Regency Care Of Arlington, LLC
1785 South Hayes Street, Arlington, VA 22202 · For profit - Individual · 240 certified beds · (703) 920-5700 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
- its last standard health inspection was over 3 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 3 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 held steady at 3 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 | 21.0% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.7% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.2% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 18.7% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.2% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.1% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.2% | 15.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 78.5% | 94.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 7.9% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.4% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 29.4% | 73.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.0% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.5% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.79 | 1.52 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.61 | 1.48 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
47.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.5% 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 59 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.
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 | 47.4%CMS range 36.3–58.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.5%CMS range 9.6–15.6 | 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 | 47.5% | 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 | 57.6% | 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 | 45.8% | 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 | 91.8% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 2.1% | 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 | 6.3%CMS range 3.4–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
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 3 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Ecited before2023-07-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, review of facility policies, the facility failed to ensure food was stored, prepared, and maintained in accordance with professional standards for food service safety. a sanitary manner. This failure had the potential to affect 136 of 155 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety Requirements dated 2023 revealed . food should be labeled and dated. Foods should be used by its use-by date or discarded. Review of the facility's policy titled, Date Marking for Food Safety dated 2023 revealed . food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening the food shall be responsible for dating the food item when it is opened. Review of the facility's policy titled, Use and Storage of Food Brought in by Family and Visitors dated 2023 revealed . food items brought in by family or visitors must be labeled with…
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 before2023-07-12 · tag F0880 — failed to prevent and control infections — patternProvide 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, interview, record review, and review of facility policy, the facility failed to ensure proper hand hygiene during meal service for 12 residents (R) from a sample of 35 residents. Staff failed to perform hand hygiene when passing meal trays to R63, R75, R86, R103, R122, R133, R409, R411, R412, R413, 414, and R415. Staff handled residents' food without wearing gloves. The facility also failed to post the correct signage for personal protective equipment (PPE) for two residents of six residents on transmission-based precautions. (R3 and R139). The facility also failed to ensure that the posted precautions were followed for one of six residents on transmission-based precautions (Resident #34). These combined failures have the potential to widely transmit infectious agents and increase the risk of facility-acquired infections. Finding include: 1. Staff failed to perform hand hygiene when passing meal trays. Review of the facility's undated policy titled Serving a Meal reads in part Perform hand…
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 · D2023-07-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, staff interviews, and chart review, the facility failed to maintain a clean, home-like environment for one resident, Resident #49, out of thirty-five residents in the survey sample, as well as for one of four units (300 unit) in the facility. The findings include: 1. Resident #49 (R49) did not have her personal items and clothing returned after a room change. R49 was admitted to the facility with diagnoses that included paraplegia, hypertension, gastroesophageal reflux disease, gastric ulcer, diabetes, COPD (chronic obstructive pulmonary disease), polyneuropathy, major depression disorder and anemia. The minimum data set (MDS) dated [DATE] assessed R49 as cognitively intact and to require the extensive assistance of two people for bed mobility, transfers, dressing and hygiene. On 7/10/23 at 12:00 p.m., R49 was interviewed about quality of life/care in the facility. R49 stated during this interview that she moved rooms a couple of months ago and many of her personal items were missing and…
