after admission. Staff interviews confirmed that diabetes should have been included in the baseline care plan, and documentation review supported the omission. The deficiency was acknowledged by administrative staff, with no additional information provided prior to survey exit.

Penalty

Fine: $14,300

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to develop a comprehensive, person-centered care plan to address the risk of pressure ulcer development for one resident who had a history of a sacral ulcer and was identified as being at risk for pressure injuries. Upon re-admission, the resident's Braden Scale assessment indicated risk, but the care plan did not include specific interventions for pressure ulcer prevention. Staff interviews revealed that weekly skin reviews were not consistently performed according to facility policy, and preventive measures such as air mattress use, protein supplementation, frequent turning and repositioning, and off-loading of heels were not documented in the care plan prior to the development of new pressure injuries. The care plan also lacked documentation addressing the resident's refusal of care, including baths, skin assessments, and dialysis treatments. Facility policy required the interdisciplinary team to develop a care plan with measurable goals and appropriate interventions for residents at risk of pressure injuries, but this was not followed. The deficiency was confirmed through staff interviews, clinical record review, and facility documentation, with no additional information provided by facility staff during the exit meeting.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that a medication cart was kept locked or under the direct observation of authorized staff in an area accessible to residents. During an observation tour, a medication cart was found unlocked outside the nursing station with no authorized staff in sight. The Unit Manager was unaware of the nurse assigned to the cart's whereabouts. Shortly after, the assigned LPN returned from outside the building, stating she had been making a phone call and acknowledged that leaving the cart unlocked and unattended was a mistake. The facility's policy requires that only licensed nurses, pharmacy personnel, or those lawfully authorized to administer medications have access to medications, and that medication carts must be locked when not attended by authorized personnel. Interviews with the Unit Manager and the LPN confirmed that the cart was left unattended and unlocked, contrary to facility policy. No further comments or concerns were voiced by facility leadership during the final interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide adequate supervision and care to prevent resident-to-resident altercations and ensure a safe environment for multiple residents. Several residents with known histories of aggressive behaviors, cognitive impairment, traumatic brain injury, or dementia physically assaulted other residents on multiple occasions. In several cases, residents had active provider orders for 1:1 supervision, yet were still able to engage in physical altercations resulting in injuries to others. Documentation revealed that after each incident, care plans and interventions were not reviewed or revised to address the ongoing risks, and there was a lack of consistent documentation regarding the incidents and supervision provided. In one instance, a resident with a traumatic brain injury and intellectual disability, who had a history of aggression and was under orders for 1:1 supervision, physically assaulted other residents on three separate occasions, causing injuries that required hospital evaluation and treatment. Another resident with severe cognitive impairment and behavioral issues also physically assaulted other residents multiple times, with no evidence of care plan updates or intervention changes following these events. Additionally, two residents in a designated smoking area, both assessed as requiring supervision while smoking, were left unsupervised, resulting in one resident being pulled from his wheelchair and assaulted, sustaining injuries that required medical treatment. Staff and resident interviews confirmed that supervision was not present at the time of the incident, and documentation errors further complicated the facility's response. Other deficiencies included a resident on 1:1 supervision who was able to strike another resident, and a resident assessed as needing supervised smoking who was observed carrying smoking materials independently through the facility, contrary to safety protocols. Multiple staff interviews confirmed that residents requiring supervision were not being adequately monitored, and that facility policies did not clearly address the requirements for 1:1 supervision or the handling of smoking materials for residents assessed as needing supervision. These failures resulted in harm to residents and placed all residents at risk of abuse and unsafe conditions.

Removal Plan

• Resident #32, #7, #26 is now under 1:1 supervision being in close proximity to ensure staff can deescalate or intervene with any possible altercations.
• Resident #40 will not be allowed to smoke unsupervised.
• Resident #26 will not be allowed to smoke unsupervised.
• A dedicated staff member has been assigned to always monitor residents #40 and #26 during smoking breaks.
• The dedicated staff member has been established to the designated smoking area within a secure part of the facility grounds.
• The facility will educate all staff on the abuse policy.
• The DON or designee will educate on abuse and 1:1, ensuring that staff doing 1:1 are in close proximity to the resident to de-escalate or intervene with any possible altercations and will provide privacy while performing bodily functions outside of the door.
• The DON or designee will conduct an audit of those residents currently on 1:1 to ensure the person assigned is monitoring the patient.
• Nursing staff on all shifts will document any unusual, increased, or change in behaviors, which will be reported and documented in the medical records.
• During clinical review, residents at risk for aggressive behaviors will be determined and appropriate interventions will be put in place.
• Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine a need for supervision.
• Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
• The facility will schedule a staff member to be in the courtyard while smoking occurs.
• The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
• IDT will be educated on what a 1:1 entails, which includes maintaining arm's length while inside and outside of the room.
• Anyone providing 1:1 care will be scheduled by staffing, with their relief person for break noted on the schedule.
• Resident on 1:1 will be documented on daily by assigned staff, and this will be collected by the charge nurse.
• Staff will be educated that you may not leave the resident until you have a relief person; you have to remain in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations while on one-to-one inside and outside of room.
• The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking, ensuring all residents requiring supervision are supervised while smoking.
• The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
• This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
• A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
• The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations.
• Facility will monitor all residents who have been identified as supervised smokers.
• All supervised smokers will smoke in the designated smoking area that has been established within a secure part of the facility grounds.
• If supervision is deemed necessary, the resident will be supervised by a designated staff.
• The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to protect multiple residents from physical abuse by other residents, resulting in several incidents of harm and injury. In several documented cases, residents were physically assaulted by peers, including being punched in the face, head, or chest, and in some cases, these assaults resulted in hospital transfers, visible injuries such as bruising, lacerations, abrasions, and the need for medical treatment. The incidents involved residents with known behavioral issues or histories of aggression, some of whom had orders for 1:1 supervision or required supervision during specific activities such as smoking. Despite these known risks, staff did not consistently provide the required supervision or intervene in time to prevent altercations. Specific events included one resident being repeatedly assaulted by a roommate, another being attacked in a smoking area where supervision was required but not provided, and others being struck in common areas or hallways. In several cases, staff documentation was incomplete or failed to describe the altercations, and there were lapses in following care plans or behavioral interventions. Witness statements and staff interviews confirmed that staff were not always present or able to intervene promptly, and that some residents were fearful of aggressive peers due to repeated incidents. The facility's own policies defined physical abuse as intentional harm by another person, and staff interviews confirmed their understanding of the responsibility to protect residents from abuse by anyone, including other residents. However, the documented events show that staff did not consistently implement or maintain necessary supervision, failed to reassess and update care plans in response to behavioral changes, and did not always document or communicate incidents effectively. These failures resulted in immediate jeopardy to resident safety and placed all residents at risk of abuse.

