Burke Health & Rehabilitation Center
9640 Burke Lake Road, Burke, VA 22015 · For profit - Corporation · 120 certified beds · (703) 425-9765 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 25% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.0% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.2% | 5.4% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 21.3% | 18.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 3.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.0% | 15.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.1% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.8% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.7% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.2% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.3% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 94.6% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.2% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.5% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.98 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.12 | 1.48 | 1.80 | better |
‡ 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.
61.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 900 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 86.3% 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 277 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 0.91 therapist hours per resident per day in 2026Q1 — more than 96% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.7%CMS range 58.2–65.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 9.4–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 86.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 83.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 79.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 6.5–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 115.5 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.80 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.76 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Ecited before2023-06-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a clean homelike environment for 1 Resident (Resident #38) in a survey sample of 38 Residents. The findings included: For Resident #38, the facility staff failed to provide a clean and homelike environment by ensuring cobwebs were removed. On 6/27/23 at approximately 2:00 PM, Surveyor C visited Resident #38 in his room. Surveyor C noticed 2 cobwebs in the ceiling corner of the room over the Resident's bedside table. On 6/27/23 at 2:50 PM, LPN C accompanied Surveyor C to Resident #38's room. LPN C was shown the cobwebs and confirmed them. On 6/27/23 at approximately 3 PM, the Director of Nursing came to the room and confirmed the above findings. The DON confirmed that this was not acceptable and reported rooms are cleaned by housekeeping. On 6/28/23, an interview was conducted with the housekeeping manager/Employee F. Employee F confirmed that housekeeping cleans rooms daily and performs deep cleaning of rooms monthly. Employee F provided Surveyor C…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-29 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure nursing standards of practice were followed for 2 Residents (Resident #15 and #217) in a survey sample of 38 Residents. The findings included: 1) For Resident #15, LPN D failed to verify the right resident during medication pass. On 6/29/23 at 9:58 AM, LPN D was observed during the medication administration. LPN D pulled and prepared the medication for Resident #217, which was a total of 8 pills (tablets and capsules). The medications were: Amlodipine Besylate 10 MG tablet for hypertension/blood pressure, Oxycodone 5 mg immediate release tablet for pain, Budesonide extended release 3 mg capsule for Crohn's disease, Carvedilol 6.25 mg tablet for hypertension, Venlafaxine HCl extended release 150 mg capsule for depression, Prevacid delayed release 30 mg capsule for gastroesophageal reflux, Dicyclomine HCl 20 mg tablet for irritable bowel syndrome and Sodium Bicarbonate 650 mg tablet for hyponatremia. Upon entering the room, LPN D approached Resident #15, who…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-29 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 facility documentation review, the facility staff failed to implement a system to account for and reconcile controlled drugs on 1 of 2 nursing units. The findings included: 1. The facility staff failed to implement their system of reconciliation to ensure the appropriate quantity of controlled medications was accurate on 2 of 4 medication carts inspected. 1a. On 06/28/23 at 05:19 PM, a medication storage inspection was conducted of the second floor, medication cart 1 with LPN E. During the verification of the controlled medications, it was determined that the controlled count was not correct. For one Resident who had Gabapentin 100 mg capsules, the medication card had 25 capsules, the reconciliation sheet said there should be 24 capsules present. For another Resident who had Armodafinil 200 mg tablets, the medication card had 19 tablets and the count sheet/reconciliation sheet indicated that 18 tablets should be present. LPN E confirmed the above findings. When asked about the process, LPN E said that at each shift change the off-going and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-29 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 9 medication errors in 31 opportunities, resulting in an 29.03% error rate. The findings included: On 6/29/23 at 9:58 AM, LPN D was observed during medication administration. LPN D pulled and prepared the medication for Resident #217, which was a total of 8 pills (tablets and capsules). The medications were: Amlodipine Besylate 10 MG tablet for hypertension/blood pressure, Oxycodone 5 mg immediate release tablet for pain, Budesonide extended release 3 mg capsule for Crohn's disease, Carvedilol 6.25 mg tablet for hypertension, Venlafaxine HCl extended release 150 mg capsule for depression, Prevacid delayed release 30 mg capsule for gastroesophageal reflux, Dicyclomine HCl 20 mg tablet for irritable bowel syndrome and Sodium Bicarbonate 650 mg tablet for hyponatremia. Upon entering the room, LPN D approached Resident #15, who was the roommate of Resident #217. LPN D made no attempts to verify the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-29 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications on 2 of 4 medication carts inspected. The findings included: For 2 of 4 medication carts inspected, the facility staff failed to label insulin with the open date to ensure it is not used beyond the expiration date. On [DATE] at 05:19 PM, an inspection was conducted of the second-floor cart 1, in the presence of LPN E. The following was noted: A Lantus Solostar pen was open, had been used, and had no open date. A Humalog 100-unit multi-dose vial was dated [DATE]. LPN E stated, today is last day, indicating it was good for 31 days. On [DATE] at 05:34 PM, an inspection of the 2nd floor, cart 2, was conducted. LPN F was present during the inspection and confirmed the findings. The following was noted. An Insulin Aspart 100 U/ML multi-dose vial was opened and had no date to indicate when it was opened. The label said, discard after 28 days. LPN F confirmed she had no way 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.