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 · D2023-07-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and policy review, the facility failed to ensure an allegation of abuse was reported to the Administrator and to the State Agency within two hours of the allegation being reported to facility staff. This involved one resident (R)84) in the sample of 35 residents. Findings include: During an interview on 07/10/23 at 12:30 PM, R84 stated that a male aide was rough with her during perineal care and had cursed at her. When asked if he hurt her, R84 stated he hurt her bottom. R84 stated it had occurred on the 3:00 PM to 11:00 PM shift and it has been ongoing. At 12:32 PM, the Unit Manager/Registered Nurse (RN)3 entered R84's room. R84 told the Unit Manager that the male aide on the evening shift was rough with her, that she did not want him caring for her, and that she preferred to have a female aide. On 07/10/23 at 3:22 PM, the resident was asked by the surveyor if she knew who was assigned to care for her on the 3:00 PM to 11:00 PM shift that evening. R84 answered that the same male aide had been assigned to her, and she was not happy about it. 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 · D2023-07-12 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to adversely affect the residents and their Resident Representatives (RR) by not having the knowledge of where and why a resident was being transferred, and/or how to appeal the transfer, if desired, as well as preventing the State LTC Ombudsman from identifying inappropriate discharges. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA) dated 2022 provided by the Administrator, revealed the facility will provide a notice of transfer to the resident and representative as indicated. The Social Services Director, or designee, will provide copies of notices 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 · D2023-07-12 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 35 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA) dated 2022 provided by the Administrator, revealed that the facility will provide the facility's bed hold policy to the resident and representative as indicated. Review of the facility's policy titled, Bed Hold Notice Upon Transfer dated 2022 provided by the Administrator, revealed: 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and /or 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 before2023-07-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 complete an accurate minimum data set (MDS) for two of thirty-five residents in the survey sample (Residents #129 and #359). The findings include: 1. Resident #129's MDS dated [DATE] failed to accurately assess the resident's actual dental problems. Resident #129 (R129) was admitted to the facility with diagnoses that included quadriplegia, respiratory failure, neurogenic bladder, anemia, anxiety, history of pulmonary embolism, pressure ulcers and depression. The minimum data set (MDS) dated [DATE] assessed R129 as cognitively intact. On 7/10/23 at 3:15 p.m., R129 was interviewed about quality of care in the facility. R129 stated during this interview that she was missing all but her front upper teeth and that she had tooth decay. R129 then displayed her front teeth. The teeth were dark around the edges with broken, jagged surfaces. R129 was missing the upper back and lower teeth. Resident #129's…
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 before2023-07-12 · 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 observation, record review, interview, and review of facility policy, the facility failed to develop care plan interventions for one resident (Resident #3) from a sample of 35 residents. Resident #3 (R3) had physician's orders for care of his suprapubic catheter site but no interventions were care planned for this device. This failure has the potential for the resident not to receive the proper care of his catheter. Findings include: Review of the facility's policy titled Comprehensive Care Plans with an October 2022 revision date reads in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment. During an observation of morning care on 07/11/23 at 10:30AM, R3 was observed to have a suprapubic catheter draining cloudy…
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 · D2023-07-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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, interview, record review, and review of facility policy, the facility failed to provide appropriate suprapubic catheter care and handling for one resident (Resident # 3) from a sample of 35 residents. This failure increases the potential for R3 to develop recurring urinary tract infections (UTIs) or other complications. Findings include: Review of the facility's policy titled Catheter Care-Suprapubic dated October 2022 reads in part .Ensure drainage bag is located below the level of the bladder to discourage backflow of urine .Suprapubic catheter care will be performed every shift and as needed by nursing personnel. Observation on 07/11/23 at 10:30AM revealed R3 receiving morning care. R3 was positioned on his back in bed. The catheter tubing was secured to R3's right thigh area with a leg strap. The catheter site did not have a dressing covering it. Certified Nursing Assistant (CNA) 6 and CNA8 were providing care to this resident. CNA 6 held the catheter drainage bag above the level 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 · D2023-07-12 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, interviews, record review, and review of facility policy, the facility failed to ensure that one resident (Resident #3) from a sampled 35 residents was properly positioned while receiving gastrostomy tube feeding. This failure has the potential for the resident to develop aspiration problems from the tube feeding. Finding include: Review of the facility's policy titled Care and Treatment of Feeding Tube dated October 2022 reads in part The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. Review of the facility's policy titled Flushing a Feeding Tube dated October 2022 reads in part Prevent aspiration risk by keeping the head of bed elevated at a minimum of 30 degrees. Observation on 07/11/23 at 10:30AM of morning care revealed R3 in bed with the head of the bed (HOB) elevated less than 20 degrees, with the tube feeding infusing. While providing care the two Certified Nursing Assistants (CNA)6 and CNA 8…
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 17 citations
