Fairmont Crossing Health And Rehab Center
173 Brockman Park Drive, Amherst, VA 24521 · For profit - Limited Liability company · 120 certified beds · (434) 946-2861 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,740 in federal fines (most recent 2026-03-05)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.8% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.0% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 35.1% | 18.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.0% | 15.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 20.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 26.7% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.6% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 70.1% | 73.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.0% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.9% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.89 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.22 | 1.48 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 214 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.4%CMS range 52.3–66.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.6–13.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 65.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.0–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 112.6 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.551 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.45 on weekdays — 16% thinner on weekends. RN hours go from 0.64 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2020-03-04 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, facility staff failed to ensure 1 one of 25 residents, Resident #88 was free from a significant, medication error, causing harm. The facility implemented a plan of correction for this deficiency and no other issues were identified during the survey. This is cited as past non-compliance. Findings included: Resident #88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: CVA (cerebrovascular accident) with hemiplegia, Hypertension, Dementia, Psychosis and Accidental Opiate Overdose. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/22/2020. Resident #88 was assessed as cognitively intact with a total cognitive score of 13 out of 15. On 03/03/2020 at 2:00 p.m, Resident #88 was observed sitting in a Broda chair watching television, in the day area with other residents. She was alert, but non-verbal. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2019-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to ensure one of 25 residents in the survey sample was free of an accident with injury, Resident #84. Facility staff failed to ensure Resident #84 did not sustain first and second degree burns on her thighs from spilled coffee on 07/05/2018. Findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Heart Disease, Chronic Atrial Fibrillation, Hypertension, Diverticulitis, Stage 3 Pressure Ulcer, Neuropathy, and Dementia. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/12/2018. Resident #84 was assessed as severely impaired in her cognitive status with a total cognitive score of three out of 15. Resident #84's clinical record was reviewed on 01/23/19 at 10:00 a.m. During this review a clinical note dated 07/05/18 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-22 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility documentation review, the facility staff failed to ensure a clean and sanitary environment in one of two dining rooms within the facility. The findings included:The facility staff failed to ensure a clean environment on the first-floor dining room area.On 4/20/26 at 12:00 pm an observation was conducted in the dining room area on the first floor of the facility. During the observation, there was a light fixture with a bug light underneath, and it was observed that there were cobwebs all over the bottom of the light fixture and top of the bug light. Also, observed were dead bugs on the top and sides of the bug light. There was a resident observed at a table right under the bug light.An interview was conducted with a certified nursing assistant, CNA#1 (CNA1). CNA1 showed the light fixture and bug light, and she said, that looks like it has been there for a while. CNA1 was observed making a disappointed facial expression. CNA1 looked on top of the bug light and said, yeah, it's full of bugs.On 4/21/26 at 2:06 pm an interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-22 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for six of fifteen residents in the survey sample (Residents #106, #109, #111, #113, #114 and #115). The findings include:1. Resident #109's plan of care was not revised regarding Covid-19 infection and discontinued use of enhanced droplet precautions. Resident #109 (R109) was admitted to the facility with diagnoses that included multiple sclerosis, insomnia, hypothyroidism, major depressive disorder and dysphagia. The minimum data set (MDS) dated [DATE] assessed R109 as cognitively intact. Review of R109's clinical record revealed a physician's order dated 2/26/26 for enhanced droplet precautions for seven days due to the resident testing positive for Covid-19. The clinical record documented the order for enhanced droplet precautions was discontinued on 3/5/26. Resident #109's current plan of care (revised 3/2/26) documented the resident had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-22 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility document review the facility staff failed to ensure that meals were served at palatable