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Heritage Hall Blacksburg

3610 South Main Street, Blacksburg, VA 24060 · For profit - Corporation · 179 certified beds · (540) 951-7000 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Feb 20201 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

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
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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • 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) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3706 S Main St · (540) 443-3832 · Call to confirm hours
Pharmacy
1775 S Main St · (540) 951-8595 · Call to confirm hours
Grocery
3115 N Franklin St · (540) 251-5618 · Call to confirm hours
Park
1156 Hightop Rd · (540) 552-3034 · Typically dawn to dusk
Place of worship
560 Cinnabar Rd · (540) 449-3620

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 5 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 improved from 1 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 increased10.9%14.9%15.4%better
Long-stay residents who lose too much weight4.0%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.5%1.6%2.0%better
Long-stay residents with depressive symptoms7.4%18.7%6.5%better 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 injury3.9%3.6%3.3%worse
Long-stay residents whose ability to walk worsened12.4%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.9%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine96.5%94.0%95.3%typical
Long-stay residents with pressure ulcers3.0%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control17.0%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.5%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine76.3%73.6%79.4%typical
Short-stay residents rehospitalized after admission21.2%22.3%22.6%typical
Short-stay residents with an outpatient ER visit15.2%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.511.521.67typical
Long-stay outpatient ER visits per 1,000 resident days1.411.481.80better

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.

53.0% 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 223 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.0%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
69.8%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 69.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 116 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF53.0%CMS range 46.5–58.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.8–13.710.7%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 discharge69.8%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 discharge62.1%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 discharge65.5%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 identified94.0%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 setting100.0%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 discharge100.0%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 stay0.0%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 worsened2.4%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 hospitalization7.5%CMS range 4.9–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 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
1.02
LPN hours/ resident / day
1.82
Aide hours/ resident / day
3.23
Total nurse hours/ resident / day
0.16
RN hoursweekends
42.9%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 179 beds and averages 132.3 residents a day — about 74% occupied, or roughly 47 beds typically open. It usually has some room. 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.70 hrs/resident/day on weekends vs 3.44 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.48 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2024-08-29)
2
at the previous standard inspection (2023-01-19)

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 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.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · K2020-02-10 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 assess the resident for risk of entrapment from bed rails and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use of the bedrails for 54 out of 139 beds, including Resident #135. The scope and severity was originally cited at Immediate Jeopardy, Level IV Widespread and was reduced to a Level II Widespread after the facility was cleared of Immediate Jeopardy. The administrator, assistant administrator, director of nursing, assistant director of nursing, and the regional nurse consultant were notified on 2/07/20 that the extended survey process had begun at 11:50 am, as the survey team had identified Immediate Jeopardy and Substandard Quality of Care in the area of Quality of Care. Upon Office of Licensure and Certification supervisory review of the interviews and documentation, the Scope and Severity was adjusted to Immediate Jeopardy, Level IV, Pattern and was reduced to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2020-02-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review and facility document review the facility staff failed to ensure an accident free environment for 1 of 31 residents, Resident #135. For Resident #135, the facility staff failed to assess for the safe use of bedrails and risk of entrapment prior to implementing side rails. Following an incident when the resident's arm became trapped in the bed rail, the resident's arm was described as still red and acted as if moving it was tender to touch seven days later. This is harm. The findings included: Resident #135's diagnosis list indicated diagnoses, which included, but not limited to Malignant Neoplasm of Unspecified Site of Right Breast, Unspecified Dementia without Behavioral Disturbance, Bipolar Disorder, unspecified, and Contracture of Left Hand. The most recent annual MDS with an ARD (assessment reference date) of 1/14/20 coded the resident as being severely impaired in cognitive skills for daily decision making with short term and long term memory loss in section C, Cognitive Patterns. Resident #135 is also coded as requiring 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 · Ecited before2026-02-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, clinical record review, and facility document review, the facility staff failed to ensure electronic cigarettes (vapes) and/or illicit substances were stored in a manner to prevent misuse from other vulnerable residents and/or a fire hazard for four (4) of four (4) sampled residents, Resident #1, Resident #2, Resident #3, and Resident #4. The findings included:1. For Resident #1, the facility staff failed to ensure an electronic cigarette (vape) was securely stored. A facility policy titled, Resident Smoking, dated 2/21/24 specified, Smoking and/or vaping is not allowed inside the facility under any circumstances. The policy also specified, All smoking paraphernalia cigarettes, cigars, e cigs, vapes, etc. will not be left in the possession of any resident at any time. These items must be kept at the nurse's station or locked inside the med room or additional locked safe area designated by the facility.An admission Record indicated the facility admitted Resident #1 on 5/22/23. According to the admission Record, Resident #1 had 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review and facility document review, the facility staff failed to notify the physician and/or responsible party of a significant change in the resident's physical, mental, or psychosocial status for one of 30 residents in the survey sample, resident #44. The findings included: The facility staff failed to notify resident # 44's responsible party of a significant weight loss. Resident # 44's diagnoses included but were not limited to gastroesophageal reflux disease (GERD), unspecified dementia with psychotic disturbance, major depressive disorder and anxiety disorder. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/31/24 assigned the resident a brief interview for mental status (BIMS) score of 03 out of 15 indicating significant cognitive impairment. During a review of the clinical record surveyor noted a 11.50 % weight loss in 5 months. Resident # 44 weighed 127 pounds (lbs.) in March and on 8/22/24 their weight was recorded at 112.4 lbs. and on 8/29/24 was recorded at 111 lbs. The progress notes for resident # 44…

