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Westminster Canterbury Blue Ri

250 Pantops Mountain Rd, Charlottesville, VA 22911 · For profit - Corporation · 27 certified beds · (434) 972-3100 Medicare & Medicaid certified

Call the home — (434) 972-3100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0609) — most recent Apr 20261 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, 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
1460 Pantops Mountain Pl · (434) 234-4910 · Call to confirm hours
Pharmacy
314 Rolkin Rd · (434) 979-9905 · Call to confirm hours
Grocery
Giant0.4 mi
1900 Abbey Rd · (434) 244-4300 · Call to confirm hours
Park
Chesapeake St & Riverside Ave · 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
Long-stay residentspeople who live here 4 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 held steady at 5 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 rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.4%14.9%15.4%typical
Long-stay residents who lose too much weight9.6%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.5%1.6%2.0%better
Long-stay residents with depressive symptoms0.8%18.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.9%3.6%3.3%worse
Long-stay residents whose ability to walk worsened16.0%15.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication21.8%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers7.7%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control16.5%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.3%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%73.6%79.4%better
Short-stay residents rehospitalized after admission22.3%22.3%22.6%typical
Short-stay residents with an outpatient ER visit7.0%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.711.521.67typical
Long-stay outpatient ER visits per 1,000 resident days1.401.481.80better

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

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

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

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

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

73.7% 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 141 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

73.7%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
81.9%U.S. median 56.6%
Met the expected recovery
0.77U.S. median 0.31
Therapy hours / resident / day
0.46hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 81.9% 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 83 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 0.77 therapist hours per resident per day in 2026Q1 — more than 94% 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 SNF73.7%CMS range 68.4–78.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 5.5–12.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge81.9%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 discharge79.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge78.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.0%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 hospitalization5.7%CMS range 3.1–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 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

1.33
RN hours/ resident / day
0.63
LPN hours/ resident / day
3.44
Aide hours/ resident / day
5.40
Total nurse hours/ resident / day
1.01
RN hoursweekends
40.7%
Total nursing turnover
33.3%
RN turnover

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 5.40 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.33 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.44 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.79 hrs/resident/day on weekends vs 5.65 on weekdays — 15% thinner on weekends. RN hours go from 1.46 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

13
deficiencies at the latest standard inspection (2026-04-15)
8
at the previous standard inspection (2023-03-09)

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.

