No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Stanleytown Health And Rehabilitation Center

240 Riverside Drive, Bassett, VA 24055 · For profit - Partnership · 120 certified beds · (276) 629-1772 Medicare & Medicaid certified

Call the home — (276) 629-1772 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Apr 2023
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)
  • about 20% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2202 Daniels Creek Rd · (276) 647-5133 · Call to confirm hours
Pharmacy
335 Riverside Dr · (276) 627-0536 · Call to confirm hours
Grocery
Food Lion0.5 mi
951 Fairystone Park Hwy · (276) 629-7232 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
275 Riverside Dr · (276) 226-6763

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 5 of 5
Long-stay residentspeople who live here 5 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 improved from 3 to 4 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.2%14.9%15.4%typical
Long-stay residents who lose too much weight2.9%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.4%1.6%2.0%better
Long-stay residents with depressive symptoms51.4%18.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.3%3.6%3.3%worse
Long-stay residents whose ability to walk worsened21.7%15.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication24.4%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers1.2%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control21.5%21.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table23.4%14.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine94.0%73.6%79.4%better
Short-stay residents rehospitalized after admission13.8%22.3%22.6%better
Short-stay residents with an outpatient ER visit7.2%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.191.521.67better
Long-stay outpatient ER visits per 1,000 resident days0.001.481.80better

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.

55.5% 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 363 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.5%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
61.2%U.S. median 56.6%
Met the expected recovery
0.60U.S. median 0.31
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 61.2% 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 170 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.5%CMS range 50.3–60.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.9–14.210.7%Oct 2022–Sep 2024no 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 discharge61.2%56.6%Oct 2024–Sep 2025CMS 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 discharge61.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.1%50.0%Oct 2024–Sep 2025CMS 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 identified99.1%98.7%Oct 2024–Sep 2025CMS 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 setting99.2%100.0%Oct 2024–Sep 2025CMS 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 discharge92.2%98.7%Oct 2024–Sep 2025CMS 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 stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization10.3%CMS range 6.5–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 2022–Sep 2024CMS 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

0.39
RN hours/ resident / day
1.19
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.17
RN hoursweekends
57.9%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.8 residents a day — about 95% occupied, or roughly 6 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.20 hrs/resident/day on weekends vs 3.90 on weekdays — 18% thinner on weekends. RN hours go from 0.47 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above 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

3
deficiencies at the latest standard inspection (2024-04-18)
7
at the previous standard inspection (2023-04-13)

Deficiencies are fewer than at the previous inspection — improving. 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 2 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.