    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 · D2024-08-29 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 an accurate minimum data set assessment for 2 of 3 closed record reviews, Resident #125 and Resident #127. The findings included: 1. For Resident #125 the facility staff incorrectly coded the resident's discharge status. Resident #125's face sheet listed diagnoses which included but not limited to obesity, encephalopathy, and anemia. Section A of Resident #125's discharge minimum data set (MDS) with an assessment reference date of 06/01/24 coded the resident as being discharged home. Resident #125's clinical record was reviewed and contained a nurse's progress note which read in part, 6/1/2024 17:50 Spoke with . (name omitted) at . (hospital name omitted) ED (emergency department) who stated rsd (resident) was being admitted and transferred to . (hospital name omitted) for CHF (congestive heart failure) per wife request to transfer. MD aware. RP (responsible party) aware. Surveyor spoke with MDS coordinator on 08/28/24 at 5:10 pm regarding Resident #125's MDS assessment.…

    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 before2024-08-29 · 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 observation, staff interview, and clinical record review, the facility staff failed to ensure a medication was available for administration for 1 of 30 sampled residents (Resident #10). The findings included: For Resident #10, the facility staff failed to ensure Zofran, a medication used to treat nausea and vomiting, was available for administration. Resident #10's diagnosis list indicated diagnoses, which included, but not limited to Nausea and Vomiting, Generalized Abdominal Pain, Gastro-Esophageal Reflux Disease (GERD), Alzheimer's Disease, Guillain-Barre Syndrome, Chronic Obstructive Pulmonary Disease, and Chronic Ischemic Heart Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/11/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #10's current comprehensive person-centered care plan included a focus area stating the resident had a history of GERD with an intervention to administer medications per orders. Resident #10'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0757 — failed to avoid unnecessary drugs — isolated
    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, clinical record review, and facility document review, the facility staff failed to ensure 1 of 30 sampled residents was free of unnecessary medication, Resident #54. The findings include: For Resident #54 the facility staff failed to ensure the resident was free of an unnecessary medication, Hydralazine. (Hydralazine is a medication used to treat hypertension (high blood pressure)) Resident #54's diagnosis list indicated diagnoses that included, but were not limited to, Muscle Weakness, Cognitive Communication Deficit, Dementia, Atrial Fibrillation, Congestive Heart Failure, Hypertension (HTN), Peripheral Vascular Disease, and Cerebral Infarction (stroke). The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/12/24, assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating Resident #54 was moderately impaired in cognition. An active medical provider order dated 5/22/24 read in part, .Hydralazine 25 MG (milligrams) tablet orally two times a day for HTN Hold…