- Potential for harm · D2023-07-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed two errors out of thirty-four opportunities resulting in a 5.8% error rate. The findings include: 1. On 7/11/23 at 8:00 a.m., a medication pass observation was conducted with licensed practical nurse (LPN #2) administering medications to Resident #134 (R134). Included in the medications administered to R134 was Senna Plus 8.6/50 milligrams (mg). R134's clinical record documented a physician's order dated 6/19/23 for Senna 8.6 mg once per day for bowel management. R134 had no order for the Senna Plus 8.6/50 mg administered during the observed medication pass. On 7/11/23 at 9:25 a.m., LPN #2 was interviewed about the Senna Plus administered to R134. LPN #2 reviewed the orders and stated the order was for plain Senna and not Senna Plus, which included a stool softener. LPN #2 stated both senna products were from house stock and were available in the medication cart. This finding was reviewed with…
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 · F2022-08-31 · 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 facility document review, clinical records review and staff interview, the facility staff failed to ensure the infection prevention and control program (IPCP) antibiotic stewardship included antibiotic use protocols and an accurate system for monitoring antibiotic use. Findings include: On 08/31/22, the facility's antibiotic stewardship book/program was reviewed. The book/program did not consistently identify the type of infection, the antibiotic used, did not identify the specific organism, did not include the date of infection, specific symptoms and/or means of confirming infection prior to the prescribing and/or administering antibiotics. There was not a way to confirm the antibiotic prescribed was for the correct indication, dose, and duration to appropriately treat the resident. The antibiotic stewardship program for antibiotic use protocol(s) did not address antibiotic prescribing practices (i.e., documentation of the indication, dose, and duration of the antibiotic; review of laboratory reports to determine if the antibiotic is indicated or needs to be adjusted; an…
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 · F2022-08-31 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 ensure at least one staff member was designated as the infection preventionist who is responsible for the facility's IPCP (infection prevention and control program). Findings include: On 08/31/22 at approximately 7:30 AM, the facility's IPCP/antibiotic stewardship program was reviewed. The program presented did not consistently identify the type of infection, did not identify the specific organism, did not identify the antibiotic used/prescribed, did not include the date of infection, specific symptoms and/or means of confirming infection prior to the prescribing and/or administering antibiotics to residents. On 08/31/22 at approximately 9:30 AM, the administrator stated that they do not currently have an IPCP preventionist at this time and stated that she (infection preventionist) has been gone since June 24th and that they have not had anyone in that role, but did recently hire someone for that role. The administrator stated that the person has not actually worked yet and was supposed to start on…
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 before2022-08-31 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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, the facility failed to ensure an accurate MDS (minimum data set) assessment for three of 18 resident's in the survey sample. 1. Resident #82's MDS section B (vision) and section H (Bladder and Bowel) was coded incorrectly. 2. Resident #133's MDS section A (discharge) was coded incorrectly. 3. Resident #131's MDS section A (discharge) was coded incorrectly. The Findings Include: 1. Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of [DATE]. Resident #82's cognitive score was a 13 indicating cognitively intact. On [DATE] at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were…
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 before2022-08-31 · 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 staff interview, clinical record review and facility document review, the facility staff failed to review and revise the CCP (comprehensive care plan) for six of 29 residents in the survey sample, Resident #47, #97, #118, #131, #107 and #8. 1.) The facility staff failed to update Resident #47's care plan related to snacks and an AV (arteriovenous) fistula (no longer in use). 2.) The facility failed to update Resident #97's care plan related to trach care interventions for dislodgement of a tracheotomy tube. 3.) Resident #118's care plan was not reviewed and revised to remove the focus area, Resident is a smoker. 4.) Resident #131's care plan was not reviewed and revised to include his repositioning of his tracheotomy tube, nor was the care plan revised to delete the use of hemostats to open up the stoma in the event the tube was coughed out. 5). Resident #107's CCP was not reviewed & revised for code status change. 6.) Resident #8's CCP was not reviewed & revised for discontinuation of anticoagulant…
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 before2022-08-31 · 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
Based on Resident interview, staff interview and clinical record review, the facility failed to develop a care plan for one of 29 resident's. Resident #82 did not have a care plan for vision. The Findings Include: Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 7/26/22. Resident #82's cognitive score was a 13 indicating cognitively intact. On 8/30/22 at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were broken off). On 8/30/22 Resident #82's clinical record was reviewed. Section B1000 (Vision) of Resident #82's most recent MDS documented Resident #82's vision was adequate and no corrective lenses were needed. Resident #82's care plan was also reviewed and revealed no documentation of a care…
