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Bridgewater Home , Inc.

302 North Second Street, Bridgewater, VA 22812 · Non profit - Corporation · 127 certified beds · (540) 828-2531 Medicare & Medicaid certified

Call the home — (540) 828-2531 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

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 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
402 E College St · (540) 828-5384 · Call to confirm hours
Pharmacy
509 N Main St · (540) 828-6000 · Call to confirm hours
Grocery
519 N Main St · (540) 828-3010 · Call to confirm hours
Park
412 N Main St · (540) 908-3799 · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 3 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 fell from 5 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 increased23.1%14.9%15.4%worse
Long-stay residents who lose too much weight4.3%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.0%1.6%2.0%typical
Long-stay residents with depressive symptoms0.0%18.7%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.3%3.6%3.3%worse
Long-stay residents whose ability to walk worsened20.9%15.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication32.6%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine99.2%94.0%95.3%typical
Long-stay residents with pressure ulcers3.3%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control25.7%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table5.2%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine92.9%73.6%79.4%better
Short-stay residents rehospitalized after admission27.1%22.3%22.6%worse
Short-stay residents with an outpatient ER visit14.5%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.601.521.67typical
Long-stay outpatient ER visits per 1,000 resident days1.181.481.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.2% 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 172 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.2%U.S. median 51.5%
Got home and stayed home
8.4%U.S. median 10.7%
Went back to hospital
54.6%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 54.6% 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 97 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF50.2%CMS range 43.0–57.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.4%CMS range 5.8–11.310.7%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 discharge54.6%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 discharge50.5%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 discharge55.7%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 identified100.0%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 stay1.7%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 worsened2.5%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 hospitalization8.0%CMS range 5.0–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 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

0.70
RN hours/ resident / day
0.82
LPN hours/ resident / day
3.11
Aide hours/ resident / day
4.63
Total nurse hours/ resident / day
0.45
RN hoursweekends
31.9%
Total nursing turnover
30.4%
RN turnover

How full it usually is: this home is certified for 127 beds and averages 120.2 residents a day — about 95% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.11 is at or above 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 4.04 hrs/resident/day on weekends vs 4.87 on weekdays — 17% thinner on weekends. RN hours go from 0.80 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below 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

10
deficiencies at the latest standard inspection (2026-01-22)
9
at the previous standard inspection (2022-01-13)

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.

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Fcited before2026-01-22 · tag F0656 — failed to write and follow a full care plan — widespread
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to develop comprehensive care plans (CCPs) that included the residents current code status for all residents in the survey sample. The findings included:The facility staff failed to develop CCPs that included the residents current code status. During the clinical record review, the surveyors were unable to locate information on the resident's CCPs that referenced their current code status. On 01/21/26 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), and Infection Preventionist the issue with the code status not being on the resident's CCP was reviewed. On 01/22/26 at 10:00 a.m., the facility staff provided the survey team with a copy of their policy titled, Comprehensive Person-Centered Care Planning. This policy read in part, .will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial…

    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 · E2026-01-22 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, and facility document review, the facility staff failed to recognize and respect the residents' right to exercise their rights as a resident/citizen of the United States to send/receive mail. The findings included:For the facility, the facility staff failed to recognize and respect the residents' right to exercise their rights as a resident/citizen of the United States to send/receive mail on Saturdays. On 1/21/2026 at 2:50 PM, this surveyor met with six members of the Resident Council, Resident #12, Resident #77, Resident #85, Resident #101, Resident #104, and Resident #117. The residents' concurred mail is not delivered to them on Saturdays at the facility. This concern was discussed at the end of day meeting on 1/21/26 at 5:08 PM with the administrator, director of nursing, and infection preventionist. On 1/22/26 at 8:41 AM, this surveyor interviewed other staff #4 (OS#4) and OS#4 informed surveyor the post office takes the mail to the main desk in the main lobby and the post office does not deliver mail on Saturdays because there is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and clinical record review, the facility staff failed to maintain a comfortable homelike environment for 1 of 28 residents in the survey sample, Resident #105.The findings included:A large area of drywall/sheetrock next to the resident's bed was visibly scuffed and damaged.Resident #105's diagnoses included Alzheimer's disease and dementia.Section C (cognitive patterns) of Resident #105's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/24/25 had been coded to indicate this resident was moderately impaired in cognitive skills for daily decision making.On 01/20/26 during initial tour of the facility the surveyor observed a large area of drywall beside the resident's bed to be scuffed and damaged.A second observation was made of this area on 01/21/2026 at 4:39 p.m. On 01/21/2026 at 5:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing, and Infection Preventionist the issue with Resident #105's drywall being damaged and in need of repair was reviewed. On 01/22/2026 at 8:30…

