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Colonnades Health Care Center

100 Colonnades Hill Drive, Charlottesville, VA 22901 · For profit - Corporation · 34 certified beds · (804) 963-4198 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citations — no harm found (F0744, F0758)2 immediate-jeopardy citations1 Medicare payment denial
Insights

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

In its favor
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • 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- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1170 Emmet St N · (800) 746-7287 · Call to confirm hours
Pharmacy
1170 Emmet St N · (434) 293-9151 · Call to confirm hours
Grocery
Kroger0.2 mi
1904 Emmet St N · (434) 295-8334 · Call to confirm hours
Park
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 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 5 to 2 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 rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.8%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine97.5%73.6%79.4%better
Short-stay residents rehospitalized after admission28.2%22.3%22.6%worse
Short-stay residents with an outpatient ER visit7.5%11.5%12.0%better

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.

72.2% 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 279 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

72.2%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
77.5%U.S. median 56.6%
Met the expected recovery
1.34U.S. median 0.31
Therapy hours / resident / day
0.55hours / resident / day
Physical therapy
0.59hours / resident / day
Occupational therapy
0.20hours / resident / day
Speech therapy

Met the expected recovery: 77.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 120 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 1.34 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF72.2%CMS range 68.4–76.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 7.7–14.910.7%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 discharge77.5%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 discharge78.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge65.0%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 discharge97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.7%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 worsened2.1%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 hospitalization6.4%CMS range 3.8–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 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

1.30
RN hours/ resident / day
1.58
LPN hours/ resident / day
3.85
Aide hours/ resident / day
6.72
Total nurse hours/ resident / day
0.68
RN hoursweekends
36.4%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 34 beds and averages 20.1 residents a day — about 59% occupied, or roughly 14 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 6.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.30 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.85 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 6.07 hrs/resident/day on weekends vs 6.99 on weekdays — 13% thinner on weekends. RN hours go from 1.55 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

22
deficiencies at the latest standard inspection (2024-11-01)
3
at the previous standard inspection (2023-03-15)

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 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · K2024-11-01 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the residents' right to be free from mental abuse/verbal abuse/ and physical abuse by a staff member for four residents, (Resident #5 (R5), Resident #7 (R7) Resident #20 (R20) and Resident #177 (R177)) out of a survey sample of 20 residents, which resulted in psychosocial harm for R20. Immediate jeopardy (IJ) and substandard quality of care in the area of abuse was identified. The findings included: 1. For R5 and R20, the facility staff failed to protect the resident's right to be free from physical abuse, mental abuse and verbal abuse. On 10/29/24, a clinical record review was conducted of R5's chart, which noted she had been discharged and was no longer a resident of the facility. Therefore, an interview could not be conducted with R5. On 10/29/24 at 9:08 a.m., an interview was conducted with R20. R20 said, [Certified nursing assistant #1 (CNA 1)'s name redacted] treated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2024-11-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated. The findings included: For all of the residents residing on the one nursing unit in the facility, the facility staff had not assessed the residents ability to manage hot liquids, when hot coffee was available and accessible to residents in the lobby, and the facility failed to maintain a consistent system in place to monitor temperatures of hot liquids being served in the dining…

