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Chatham Health & Rehabilitation Center

100 Rorer Street, Chatham, VA 24531 · For profit - Corporation · 85 certified beds · (434) 432-0471 Medicare & Medicaid certified

Call the home — (434) 432-0471 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$8,018 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,018 in federal fines (most recent 2024-06-11)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
19144 US Highway 29 · (434) 432-0216 · Call to confirm hours
Pharmacy
13701 Us Highway 29 Ste H1 · (434) 432-0780 · Call to confirm hours
Grocery
Food Lion1.2 mi
13701 US-29 · (434) 432-0500 · Call to confirm hours
Park
Hawk Park9.6 mi
201 Coffey St · Typically dawn to dusk
Place of worship
153 Clement St · (434) 432-1088

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 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 improved from 4 to 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 increased24.4%14.9%15.4%worse
Long-stay residents who lose too much weight2.5%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.0%1.6%2.0%worse
Long-stay residents with depressive symptoms18.3%18.7%6.5%typical for the 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 injury4.1%3.6%3.3%worse
Long-stay residents whose ability to walk worsened35.7%15.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.6%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers1.4%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control15.7%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.9%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine96.5%73.6%79.4%better
Short-stay residents rehospitalized after admission13.2%22.3%22.6%better
Short-stay residents with an outpatient ER visit6.1%11.5%12.0%better

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

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

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

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

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

49.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 105 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
56.6%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 56.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 53 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 SNF49.1%CMS range 40.1–59.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.2–14.710.7%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 discharge56.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.7%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 discharge54.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.1%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 4.3–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.52
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.05
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.22
RN hoursweekends
39.1%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 85 beds and averages 81.1 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.75 on weekdays — 15% thinner on weekends. RN hours go from 0.65 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2024-03-21)
13
at the previous standard inspection (2022-07-27)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2024-06-11 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 6 sampled residents resulting in a transfer to a higher level of care (Resident #1). The findings included: For Resident #1, the facility staff administered another resident's medication which included five (5) medications used to lower blood pressure, two (2) medications used to lower blood sugar levels, a medication used to prevent blood clots, and an over-the-counter Aspirin resulting in the resident being transferred to a higher level of care with a subsequent 3-day hospital stay including overnight in the intensive care unit (ICU). This was a closed record review. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis, Hypercalcemia, Essential Hypertension, and Chronic Obstructive Pulmonary Disease. The minimum data set (MDS) with an assessment reference date (ARD) of 4/04/24 assigned 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-11 · 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 observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were 3 medication errors in 34 opportunities for a medication error rate of 8.82%. These medication errors affected Resident #3 and #4. The findings included: 1. For Resident #3, the facility staff administered the incorrect dosage of a topical Lidocaine medicated patch and failed to administer a multivitamin with iron according to the medical provider's order. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Nontraumatic Ischemic Infarction of Muscle of Left Lower Leg, Chronic Kidney Disease Stage 3, Bipolar II Disorder, and Peripheral Vascular Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/08/24 assigned the resident brief interview for mental status (BIMS) summary…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment and help prevent the development and transmission of communicable disease or infections on 1 of 2 resident care units (200 Hall). The findings included: During a medication pass and pour observation, the facility staff failed to perform hand hygiene, administered a tablet that had been dropped on the top of the medication cart, and touched two medications with their bare hands. On 6/11/24 at 8:09 AM, surveyor observed Licensed Practical Nurse (LPN) #1 remove a Vitamin D3 gel capsule from a medication cup with their bare fingers and return the capsule to the multi-dose house stock bottle of Vitamin D3. LPN #1 then placed the bottle back into the medication cart. On 6/11/24 at 8:15 AM, surveyor observed LPN #1 assist in repositioning Resident #4 in bed by touching the resident's upper right arm and then administered the resident's medications. LPN #1 did not wash their hands or use hand sanitizer…

    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 · D2024-03-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, the facility staff failed to accurately complete a discharge Minimum Data Set (MDS) assessment for 1 of 5 closed record reviews, Resident #80. The findings included: The facility staff coded Resident #80's discharge MDS assessment as if they had discharged to a hospital. Resident #80 had discharged home. Resident #80's diagnoses included, but were not limited to, acute respiratory failure with hypoxia, acute pulmonary edema, and diabetes. Section C (cognitive patterns) of Resident #80's discharge MDS assessment with an Assessment Reference Date (ARD) of 02/20/24 included a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points. Section A (identification information) was coded to indicate Resident #80 was discharged to a short-term general hospital. Resident #80's clinical record included a progress note dated 02/20/24 that read in part, Resident discharged home . On 03/20/24 at 10:20 a.m., Registered Nurse (RN) #3 reviewed the record with the surveyor and confirmed the MDS was coded incorrectly. RN #3…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan for one of 18 residents in the survey sample, resident # 56. The findings included: For resident # 56 the facility staff failed to administer oxygen as ordered by the physician and according to the residents comprehensive person-centered care plan. Diagnoses for resident # 56 included but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension (HTN), history of cerebrovascular accident (CVA) with left hemiplegia, atrial fibrillation A-fib, anxiety and major depressive disorder. The quarterly minimum data set (MDS) assessment with an assessment reference date of 12/9/23 assigned the resident a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Resident # 56's current orders included an active order dated 7/25/22 for oxygen a 4 liters per minute via nasal cannula. Resident # 56's comprehensive care plan included a problem statement…