    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 · D2026-01-22 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 provide written notification of the reason(s) for transfer/discharge to the resident's representative and/or failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer/discharge for (2) two of (28) twenty-eight sampled residents, Resident #121 and Resident #2. The findings included:1.For Resident #121 the facility staff failed to provide written notification of the reason(s) for transfer/discharge to the resident's representative and failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer/discharge for a transfer/discharge that occurred on 12/8/25. Resident #121's diagnosis list indicated diagnoses that included, but were not limited to, neoplasm of the brain, hydrocephalus, hypertension, urinary retention, and hyponatremia. The most recent admission minimum data set (MDS) with an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-22 · 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, facility document review and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for two of twenty-eight residents in the survey sample (Residents #3 and #13).The findings include:1. Resident #3's quarterly MDS dated [DATE] inaccurately documented the resident took anticoagulant medication and failed to indicate the resident took an antiplatelet medication.Resident #3 (R3) was admitted to the facility with diagnoses that included hypertension, hypothyroidism, anxiety, osteoarthritis, osteoporosis, vascular dementia, cerebral infarction, psychotic disturbance, mood disorder, chronic kidney disease, atrioventricular block, heart failure and hypoxia. The MDS dated [DATE] assessed R3 with severely impaired cognitive skills.R3's clinical record documented a physician's order dated 6/22/22 for aspirin 81 milligrams each day for treatment of cerebral infarction. R3's clinical record documented no physician's order for any anticoagulant…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and clinical record review, the facility staff failed to review and revise a care plan for one of twenty-eight residents in a survey sample.The Findings Include:Resident #56 (R56) care plan was not updated to include hearing aids.R56 diagnoses included communication deficit related to hard of hearing, depression, and pulmonary embolism. The most current MDS (Minimal Data Set) was a quarterly with an ARD (Assessment Reference Date) of 11/10/25. R56 was assessed with a cognitive score of 13 indicating cognitively intact. Review of R56's admission assessment dated [DATE] and section B (hearing and vision) of the MDS documented R56 used hearing aids.Review of R56's care plan for communication related to hearing deficit indicated how to speak with R56 (face to face without limited background noise) but did not indicate R56 wore hearing aids or any interventions regarding hearing aid usage and monitoring.On 1/22/2026 at 10:37a.m. registered nurse (RN # 1, MDS coordinator) was interviewed. RN…