    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 · F2024-11-01 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to effectively administer the facility for residents to maintain their highest practicable well-being, which had the potential to affect all residents residing in the facility. The findings included: For the resident's residing in the facility, the facility administration failed to effectively and efficiently administer the facility to ensure residents were free from and protected from abuse. The facility administrator, who was the abuse coordinator, failed to implement the facility's abuse policy to ensure residents were protected, allegations were reported and investigated timely, and residents were free from abuse, which resulted in the identification of immediate jeopardy and substandard quality of care. 1. On 10/29/24 at 9:08 a.m., an interview was conducted with resident #20 (R20). R20 said, [Certified nursing assistant #1 (CNA 1)'s name redacted] treated me like slapping…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-01 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    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 ensure residents were free from a significant medication error for one resident (Resident #7-R7) in a survey sample of 20 residents. The findings included: For R7, the facility staff failed to administer an antibiotic resulting in a two-day delay in the order being carried out and then resulting in multiple missed doses. On 10/29 and 10/30/24 a clinical record review was conducted of R7's chart. This review revealed R7 had a visit to the hospital on [DATE], following a fall where she sustained a laceration to the back of her head which required medical attention. R7 returned to the facility on [DATE]. According to the hospital records within R7's paper chart, the ED [emergency department] After Visit Summary dated 10/25/24, noted Reason for Visit: Fall. Diagnoses: Fall, initial encounter, Hematoma of scalp, initial encounter, Cystitis, Traumatic tear of thoracic aorta, initial encounter. That same…