ABCDEFGHIJKL

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 · E2024-04-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 observations, interviews, and facility document review, the facility staff failed to appropriately store and/or serve resident food items. The findings include: The facility staff failed to ensure residents' beverages (orange juice, apple juice, cranberry juice, and iced tea) were appropriately stored and/or served. The following information was found in a facility dietary policy titled Meal Distribution (with a date of October 2019): It is the center policy that meals are transported to the dining locations in a manner that insures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. On 4/16/24 at 9:25 a.m., two (2) carts used to transport breakfast to the facility's residents on the nursing units were noted to have been placed outside a door leading to the facility's kitchen. One of these carts had three (3) pitchers of beverages placed on the top of the cart; the Dietary Services Manager (DSM) reported that the beverages were orange juice, cranberry juice, and apple juice. The other cart had one (1) pitcher 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 observation, resident interview, staff interview, and clinical record review, facility staff failed to administer medicated shampoo as ordered for 1 of 23 residents in the survey sample (Resident #42). Resident #42 was admitted to the facility with diagnoses including psoriasis, above the knee amputation, hypertension, peripheral vascular disease, end stage renal disease, anxiety, depression, bipolar disorder, and schizoaffective disorder. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview For Mental Status and was assessed as without signs of delirium, psychosis, behaviors affecting care, or rejecting care. The assessment indicated the resident was fully dependent for showering and bathing and required substantial/maximal assistance for personal hygiene (includes washing and drying face and combing hair). During initial tour on 4/15/24 at approximately 4:20 PM, the resident's face appeared red and skin was peeling over about 30% of face. The resident's hair…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    Based on interviews and clinical record review, the facility staff failed to ensure complete and/or accurate clinical records for one (1) of 23 sampled residents (Resident #82). The findings include: Resident #82's clinical record included documentation that indicated the resident was administered medications when the resident was not present at the facility. Resident #82's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/2/24, was signed as completed on 3/6/24. Resident #82 was assessed as being able to make self understood and as able to understand others. Resident #82's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #82 was assessed as requiring assistance with toileting hygiene, dressing, and bathing. Resident #82's clinical documentation indicated the resident was not present at the facility on 4/5/24. Resident #82's medication administration record (MAR) indicated the following medications were administered at 9:00 a.m. on 4/5/24 (when 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 resident who is fed by enteral means received the provider ordered tube feeding nutrition and hydration for 1 of 2 residents who received tube feedings, Resident #5. The findings included: The facility nursing staff failed to set Resident #5's tube feeding at the provider order rate of 60 ml/hour. The rate was observed to be set at 55 ml/hour. Resident #5's diagnoses included, but were not limited to, aphasia, gastrostomy status, diabetes, and dysphagia. There was no completed Minimum Data Set assessment for this resident. Resident #5 was nonverbal. Resident #5's care plan included the focus area at risk for complications related to the need for an enteral tube feeding. Interventions included, administer tube feedings and flushes per order and Registered Dietician consult as needed. Resident #5's clinical record included a provider order for Glucerna 1.5 at 60 ml/hour. The order date was documented as 02/09/24. On 02/09/24 the dietician had transcribed a progress note that read…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, employee record review, and facility document review, the facility staff failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property as evidenced by failure to pre-screen 2 of 25 new hire employees #22 and #25. Both employees were agency Certified Nursing Assistants (CNAs). The findings included: The facility staff failed to obtain reference checks per their policy for two agency employees #22 and #25. A review of employee records revealed the following. New hire #22 (agency) hire date 01/24/23 employee file did not include any reference checks. This staff last worked at the facility in 02/17/23. New hire #25 (agency) hire date 02/03/23 employee file did not include any reference checks. This staff last worked at the facility on 03/31/23. The facility provided the survey team with a copy of their policy titled, Prevention/Screening/Training. This policy read in part, .Criminal background and reference checks are performed on all employees . 04/12/23…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on resident representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the residents receive care in accordance with the comprehensive person-centered care plan and/or medical provider orders for 2 of 25 residents in the survey sample, Residents #25 and #264. The findings included: 1. For Resident #25, the facility staff failed to perform a hemoccult test to detect the presence of occult blood in the stool according to the medical provider's direction. Resident #25's diagnosis list indicated diagnoses, which included, but not limited to Fibromyalgia, Chronic Obstructive Pulmonary Disease, History of Venous Thrombosis and Embolism, Peripheral Vascular Disease, and Alzheimer's Disease. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/04/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #25's current comprehensive person-centered care plan…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and physician's orders for 1 of 25 residents in the survey sample, Resident #75. The findings included: For Resident #75, the facility staff failed to administer oxygen as ordered by the physician. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Nonrheumatic Aortic Insufficiency, Paroxysmal Atrial Fibrillation, Obstructive Sleep Apnea, Dependence on Supplemental Oxygen, Chronic Kidney Disease, Morbid Obesity, Dementia, and Type 2 Diabetes Mellitus. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #75 was coded as requiring extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-13 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 2 of 25 residents in the survey sample, Residents #75 and #30. The findings included: 1. For Resident #75, the facility staff failed to administer Novolin 70/30 as ordered by the medical provider. Novolin 70/30 is an intermediate acting insulin used to control blood sugar. Resident #75's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Nonrheumatic Aortic Insufficiency, Paroxysmal Atrial Fibrillation, Obstructive Sleep Apnea, Chronic Kidney Disease, and Morbid Obesity. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #75's current physician's orders included active orders for Novolin 70/30 10 units subcutaneously in the morning and hold if blood sugar was less than…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-13 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 laboratory services to meet the needs of the resident for 1 of 25 residents, Resident #94. The findings included: For Resident #94, the facility staff failed to obtain the provider ordered labs TSH (thyroid stimulating hormone) and LFT (liver function test). Resident #94's diagnosis included, but were not limited to, adult failure to thrive, hyperlipidemia, and chronic kidney disease. Section C (cognitive patterns) of Resident #94's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 02/15/23 included a brief interview for mental status (BIMS) summary score of 11 out of a possible 15 points. Resident #94's clinical record included a pharmacy recommendation dated 01/16/23 for a LFT and TSH due to the residents Amiodarone therapy. 02/08/23, Family Nurse Practitioner ordered LFT and TSH laboratory tests due to Amiodarone therapy. During the clinical record review, the surveyor was unable to locate any results for the ordered laboratory tests. 04/11/23 11:20 a.m.,…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    Based on interviews, clinical record review, and facility document review, the facility staff failed to maintain a complete and accurate clinical record for one (1) of 25 residents (Resident #100). The findings include: Resident #100's clinical record included a list of diagnoses. End Stage Renal Disease (ESRD) was incorrectly listed as one of Resident #100's diagnoses. No medical provider documentation was found to support the diagnosis of ESRD. Resident #100's Minimum Data Set (MDS) assessment, with an Assessment Reference date (ARD) of 2/26/23, was dated as completed on 3/4/23. Resident #100 was assessed as able to make self understood and as able to understand others. Resident #100's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. Resident #100 was assessed as requiring assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #100 discharge documentation, from a local hospital, included the medical problem of Acute Renal Failure. This discharge document 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2023-04-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility document review, and during the course of a medication pass and pour observation, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment to help prevent the development and transmission of communicable disease and infections on one of two facility units, unit 1. The findings include: During a medication pass and pour observation, Licensed Practical Nurse (LPN) #1 failed to change gloves and perform hand hygiene after administering eye drops to resident #9. On 4/11/23 at 08:39 AM surveyor observed LPN #1 during a medication pass and pour observation administer Artificial Tears eye drops to resident #9. After administering the eye drops, LPN #1 gave the resident their pills by using their fingers to pick each pill out of the medication cup individually, place the pill onto a spoon with pudding then put in the resident's mouth. LPN #1 did not change their gloves or perform hand hygiene after administering the eye drops. Surveyor asked LPN #1 what the facility policy was for 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-11-19 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 and clinical record review, the facility staff failed to complete drug regimen reviews for 4 of 25 residents and failed to follow up on a pharmacy recommendation for 1 of 25 residents. Residents #10, #34, #49 and #79. The findings included: 1. Resident #10's clinical record included the diagnoses hypertension, congestive heart failure, dementia, and anxiety. Section C (cognitive patterns) of Resident #10's significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/01/21 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. On 11/18/21 at 4:16 p.m., during a review of the Resident #10's clinical record, the pharmacy drug regimen review for July 2021 was not located. On 11/18/21 at 5:15 p.m., the missing drug regimen review was requested from the administrator, DON (director of nursing), and nurse consultant. The administrative staff stated they had recently changed their pharmacy. On 11/19/21 at 8:58 a.m., the DON stated they were unable to find a pharmacy drug regimen…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-11-19 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 ensure 1 of 25 residents was free from unnecessary medications, Resident #49. The facility staff failed to hold the blood pressure medication, hydralizine, when it should have been held based on a blood pressure reading/pulse on 6 occassions in the month of November 2021. The findings included: Resident #49's diagnoses included but were not limited to, diabetes mellitus II, chronic kidney disease, anorexia, hypertension, hypothyroidism, insomnia, constipation, depression, dementia and anxiety. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/08/21 assigned the resident a BMS (brief interview for mental status) score of 0 out of 15. This indicated that the resident was severely cognitively impaired. Resident #49's clinical record was reviewed on 11/18/21 and contained a physician's order summary for the month of November 2021, which read, hydrALAZINE HCl tablet 50 mg. Give 1 tablet by mouth two times a day for HTN (hypertension). Hold if SBP (systolic blood…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 interview, clinical record review, and facility document review, the facility staff failed to follow infection control policies and procedures for preventing the spread of COVID-19 on 1 of 2 units, unit 2 the observation wing, and failed to ensure screening of employees prior to work. The facility staff failed to donn PPE (personal protective equipment) before entering resident rooms that were on droplet/contact precautions, failed to perform any hand hygiene prior to/after exiting these rooms; failed to doff PPE when exiting a resident's room who was on transmission-based precautions; failed to ensure proper infection control signage on Resident #33's and Resident #42's room; and failed to ensure staff were screened for symptoms of COVID-19 prior to working at the facility. The findings included: 1. On 11/16/21 upon entrance to the facility, the administrator confirmed they currently had 20 in house residents and 15 staff that were positive for COVID-19. The facility had a hot unit for positive COVID-19 residents and a warm unit for observation. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-11-19 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to properly prevent COVID-19 by failing to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine for 5 of 5 sampled residents (#1, #4, #17, #29, and #67) and 2 agency nurses. The findings included: 1. For Resident #1, the facility staff failed to provide evidence of education regarding the benefits and potential risks associated with the COVID-19 vaccine and declination of the vaccine. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Atrial Fibrillation, Acute Kidney Failure, Peripheral Vascular Disease, Chronic Diastolic (Congestive) Heart Failure, and Muscle Weakness. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/20/21 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, Cognitive Patterns. A review of Resident #1's clinical record revealed documentation…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 accurately complete DDNR's for 2 of 25 residents, Residents #34 and #97. The findings included: 1. Resident #34's clinical record included the diagnoses of of diabetes, depression, and hypertension. Section C (cognitive patterns) of Resident #34's quarterly MDS (minimum data set) assessment with an (ARD) assessment reference date of [DATE] included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Resident #34's clinical record included a DDNR order form from the Virginia Department of Health. This form was dated [DATE] and read in part. Under section 1 I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. [DATE] 8:40 a.m., LPN…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-19 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, employee record review, and facility document review, the facility staff failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property as evidenced by failure to pre-screen 5 of 25 new hire employees (LPN (licensed practical nurse) #1, LPN #4, LPN #16, LPN #17, and LPN #20). The findings included: The facility staff failed to obtain reference checks for agency LPNs #1, #4, #16, #17 and #20. A review of the employee records provided by the facility for agency LPNs #1, #4, #16, #17, and #20 revealed the following documentation: LPN #1 was employed through (name omitted) staffing agency on 10/11/21. LPN #1's employee record did not contain documentation of a reference check review. LPN #4 was employed through (name omitted) staffing agency on 9/13/21. LPN #4's employee record did not contain documentation of a reference check review. LPN #16 was employed through (name omitted) staffing agency on 10/14/21. LPN #16's employee record did not contain…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0641 — isolated
    Ensure 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 staff failed to ensure an accurate MDS (minimum data set) for 1 of 25 residents in the survey sample, Resident #103. For Resident #103, the facility staff coded the resident as being discharged to an acute hospital when in fact the resident had been discharged home. The findings included: Resident #103's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Dementia without Behavioral Disturbance, Muscle Weakness, Adult Failure to Thrive, and Bipolar Disorder. The most recent discharge MDS with an ARD (assessment reference date) of 10/09/21 assigned the resident a BIMS (brief interview for mental status) score of 7 out of 15 in section C, Cognitive Patterns. Resident #103 was coded as being discharged to an acute hospital in section A, Identification Information. A review of Resident #103's clinical record revealed a physician's order stating in part discharge date : [DATE], Home Health Agency (name omitted) PT…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    Based on staff interview and clinical record review, the facility staff failed to review and revise comprehensive care plans for 3 of 25 residents, Residents #1, #104, and #42. For Resident #1, the facility staff failed to review and revise the residents care plan when a PICC line was discontinued. For Resident #104, the care plan included the focus area for enhanced droplet precautions when Resident #104 was not on enhanced droplet precautions. Resident #42's care plan failed to address the resident's significant weight loss. The findings included: 1. Resident #1's diagnoses included, but were not limited to, hypertension, gastro-esophageal reflux disease, chronic atrial fibrillation, acute kidney failure, and peripheral vascular disease. Section C (cognitive patterns) of Resident #1's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/20/21 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. Resident #1's current CCP (comprehensive care plan) included the focus area PICC line Left arm. with 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to provide services to meet professional standards of practice for 1 of 25 residents, Resident #37. For Resident #37, the facility staff signed that they had administered the medication Lexapro 10 mg, when it had not been administered. The findings included: Resident #37's face sheet listed diagnoses which included but not limited to depression, schizophrenia, hypertension, and insomnia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/24/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #37's comprehensive care plan was reviewed and contained a care plan, which read in part The resident uses psychotropic medications r/t depression, suicidal ideation schizophrenia, insomnia. Interventions for this care plan included administer meds as ordered. LPN…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 observation, staff interview, resident interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure that residents who were unable to carry out ADL's (activities of daily living) received the necessary care and services to maintain personal hygiene for 3 of 25 Residents, Residents #62, #1 and #104. The facility staff failed to provide incontinence care for Resident #62. For Resident #1 and #104, the facility staff failed to provide nail care. Resident #1 and #104's toenails were observed long and jagged. The findings included: 1. Resident #62's diagnoses included, but were not limited to, muscle weakness, diabetes, anxiety disorder, and chronic kidney disease. Section C (cognitive patterns) of Resident #62's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/09/21 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Section G (functional status) was coded 3/2 extensive assistance of one person for toilet use and personal hygiene.