    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 before2026-01-22 · 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 staff interview, clinical record review and facility policy review, the facility staff failed to follow physician's orders for 1 of 28 residents, Resident #11.The findings included:For Resident #11 the facility staff held the medication polyethylene glycol without a physician's order.Resident #11's clinical record listed diagnoses which included but not limited to major depressive disorder, recurrent, unspecified and other chronic pain.Resident #11's most recent minimum data set with an assessment reference date of 10/23/25 assigned the resident a brief interview for mental status score of 4 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired.Resident #11's comprehensive care plan was reviewed and contained a plan for The resident uses antidepressant medication r/t (related to) Depression and insomnia. Interventions for this plan include Monitor/document/report PRN (as needed) adverse reaction to ANTIDEPRESSANT therapy: . constipation, fecal impaction, diarrhea.Resident #11's clinical record contained a physician'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain a safe room environment for one of twenty-eight residents in the survey sample (Resident #99).The findings include:A portable heater was in use in Resident #99's room. The heater, placed during a heat outage, was not removed from the room when emergency use was no longer required.Resident #99 (R99) was admitted to the facility with diagnoses that included cerebral infarction, major depressive disorder, anxiety, benign prostatic hypertrophy, atrial fibrillation, chronic kidney disease, congestive heart failure, cervical disc disorder, neuromuscular dysfunction of bladder and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed R99 as cognitively intact and as requiring the assistance of one person for safe transfers.On 1/20/26 at 2:39 p.m., R99 was observed in a chair in the resident's room. Positioned near the center of the room was an electric heater plugged into a wall outlet.…

    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 before2026-01-22 · 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 maintain a complete and accurate clinical record for 2 of 28 residents in the survey sample, Residents #10 and #84.The findings included:1. For Resident #10, the clinical record included provider orders for Acetaminophen and Milk of Magnesium by mouth. Resident #10 had a feeding tube and was NPO (nothing by mouth). Resident #10's diagnoses included, spastic quadriplegic cerebral palsy, epilepsy, and dysphagia. Section C (cognitive patterns) of Resident #10's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 10/28/25 was coded to indicate the resident was severely impaired in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate this resident had a feeding tube. Resident #10's comprehensive care plan (CCP) included the focus area all nutrition and fluids via feeding tube. Resident #10's clinical record included the following provider orders. NPO/Tube Feeding diet NPO texture, no liquids by mouth consistency for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during tracheostomy care for one of twenty-eight residents in the survey sample (Resident #13).The findings include:Infection control practices regarding hand hygiene and glove changes were not followed during Resident #13's tracheostomy care.Resident #13 (R13) was admitted to the facility with diagnoses that included dysphagia, neuromuscular dysfunction of bladder, chronic respiratory failure, dementia, psychotic disturbance, mood disturbance, anxiety, dysarthria, hypertension and depression. The MDS dated [DATE] assessed R13 as cognitively intact.R13's clinical record documented a physician order dated 7/1/25 for tracheostomy care each day that included cleaning around stoma with cotton swab wet with saline/hydrogen peroxide mix and an order dated 7/4/25 to insert new sterile inner cannula to tracheostomy (trach) daily.On 1/22/26 at 8:58 a.m., with R13'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · E2022-01-13 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review and complaint investigation, the facility staff failed to employ a qualified activity professional for the facility. For two years, the facility had no qualified therapeutic recreation specialist or activities professional providing direction/supervision of the activity programs for residents. The findings include: During a complaint investigation regarding Resident #37's activities, the household coordinator (CNA #1) was identified as the staff person responsible for providing recreational activities on the resident's living unit. On 1/12/22 at 2:37 p.m., certified nurses' aide (CNA) #1 was interviewed about Resident#37's activities program. During this interview, CNA #1 stated she was responsible for completing activity assessments and implementing the activity programs for residents on her assigned unit. When asked what training and/or qualifications she had regarding recreational activities, CNA #1 stated the previous CNA household coordinator provided her training. CNA #1 stated she had received training about dementia care but…

    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 before2022-01-13 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to ensure 2 of 26 residents in the survey sample were free from unnecessary psychotropic medications, Resident #45 and Resident #37. Resident #45 had physician orders for as needed (PRN) antianxiety medication Xanax that extended more than 14 days without a stop date. Resident #37 had physician orders for as needed (PRN) antipsychotic medication Zyprexa and the antianxiety medication Lorazepam that extended for more than 14 days without a stop date; and an as needed (PRN) dose of Zyprexa was administered to Resident #37 without an indication for use or documented prior attempts of non-drug interventions. The findings include: 1. Resident #45 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia with behavioral disturbance, depression, dementia with lewy bodies, Parkinson's Disease, generalized anxiety disorder, type 2 diabetes, and delusional disorders. The most recent minimum…