    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 before2024-11-01 · tag F0761 — failed to label and store drugs safely — pattern
    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, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were securely stored in 1 of 2 medication carts and for 1 resident (resident #128) in a survey sample of 20 residents. The facility staff also failed to ensure that expired medications were not available for use in 1 of 1 medication rooms. The findings included: 1. For R128, the facility staff permitted the resident to have eye drops at the bedside which were not secured. On 10/29/24 at 9:49 a.m., observations were conducted in R128's room and an interview conducted with the resident. On R128's over bed table the surveyor noted a bottle with a prescription label. When asked, R128 said it was eye drops and I use them when my eyes get dry or itchy. R128 reported that he had received them when he was in the hospital. R128 handed the surveyor the bottle and it was noted to be Carboxymethylcellulose Refresh 1% a 15 ml container of ophthalmic gel. The instructions read, 1 drop both eyes. It had a hospital pharmacy label with a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. Four food bins containing rice, flour, sugar, and bread crumbs were labeled as expired and were accessible for distribution in the main kitchen. The findings included: On 10/29/24 at 8:40 a.m. during the initial tour of the main kitchen with dietary manager (other staff, OS #1) four large food bins containing rice, flour, sugar, and bread crumbs all with an expiration date of 9/21/24 were accessible for distribution. OS #1 also observed the food bins and verbalized that either a staff member had not relabeled the food bins when new food was added or the food is out of date, verbalizing the food will be removed and replaced along with new expiration dates. A policy titled Food Storage, Preparation and Service was obtained and read in part: General Food Handling [ .] d. All food items are labeled, dated and rotated to maintain a system of First In First Out. e. Expired food is discarded. On 10/3024 at 5:01 p.m. the administrator and director of nursing (DON) were notified of the above finding. No other information was provided prior to exit conference on 11/1/24. Based on…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-01 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility documentation review, the facility staff failed to ensure that the facility assessment involved the appropriate participants, which had the potential to affect all operations and residents within the facility. The findings included: The facility staff failed to ensure the active involvement of direct care staff and solicit input from residents, resident representatives and family members in the development of the facility assessment. On 10/31/24, a review of the facility assessment was conducted. This review revealed no evidence of direct care staff, residents, resident representatives or family members being involved and/or their input being solicited for the development of and/or review of the resident assessment. The facility assessment was updated 5/23/24 and reviewed with the governing body on 5/16/24. According to the persons involved in completing assessment it included the administrator, director of nursing, governing body representative, medical director, social services coordinator, resident assessment coordinator and dietary services…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-01 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 3. For R12, who had multiple falls and sustained a significant head injury, the facility failed to maintain a complete and accurate clinical record to include the details of the fall and the facility's response. On 10/29/24 at 11:03 a.m., during an interview with R12 and his spouse, the spouse reported, He had several falls here, which resulted in a head injury. The first one they called me, he hit his head badly and was bleeding and had to have some surgery on his brain. On the evening of 10/30/24, during a clinical record review, the following was noted. R12 had a fall on 6/10/24. The Fall Progress Note read, Fall was unwitnessed in residents room [ROOM NUMBER]/10/2024 8:00 PM. Residents description of event and how they were feeling: Guest stated that he was going to bed. He stated that he was ok before he fell .No injury noted at time of fall. [R12's spouse's name redacted] Your husband fell. He is ok. was notified on 06/10/2024 11:00 PM [Doctor's name redacted], MD was notified on 06/10/2024 9:00 PM with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-01 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 education and offer COVID immunizations, to 4 of 5 residents (resident #7-R7, resident #17-R17, resident #76- R76 and Resident #20-R20) sampled for immunizations and failed to have evidence of having provided staff education regarding COVID immunizations for 3 (licensed practical nurse #1- LPN #1, certified nursing assistant #6- CNA #6, and other employee #5- OE#5) of 3 staff sampled. The findings included: On 10/30/24, a sample of five residents was selected for review of immunizations. Review of the clinical records for each resident revealed the following: 1. R7 had no information noted with regards to the status of her COVID immunizations. There was no indication that the facility had offered any education with regards to COVID immunizations. 