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2026-04-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident, staff, and family interviews, the facility staff failed to ensure safe transfer from bed to wheelchair for one (1) of 24 residents (Resident #7) in the survey sample, which resulted in harm, sustaining a right hip fracture. The findings included: Resident #7 was originally admitted to the facility on [DATE] and most recently transferred to the local hospital on 4/10/26, diagnosed with a hip fracture and readmitted to the nursing facility on 4/15/26. The current diagnoses included: incomplete paraplegia and relapsing remitting Multiple Sclerosis.The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/02/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #7's cognitive abilities for daily decision-making were intact. [NAME] BlvdIn section GG (Functional Abilities), the resident was coded as dependent in personal hygiene, upper-body dressing,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and a review of clinical records, the facility staff failed to accurately assess and classify an open wound for 1 of 24 residents (Resident #30) in the survey sample. The findings included: Resident #30 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with left hemiplegia. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/03/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 11 out of 15. This indicated that Resident #30's cognitive abilities for daily decision-making were moderately impaired. The resident's person-centered care plan with a revision date of 3/27/26 stated that the resident had an activity of daily living self-care performance deficit related to an activity intolerance, Disease Process, and limited mobility. The goal stated that the resident would maintain the current level of function through the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-15 · tag F0837 — pattern
    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and review of facility documents, the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective systems were in place to assure the quality of life for the residents in the area of foot care and treatment/services to prevent/heal pressure ulcers.The findings included:During the recertification survey completed on 4/15/26 the facility failed to provide podiatry services for Resident #11 and provide treatment and services to prevent and heal pressure ulcers for Resident #30. On 4/15/26 at 4:12 PM an interview was conducted with the Administrator and the Director of Nursing (DON) regarding podiatry services and treatment and services to prevent and heal pressure ulcers. The Administrator stated that she is not sure if the Quality Assurance and Performance Improvement (QAPI) committee discussed foot care and podiatry services. The Administrator also stated that the facility identified issues regarding podiatry services but no action plan was put in place. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-15 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, and implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies if the area of foot care and treatment/services to prevent/heal pressure ulcers.The findings included:During the recertification survey completed on 4/15/26 the facility failed to provide podiatry services for Resident #11 and provide treatment and services to prevent and heal pressure ulcers for Resident #30. On 4/15/26 at 4:12 PM an interview was conducted with the Administrator and the Director of Nursing (DON) regarding podiatry services and treatment and services to prevent and heal pressure ulcers. The Administrator stated that she is not sure if the Quality Assurance and Performance Improvement (QAPI) committee discussed foot care and podiatry services. The Administrator also stated that the facility identified issues regarding podiatry services but 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 observations, staff interviews, and a review of the clinical record, the facility staff failed to treat 1 of 24 residents (Resident 20) in the survey sample with respect and dignity. The findings included: Resident #20 was admitted to the facility on [DATE]. The residents' current diagnoses included dementia and diabetes. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/11/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident # 20's cognitive abilities for daily decision making were severely impaired. In section GG0130 (Functional Abilities), the resident was coded as requiring setup or clean-up assistance with oral hygiene, supervision or touching assistance with eating, substantial/maximal assistance with shower/bathe self and upper body dressing, dependent with Lower body dressing, personal hygiene, and putting on/taking off footwear.On 4/13/26 at approximately 12:50 PM,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility staff failed to ensure that resident care equipment was kept clean for 1 of 24 residents (Resident 31) in the survey sample.The findings included: Resident #31 was admitted to the facility on [DATE]. The residents' current diagnoses included dementia and heart failure. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/2/26, coded the resident as unable to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-term and short-term memory problems, as well as severe impairment for daily decision making.In section GG0130 (Functional Abilities), the resident was coded as requiring setup or clean-up assistance with eating; being dependent with shower/bathe; and with upper body dressing, lower body dressing, personal hygiene, and putting on/taking off footwear. The resident was also coded at section GG0170. (Mobility) dependent on the use of a wheelchair operated by staff.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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 observations, staff interviews, and a review of the clinical record, the facility staff failed to ensure that 1 of 24 residents (Resident 49) in the survey sample was free from a physical restraint. The findings included: Resident #49 was admitted to the facility on [DATE]. The residents' current diagnoses included dementia and Parkinson's disease. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed; therefore, the following information was obtained from the Nurses' admission Functional assessment with a lock date of 4/11/26. The admission assessment revealed the resident was oriented to person only, and his cognitive status was severely impaired. The assessment also indicated that the resident was dependent in all activities of daily living (ADL). On 4/14/26 at approximately 10:59 AM, Resident #49 was observed in a reclined chair in the living room area. An interview with the Clinical Care Coordinator (CCC) was conducted at 12:48 PM. The CCC…

    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 · D2026-04-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, it was determined that facility staff failed to report an allegation of verbal abuse in a timely manner to the appropriate state agencies for 1 of 24 residents (Resident #11) in the survey sample. Resident #11 was originally admitted to the facility 6/10/24 after an acute care hospital stay and re-admitted on [DATE] from an acute care facility. The current diagnoses included; Foot Drop, Peripheral Vascular Disease.The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/02/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral hygiene, toileting hygiene, shower/bathe self. Requires set-up or clean-up assistance with eating.The person-centered care plan dated 03/06/26 read 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 interviews and clinical record review, the facility staff failed to ensure 1 resident (Resident #11), in the survey sample of 24 Residents who were unable to carry out activities of daily living receive the necessary services to maintain podiatry services.The findings included: Resident #11 was originally admitted to the facility 6/10/24 after an acute care hospital stay and re-admitted on [DATE] from an acute care facility. The current diagnoses included; Foot Drop, Peripheral Vascular Disease. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/02/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral hygiene, toileting hygiene, shower/bathe self. Requires set-up or clean-up assistance with eating. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the clinical record, the facility staff failed to provide necessary incontinence care for 1 of 24 residents (Resident 20) in the survey sample. The findings included: Resident #20 was admitted to the facility on [DATE]. The residents' current diagnoses included dementia, diabetes, and a history of recurrent urinary tract infections secondary to hydronephrosis related to obstruction. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/11/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident # 20's cognitive abilities for daily decision making were severely impaired. In section GG0130 (Functional Abilities), the resident was coded as requiring setup or clean-up assistance with oral hygiene, supervision or touching assistance with eating, substantial/maximal assistance with shower/bathe self and upper body dressing, dependent with lower…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the clinical record, the facility staff failed to serve 1 of 24 residents (Resident 20) in the survey sample the food necessary to support nutritional needs. The findings included: Resident #20 was admitted to the facility on [DATE]. The residents' current diagnoses included dementia and diabetes. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/11/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident # 20's cognitive abilities for daily decision making were severely impaired. In section GG0130 (Functional Abilities), the resident was coded as requiring setup or clean-up assistance with oral hygiene, supervision or touching assistance with eating, substantial/maximal assistance with shower/bathe self and upper body dressing, dependent with Lower body dressing, personal hygiene, and putting on/taking off footwear.On 4/13/26 at…