    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 before2022-01-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to develop a comprehensive plan of care for two of 26 residents in the survey sample. Resident #37 had no care plan developed regarding hydration and behaviors. Resident #60 had no care plan about behaviors. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's, dementia with behaviors, insomnia, urinary tract infection, atrial fibrillation with pacemaker, hypertension, gastroesophageal reflux disease, hypothyroidism, history of kidney cancer, history of colon cancer and major depressive disorder. The minimum data set (MDS) dated [DATE] assessed Resident #37 with short and long-term memory problems and severely impaired cognitive skills. This MDS documented the resident demonstrated physical behaviors directed toward others (hitting, kicking, grabbing), verbal behaviors (screaming, yelling) and other behaviors such as hitting,…

    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 before2022-01-13 · 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 observation, staff interview, and facility document review, the facility staff failed to perform quality control checks for a glucometer (a device to measure blood sugar) on one of 6 units, [NAME] unit. A glucometer located in the medication cart had not had a quality control check since October 2021. Findings include: On 1/12/22 at 9:45 an inspection of the medication cart was conducted with LPN (licensed practical nurse) #4. A glucometer was located in the first drawer, and LPN #4 was asked when the most recent quality control had been performed. LPN #4 stated she did not know, as that was done on second or third shift. LPN #4 was then asked if there was a log for the quality control checks. She stated there was, and retrieved the book. The review revealed that the checks had been performed monthly, and the last documented quality control check was 10/21. LPN #4 stated Ill get the clinical coordinator; I'm not sure why that's the last time it was performed, but I don't know why LPN #4 then went and got LPN #3, who was the clinical coordinator. LPN #3 stated there were no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family interview, staff interview and clinical record review, the facility staff failed to perform routine skin assessments prior to development of a pressure ulcer for one of 26 residents in the survey sample, Resident #79. Resident #79 developed a stage 2 pressure ulcer on her sacrum after going over four months without a documented skin assessment for pressure ulcer prevention. The findings include: Resident #79 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #79 included Alzheimer's dementia, heart failure, protein-calorie malnutrition, cerebrovascular disease, dysphasia, hypertension, cerebral infarction, osteoporosis, anemia, depression, atherosclerotic heart disease, hyperlipidemia, irritable bowel syndrome, glaucoma and osteoarthritis. The minimum data set (MDS) dated [DATE] documented Resident #79 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of one…

    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 · D2022-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide appropriate catheter care for one of 26 residents in the survey sample, Resident #60. Resident #60 had a urinary catheter in use without the tubing secured to prevent pulling/tugging at the insertion site. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's, hypothyroidism, diabetes, coronary artery disease, atherosclerotic heart disease, obstructive uropathy due to benign prostatic hypertrophy (BPH), hypertension, depression and venous thrombosis. The minimum data set (MDS) dated [DATE] documented Resident #60 had short and long-term memory problems and moderately impaired cognitive skills. Resident #60's clinical record documented a physician's order dated 3/16/20 for an indwelling Foley catheter due to obstructive uropathy. On 1/12/22 at 2:13 p.m., certified nurses' aide (CNA) #2 was interviewed about Resident #60's catheter.…