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 before2020-02-27 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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, observations, and staff interview, the facility staff failed for one of 37 residents in the survey sample, Resident # 36, to implement the plan of care. Resident # 36, who had a diagnosis of Huntington's, had a care plan intervention to add padding to the walls of the resident's room that was not implemented. The findings were: Resident # 36 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included anemia, Non-Alzheimer's dementia, Huntington's disease, seizure disorder, anxiety disorder, depression, psychotic disorder, schizophrenia, and mood disorder. According to the most recent MDS, Quarterly review, with an ARD of 12/7/19, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 00 out of 15. During the orientation tour at 8:30 a.m. on 2/25/2020, the resident's room was noted to have two twin size mattresses, both covered with sheets, placed side-by-side on…
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 before2020-02-27 · 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 2. Resident #111 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, peripheral venous insufficiency, depression, osteomyelitis in left foot, diabetes, methicillin resistant staphylococcus aureus infection, cerebrovascular disease, heart failure, chronic kidney disease, atrial fibrillation and insomnia. The minimum data set (MDS) dated [DATE] assessed Resident #111 as cognitively intact. Resident #111's clinical record documented a physician's order dated 2/4/20 for Vancomycin solution 750 mg (milligrams) to be administered intravenously twice per day for treatment of osteomyelitis in the left foot via a PICC (peripherally inserted central catheter). The record also documented physician orders dated 1/21/20 for use of Heparin solution (10 units/milliliter) to flush the right arm PICC two times a day to maintain patency. Resident #111's clinical record documented the resident was placed on contact precautions at the time of admission due to the infected wound on the left…
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 · E2020-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, facility staff failed to provide showers for one of 39 residents in the survey sample, Resident #107. Findings included: Resident #107 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Diabetes, Peripheral Vascular Disease (PVD), Left AKA (above knee amputation), and Right BKA (below knee amputation. The most recent MDS (minimum data sheet) was a quarterly assessment with an ARD (assessment reference date) of 02/20/2020. Resident #107 was assessed as moderately impaired in his cognitive status with a total cognitive score of 12 out of 15. Resident #107 was interviewed on 02/25/2020 at 10:50 a.m. The resident was lying in the bed, alert and oriented, with his Bipap in place over his nose. Resident #107 was asked about getting showers. Resident #107 stated Huh, I get a shower about once, every other week. I give myself a bed bath the rest of the time. The staff give me my supplies and water. I like to get a…
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 · E2020-02-27 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on individual resident interview, resident group interview, staff interview, facility document review, and in the course of a compliant investigation, the facility staff failed to respond to call bells in a timely manner for 9 out 39 residents in the survey sample, Resident #s 152, 69, 121, 130, 151, 139, 76, 2, 117. Residents and the resident group council reported lengthy call bell response with waiting between 15 to 30 minutes and up to 2 hours for staff response. The findings include: On 2/25/20 at 9:00 a.m., Resident #152 was interviewed about sufficient staffing and call bell response. Resident #152 stated call bell response on his unit was slow and he waited at times up to an hour for staff response. Resident #152 stated call bell response was worse on the night (11:00 p.m. to 7:00 a.m.) shift. Resident #152 stated he did not think they had enough staff to get to everyone when needed. On 2/25/20 at 9:15 a.m., Resident #69 was interviewed about staffing and call bell response. Resident #69 stated his roommate frequently activated the call bell and had extended wait times…
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 before2020-02-27 · 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 and staff interview, the facility failed to ensure proper handling techniques while serving food from the steam table on one of 4 units, unit #4; and failed to ensure expired yogurt, orange juice, and flavored water was not available for distribution in the main kitchen. The findings Include: 1. On 02/25/20 at 08:31 AM, dietary aide (Other Staff, OS #4) was observed plating toast, bacon, boiled eggs directly with gloved hands. OS #4 was also observed touching the side of his face. OS #4 was interviewed at this time and stated he didn't know where the utensils were to handle the food, turned to another staff member and asked if they could call the kitchen to get some utensils. OS #4 then asked the surveyor if he could continue using his gloved hands to plate food. OS #4 was told he could not tell OS #4 what he should be doing. OS #4 then received tongs and began using them for the bacon but continued to use gloved hands for toast and boiled eggs. On 02/26/20 at 07:48 AM, the dietary manager (OS #2 ) was interviewed. OS #2 stated dietary assistant should be using…
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 · D2020-02-27 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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, staff interview, and during the course of a complaint investigation, the facility staff failed to develop and implement a baseline care plan for for dialysis within 48 hours of admission for one of 39 residents (Resident #170). Findings include: Resident #170 was originally admitted to the facility on [DATE]. The resident was discharged from the facility on 07/01/19, with another readmission to the facility on [DATE]. The most current MDS (minimum data set) during that time was the resident's discharge return anticipated MDS dated [DATE]. This MDS documented that the resident's cognitive status as having no short term or long term memory impairment and no issues with daily decision making skills. The resident was assessed as receiving dialysis services in Section O. (Special Treatments) J. Dialysis while not a resident and while a resident in the last 14 days. During the closed clinical record review, the resident's care plan was reviewed. The care plan did not have any…