- Potential for harm · E2023-06-29 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 bivalent vaccines for 4 residents, Residents #19, #31, #54, and #67, out of 5 residents reviewed for COVID-19 bivalent immunization. The findings included: The facility staff failed to provide COVID-19 bivalent immunization for Residents #19, #31, #54, and #67. On 6/28/23 at approximately 2:30 PM, clinical record reviews were performed and revealed the following: A. For Resident #19, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical contraindication. B. For Resident #31, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical contraindication. C. For Resident #54, the clinical record review revealed no evidence of an offer to provide the resident with a COVID-19 bivalent vaccine or documentation of resident refusal or medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-29 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, Resident and family interview, staff interviews and facility documentation review, the facility staff failed to maintain a sanitary and comfortable environment for Residents on 2 nursing halls in a sample of 6 nursing halls inspected. The findings included: On 6/27/23, during initial tour observations were made in multiple rooms on the first floor, halls 2 and 3 of privacy curtains (located to wrap around the bed for each Resident) to have brown stains and brown solid matter on them. On the afternoon of 6/27/23, an interview was conducted with Resident #320, who had a family member visiting. Resident #320 pointed out to Surveyor C the privacy curtain which had brown stains and solid matter that the Resident identified as feces. Resident #320 reported he had let facility nursing staff know but nothing had been done. The family member of Resident #320 showed Surveyor C her bag that she brings in daily with a disinfectant cleaner and Lysol spray because when she arrives, she, has to empty, clean and disinfect the bedside commode, because the facility staff do not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to offer and/or provide Advance Directive planning for 1 Resident, (Resident #317), in a survey sample of 38 Residents. The findings included: The facility staff failed to identify the wishes of Resident #317 with regards to code status, to uphold the Residents wishes in the event of cardiac arrest. On [DATE], a clinical record review of Resident #317's record was conducted. This review revealed that in the hospital records Resident #317 was noted as a code status of DNR (do not resuscitate). Review of the physician orders noted there was no order with regards to code status, which would direct facility staff in the event of cardiopulmonary arrest, if they were to perform CPR (cardiopulmonary resuscitation) or not. Review of the care plan for Resident #317 was reviewed and the code status and advance directive wishes of Resident #317 were not addressed. All the progress notes for Resident #317 were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident interview, clinical record review and facility documentation review, the facility staff failed to provide assistance with eating for 1 resident (Resident #84) in a survey sample of 38 Residents. The findings included: For Resident #84, who was dependent upon facility staff for assistance with eating, the facility staff failed to provide meal set-up and feeding assistance. Resident #84's most recent MDS (minimum data set) assessment with an assessment reference date of 5/24/23. This assessment noted Resident #84 as having required extensive assistance of one staff member for eating. Review of the clinical record was conducted. This review revealed Resident #84 was on hospice care. Resident #84 was identified in his care plan as being at risk for weight loss. It read, Nutritional Risk: [name redacted] is at nutritional risk d/t [due to] hx [history] pressure ulcers, on hospice care with expended medical decline. The goal read, [different Resident name, not Resident #84, name redacted] will have adequate nutrition for comfort/autonomy through next review.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide respiratory care as ordered by the physician and consistent with professional standards of practice for 1 Resident (Resident #38) in a survey sample of 38 Residents. The findings included: For Resident #38, the facility staff failed to 1) provide oxygen via a concentrator, at the level ordered by the physician 2) failed to store the suction Yankauer in a manner to prevent contamination, 3) failed to replace the suction tubing routinely, 4) failed to change the oxygen tubing weekly as ordered, 5) failed to change the humidifier bottle weekly as ordered, 6) failed to change the nebulizer tubing weekly as ordered. On 6/27/23 at approximately 2:00 PM, Surveyor C visited Resident #38 in his room. Resident #38 was able to communicate and when asked about the oxygen, the Resident was not able to recall the rate of oxygen flow ordered. Surveyor C noted the oxygen concentrator was set on 5 liters of oxygen. Further observations in the room revealed a suction…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2023-06-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 documentation review, the facility staff failed to provide an influenza vaccine for 1 resident, Resident #54, out of 5 residents reviewed for influenza immunization