Removal Plan

• Resident #32, #7, #26 are under 1:1 supervision with staff in close proximity to deescalate or intervene with any possible altercations.
• Resident #40 and #26 will not be allowed to smoke unsupervised.
• A dedicated staff member has been assigned to monitor residents #40 and #26 during smoking breaks.
• A dedicated staff member has been established in the designated smoking area within a secure part of the facility grounds.
• Resident #37, #41, and #39 will have trauma screens performed on all residents that were abused by other residents.
• Resident #12 and #43 no longer reside in the facility.
• All staff will be educated on the abuse policy.
• The DON or designee will educate on abuse and 1:1, ensuring staff doing 1:1 are in close proximity to intervene and provide privacy during bodily functions.
• The DON or designee will conduct an audit of residents currently on 1:1 to ensure the person assigned is monitoring the patient.
• Nursing staff on all shifts will document any unusual, increased, or change in behaviors in the medical records.
• Clinical review will determine residents at risk for aggressive behaviors and appropriate interventions will be put in place.
• All residents that require supervised smoking will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed.
• Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
• The facility will schedule a staff member to be in the courtyard while smoking occurs.
• The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
• IDT will be educated on what a 1:1 entails, including maintaining arm's length inside and outside of the room.
• Anyone providing 1:1 care will be scheduled by staffing with their relief person for break noted on the schedule.
• Resident on 1:1 will be documented on daily by assigned staff, collected by charge nurse.
• Staff will be educated that they may not leave the resident until they have a relief person and must remain in close proximity to intervene.
• The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking.
• The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
• This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
• A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
• The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to intervene.
• Facility will monitor all residents who have been identified as supervised smokers.
• All supervised smokers will smoke in the designated smoking area within a secure part of the facility grounds.
• If supervision is deemed necessary, the resident will be supervised by a designated staff.
• The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to employ a full-time, qualified social services worker to meet residents' individual needs. Interviews and document reviews revealed that the facility did not have a full-time social services director on-site. The social services assistant confirmed she did not have the qualifications to serve as the director, and the current social services director was reported to be working remotely, primarily during evenings and weekends, rather than being present in the facility. Further interviews established that the social services director had accepted full-time employment elsewhere and was only working part-time at the facility as needed, focusing on audits and compliance checks rather than providing direct, full-time services. Prior to this change, the director was responsible for trauma screenings, psychosocial assessments, MDS reviews, and direct support to residents and families. The absence of a full-time, qualified social services director resulted in the facility not meeting the requirement to provide adequate social services staffing for its residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to maintain an effective quality assurance program focused on outcomes of care and quality of life, resulting in multiple residents across all units being victims of abuse. Survey findings revealed that seven residents were abused by staff and/or other residents, with failures in reporting allegations, investigating incidents, and preventing further abuse. The facility's quality assurance program was involved in developing a plan of correction and ongoing monitoring, but these actions did not sustain compliance. During a subsequent survey, nine residents were identified as victims of abuse, with continued failures in reporting, investigation, and supervision, leading to deficiencies in abuse prevention and quality of care. Further review showed that the facility was previously cited for failing to protect residents from abuse, failing to report and investigate abuse, and not correcting repeated willful abuse. Despite audits and staff education on abuse policies, additional residents were found to have been abused, and immediate jeopardy was identified due to the facility's failure to protect residents' rights. The facility did not implement interventions such as 1:1 supervision, psychiatric services, timely reporting, thorough investigations, and staff education as outlined in their plan of correction. The DON acknowledged the lack of evidence for an effective QA program, and the administrator was not available for interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours per day on three separate days in December 2025. Review of the as-worked nursing schedule confirmed that no RN was present on 12/7/25, 12/13/25, or 12/14/25. During interviews, the scheduler stated that no RNs were available to work on those dates, and the DON confirmed that the RN who typically worked weekends was on medical leave. The DON also noted that while there were sufficient licensed practical nurses available, there was a shortage of RNs to cover the required shifts. No additional information was provided by the facility administration prior to the end of the survey.