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on resident interview, staff interview, and clinical record review the facility staff failed to follow physician's orders for 3 of 25 residents, Resident #79, Resident #68, and Resident #10. For Resident #79 the facility staff failed to check resident's blood pressure prior administering the medication Metoprolol, per the physician's order. For Resident #68 the facility staff failed to follow physician's orders for the administration of prn (as needed) medications for constipation. For Resident #10, the facility staff failed to follow physician ordered parameters when administering blood pressure medications. The findings included: 1. Resident #79's face sheet listed diagnoses which included, but not limited to dementia, anemia, anxiety, gastroesophageal reflux disorder, insomnia, psychotic disorder, and hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/27/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15. This indicated that the resident was severely cognitively impaired.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and the review of documents, the facility staff failed to provide respiratory services and/or care for two (2) of 25 residents, Resident #42 and Resident #158. The facility staff failed to ensure Resident #42's oxygen was provided when the resident was transported outside to the facility's gazebo for a family visit. The facility staff failed to consistently complete respiratory assessments every shift as detailed in Resident #158's COVID-19 care plan. The findings include: 1. Resident #42's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/2/21, was completed on 10/5/21. Resident #42 was assessed as able to understand others and as able to make themself understood. Resident #42's Brief Interview for Mental Status (BIMS) summary score was documented as a five (5) out of 15 (this indicated severe cognitive impairment). Resident #42's diagnoses included, but were not limited to: pneumonia, thyroid disorder, osteoporosis, dementia, and lung disease. A family member of Resident #42 (FM #1) was interviewed on 11/17/21. FM #1 reported, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review and during a medication pass and pour observation the facility staff failed to ensure the medications Cymbalta 30 mg and Tylenol 325 mg were available for administration for 1 of 25 residents, Resident #8. The findings included: Resident #8's diagnoses included but were not limited to multiple sclerosis, depression, insomnia, hypertension, and quadriplegia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/03/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Resident #8's comprehensive care plan was reviewed and contained a care plan for pain. Interventions for this care plan included Medicate as ordered. LPN (licensed practical nurse) #2 was observed during a medication pass and pour on 11/17/21 at 8:30 am. LPN #2 prepared Resident #8's medications, but stated that they could not locate the resident's Cymbalta 30 mg or Tylenol 325…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were two errors in 26 opportunities for a medication error rate of 7.69%. The findings included: Resident #37's diagnoses included but were not limited to, depression, schizophrenia, hypertension, and insomnia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/24/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident was cognitively intact. LPN (licensed practical nurse) #1 was observed on 11/17/21 at 8:45 am during a medication pass and pour. LPN #1 prepared and administered the medications Colace 100 mg, Lexapro 5 mg, Miralax 17 gm, Claritin 10 mg and Azelastine HCl nasal spray, 2 sprays per nostril, to Resident #37. LPN #1 did not administer Lexapro 10 mg to Resident #37. Resident #37's clinical record was reviewed and contained…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0801 — isolated
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 the dietary manager for the facility possessed the required education and/or certification. The findings include: On 11/19/21 at approximately 11:20 a.m., the facility's administrator acknowledged the facility's dietary manager did not have a certification or the education required for the position of dietary manager. The administrator explained the dietary manager was currently enrolled in an online training course and had one year to complete the course. The administrator provided a document which indicated the Dietary Manager Training pathway had been ordered (with the employee's name) however he/she denied knowing when that training pathway had been ordered. The only date on the document was 11/19/21, 11:14 a.m., which the administrator stated was the date/time the document was printed. The administrator provided a letter which indicated the facility's previous certified dietary manager had resigned in September 2021 with a last work day for the contracted dietary service being 10/10/2021.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0886 — failed to test for COVID-19 as required — isolated
    Perform COVID19 testing on residents and staff.
    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 conduct routine COVID-19 testing for 1 of 3 sampled employees (Staff Member #2) and 2 agency nurses. The findings included: 1. On 11/17/21, the administrator provided a signed document stating We have remained in high community transmission rate since 10/01/21. A review of SM #2's COVID-19 testing since 10/01/21, included documentation of testing performed on 10/04/21, 10/14/21, 10/21/21, 10/28/21, 11/08/21, and 11/12/21 each with negative results. A copy of SM #2's COVID-19 Vaccination Record Card documented they received their first dose of the (name omitted) COVID-19 vaccine on 9/17/21 but had not received the second dose. The facility policy entitled, COVID-19 Testing documented: 1. Routine testing of employees .b. Unvaccinated employees are to be routinely tested based on the center's county level of community transmission. On 11/18/21 at 5:15 pm, the administrator, director of nursing, and the regional nurse consultant were notified of the missing routine COVID-19 testing for SM #2. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFEWORKS REHAB — 64 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 →