2. For R17, the clinical record indicated that the resident was eligible for the spike vaccination of COVID-19. 3. R76's clinical record indicated 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-01 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and facility documentation review, the facility staff failed to provide as part of their Quality Assurance and Performance Improvement (QAPI) program mandatory training for five employees (certified nursing assistants- CNA #1, #4 and #5, licensed practical nurse LPN #4, and registered nurse RN #2) in a sample of five staff members reviewed for educational requirements. The findings included: On 10/31/24, a survey sample of five staff members was selected for review of their education and training. The sample included: CNA #1, CNA #4, CNA #5, LPN #4 and RN #2. The facility administration was given the names and asked to provide all evidence of education and training provided to those employees for the past two years. On 11/1/24, the general manager (GM) provided the survey team with transcript reports of education for each of the five sampled staff. The GM was asked if all the staff education is conducted as computer-based training and the GM stated that it was, and the facility used Relias for staff training. The GM also confirmed that they have a training…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0573 — isolated
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility documentation review, the facility staff failed to respond timely to a clinical record request for 1 resident of 20 residents, resident #26 (R26). The findings included: For R26, whose power of attorney requested copies of the resident's clinical record, the facility staff failed to fulfil the request for over six weeks. On 11/1/24, a closed clinical record review was conducted of R26's chart. This review revealed no information with regards to a request for clinical records being made. On 11/1/24 at 9:49 a.m., an interview was conducted with the medical records employee. The medical records employee reported that the process when a person requests medical records is that they fill out a form, it is forwarded to the records management team and documents are uploaded for them to review. Once approval is received from the records management team, she releases the requested records. The medical records employee reported she had only been in the role about two months and therefore had no knowledge of a request for records involving R26. On 11/1/24…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement Quality Assurance and Performance Improvement (QAPI) policy for abuse and failed to implement abuse policy regarding an allegation of abuse and injury of unknown origin for one of 20 residents (Resident #7). The Findings Include: 1. The facility did not communicate or monitor feedback of allegations of abuse during QAPI meetings as directed in the QAPI policy. Review of facility reported incidents indicated that the facility reported an allegation of abuse between a staff member and two residents on 10/2/24. Review of the facility QAPI policy read in part 4. The SNA/designee [skilled nursing administrator] will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include. but is not limited to: b. Systems and reports demonstrating systematic identification, reporting, investigation,analysis, and prevention of adverse events. [ .] The community maintains procedures for feedback,data collection systems, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-11-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    For Resident #7 (R7) who made an allegation of abuse/mistreatment, the facility staff failed to report the abuse allegation to the required agencies timely. On 10/29/24 at 10:47 a.m., during an interview with R7 she reported the staff are rough when they help you to stand up or change your diaper. When R7 was asked about the bruising to her right wrist, the resident said, they are very rough. On 10/29/24 at 10:51 a.m., following the above interview with R7, the surveyor was unable to locate the facility administrator to report the allegation. The surveyor then made the acting director of nursing (DON) aware of the allegation. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. There was a progress note entry dated 10/29/24 at 11:14 a.m., by the DON that read, ADNS [acting director of nursing services] was asked to follow up on resident statement that when she was asked how she got the bruise on her wrist, she stated staff was sometimes…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to complete a thorough investigation for an allegation of abuse for three residents, Resident #5 (R5), Resident #20 (R20), and Resident #177 (R177), in a survey sample of 20 residents. The findings included: 1. For R5 and R20 who reported an allegation of abuse, the facility staff failed to provide evidence that a thorough investigation to include interviews with other residents to determine if they may have been affected. According to the personnel records, the alleged perpetrator was terminated for abuse, but the facility administrator noted that the allegation of abuse was unsubstantiated. Following the abuse report, some facility staff were educated on customer service. On 10/29/24, a clinical record review was conducted of R5's chart, which noted the resident had discharged and was no longer a resident of the facility. Therefore, an interview could not be conducted with R5. On…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · 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

    Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to adequately develop a comprehensive care plan to address the behavioral health care needs for one resident (Resident #7 - R7), in a survey sample of 20 residents. The findings included: For R7, who had a diagnosis of dementia, had documented behaviors, and was given psychotropic medications on a scheduled/routine basis, the facility staff failed to develop a comprehensive care plan to include the routine use of psychotropic medication with the targeted behaviors being treated, as well as how facility staff were to provide routine care in the presence of behaviors. On 10/29/24 at 10:47 a.m., R7 was visited and interviewed in her room. R7 was noted to be very hard of hearing but was able to engage in conversation and interview appropriately. R7 displayed no behaviors during the interview. On 10/29/24-10/30/24, a clinical record review was conducted. This review revealed that R7 had a diagnosis of dementia and an active order, that read, Haloperidol Lactate Oral…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #102-R102) in a survey sample of nine residents. The findings included: For R102 the facility nursing staff failed to clarify a physician order for insulin, where the number of units to be administered had two different values within the administration directions. On 1/7/25, during a clinical record review, it was noted that R102 was admitted to the facility on [DATE], following an acute care hospitalization. Discharge orders from the hospital indicated that R102 was to receive Tresiba FlexTouch U-100, 100 unit/mL (3 mL) Insulin Pen. This medication order read, Inject 86 units beneath the skin every night at bedtime. R102's admission orders which were signed by the attending physician and medical director of this facility on 1/3/25, indicated that the 86 units of Tresiba were to be given nightly at bedtime. According to R102'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · 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, clinical record review, and facility document review, the facility staff failed to follow physician orders for two of twenty residents in the survey sample (Residents #14 and #26). The findings include: 1. License practical nurse (LPN #2) pulled one vitamin D3 25 mcg (micrograms) for Resident #14 (R14) when the physician's order required two tablets of vitamin D3 mcg. A medication pass observations was conducted on 10/30/24 at 8:20 a.m. with LPN #2 administering medications to R14. Among the medications administered was one tablet of vitamin D3 25 mcg. The label of the medication was reviewed and indicated R14 was to receive two vitamin D3 25 mcg tablets. LPN #2 continued to pull medications for R14 and place them into a medication cup. LPN #2 then put all medications cards back into the cart, closed and locked the cart and started to step away from the cart to distribute the medications in the cup. LPN #2 was questioned regarding the vitamin D3. LPN #2 observed one vitamin D3 in the cup then reviewed the physicians order and verbalized 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement non-pharmacological interventions for pain for one of twenty residents in the survey sample (Residents #14, R14). The findings include: Diagnoses for R14 included; post surgical hip repair, chronic kidney disease, major depression, and chronic pain. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/22/24. R14 was assessed with a cognitive score of 12 out of 15, indicating cognitively intact. Review of Physician orders indicated an order dated 9/16/24 for Oxycodone 10 mg [milligrams] give 2 tablets by mouth every 6 hours for severe pain. Review of R14's medication administration record (MAR) for September and October 2024 indicated R14 received Oxycodone on 9/19/24, 9/28/24, and 10/10/24. Review of R14's progress notes surrounding the dates Oxycodone was given were reviewed and did not indicate non-pharmacological interventions were performed. On 10/31/24 at 6:12 PM the director of nursing (DON) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 ensure appropriate dementia care with individualized interventions was in place for one resident (Resident #7 - R7), in a survey sample of 20 residents. The findings included: For R7, who had dementia, the facility staff failed to develop resident specific interventions to ensure the resident received appropriate treatment to maintain the resident's highest practicable well-being. On 10/29/24 at 10:47 a.m., R7 was interviewed in her room. R7 was noted to be very hard of hearing but was able to engage in conversation/interview appropriately. R7 displayed no behaviors during this interview. On 10/29/24-10/30/24, a clinical record review was conducted. This review revealed that R7 had a diagnosis to include, unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety. According to R7's care plan, there was a focused care area devised on 4/11/24, that read, The resident has impaired cognitive…