    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
Show the remaining 11 citations
  • Potential for harm · D2026-04-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations during the medication administration task, staff interviews, and a review of the clinical record, the facility staff failed to ensure that its medication error rate was not 5% or greater. The medication error rate was identified as 11.54%.The findings included:On 4/14/26, Licensed Practical Nurse (LPN) #2 failed to complete the administration of MiraLax Oral Powder 17 GM/SCOOP (polyethylene glycol 3350), 17000 MG Powder for Oral Solution to 3 of 3 residents observed during the medication administration task:1. Resident #32's MiraLax was not administered as ordered by the physician and/or Practitioner.Resident #32 was admitted to the facility on [DATE]. The residents' current diagnoses included atrial fibrillation and anemia. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/05/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 7 out of 15. This indicated that Resident #32's cognitive abilities for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interview, the facility's staff failed to provide a homelike environment for one resident (Resident #4) in the survey sample of 24 residents. Resident #4 was originally admitted to the facility 02/06/23 after an acute care hospital and readmitted on [DATE]. The current diagnoses included; Major depressive disorder and Muscle weakness, generalized.The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/02/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #4 cognitive abilities for daily decision making were intact. On 4/14/26 at approximately 11:30 am., during the initial tour of room [ROOM NUMBER]-1 Resident #4 was observed sitting in his recliner. The wall located behind the resident's recliner was observed to have a medium sized hole in it. Resident #4 stated I never knew it was there. The wall to the right of the resident's recliner…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-09 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, facility document review and staff interview, the facility staff failed to ensure proper function of one of two walk-in freezers serving the main kitchen. The findings include: The walk-in freezer in the main kitchen was observed with heavy ice build-up across the ceiling and on the floor with frozen drips noted on the outside of food packaging. Staff reported this frozen condensation build-up had been ongoing for over five months. On 3/7/23 at 11:13 a.m., accompanied by a dining manager (other staff #2) and the registered dietitian (other staff #3), the walk-in freezer in the main kitchen was inspected. Thick, frozen condensation was observed across the entire ceiling. The left ceiling area had heavier ice build-up several inches thick. Dripped condensation was frozen on boxes of food stored on the top shelf of the freezer. Ice approximately one inch thick was observed across the floor of the freezer. On 3/7/23 at 11:20 a.m., the sous chef (other staff #1) was interviewed about the widespread ice build-up on the freezer ceiling and floor. The sous chef stated,…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of fifteen residents in the survey sample (Resident #32). The findings include: Resident #32's MDS inaccurately documented the resident received hospice services. Resident #32 was admitted to the facility with diagnoses that included Alzheimer's dementia, anxiety, mood disorder, cerebral infarction, pelvic fracture, and depression. The MDS dated [DATE] assessed Resident #32 with severely impaired cognitive skills. Section O. of Resident #32's MDS (minimum data set), dated 12/16/22, documented the resident received hospice services while in the nursing facility. Review of Resident #32's clinical record documented no provision of hospice services. The record documented a physician's order dated 12/14/22 for a Do Not Hospitalize status, in addition to a Do Not Resuscitate/Do Not Intubate order. The record also documented a physician's order dated 12/14/22 for a hospice consult, but…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of fifteen residents in the survey sample (Resident #25). The findings include: Resident #25, treated with a hypnotic medication for insomnia, had no plan of care developed addressing sleep problems. Resident #25 was admitted to the facility with diagnoses that included hypothyroidism, insomnia, osteoarthritis, hyperlipidemia, depressed mood, and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed Resident #25 as cognitively intact. Resident #25's clinical record documented a physician's order dated 2/14/22 for Ambien (zolpidem tartrate) 5 milligrams at each bedtime for insomnia. Resident #25's medication administration record documented nightly administration of the Ambien from 3/1/23 through 3/7/23. Resident #25's plan of care (dated 2/6/23) included no problems, goals and/or interventions regarding insomnia. On 3/8/23 at 4:47 p.m., 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility policy review, the facility staff failed to ensure professional standards of nursing were followed for one of 15 residents, Resident #4. Findings include: Resident # 4 was admitted to the facility 2/7/23 with diagnoses to include, but were not limited to: orthopedic aftercare, heart failure, and diabetes. The admission MDS (minimum data set) dated 2/13/23 had Resident # 4 assessed as cognitively intact with a score of 13/15. On 3/9/23 at 8:20 a.m., accompanied by licensed practical nurse (LPN) #2, a medication cart on the second floor was inspected. An opened 10 ml (milliliter) vial of Lantus insulin (100 units/ml) was stored in the cart. The vial was marked with an opened date of 2/8/23 and was labeled for a current resident (Resident #4). LPN # 2 stated the insulin should have been discarded 3/7/23. On 3/9/23 at approximately 10:05 a.m., the DON (director of nursing) was made aware of the finding. When asked if it was known if the expired insulin had been administered, the DON stated that she would check. The DON…