    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 · Dcited before2024-08-29 · 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 are free of significant medication errors for 3 of 30 sampled residents (Resident #5, Resident #93, and Resident #108). The findings included: 1. For Resident #5, the facility staff failed to administer Lantus, Humalog, and Bactrim DS as ordered by the provider. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease, Heart Failure, and Chronic Obstructive Pulmonary Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/18/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #5's current comprehensive person-centered care plan included a focus area stating the resident had a diagnosis of Type 2 Diabetes with an intervention to administer medications and insulin per orders. Resident #5's current provider orders included the following insulin…

    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 · Dcited before2024-08-29 · 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 staff interviews, clinical record reviews, and facility document review, the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of 30 sampled residents, resident # 44. The findings included: The facility staff failed to document baths in the electronic medical record for resident # 44. Resident # 44's diagnoses included but were not limited to anxiety disorder, muscle weakness, need for assistance with personal care, unspecified dementia with psychotic disturbance and major depressive disorder. Resident # 44's minimum data set (MDS) assessment with an assessment reference date of 7/31/24 assigned the resident a brief interview for mental status (BIMS) score of 03 out of 15 indicating severe cognitive impairment. The electronic medical record for resident # 44 was reviewed. This surveyor was unable to locate documentation that resident # 44 had been bathed in the month of August. On 8/28/24 at 5:27 PM the survey team met with the Administrator, Assistant Administrator, Director of Nursing (DON) and Regional Director of Clinical…

    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 before2024-08-29 · 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 observations, resident interviews, staff interviews, and facility document review, the facility staff failed to follow the infection prevention and control program guidelines to provide a sanitary environment for 2 of 30 sampled residents, Resident #38 and Resident #55. The findings were: 1. For Resident #38, facility staff failed to return urine collection containers (urinal and urine collection bag) to the resident's bedside after use. The containers were left in the bathroom which was shared between two semi-private resident rooms. Resident #38's minimum data set assessment with an assessment reference date of 08/12/24 noted the resident was rarely/never understood and therefore a brief interview for mental status was not conducted. Resident #38 had one roommate in a semi-private room which shared a bathroom with another semi-private room occupied by two (2) residents. The total of four (4) residents shared one bathroom which contained only a commode. In an interview with one of the four residents' family members on 08/27/24 at 2:39 p.m., the family member reported…

    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 · E2023-01-19 · 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 observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The Bistro refrigerator and 2 of 3 pantry refrigerators (Center and Villa) contained out of date milk. The findings included: The Bistro refrigerator and the pantry refrigerators on the Center and Villa units were observed to contain out of date milk. 01/17/23, during the initial tour of the facility, the surveyor observed a tray of milk in the Bistro refrigerator with an expiration date of 01/16/23. The Assistant Dietary Manager (ADM) removed the tray of milk from the refrigerator and stated they would dispose of the milk. 01/18/23 3:39 p.m., the pantry refrigerator on the Center unit was observed by the surveyor to contain one carton of frozen milk with an expiration date of 01/16/23. The Villa unit pantry refrigerator contained two cartons of milk with an expiration date of 01/16/23. 01/18/23 3:40 p.m., the Director of Nursing (DON) was shown the outdated milk from the pantry refrigerators. 01/18/23 3:41 p.m., rechecked 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-19 · 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 observations, staff interviews, and documentation review, the facility staff failed to consistently perform hand hygiene during wound care for one (1) of 26 sampled current residents, Resident #11. The findings include: Licensed Practical Nurse (LPN) #3 failed to change gloves and perform hand hygiene after cleaning an open wound and prior to applying a new dressing/bandage to one of Resident #11's pressure wounds/areas. Resident #11's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/31/22, was dated as completed on 1/3/23. Resident #11 was assessed as able to make self understood and as able to understand others. Resident #11's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15 (this indicated intact and/or borderline cognition). Resident #11 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #11 was assessed as having Stage 2 pressure ulcers present on admission to the facility. The facility's policy titled Handwashing/Hand 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · E2020-02-10 · tag F0607 — failed to have anti-abuse policies — pattern
    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, facility document review and employee record reviews 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. The findings included: The facility failed to obtain a criminal background check for RN (registered nurse) #1, reference check reviews for CNA (certified nursing assistant) #1, CNA #2, LPN (licensed practical nurse) #1 and non-licensed staff member #1, and license verifications for CNA #1 and LPN #1 prior to employment with the facility. A review of the employee records revealed the following documentation: 1. RN #1's was employed by the facility on 8/02/18. RN #1's employee record did not contain documentation of a Virginia State Criminal Background Check prior to employment. RN #1 is currently employed by the facility. 2. CNA #1 was employed by the facility on 2/22/19. CNA #1's employee record did not contain documentation of license verification or 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-02-10 · tag F0625 — pattern
    Notify 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 staff interview, clinical record review, resident interview and facility document review the facility staff failed to provide notice of bed hold policy for 4 of 31 residents, #101, #74, #29, and #44. The findings included: 1. For Resident #101 the facility staff failed to offer a written notice of bed hold when the resident was discharged to the hospital. Resident #101's face sheet listed diagnoses which included but not limited to dysphagia, gastro-esophageal reflux disease, anxiety, benign prostatic hyperplasia, and cognitive communication deficit. Resident #101's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 01/09/2020 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, cognitive patterns. Resident #101's clinical record was reviewed on 02/06/2020. It contained a nurse's progress note, located in the notes section of the clinical record, dated 02/27/2020, which indicated the resident was sent to the hospital. 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-02-10 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to ensure that pain management is provided to residents who require such services for 6 of 31 residents, #120, #236, #34, #101, #66 and #25. This is a complaint deficiency. 1. For Resident #34, facility staff failed to account for all pain medication signed out of the narcotic ledger and documented pain medication administration for doses not signed out of the ledger. Resident #34 was admitted to the facility with diagnoses including unspecified dementia, malignant neoplasm of the mouth, osteoarthritis of the hip and hereditary and idiopathic neuropathy. On the most recent minimum data set assessment, the resident scored 6/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident was assessed as receiving scheduled pain medication 7/7 days in the look back period and as needed pain…