and facility staff failed to provide a pneumococcal vaccine for 1 resident, Resident #67, out of 5 residents reviewed for pneumococcal immunization. The findings included: 1. The facility staff failed to provide influenza immunization for Resident #54. On 6/28/23 at approximately 2:30 PM, a clinical record review was performed for Resident #54 and revealed that Resident #54 had received influenza immunization on 10/19/21, however there was no documentation of the flu vaccine being offered, refused, contraindicated, or administered for the current year, 2022. On 6/28/23 at approximately 2:45 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Resident #54 and verified the findings stating, it appears to be an oversight. A facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-03-19 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Review of R32's admission MDS assessment with an ARD of [DATE] revealed he was admitted to the facility on [DATE] and had a BIMS score of 15, indicating he was cognitively intact. Review of R32's Clinical Patient Profile located under the Profile tab of his electronic health record, revealed R32 was a full code resuscitation status. Review of R32's Interdisciplinary Team (IDT) notes, located under the Progress Notes tab of his electronic health record for [DATE] at 11:35 AM revealed the IDT offered R32 information on advanced directives, but the resident did not want them. Review of R32's admission Agreement, dated [DATE] and obtained from the facility's Director of Admissions, revealed an MFA Policies Governing the Implementation of Self-Determination Rights. Further review of the document revealed, . It is the policy of this Health and Rehabilitation Center to initiate cardiopulmonary resuscitation (CPR) as a resuscitation procedure . except when the resident's physician has specifically and appropriately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-03-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review the facility failed to ensure medications were secured and outdated medications were discarded. As a result of this deficient practice medications past their effective date may have been administered for two of two medication carts inspected for outdated medications. Findings include: 1. On [DATE] at 4:49 PM, on the second floor in the office area for charge nurses, outside the unit manager's office, the door was open, and medications were sitting on the counter unsecured. The medications were six cards of bubble packed variety of medications, eye drops and two Lovenox injection doses (anticoagulant). On [DATE] at 4:50 PM the Registered Nurse (RN) 1 confirmed the six bubble pack cards of medications, eye drops and two Lovenox doses should not be sitting on the counter in the office and should be secure. The medications should never have been left on the counter in the office. 2. On [DATE] at 3:05 PM, in the medication cart identified as third assignment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview it was determined the facility failed to protect the dignity of two of 20 Residents (R) (R 211 and R226). This failure created the potential for residents to experience decreased feelings of self-worth. Findings include: 1. Review of R226's Census tab of her electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of her Diagnosis tab of her EMR revealed diagnoses which included vascular dementia with behavioral disturbances. An observation on 03/18/21 at 1:11 PM revealed R226 arriving at the facility for admission on a gurney via non-emergent transport. A continuous observation on 03/18/21 from 1:54 PM to 2:39 PM revealed R226 sitting in her room next to her bed with a meal tray with a hot dog on her overbed table, calling out for help in a distressed manner. Certified Nursing Assistant (CNA) 1 approached the doorway to R226's room and asked what she needed. R226, still in a distressed manner, Is this beef? I don't eat pork. I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility failed to maintain a clean, comfortable, and homelike environment for 1 of 20 residents (Resident) (R) 211) sampled for environment. The failure created an increased risk for the resident to experience decreased feelings of self-worth. Findings include: An observation and interview with R211 on 03/16/21 at 12:42 PM revealed R211's room had multiple areas of disrepair. R211 showed the surveyor an area of broken tiles in his bathroom near the toilet and another area of broken tiles in his room under the bed. R211 also pointed out rust surrounding the drain of the bathtub in his bathroom, a brown gummy substance between the floor tiles and along the baseboards in his room and bathroom, rust around the bottom of the door frame between his room and his bathroom, buckling throughout the baseboards in his room causing gaps between the wall and baseboards, and dried red, blue, and yellow paint splatters on top of his heating unit. R211 also showed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the facility's grievance file, it was determined the facility failed to recognize and follow up on concerns for one of 20 sampled Residents (R) R211). This failure created the potential for residents to experience a decreased sense of autonomy and self-worth. Findings include: An interview with R211 on 03/16/21 at 12:42 PM revealed he had multiple grievances regarding his care and