temperatures for one of two kitchenettes within the facility. The findings included:The facility staff served residents on the first-floor nursing units (two units) lunch meals at temperatures that were not palatable.On 4/20/26 at 11:45 pm, an observation was made of the kitchenette on the first floor preparing to plate and serve the lunch meal to the residents.The dietary aide, other staff #7 (OS7) was observed obtaining the temperatures of the food from the steam table and the temperatures were as follows:Ham - 100 Puree ham- 90 Sweet potatoes- 110 Grilled chicken- 95 Noodles- 100 Chopped ham - 100 Puree broccoli- 95 Pork chops- 95 Broccoli- 100 Puree bread- 100OS7 was observed shaking her head while obtaining temperatures. OS7 said, it is not reaching the right temperature. OS7 continued to plate the food and was served to the residents on the first-floor of the facility with unsafe temperatures.On 4/20/26 at 2:42 pm, the dietary manager was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility documentation review the facility staff failed to ensure food items in the walk-in freezer were within expiration dates in the main kitchen. The findings included:The facility staff failed to remove expired yogurt stored in the walk-in freezer.On 4/20/26 at 2:30 pm, an observation of the kitchen was conducted. During the observation, the dietary manager was present. In the walk-in freezer, a case of Dannon yogurt labeled with an expiration date of 4/17/26 was observed stored for use after its expiration date. On 4/20/26 at 2:32 pm, an interview was conducted with the dietary manager. During the interview, the dietary manager picked up the case, reviewed the date, and said, yes, it is expired, then shook his head and stated he does not know how the case was missed. He then reviewed the date on the case beside Dannon yogurt.On 4/21/26 a review of facility policy was conducted. The policy titled, Food storage and labeling, read in part, .All food shall be stored, labeled, and dated to prevent contamination and ensure freshness.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interviews, and clinical record reviews, the facility staff failed to implement measures to promote healing to pressure ulcers for one resident, Resident #111 (R111) out of a survey sample of 15 residents. The findings included:The heels up and heel protectors (pressure relieving devices) were not available in R111's room to be offered/used for use to promote wound healing.On 4/21/26 at 10:40 am, an observation was conducted of R111's room. There were no heels up or heel protectors visible in the room or on the bed at the time of observation.On 4/21/26 at 10:47 am, an interview was conducted with a certified nursing assistant, CNA#2 (CNA2). During the interview, CNA2 stated this was the first time taking care of R111. She stated that there were no heels up on his bed or heel protectors on his heels this morning upon her arrival to take care of him today.On 4/21/26 at 10:50 am, an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility documentation the facility staff failed to ensure appropriate infection control practices for one resident, Resident #111 (R111) out of a survey sample of 15 residents. The findings included:Facility staff failed to ensure R111's nasal cannula tubing and CPAP (continue positive airway pressure) mask were stored appropriately to prevent infection and maintained infection control practices.On 4/20/26 at 2:45 pm, an observation was conducted in R111's room of his nasal cannula tubing and CPAP mask lying on the floor in his room.On 4/20/26 at 2:50 pm, an interview was conducted with the unit manager, registered nurse, RN#2 (RN2). During the interview, RN2 said, I will get another nasal cannula tubing for him, and it should be stored in a bag when not in use.On 4/21/26 at 10:30 am, a second observation was made of R11's room and the nasal cannula tubing and CPAP mask were on the floor. On 4/21/26 at 10:47 am, an interview was conducted with certified nursing assistant, CNA#2, (CNA2). During the interview, CNA2 stated that this was the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to provide timely toileting assistance for one of eleven residents in the survey sample (Resident #10). The findings include: Resident #10's request for toileting assistance was delayed until after meal trays were delivered to other residents on the living unit. Resident #10 (R10) was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, morbid obesity, chronic obstructive pulmonary disease, respiratory failure, and dysphagia. The minimum data set (MDS - assessment tool) dated 2/28/24 assessed R10 as cognitively intact and as dependent upon staff assistance for toileting and transfers. R10's closed clinical record documented a nursing note dated 3/12/24 stating, .18:00 [6:00 p.m.] resident turned call light, CNA's [certified nurses' aides] were passing trays. Residents CNA checked to see what was needed resident needed to go to the bathroom. CNA told her [R10] she would be able to after dinner (per facility policy) .Resident has done this several times knowing what the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-25 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to use a meal ticket that accurately reflected food allergies for one of eleven residents in the survey sample (Resident #3). The findings include: Resident #3 (R3) was admitted to the facility with diagnoses that included hypothyroidism, anemia, gastroesophageal reflux disease, venous insufficiency, depression and neuropathy. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented a physician's order dated 7/27/23 for a regular high protein diet. The clinical record documented R3's food allergies of aspartame and food preservatives. On 6/25/24 at 8:12 a.m., R3 was observed eating breakfast. With the resident's permission, the breakfast meal ticket was reviewed. R3's meal ticket matched the food items served but documented no mention of the resident's allergy and/or intolerance of aspartame and food preservatives. R3 was interviewed at this time about…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-25 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, facility document review, and clinical record review, the facility staff failed to accommodate food allergies for one of eleven residents in the survey sample (Resident #10). The findings include: Resident #10 (R10) was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, morbid obesity, chronic obstructive pulmonary disease, respiratory failure and dysphagia. The minimum data set (MDS- assessment tool) dated 2/28/24 assessed R10 as cognitively intact. R10's clinical record documented a physician's order dated 2/21/24 for a regular textured diet with food allergies listed as broccoli, cauliflower, carrots, yellow dye, and lemonade. R10's diet was changed on 2/22/24 to a 2-gram sodium diet and then on 2/23/24 to a 2-gram sodium dysphagia diet, advanced texture. Facility menus for February 2024 included at least four meals served with mixed vegetables that included broccoli, cauliflower, and/or carrots. On 6/24/24 at 2:25 p.m., the dietary manager (other staff #5) was interviewed about accommodation of food allergies for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-06-02 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and facility document review, the facility staff failed to implement an antibiotic stewardship program. The facility's documented program regarding protocols and monitoring of antibiotic use was not implemented. The census in the facility was 111 residents. Findings were: On 06/01/2022 at approximately 1:55 p.m., the interim DON (director of nursing), who also identified herself as the IP (Infection preventionist) was interviewed regarding the antibiotic stewardship program at the facility. She stated, I'm not sure what we have, I will need to look .I've been doing this position less than 24 hours. At approximately 3:00 p.m. she presented a policy and procedure Antibiotic Stewardship Program that contained the following: .The goals of the program include: Ensuring residents .are prescribed the appropriate antibiotic, reducing the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. The Antibiotic Stewardship team will analyze infection data [including type of infection or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · E2022-06-02 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility document review, the facility failed to ensure drug irregularities were noted in the pharmacy review for one of 25 residents, Resident #42. The pharmacy did not report an ongoing order of an as needed (PRN) anti-psychotic medication for Resident #42. The Findings Include: Resident #42 was admitted with diagnoses which included: Dementia with behaviors, cerebrovascular disease, dysphagia, and hypertension. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/30/22. Resident #42's cognitive score indicated having long and short-term memory problems and severely impaired cognitively. Resident #42's physician orders documented an order dated 2/4/22 that read: Quetiapine (seroquel, antipsychotic) tablet 25 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for agitation . Review of monthly pharmacy medication record review (MRR) from 2/28/22 through 5/30/22 evidenced that the reviews had been completed, but did not include any recommendations to stop the as needed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-02 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility document review, the facility failed to ensure an as needed anti-psychotic medication was limited to 14 days for one of 25 resident's. Resident #42's as needed order for Seroquel was in place for 4 months. The Findings Include: Diagnoses for Resident #42 included: Dementia with behaviors, cerebrovascular disease, dysphagia, and hypertension. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/30/22. Resident #42's cognitive score indicated having long and short-term memory problems and severely impaired cognitively. Resident #42's physician orders documented an order dated 2/4/22 that read: Quetiapine (seroquel, antipsychotic) tablet 25 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed (PRN) for agitation . Review of Resident #42's medication administration record (MAR) evidenced the PRN order for Seroquel was available for distribution, but was not given from he time it was ordered (2/4/22) through 5/31/22. On 06/02/22 at 12:01 PM, RN #2 stated the process is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facility document review, the facility staff failed to ensure food was properly stored in the main kitchen. Findings were: Initial tour of the kitchen was conducted on 06/01/2022 at approximately 10:40 a.m. with the dietary manager (DM). In the walk in refrigerator was a cart with an opened partial gallon of whole milk. The manufacturer's stamped date on the milk jug was 05/27/2022. On the side of the jug was written, Opened 05/30/2022. He was asked what the dates signified. He stated that date of 05/30/2022 was when the milk had been opened by the dietary staff. He was asked what