    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 · Ecited before2020-02-10 · tag F0755 — failed to provide safe pharmacy services — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each residents for 5 of 31 residents, #236, #34, #120, #101 and #66, and 2 out of 3 medication rooms in the facility. 1. While checking medication storage rooms for medication storage practices on [DATE], the surveyor discovered expired intravenous fluids in the medication storage room for the skilled therapy unit with room numbers in the 100s. One 1 liter Dextrose 5% expired [DATE] and two 1 liter Dextrose 5% expired [DATE]. On [DATE] at 10:12 AM, the surveyor talked with the unit manager about the expired IV fluids. The unit manager said they did not have anyone on IVs right now. The last person went home last week. When asked how often they clean the storage cabinets and remove…

    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 · Dcited before2020-02-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interview and facility document review, the facility staff failed to notify the physician and the resident representative of an accident involving the resident which results in an injury and has the potential for requiring physician intervention for 1 of 31 residents, Resident #135. The findings included: For Resident #135, the facility staff failed to notify the physician and resident representative of resident's right arm becoming trapped in the bed rail resulting in redness to the right arm. Resident #135's diagnosis list indicated diagnoses, which included, but not limited to Malignant Neoplasm of Unspecified Site of Right Breast, Unspecified Dementia without Behavioral Disturbance, Bipolar Disorder, unspecified, and Contracture of Left Hand. The most recent annual MDS with an ARD (assessment reference date) of 1/14/20 coded the resident as being severely impaired in cognitive skills for daily decision making with short term and long term memory loss in section C, Cognitive Patterns. Resident #135 is also coded as requiring the extensive…

    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 · D2020-02-10 · 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

    3. For Resident #8, facility staff failed to perform an intermittent catheterization every night at bedtime and document the results as ordered by the physician. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Paraplegia, Chronic Kidney Disease, Retention of Urine, and Personal History of Urinary Tract Infections. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 1/30/20 assigned the resident a BIMS (brief interview for mental status) score of 6 out of 15 in section C, Cognitive Patterns. Resident #8 is also coded as frequently incontinent of urine and for the use of intermittent catheterization in section H, Bladder and Bowel. A review of Resident #8's medical record revealed an active physician's order dated 8/16/18 stating Straight cath (catheterization) every night at bedtime and document results. The resident's comprehensive care plan included the problem area of Urinary Incontinency: (name omitted) is at risk for UTIs (urinary tract infections) and skin breakdown related to hx (history) of UTIs,…