RatingThis homeChain avg
Overall 4 of 52.1+1.9 vs chain
Health inspection 4 of 52.0+2.0 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 53.9+1.1 vs chain
The other 63 homes this chain runs (chain average 2.1★, per CMS)
1 of 5APPOMATTOX HEALTH & REHABILITATiON CENTERAppomattox, VA 1 of 5Alamance Health Care CenterBurlington, NC 1 of 5Bayside Health & Rehabilitation CenterVirginia Beach, VA 1 of 5Cabarrus Health and Rehabilitation CenterConcord, NC 1 of 5Charlotte Health & Rehabilitation CenterCharlotte, NC 1 of 5Chesapeake Health And Rehabilitation CenterChesapeake, VA 1 of 5Colonial Heights Rehabilitation And Nursing CenterColonial Heights, VA 1 of 5Elkton Nursing And Rehabilitation CenterElkton, MD 1 of 5Greenville Health and Rehabilitation CenterGreenville, NC 1 of 5Guilford Health Care CenterGreensboro, NC 1 of 5Harrisonburg Hlth & Rehab CntrHarrisonburg, VA 1 of 5Largo Nursing And Rehabiliation CenterGlenarden, MD 1 of 5Layhill Nursing And Rehabilitation CenterSilver Spring, MD 1 of 5Lenoir Health and Rehabilitation CenterLenoir, NC 1 of 5Lynchburg Health & Rehabilitation CenterLynchburg, VA 1 of 5Norfolk Health Care CenterNorfolk, VA 1 of 5Oxford Health and Rehabilitation CenterOxford, NC 1 of 5Parham Health Care & Rehab CenterRichmond, VA 1 of 5Salem Health & RehabilitationSalem, VA 1 of 5University Health and Rehabilitation CenterDurham, NC 1 of 5Virginia Beach Healthcare And Rehab CenterVirginia Beach, VA 1 of 5Westport Rehabilitation And Nursing CenterRichmond, VA 1 of 5White Oak Rehabilitation And Nursing CenterHyattsville, MD 1 of 5Williamsport Health And Rehabilitation CenterWilliamsport, MD 2 of 5Adelphi Nursing And Rehabilitation CenterAdelphi, MD 2 of 5Albemarle Health & Rehabilitation CenterCharlottesville, VA 2 of 5Beaufont Health And Rehabilitation CenterRichmond, VA 2 of 5Belaire Health Care CenterGastonia, NC 2 of 5Charlottesville Health & Rehabilitation CenterCharlottesville, VA 2 of 5Cherrydale Health & Rehabilitation CenterArlington, VA 2 of 5Culpeper Health & Rehabilitation CenterCulpeper, VA 2 of 5Fairfax Rehabilitation And Nursing CenterFairfax, VA 2 of 5Glenburnie Rehab & Nursing CenterRichmond, VA 2 of 5Hanover Health And Rehabilitation CenterMechanicsville, VA 2 of 5Lexington Health Care CenterLexington, NC 2 of 5Litchford Falls Health and Rehabilitation CenterRaleigh, NC 2 of 5Pike Creek Nursing & Rehabilitation CenterWilmington, DE 2 of 5Regency Health And Rehabilitation CenterYorktown, VA 2 of 5Shady Grove Nursing And Rehabilitation CenterRockville, MD 2 of 5The Nursing And Rehab Center At Stadium PlaceBaltimore, MD

Showing 40 of 63; 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 / managerTypeRoleShareSince
STANLEYTOWN HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/28/2021
AMERICA WEST LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
CHARLES 1994 & FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
CHARLES 1994 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
CHARLES 1994 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
EDWARD 1998 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
REDROCK WEST LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
SAUL 2012 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
FLYNN, KENNEDYIndividualW-2 MANAGING EMPLOYEEsince 05/28/2021
RAJCHENBACH, MOSHEIndividualCORPORATE OFFICERsince 03/28/2021

8 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.

$16.0M
Net patient revenuemost recent cost report
+4.8%
Operating marginrevenue minus expenses
$3.1M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 20%Other / private 26%

This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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

$373per resident / day
operating cost
$11,347per month
≈ monthly operating cost
$392per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Virginia
$10,250/mo
Nursing home (semi-private)
$11,680/mo
Nursing home (private)
$6,945/mo
Assisted living

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 495216. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-18, 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 →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next