Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
4E
1F
Potential for minimal harm
0A
0B
0C
April 5, 2023Standard inspection · 4 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to maintain the dumpster area in a clean and sanitary manner for one of one dumpster.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 26 residents in the survey sample, Residents #56 and #28.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications for two of 26 residents in the survey sample, Residents #56 and #28.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to ensure food items available for use were used or discarded prior to the best when used by date, in one of eight small house kitchens, the occoquan kitchen.
October 14, 2021Standard inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed Store, food in accordance with professional standards for food service safety in one of eight kitchens observed, [NAME] small house kitchen. The facility failed to dispose of plain Greek yogurt with a best by date of 9/19/21 and honey mustard dressing with a use by date of 1/13/21 located on the [NAME] small house kitchen.
January 31, 2019Standard inspection · 9 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a safe and sanitary manner, in two of eight facility household kitchens, the Maherrin household kitchen and the Rappahannock household kitchen. 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. 1. b. The facility staff failed to hold cold food at a safe temperature in the Maherrin and Rappahannock household kitchens. 2. The facility staff failed to store dishware in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote dignity for one of 31 residents in the survey sample, Resident # 37. During a dining observation, in the [NAME] household unit dining room, Resident # 37 was observed sitting at the dining room table and waiting 23 minutes to be served and assisted with eating his meal by staff, while watching seven residents seated at the table with him, eat their dinner.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to meet the appropriate transfer requirements for three of 31 residents in the survey sample; Resident # 46, # 21, and # 69. 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated 01/06/2019. 2. The facility staff failed to evidence that Resident # 21's comprehensive care plan goals were sent with the resident to the hospital for facility initiated transfer dated 01/07/2019. 3. The facility staff failed to provide the receiving facility with the Resident #69's comprehensive care plan goals for a facility initiated transfer to hospital that occurred on 12/11/18.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to complete a discharge minimum data set (MDS) assessment for one of 31 residents in the survey sample; Resident #2. Resident #2 expired in the facility on [DATE]. The most recent MDS in the facility's system was a quarterly MDS with an ARD (assessment reference date) of [DATE]. As of [DATE], the date of the survey, there had been no discharge MDS assessment completed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure the comprehensive care plan was implemented for two of 31 residents in the survey sample, Resident # 72 and Resident #70. 1. During multiple observations, Resident #72 was receiving oxygen at 2 (two) and a half, liters instead of the 2 L (two liters) ordered by the physician and per the residents comprehensive care plan. 2. The facility staff failed to implement Resident #70's comprehensive care plan to offer non-pharmacological pain relief methods as needed and prior to the administering as needed pain medication to Resident #70.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure respiratory care and services were provided in accordance with professional standard of practice and the comprehensive person-centered care plan for one of 31 residents in the survey sample, Resident # 72. The facility staff failed to administer Resident # 72's oxygen according to the physician's orders.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that facility staff failed to provide pain management for two of 31 residents in the survey sample, Residents # 46 and # 70. 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. 2. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #70.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for three of 31 residents in the survey sample, Residents #223, #127 and #68. 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple dates in January 2019. 2. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #127, on 8 occasions in January 2019. 3. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #68, on 10 occasions in January 2019.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve food in a sanitary manner in two of eight resident dining rooms. 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the [NAME] household unit. 2. CNA (Certified nursing assistant) #1 failed to change gloves in between touching cabinet handles and the food contact areas of a bowl and a plate that was used to serve food in the Maherrin household unit.
Fire safety inspections
14 fire safety citations on file: 3 on October 14, 2021, 11 on January 31, 2019.
Every fire safety citation14 citations
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · October 14, 2021 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 300 · October 14, 2021 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · October 14, 2021 · Corrected (the home has a date of correction)
- F
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · January 31, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 31, 2019 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 31, 2019 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 31, 2019 · Corrected (the home has a date of correction)
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
K 901 · January 31, 2019 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 31, 2019 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · January 31, 2019 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · January 31, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 31, 2019 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 31, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 31, 2019 · Corrected (the home has a date of correction)