    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 · D2022-01-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and review of facility documents, the facility failed to maintain acceptable parameters of nutrition for one of 26 residents in the survey sample, Resident # 81. Upon the identification of a significant weight loss of 19.2 pounds (13.8% loss) in 30 days, the facility failed to initiate measures to prevent further unplanned weight loss. No interventions were implemented until a month after the initial significant weight loss occurred and the resident continued to lose weight. The findings were: Resident # 81 in the survey sample was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, hypertension, stage 3 chronic kidney disease, anxiety disorder, depression, age related physical debility, malaise, slow transit constipation, polyosteoarthritis, gastroesophageal reflux disease, and hyperlipidemia. According to the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/2021, the resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility document review, the facility staff failed to ensure an open bottle of liquid Ativan (an anti-anxiety medication) was dated when opened, on one of 6 units, [NAME] unit. Findings include: On 1/12/22 at 9:30 a.m. an inspection of the [NAME] unit's medication room was conducted with LPN (licensed practical nurse) #4. Two bottles of liquid Ativan were located in the narcotic drawer of the refrigerator. One bottle was open, but did not have a date when opened on any of the packaging. LPN #4 stated I'm not sure about what to do with that, let me get the clinical coordinator. LPN # 4 left the medication room and returned with LPN #3, who was the clinical coordinator. LPN #3 was shown the box and vial of Ativan, and was asked if there should be an opened date. LPN #3 stated Yes, and I don't see one either. She then turned the box upside down and stated Well, there is smudged writing on here, I can't tell what it says, but I think that's maybe the date .looks like some condensation occurred and has smudged the writing. On 1/12/22 at 10:15…

    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 before2022-01-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to maintain a complete and accurate clinical record for two of 26 residents, Resident #76 and #103. Resident #76's pharmacy review for December was altered. Resident #103's code status was not correctly identified in the clinical record. Findings were: 1. Resident #76 was added to the survey sample for review of unnecessary medications. The clinical record was reviewed on 01/12/2022. A pharmacy review for the month of December 2021 was not observed. On 01/13/2021 a pharmacy review was presented by the Director of Nursing (DON). The form provided was a Medication Review Regimen Review-Note to Attending Physician. The MRR (Medication Review Date) was 12/21/2021. The form was recognized as the form that was observed the previous day that had been signed by the nurse practitioner and scanned into the computer system on 01/04/2022. The form presented had been altered and signed by the clinical coordinator, LPN (licensed practical nurse)…

    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 · E2019-10-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to attempt appropriate alternatives and assess for entrapment risks prior to use of bed rails for four of 28 residents in the survey sample (Residents #10, #23, #37 and #105). Residents #10 and #23 used special mattresses with bed rails without a prior assessment for bed safety. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #10 included schizoaffective disorder, bipolar disorder, depression, bladder spasms, anxiety, anemia, sleep apnea, chronic obstructive pulmonary disease, spinal stenosis, macular degeneration, and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #10 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of two people for bed mobility. On 10/15/19 at 12:55 p.m., Resident #10 was seated in…

    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 · E2019-10-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility's consultant pharmacist failed, for six of 28 residents in the survey sample, to identify and report medication irregularities to the Nurse Practitioner/attending physician/Medical Director. The consultant pharmacist failed to identify Residents # 69, 86, 60, 25, 32, and 3 as having physician orders for as needed (PRN) psychotropic medications that extended for more than 14 days without a stop date. The findings were: 1. Resident # 69 was admitted to the facility on [DATE] with diagnoses that included anemia, coronary artery disease, hypertension, arthritis, osteoporosis, Non-Alzheimer's dementia, anxiety disorder, and depression. According to the most recent Minimum Data Set (MDS), a Significant Change with an Assessment Reference Date (ARD) of 8/22/19, the resident was assessed under Section C (Cognitive Patterns) as having a Summary Score of 07 out of 15. Resident # 69's Electronic Health Record (EHR) included the following physician's orders…

    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 before2019-10-17 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure six of 28 residents were free of unnecessary psychotropic medications. Residents # 69, 86, 60, 25, 32, and 3 had physician orders for as needed (PRN) psychotropic medications that extended for more than 14 days without a stop date. The findings include: 1. Resident # 69 was admitted to the facility on [DATE] with diagnoses that included anemia, coronary artery disease, hypertension, arthritis, osteoporosis, Non-Alzheimer's dementia, anxiety disorder, and depression. According to the most recent Minimum Data Set (MDS), a Significant Change with an Assessment Reference Date (ARD) of 8/22/19, the resident was assessed under Section C (Cognitive Patterns) as having a Summary Score of 07 out of 15. Resident # 69's Electronic Health Record (EHR) included the following physician's orders for PRN psychotropic medications: Xanax (Alprazolam) 0.5 mg (milligrams) - 0.5 mg by mouth every 6 hours as needed for anxiety disorder. The order date…