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 · D2020-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, medication pass and pour observation, staff interview, clinical record review, and in the course of a complaint investigation, facility staff failed to follow physician orders for two of 39 residents in the survey sample, Resident #83 for dressing changes and skin integrity assessments, and Resident #156 for administration of Senna; and failed to ensure Resident #170 received dialysis care and services to prevent hospitalization. Findings included: 1. Resident #83 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Lymphedema, Non-pressure Chronic Ulcers, Dementia with Behaviors, and Chronic Embolism of right lower extremity. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/2020. Resident #83 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #83's physician orders were reviewed on 02/25/2020 at approximately 2:00 p.m. Included in 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 · D2020-02-27 · 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 observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 39 residents (Resident #25) received necessary treatment and services to promote healing and prevent infection during a pressure ulcer dressing change. Findings include: Resident #25 was admitted to the facility on [DATE]. Diagnoses for Resident #25 included, but were not limited to: DM (diabetes mellitus), history of stroke with right side hemiparesis and hemiplegia, end stage renal disease (hemodialysis dependent), heart failure, high blood pressure, and kidney transplant failure. The most current, completed full MDS (minimum data set) was a 14 day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. On 02/25/20 PM at 3:25 PM, a dressing change on Resident #25's stage 4 sacral pressure ulcer was observed. LPN (Licensed Practical Nurse) #1 and #2 gathered supplies and…
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 · D2020-02-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 and staff interview, the facility staff failed to properly store and label medications and biologicals on two of four nursing units. On unit 2, two insulin pens were not labeled from the pharmacy; one multi-use vial of tuberculin PPD (purified protein derivative) solution opened greater than 30 days was available for use; and one multi-use vial of tuberculin PPD solution was without an opened date. Expired Advair was available for administration on a fourth floor medication cart. The findings include: On [DATE] at 8:12 a.m., accompanied by the licensed practical nurse unit manager (LPN #7) the medication storage refrigerator was inspected on unit two. Stored in the refrigerator was a multi-use vial of tuberculin PPD solution opened for greater than 30 days (opened on [DATE]). Another vial of tuberculin PPD solution was opened with no indication of when opened. LPN #7 was interviewed at the time of the observation about the storage of the opened tuberculin solution.…
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 · D2020-02-27 · 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 observation, staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of 39 in the survey sample, Resident #54 and Resident #14. Resident #54's clinical record inaccurately documented the resident as receiving hospice when the resident had been discharged from hospice, and there was no physician's order for the dialysis. Resident #14's name was incorrect. The findings include: 1. Resident #54 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease - requiring hemodialysis, type II diabetes, Parkinson's Disease, contracture, muscle weakness, chronic obstructive pulmonary disease (COPD), and depression. The minimum data set (MDS) dated [DATE] which was a quarterly assessment assessed Resident #54 as cognitively intact for daily decision making with a score of 15 out 15. On 02/25/20 during the initial tour, Resident #54 was interviewed regarding the quality of care…
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 before2020-02-27 · 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, facility document review, and clinical record review, facility staff failed to follow infection control practices for three of 39 residents; Resident #83 and Resident #25 during dressing changes, and Resident #166 contact isolation precautions. Findings included: 1. Resident #83 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Lymphedema, Non-pressure Chronic Ulcers, Dementia with Behaviors, and Chronic Embolism of right lower extremity. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/2020. Resident #83 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #83's physician orders were reviewed on 02/25/2020 at approximately 2:00 p.m. Included in the physician order sheet (POS) dated February 2020 was, .Cleanse right lower extremity with wound cleaner, pat dry and apply Adaptic dressing Q [every] day and evening shift…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to REGENCY CARE — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.5 | -0.5 vs chain |
| Health inspection | 3 of 5 | 3.0 | ≈ chain avg |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 1 home this chain runs (chain average 2.5★, per CMS)
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 |
|---|---|---|---|---|
| WOMACK, STEVEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 70% | since 03/01/2015 |
| MUNRO, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/14/2023 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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, FY2023). 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 495114. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-07-12, 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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