treatment at the facility. R211 stated, I've had the Administrator in here, and she sent the Director of Nursing (DON) and their consultant in here. That was over a week ago. She (the Administrator) wrote a bunch of it down, but the DON and the consultant wrote nothing down. In any event, I've heard nothing from them since, except the consultant handed me a business card one day when he saw me, while he was backing away from me. And I've got some more things they need to fix, like the bucket in my commode and the filth on my wheelchair. R211 pointed out that the waste receptacle for his bedside commode was only six inches deep, causing his waste to splash onto…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to ensure accurate resident assessments on the Minimum Data Set (MDS) for influenza immunization and psychotropic medications for two of five sampled residents (Resident (R) R2 and R28). As a result of this deficient practice inaccurate information was used to assess the relevant care areas. Findings include: Review of the facility's policy titled, Resident Assessment & Care Planning-MDS effective 11/01/19 indicated, Each person entering data into MDS will date the MDS on the MDS Signature page indicating the section(s)/questions each completed attesting to the accuracy of the sections they completed .Each person completing a CAA worksheet must sign and date the completion .The MDS and CAAs will be used to develop a plan of care addressing those problems, needs, strengths or potential problems that were identified during the assessment process. 1. Review of Face Sheet under the profile tab in the electronic medical record (EMR),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 observation, interview, and record review, it was determined the facility failed to ensure communication with the dialysis center for 1 of 1 residents (Resident (R) 32) sampled for dialysis services. This failure created an increased risk the resident would experience complications related to his dialysis services such as blood pressure changes, pressure ulcers, bleeding, and access site infection or failure. Findings include: Review of R32's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/21, revealed that he was admitted to the facility on [DATE], his diagnoses included Diabetes Mellitus (DM) and dependence on renal dialysis, and he had received dialysis treatments within the past 14 days. Review of R32's Order Recap Report located under the Orders tab of his electronic medical record (EMR) revealed he received dialysis treatments on Tuesdays, Thursdays, and Saturdays each week. Review of the facility's Hemodialysis policy dated 10/01/19 revealed, . The Dialysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review the facility failed to ensure Transmission Based Precautions (TBP) were followed when a resident without a diagnosis of Clostridium-difficile (C-difficile) shared a room with a resident diagnosed with C-difficile. This affected Resident (R) 267 and R275. 2. A resident who completed the 14-day admission isolation for observation of COVID-19 signs and symptoms, R224 shared a room with a new admission R226 who had not completed a 14 day observation for COVID-19 signs and symptoms and failed to practice TBP. Failure to follow TBP increased the potential for cross contamination and exposing other residents to C-diffcile infection and potential exposure to possible COVID-19. Findings include: Review of the facility policy titled Infection Prevention and Control Policies, Precautionary Measures, Transmission Based Precautions, effective date 02/06/20, revealed use the Contact Precaution Special Enteric sign for residents with c-diff. When cohorting with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-06-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 and staff interview, clinical record and facility documentation review, the facility failed for one Resident, Resident #6 in a survey sample of 35 residents, to ensure the resident was assessed for self administration of eye drops. Resident #6 had two bottles of Refresh eye drops on her bedside table. The resident had not been assessed for self administration. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including COPD- chronic obstructive pulmonary disease, atrial fibrillation and high blood pressure. Resident #6's most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 3-13-18. She was coded with a brief Interview of Mental Status score of 15 out of a possible 15 indicating no cognitive impairment. She required standby assistance with her activities of daily living. The resident was coded as having visual impairments. On 6/12/18 at 12:15 PM, during the initial tour, Resident #6 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-06-14 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 1 resident (Resident #34) in a sample of 35 residents. For Resident #34, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. The Findings included: Resident #34 was admitted on [DATE] with diagnoses including: Schizophrenia, and Bipolar Disorder. On 6-13-18, an observation, Resident interview, and review of Resident #34's record was conducted. Resident #34 was noted to have diagnoses including schizophrenia, and bipolar disorder. Geriatric psychiatry notes, resident history, and admission information revealed that the illnesses were long standing, and since