    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 · D2020-02-10 · tag F0729 — isolated
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    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 obtain registry verification that a CNA (certified nursing assistant) has met competency evaluation requirements as evidenced by failure to obtain state license verification prior to employment for 1 of 8 new hire CNAs. The findings included: The facility failed to perform a license verification check for CNA #1 prior to employment. CNA #1 was employed by the facility on 2/22/19. A review of CNA #1's employee record did not contain documentation of a license verification check prior to employment. On 2/06/20 at approximately 12:30pm, the surveyor notified the administrator that CNA #1's employee record did not contain documentation of a license verification check. The administrator stated the facility did not have the documentation. The surveyor requested and received the policy Abuse, Neglect and Exploitation Prevention and Reporting which stated in part: 3. d. Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-10 · 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 and clinical record review the facility staff failed to ensure 1 of 31 residents was free of significant medication error, Resident #66. The findings included: For Resident #66 the facility staff failed to administer the medication Synthroid per the physician's orders. According to the Physician's Desk Reference, Synthroid is a synthetic form of the thyroid hormone, Thyroxine, and is used to treat hypothyroidism. Resident #66's face sheet listed diagnoses including, but not limited to hypertension, hypothyroidism, migraine, hyperlipidemia, bipolar disorder, major depressive disorder, generalized anxiety disorder, and paranoid personality disorder. Resident #66's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/13/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. The orders section of Resident #66's clinical record was reviewed and contained physician's order summary dated 06/2519, which read in part Synthroid 50 mcg tablet one tablet by mouth…

    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 · D2020-02-10 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, resident interview and clinical record review, the facility staff failed to ensure the appropriate physician prescribed diet was provided for 1 of 31 residents, Resident #387. The findings included: For Resident #387, the facility staff failed to provide the correct fluid consistency as ordered by the physician. Resident #387's diagnosis list indicated diagnoses, which included, but not limited to Displaced Intertrochanteric Fracture of Left Femur, Dysphagia, Left Bundle Branch Block, and Type 2 Diabetes Mellitus. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/29/20 assigned the resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, Cognitive Patterns. Resident #387 is also coded as receiving a mechanically altered diet in Section K, Swallowing/Nutritional Status. A review of Resident #387's clinical record revealed a physician's order for nectar thickened liquids dated 1/22/20. The Baseline Care Plan dated 1/22/20 documented the resident's diet order as mechanically…

    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 before2020-02-10 · 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 staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 31 residents, Resident #83. The findings included: For Resident #83 the facility staff failed to ensure the physician's order summary was correct. Resident #83's diagnosis list included diagnoses of but not limited to Huntington's disease, depression, and protein-calorie malnutrition. Resident #83's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/02/2020 coded the resident as having both long and short-term memory problems with severely impaired cognitive skills for daily decision making. Resident #83's comprehensive care plan was reviewed and contained a care plan for Tube Feeding: Rsd (resident) is NPO (nothing by mouth) and receives bolus tube feeding and water flushes per orders. Approaches for this care plan include NPO per orders. Resident #83's clinical record was reviewed on 02/06/2020. It contained a signed physician's order summary dated 01/30/2020, which read in part NPO and amitriptyline hcl 10…

    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

“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 HERITAGE HALL — 15 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 54.1≈ chain avg
Health inspection 4 of 53.7+0.3 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 4 of 53.9+0.1 vs chain
The other 14 homes this chain runs (chain average 4.1★, 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 / managerTypeRoleSince
EAST, THOMASIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 11/20/2012
HOPKINS, WILLIAMIndividualCORPORATE DIRECTORsince 07/23/2010
GALLANT, CASSANDRAIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/07/2025
AMERICAN HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/22/2010
DALTON, BRADIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/11/2024
HAMILTON, ALYSSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/25/2026
DAVIS, BENJAMINIndividualADP OF THE SNFsince 03/25/2026

CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$15.2M
Net patient revenuemost recent cost report
+12.0%
Operating marginrevenue minus expenses
$1.1M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 11%Other / private 16%

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 $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$315per resident / day
operating cost
$9,572per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

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

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 495356. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-29, 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.

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