the manufacturer's stamped date of 05/27/2022 meant. He stated, I am going to throw that out. On a shelf in the refrigerator were three additional gallon jugs of whole milk. All with the manufacturer's stamped date of 05/27/2022. The DM was asked if the manufacturer's date on the milk jugs was a use by date or a sell by date. He stated, I'm not sure, but I will make some calls and find out. Also observed in the walk in refrigerator was an unopened 48 ounce…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to develop a comprehensive care plan for 2 of 25 residents in the survey sample, Resident #103 and Resident #89. Resident #103's care plan did not include focus areas with goals and interventions for the use Insulin and for the use of the antidepressant Venlafaxine (Effexor). Resident #89's care plan did include a focus area with goals and interventions for the use of the diuretic Furosemide (Lasix). The findings include: 1a. Resident #103 was admitted to the facility with diagnoses that included muscle weakness, traumatic brain injury, chronic respiratory failure, COPD, type 2 diabetes, hypokalemia, major depression disorder, sleep apnea, hypothyroidism, obesity, and GERD. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed Resident #103 as moderately impaired for daily decision making with a score of 8 out 15. Resident #103's electronic clinical record (EHR) was reviewed on 06/01/2022. Observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure a complete and accurate record for for one of 25 residents, Resident #71. Resident #71's advance directives were not included in the EMR (electronic medical record). Findings include: Resident #71 was admitted with diagnoses which included, but were not limited to: diabetes mellitus, chronic kidney disease, vascular dementia, constipation, and osteoarthritis. The resident's most current MDS (minimum data set) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. On [DATE] at 3:20 PM, Resident #71's clinical EMR were reviewed. The physician's order for the resident included an order for: .DNH (Do Not hospitalize) . The physician's orders did not include an order for full code and/or CPR (cardiopulmonary resuscitation) or DNR (Do Not Resuscitate). On [DATE] at 3:54 PM, the administrative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-02 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for 1 of 25 residents in the survey sample, Resident #89. Records of weekly hospice visits for Resident #89 were not provided to the facility as required in the hospice services agreement. The findings include: Resident #89 was admitted to the facility with diagnoses that included palliative care, disorientation, hypo-osmolality, hyponatremia, type 2 diabetes, unilateral inguinal hernia, peripheral vascular disease, hyperlipidemia, stage 3 chronic kidney disease, anemai, adult failure to thrive, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #89 as cognitively intact for daily decision making with a score of 15 out of 15. Under Section O - Special Treatments, Procedures, and Programs, the MDS assessed Resident #89 has receiving Hospice Services. Resident #89 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-03-04 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 25 in the survey sample. Resident #42's care plan was not revised to reflect the use of anticoagulant medication. The findings include: Resident #42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, heart failure, bilateral osteoarthritis, chronic kidney disease stage 3, hypothyroidism, vitamin d deficiency, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was an annual assessment, assessed Resident #42 as severely impaired for daily decision making with a score of 5 out of 15. Resident #42's clinical record was reviewed on 03/03/2020. Observed on the current physician order sheet was the following order: Eliquis 5mg tablet (1 tab) TABLET Oral. Two Times Daily Starting 10/09/2019. Order Date: 10/9/2019. Notes: Anticoagulant. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-01-24 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, facility staff failed to follow physician orders for one of 25 residents in the survey sample, Resident #55. Facility staff failed to obtain physician ordered daily weights from 10/21/2018 through 01/20/19 for Resident #55. Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Heart Disease, Hypertension, Anxiety, Dementia and Thyrotoxicosis. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 11/27/18. Resident #55 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #55's clinical record was reviewed on 01/23/19 at approximately 2:00 p.m. During this review a physician order dated 10/21/18 included, Weights One Time Daily Starting 10/21/2018. Subsequent review of the Resident Weight Report included recorded weights on the following dates: 10/22/18, 10/26/18, 10/30/18, 11/05/18,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-01-24 · tag F0740 — failed to provide behavioral / mental-health care — patternEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, facility staff failed to ensure one of 25 residents in the survey sample received behavioral health services, Resident #55. Facility staff failed to ensure Resident #55 was seen by behavioral health services from October 01, 2018 to currently. Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Heart Disease, Hypertension, Anxiety, Dementia and Thyrotoxicosis. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 11/27/18. Resident #55 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #55's clinical record was reviewed on 01/23/19 at approximately 2:00 p.m. During this review clinical notes included the following documentation: 10/1/18 at 11:48 a.m. resident was crying this morning after breakfast. (sic) She stated [Name], my car won't start and I need to get to class, what am…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-01-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed for one of 25 residents in the survey sample (Resident # 24), to develop a plan of care that included the resident's participation in Hospice care. Resident # 24's care plan failed to include a delineation of care functions to be carried out by the facility and by Hospice. The findings were: Resident # 24 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses that included anemia, hyponatremia, osteoporosis, aphasia, cataracts, pressure ulcer, spinal stenosis, weakness, dry eye syndrome, hypocalcemia, and macular degeneration. According to a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 10/24/18, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. According to a review of the resident's Electronic Health Record, the resident entered Hospice care on 10/15/18. Further review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-01-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility failed to ensure proper hand hygiene was performed during medication pass on one of 4 units. The medication nurse on the [NAME] Run unit did not use hand hygiene between Resident's during medication pass observation. The Findings Include: On 1/23/19 a medication pass and pour was observed from 7:47 AM to 8:10 AM. During the medication pass three Resident's were observed receiving medications from license practical nurse (LPN #1). During the observation LPN #1 was observed touching Resident's, and moving inanimate objects in Resident's rooms on top of the over bed tables. After each medication pass LPN #1 returned back to the medication cart and begin pulling medications for the next Resident without using any hand sanitizing agent or washing hands. At the end of the medication pass observation LPN #1 was interviewed regarding the observation. This surveyor verbalized the observation regarding hand hygiene. LPN #1 agreed but did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-06-02 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility staff failed to ensure proper function of the condenser in the walk in freezer of the main kitchen. The condenser was leaking water creating thick white ice on food stored underneath. Findings were: Initial tour of the kitchen was conducted on 06/01/2022 at approximately 10:40 a.m. with the dietary manager (DM). Observed in the walk-in freezer on the top shelf was a box of pepperoni. The top and sides of the box were covered in thick white ice. Above the box was a condenser that was also covered in ice. The DM was asked about the thick ice accumulation on the box. he stated, The condenser leaks water down and it freezes, it happens again as soon as we clean it up. He was asked if food should be stored under the leak. He stated he would move the box. He was asked if maintenance had looked at the condenser. He stated, Yes, I talked to (Name), he was the former maintenance worker, he said it couldn't be fixed .we have a new guy now (name). He was asked if a work order ad been put in regarding the leaking condenser. He stated, No,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2020-03-04 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility staff failed to ensure a homelike environment in one of 16 rooms on the Meadows Wing. The wall in room [ROOM NUMBER] was scuffed, gouged and without paint in one area. Findings were: During initial tour of the facility on 03/03/2020 at approximately 11:00 a.m., a wall in room [ROOM NUMBER] was observed with multiple gouges, peeling/picked wallpaper, and an area that had been partially patched but not painted. At approximately 11:30 a.m., the maintenance director was interviewed about the obseved area. He stated, I believe we've fixed that a number of times .her (the resident in the room) chair hits it and makes those areas, I'll go look at it. He returned and stated, There is a sharp corner on her chair that is doing that [marking the wall]. It's her chair so I am going to contact the family about getting it repaired. We'll fix the wall. There's an area there now that we patched, that never got painted. We will take care of it. The administrator and the DON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$12,740 in federal fines across 1 penalty.
- $12,740 — penalty dated 2026-03-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to HILL VALLEY HEALTHCARE — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 1.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 3.7 | +0.3 vs chain |
The other 42 homes this chain runs (chain average 1.8★, per CMS)
Showing 40 of 42; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AMHERST SNF HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2021 |
| TIMBERLAKE OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 11/01/2021 |
| WADE, SARAH | Individual | W-2 MANAGING EMPLOYEE | — | since 11/01/2021 |
| IDELS, SHIMON | Individual | CORPORATE OFFICER | — | since 11/01/2021 |
| HVH TIMBERLAKE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2021 |
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495363. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-06-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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