    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 · D2023-03-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to follow physician orders for one of 15 residents, Resident #4. Findings include: Resident # 4 was admitted to the facility on [DATE], with diagnoses to include, but were not limited to: orthopedic aftercare, heart failure, and diabetes. The admission MDS (minimum data set) dated 2/13/23 had Resident # 4 assessed as cognitively intact with a score of 13/15. On 3/8/23 at approximately 1:45 p.m., Resident #4's clinical record was reviewed. A nurses note, dated 2/23/23 at 3:45 a.m., documented Insulin Glargine -Inject 20 units at bedtime for Diabetes Mellitus type 2. Held per nursing judgement. Res noted to not have much of an appetite and refused bedtime snack with BS of 118. On 3/8/23 at approximately 3:05 p.m., the administrator and DON (director of nursing) were asked if they were aware of the above note. The administrator stated that she was not and thought the expectation was to call the doctor prior to a held medication. When…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interview, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to provide pressure ulcer treatment consistent with professional standards of practice. Staff failed to properly clean work surfaces, as well as employ handwashing during a dressing change. The findings were: Resident # 2 in the survey sample was admitted with diagnoses that included epilepsy, anemia, gastroesophageal reflux disease, thyroid disorder, seizure disorder, cataracts, Stage IV sacral pressure ulcer, constipation, dysuria, erythemia intertrigo, pain, urinary retention. Resident #2 was also admitted under palliative care. According to an admission Minimum Data Set with an Assessment Reference Date of 2/15/2023, Resident #2 was assessed under Section C (Cognitive Patterns) as having short and long term memory problems, with severely impaired daily decision making skills. Under Section G (Functional Status), Resident #2 was assessed as totally dependent…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, and staff interview, the facility staff failed to ensure expired insulin was not available for use on one of two inspected medication carts (second-floor cart). The findings include: A vial of Lantus insulin for a current resident that had been opened beyond 28 days was available for use on a second-floor medication cart. On [DATE] at 8:20 a.m., accompanied by licensed practical nurse (LPN) #2, a medication cart on the second floor was inspected. An opened 10 ml (milliliter) vial of Lantus insulin (100 units/ml) was stored in the cart. The vial was marked with an opened date of [DATE] and was labeled for a current resident (Resident #4). On [DATE] at 8:22 a.m., LPN #2 was interviewed about the opened vial of Lantus and the discard date. LPN #2 stated that the insulin was supposed to be discarded 28 days after opening. LPN #2 stated that the Lantus insulin in the cart was actually past the date for use. LPN #2 stated that the opened vial of Lantus insulin should…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview, and review of facility policy and procedure, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to follow infection control practices during a pressure ulcer dressing change. The staff member performing the dressing change failed to establish a clean surface for supplies, and failed to perform hand hygiene during glove changes. The findings were: Resident # 2 in the survey sample was admitted with diagnoses that included epilepsy, anemia, gastroesophageal reflux disease, thyroid disorder, seizure disorder, cataracts, Stage IV sacral pressure ulcer, constipation, dysuria, erythemia intertrigo, pain, urinary retention. The resident #2 was also admitted under palliative care. According to an admission Minimum Data Set with an Assessment Reference Date of 2/15/2023, Resident #2 was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-03 · 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 observation, staff interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 10 in the survey sample, Resident #14. Resident #14's care plan was not reviewed and revised for the discontinuation of psychotropic medication. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included hyperlipidemia, hypothyroidism, major depressive disorder, dementia with behavioral disturbance, osteoarthritis, chronic obstructive pulmonary disease (COPD), and edema. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #14 as severely impaired for daily decision making with a score of 7 out of 15. Resident #14's clinical record was reviewed on 06/02/2021. Observed within the progress notes was a Monthly Medication Review dated 05/12/2021 which documented the following: 5/12 d/c (discontinue) am (morning) dose of risperidone and taper down 2pm dose to 0.25 mg (milligrams):…

    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.

Who owns this facility

Owner / managerTypeRoleSince
WESTMINSTER-CANTERBURY OF THE BLUE RIDGEOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 11/21/1990
BRUTON, DAVIDIndividualDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERsince 03/16/2026
KENDALL, TYLERIndividualDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/08/2024

CMS files one row per role, so the 7 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.1M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 7%Other / private 93%

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

$1,307per resident / day
operating cost
$39,721per month
≈ monthly operating cost
$254per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in VA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495225. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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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