    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 · D2024-03-21 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents requiring dialysis services receive care consistent with the comprehensive person-centered care plan for 1 of 18 current residents in the survey sample, Resident #9. The findings included: For Resident #9, the facility staff failed to monitor the resident's arteriovenous (AV) fistula hemodialysis access site located in the left arm. Resident #9's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Dementia, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/19/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #9's current provider orders included an order dated 2/28/24 for Dialysis on Mondays, Wednesdays, and Fridays. The resident's current comprehensive person-centered…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan for 2 of 15 residents in the survey sample, Residents #13 and #11. The findings included: 1. For Resident #13, the facility staff failed to provide treatment to a cellulitis ulceration of the right shin as directed by the Wound Nurse Practitioner from 12/21/23 through 12/28/23. Resident #13's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Cellulitis, and Alcoholic Cirrhosis of Liver. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/24/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #13's comprehensive person-centered care plan included a focus area stating in part . R (right) shin cellulitis ulceration . with an intervention stating…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-10 · 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 observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide necessary pressure ulcer treatment consistent with medical provider orders to promote healing for 2 of 15 residents in the survey sample, Resident #8 and #10. The findings included: 1. For Resident #8, the facility staff failed to provide treatment to a sacral pressure ulcer as directed by the Wound Nurse Practitioner. This was a closed record review. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Fracture of Lower End of Left Femur with Routine Healing, Fracture of Left Pubis with Routine Healing, COVID-19, Osteoarthritis of Knee, Atherosclerotic Heart Disease of Native Coronary Artery. The admission minimum data set (MDS) with an assessment reference date (ARD) of 11/19/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #8 was coded as being…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents are free of significant medication errors, for 1 of 11 current residents in the survey sample, Resident #9. The findings included: For Resident #9, the facility staff failed to administer the intravenous (IV) antibiotic, Ceftriaxone on two separate occasions. Resident #9's diagnosis list indicated diagnoses, which included, but not limited to Fournier Disease of Vagina and Vulva, Fournier Gangrene, Chronic Viral Hepatitis C, Sepsis, Acute Kidney Failure with Acute Cortical Necrosis, and Type 2 Diabetes Mellitus with Chronic Kidney Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/04/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #9's comprehensive person-centered care plan included a focus area dated 11/29/23 stating Resident has Fournier gangrene open wound to perineum area on IV…

    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 · D2024-01-10 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 provide laboratory services to meet the needs of the resident for 1 of 15 residents in the survey sample, Resident #12. The findings included: For Resident #12, the facility staff failed to obtain a CBC (complete blood count) and a CMP (comprehensive metabolic panel) as requested by the physician on 12/13/23. This was a closed record review. Resident #12's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Alzheimer's Disease, Bipolar II Disorder, and Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/05/23 assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 indicating the resident was severely cognitively impaired. Resident #12's comprehensive person-centered care plan included an intervention dated 12/03/21 for meds/labs as ordered. Resident #12 was seen by the physician on 12/13/23, 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 · Dcited before2024-01-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections on one of two resident care units, Hall 200. The findings included: During a medication pass and pour observation, licensed practical nurse (LPN) #3 failed to clean and disinfect a blood glucose monitor using an approved EPA (Environmental Protection Agency) disinfectant. On 1/08/24 at 4:23 PM, surveyor observed LPN #3 obtain Resident #3's blood glucose reading using a blood glucose meter. Resident #3's name was present on the meter and LPN #3 stated each resident had their own personal meter. After obtaining the resident's blood glucose reading, LPN #3 placed the meter into a communal soft-sided bag located in the medication cart without disinfecting the meter. The bag contained multiple resident meters placed together with no separation among the meters. Surveyor then asked LPN #3 if anything…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2022-07-27 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, the facility staff failed to ensure the correct code status for 1 of 19 residents in the survey sample, Resident #39. For Resident #39, the facility staff failed to carry out the resident's and family's decision to change their code status to do not resuscitate (DNR). The findings included: Resident #39's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia. Essential Hypertension, and Cognitive Communication Deficit. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 5/31/22 assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 indicating the resident was severely cognitively impaired. Resident #39's current physician's orders included an advanced directive order dated 7/05/22 for Full Code and a 7/12/22 order stating resident is comfort care. The resident's clinical record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review the facility staff failed to follow physician's orders for 2 of 19 residents, Resident #59 and Resident #68. For Resident #59 the facility staff failed to notify the physician when the resident's blood sugars were outside of the ordered parameters. For Resident #68 the facility staff failed to administer the medication, Keflex as ordered by the physician. The findings included: 1. Resident #59's face sheet included diagnoses which included but not limited to type 2 diabetes mellitus with diabetic polyneuropathy, other specified complication and other circulatory complications, depression, benign prostatic hyperplasia with lower urinary tract symptoms, other seizures, and hypertension. Resident #59's admission minimum data set with an assessment reference date of 06/09/22 assigned the resident a brief interview for mental status score of 15 of 15 in section C, cognitive status. Resident #59's comprehensive care plan was reviewed and contained a care plan for At risk for hypoglycemia/hyperglycemia r/t (related to) Diabetes, insulin.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-27 · 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