    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 · D2024-11-01 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to respond to a medication regime review and recommendations from the pharmacy for 1 resident (Resident #11-R11) in a survey sample of 20 residents. The findings included: For R11, who was receiving two psychotropic medications, the facility's medical provider failed to respond to the pharmacy recommendation for a gradual dose reduction. On 10/29/24 at 11:45 a.m., during an interview with R11, the resident was observed to have constant lip smacking while talking to the surveyor, which could be indicative of tardive dyskinesia, which is a chronic condition that causes involuntary, repetitive movements in the body. On 10/30/24, during a clinical record review of R11's chart. According to the physician orders, R11 was receiving Buspirone HCl 15 mg tablet three times daily for anxiety since 12/16/2022. There was no indication that R11 had a dose change in the Buspirone. The physician orders also indicated R11 received Remeron 45 mg at bedtime for major depressive disorder,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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

    Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure a gradual dose reduction was performed for one resident (Resident #11- R11), failed to ensure one resident (Resident #7- R7) was free from unnecessary psychotropic medications, and failed to document assessment and monitoring of psychotropic medications effect on two residents (Resident #14-R14 and Resident #7-R7) in a survey sample of 20 residents. The findings included: 1. For Resident #11, who was on a psychotropic medication for 22 consecutive months, the facility staff failed to attempt a gradual dose reduction or have documentation from the doctor why a reduction was contraindicated. On 10/29/24 at 11:45 a.m., during an interview with R11, the resident was observed to have constant lip smacking while talking to the surveyor, which could be indicative of tardive dyskinesia, which is a chronic condition that causes involuntary, repetitive movements in the body. This prompted further investigation of R11's medications. On 10/30/24, during a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    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 physician ordered rehab therapy services to three residents in a survey sample of nine residents. The findings included: On 1/8/25, clinical record reviews were conducted of a sample of residents residing at the facility to identify residents with a BIMS (brief interview for mental status) score of 12 or less. Several residents (Resident #101-R101, Resident #102- R102, and Resident #103- R103) were all noted with a BIMS of 12 or less. Each of the residents were noted to have active physician orders for therapy to evaluate, dating as far back as 12/23/24. On 1/8/25, in the afternoon, an interview was conducted with the rehab/therapy director. The therapy director reviewed clinical records and stated that none of the three residents had been evaluated by therapy as of 1/8/25. When the therapy director was asked about the delay in treatment, the therapy manager stated that they have been busy with out-patient case load. On the evening of 1/8/25, the facility'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 · Ecited before2023-03-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility document review, the facility staff failed to store, prepare, and serve food in a sanitary manner from the main kitchen. The findings include: Foods beyond the use-by date were stored and available for use in the main kitchen's reach-in refrigerator and walk-in freezer. A bench mounted can opener in the main kitchen's pantry was dirty. Stainless prep pans on the dry rack were stored nested with staff members using paper towels to dry pans prior to use. A maintenance employee was observed in the kitchen during lunch preparation without a hair restraint. On 3/13/23 at 10:55 a.m., the kitchen and food storage areas were inspected accompanied by the dishwasher supervisor (other staff #2). Lunch preparation was in progress during this observation. Stored in a reach-in refrigerator was a container of cranberry sauce labeled with a discard date of 2/8/23. There was a container of diced tomatoes and a container of chopped cucumbers labeled to discard on 3/12/23. A manual, bench mounted can opener in the pantry room was observed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-15 · 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 interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of thirteen residents in the survey sample (Resident #10). The findings include: Resident #10's plan of care was not revised after discontinued use of an indwelling catheter, a PICC (peripherally inserted central catheter) and intravenous antibiotics. Resident #10 was admitted to the facility with diagnoses that included depression, anxiety, urinary tract infection, urine retention, congestive heart failure, hypothyroidism, cognitive communication disorder and osteoporosis. The minimum data set (MDS) dated [DATE] assessed Resident #10 with severely impaired cognitive skills. Resident #10's clinical record documented the resident had a PICC and was treated with intravenous antibiotics in September 2022 for sepsis related to a urinary tract infection. A nursing noted dated 10/4/22 documented the resident pulled out the PICC. The PICC was not replaced and the order for the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-15 · 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 a medication pass observation, staff interview, facility document review and clinical record review, the facility staff failed to accurately label a medication for one of thirteen residents in the survey sample (Resident #18). The findings include: The pharmacy label for Resident #18's medication bumetanide listed a 3 mg (milligram) daily dose when the resident was currently prescribed a 1 mg dose. A medication pass was observed on 3/14/23 at 7:35 a.m. with licensed practical nurse (LPN) #1 administering medications to Resident #18. Among medications administered was bumetanide 1 mg (milligram). The pharmacy label for the bumetanide documented the dose as 1 mg with instructions to give three tablets for total dose of 3 mg. There was nothing on the label indicating a dose or order change for the medication. LPN #1 made no comment about the label dosage not matching the current physician's order when preparing and administering the medication. Resident #18's clinical record documented a current physician's order dated 3/6/23 for bumetanide 1 mg with instructions to give 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-25 · 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 clinical record review and staff interview, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to ensure the resident's comprehensive care plan was reviewed and revised in a timely manner. Resident # 2's care plan for the use of Trazodone was not updated to reflect the current dosage. The findings were: Resident # 2 was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's dementia, heart failure, hypertension, hyperlipidemia, anxiety disorder, depression, chronic passive congestions of the liver, oteoarthritis of the right hip and right knee, and hypothyroidism. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 8/4/2021, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 01 out of 15. Review of Resident # 2's current physician's orders revealed the following medication order, dated 11/25/2020: Trazodone HCl Tablet,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-02-07 for 10 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SUNRISE SENIOR LIVING — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.5-1.5 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 5 of 53.8+1.2 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 3 homes this chain runs (chain average 3.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
WELLTOWER OPCO GROUP LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2018
WELLTOWER INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2018
WELLTOWER TRS HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/01/2018
SUNRISE SENIOR LIVING MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/19/2025
CALLOWAY, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/02/2025
COELHO, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
FALCO, DENISEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
FRANTZ, EDWARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
KESSLER, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
O'RIORDAN, DAMIENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
PAINTER, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
ROYAL, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
SEKEL, WENDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
SIMPKINS, RACHELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2023
THOMPSON, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
WELLS, ANJAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
EKI, DAVIDIndividualADP OF THE SNFsince 11/01/2022
HARRIS, TONYIndividualADP OF THE SNFsince 01/16/2025

CMS files one row per role, so the 34 rows in the source record cover these 18 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.

4 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.

$23.1M
Net patient revenuemost recent cost report
-13.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 5%Other / private 95%

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

$249per resident / day
operating cost
$7,581per month
≈ monthly operating cost
$219per 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 495254. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-01, 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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