    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 before2019-10-17 · 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 observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) regarding dental status for one of 28 residents in the survey sample (Resident #47). The findings include: Resident #47 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #47 included wrist fracture, gastroesophageal reflux disease, depression, anemia, high blood pressure and history of pulmonary embolism. The MDS dated [DATE] assessed Resident #47 as cognitively intact. On 10/15/19 at 12:00 p.m., Resident #47 was interviewed about quality of life in the facility. Resident #47's bottom, front teeth were broken with black/gray discoloration. Several of the lower front teeth were deteriorated down to the gum. The resident's top front teeth were chipped. Resident #47 was interviewed at this time about her teeth. The resident stated she had a partial plate on the top and her front teeth in the plate were chipped.…

    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 · D2019-10-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, facility staff failed to ensure a hand positioning device and an arm positioning device were in place for one of 28 residents, Resident #51. Findings included: Resident #51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Cerebral Palsy, Seizures, Spastic Quadriplegia, Aphasia, and Legal Blindness. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date of 08/13/2019. Resident #51 was assessed as severely impaired in his short and long term memory and daily decision making skills. Resident #51 was observed on 10/15/2019 at 12:15 p.m. in the living room area, reclined in a Broda chair. No positioning devices were observed. Resident #51's clinical record was reviewed on 10/16/2019 at 9:26 a.m. Included in the comprehensive care plan (CCP) was the following: .Impaired mobility/ADL [activities of daily living] Deficit related to…

    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 · D2019-10-17 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide routine dental services for one of 28 residents in the survey sample. Resident #47, with obvious decayed/deteriorated teeth, had not been offered or provided dental services since her admission on [DATE]. The findings include: Resident #47 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #47 included wrist fracture, gastroesophageal reflux disease, depression, anemia, high blood pressure and history of pulmonary embolism. The MDS dated [DATE] assessed Resident #47 as cognitively intact. On 10/15/19 at 12:00 p.m., Resident #47 was interviewed about quality of life in the facility. Resident #47's bottom, front teeth were broken with black/gray discoloration. Several of the lower front teeth had visible decay and were broken near the gum. The resident's top front teeth were chipped. Resident #47 was interviewed at this time about her teeth. 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 · D2019-10-17 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to perform bed safety inspections with use of specialty mattresses for two of 28 residents in the survey sample. Resident #10 had a wide bed with a concave mattress and bed rails in use without a prior inspection for possible entrapment risks. Resident #23 had an air mattress with bed rails in use without a prior inspection for possible entrapment risks. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #10 included schizoaffective disorder, bipolar disorder, depression, bladder spasms, anxiety, anemia, sleep apnea, chronic obstructive pulmonary disease, spinal stenosis, macular degeneration, and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #10 with short and long-term memory problems and severely impaired cognitive skills. This MDS listed the resident required the extensive assistance of two…

    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.

    Environmental 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.

Who owns this facility

Owner / managerTypeRoleSince
FLINT, ANNEIndividualCORPORATE DIRECTORsince 03/26/2019
LAMBERT, JEFFREYIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 10/24/2025
ALDERFER, RODNEY DIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2008
WEAVER, JAMESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/26/2019
BAROCO, PATRICKIndividualADP OF THE SNFsince 10/24/2025

CMS files one row per role, so the 8 rows in the source record cover these 5 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.

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.

$24.6M
Net patient revenuemost recent cost report
-6.7%
Operating marginrevenue minus expenses
$1.5M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 15%Medicare 3%Other / private 82%

This home reported $1.5M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$339per resident / day
operating cost
$10,308per month
≈ monthly operating cost
$318per 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 495370. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, 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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