the [AGE] year old Resident was a young adult. No previous to admission PASARR was found in the Electronic Health Record (EHR). Facility staff were asked to locate Resident #75's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-06-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and facility documentation review, the facility staff failed for 1 resident (Resident #240) in the survey sample of 35 residents, to provide Activities of Daily Living Care in a timely manner. The facility staff failed to answer call bells for toileting assistance for approximately 1 hour. The Findings included: Resident #240 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #240's diagnoses included Hypertension and Difficulty walking. On 6/12/18 at 12:15 P.M. an observation was conducted of Resident #240 eating in the dining room. She stated that she had to use a walker to go to the bathroom, and that the staff often take 1 hour to answer the call bell. She stated that she needed assistance for toileting, and that she usually has to wait about an hour for staff assistance. There were two other residents at the dining table, who both voiced agreement with Resident #240. On 6/13/18 a Group Interview was conducted with five…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-06-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 Staff Interview, Medical Record Review and Facility Documentation Review, facility staff failed to ensure the medication regimen was free from unnecessary psychotropic medications for 2 Residents (Resident #292 and #45) in a survey sample of 35 Residents. 1. For Resident #292, the facility staff failed to ensure that she was free from unnecessary psychotropic medications. 2. For Resident #45, the facility staff failed to ensure that she was free from unnecessary psychotropic medications. The Findings included: 1. Resident #292 was admitted on [DATE]. The most recent Minimum Data Set (MDS) Assessment was an admission Assessment with an Assessment Reference Date (ARD) of 5/29/18. The Brief Interview for Mental Status (BIMS) gave Resident #292 a score of 3, indicating significant impairment. Her diagnoses included Right femur fracture, hypertension, major depressive disorder, coronary artery disease, dementia with behavioral disturbances, anxiety, anemia, hyperlipidemia, and altered mental status. 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.
- Potential for harm · Dcited before2018-06-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #293) in the survey sample of 35 residents, to administer medications in a manner to prevent the spread of infection. The facility staff failed to perform hand hygiene prior to administering medications to Resident #293. The Findings included: Resident #293 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #293's diagnoses included Hypertension, Overactive Bladder, Claustrophobia, Hereditary Neuropathy, Gastro-Esophageal Reflux Disease, Major Depressive Disorder, Osteoporosis, and Glaucoma. The Minimum Data Set, which was an admission Assessment with an Assessment Referenced Date of 6/1/18, coded Resident #293 as having a Brief Interview of Mental Status Score of 11. This score is an indication of modified independence in cognitive skills for daily decision making. On 6/13/15 at 8:50 A.M. a Medication Pass observation was conducted. Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFEWORKS REHAB — 64 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.1 | +1.9 vs chain |
| Health inspection | 3 of 5 | 2.0 | +1.0 vs chain |
| Staffing | 2 of 5 | 1.6 | +0.4 vs chain |
| Quality measures | 5 of 5 | 3.9 | +1.1 vs chain |
The other 63 homes this chain runs (chain average 2.1★, per CMS)
Showing 40 of 63; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BURKE HOLDINGS I LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/28/2021 |
| CHARLES 1994 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| CHESAPEAKE EAST LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| EDWARD 1998 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| EK 2005 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| FAY 2014 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| FAY 2014 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| LL 2013 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| MMS 2008 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| MZR EAST LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SAUL 2012 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SILVERSTONE EAST LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SOL 2000 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SOL 2000 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| STEVENS 3920 & FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| STEVENS 3920 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| STEVENS 3920 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| KEE, TERRENCE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 09/08/2023 |
| RYLBSS EAST MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/28/2021 |
CMS files one row per role, so the 20 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
18 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $5.3M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495248. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-06-29, 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.