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing for 1 of 19 residents in the survey sample, Resident #39. For Resident #39, the facility staff failed to follow the wound care physician's treatment plan for pressure areas to the left and right buttocks. The findings included: Resident #39's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, Essential Hypertension, and Cognitive Communication Deficit. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 5/31/22 assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance with bed mobility, transfers, toilet use, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-27 · 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 observations, staff interviews, and facility document review, the facility staff failed to ensure water temperatures were maintained in acceptable parameters to decrease the risk of resident injury. The findings include: On the afternoon of 7/24/22, water temperatures at the sinks of two (2) resident bathrooms were noted to be uncomfortably hot. On 7/24/22 at approximately 4:30 p.m., the facility's Administrator checked the water temperatures from the sinks in two (2) resident bathrooms (the bathroom that was shared by resident rooms [ROOM NUMBERS] and the bathroom that was shared by resident rooms [ROOM NUMBERS]). The water temperature for the sink in the bathroom shared by resident rooms [ROOM NUMBERS] was 121.5 degrees Fahrenheit. The water temperature for the sink in the bathroom shared by resident rooms [ROOM NUMBERS] was 120.6 degrees Fahrenheit. On 7/25/22 at 4:37 p.m., the Administrator reported the facility did not have a written policy or guidance detailing: (a) how often facility water…

    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 before2022-07-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide oxygen therapy according to the physician's order and the comprehensive person-centered care plan for 1 of 19 residents in the survey sample, Resident #53. For Resident #53, the facility staff failed follow the physician's order for oxygen administration. The findings included: Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia, Dysphagia, Dysarthria and Anarthria, Chronic Pain Syndrome, Anxiety Disorder, Essential Hypertension, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease (COPD). The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 6/16/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #53 was coded as requiring extensive assistance with bed mobility, dressing, toileting, personal hygiene, and being totally dependent on staff for transfers. 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 · D2022-07-27 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to inspect the bed frame, mattress, and the bed rails for the risk of entrapment prior to resident use and failed to assess for the safe use of side rails and risk of entrapment following an incidence of entrapment for 1 of 19 residents in the survey sample, Resident #372. For Resident #372, the facility staff failed to assess the resident for the safe use of side rails and risk of entrapment following an incident where the resident's neck became stuck between the bed and bed rail. Facility staff was unable to provide evidence of a bed safety inspection for Resident #372's bed prior to the incident. The findings included: Resident #372's diagnosis list indicated diagnoses, which included, but not limited to Generalized Muscle Weakness, Dementia with Behavioral Disturbance, Dysphagia, Hypothyroidism, Essential Hypertension, Morbid Obesity, Sequelae of Cerebral Infarction, Fracture of Third Thoracic Vertebra, Displaced Fracture of Second Cervical Vertebra, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility document review, and clinical record review the facility staff failed to ensure medications were available for administration for 1 of 19 residents, Resident #59. For Resident #59 the facility staff failed to ensure the medication Neurontin was available for administration for 5 consecutive doses. Neurontin (gabapentin) is a medication used in the treatment of neuropathy and seizures. The findings included: Resident #59's face sheet included diagnoses which included but not limited to type 2 diabetes mellitus with diabetic polyneuropathy, other specified complication and other circulatory complications, depression, benign prostatic hyperplasia with lower urinary tract symptoms, other seizures, and hypertension. Resident #59's admission minimum data set with an assessment reference date of 06/09/22 assigned the resident a brief interview for mental status score of 15 of 15 in section C, cognitive status. Resident #59's comprehensive care plan was reviewed and contained a care plan for At risk for pain r/t (related to) decreased mobility/weakness,…

    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 · D2022-07-27 · 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 and clinical record review, the facility staff failed to act upon drug regimen review recommendations for 1 of 19 residents in the survey sample, Resident #53. For Resident #53, the facility staff failed to carry out a physician approved, drug regimen review recommendation for Alprazolam, a benzodiazepine used to treat anxiety and panic disorders. The findings included: Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia, Dysphagia, Dysarthria and Anarthria, Chronic Pain Syndrome, Anxiety Disorder, Essential Hypertension, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease (COPD). The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 6/16/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #53's clinical record included a drug regimen review dated 7/08/22 in which the reviewing pharmacist recommended a gradual dose reduction (GDR) of alprazolam to 0.5 mg twice 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 · Dcited before2022-07-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, clinical record reviews, and facility document reviews, the facility staff failed to ensure 1 of 19 residents, Resident #6, was free of significant medication errors. Resident #6 did not receive their insulin per provider orders. The findings include: Resident #6's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/14/22, was dated as being completed on 4/26/22. Resident #6 was assessed as able to make self understood and as able to understand others. Resident #6 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #6's diagnoses included, but were not limited to: high blood pressure, diabetes, stroke, and depression. Resident #6's medication administration records (MARs) were reviewed on the afternoon of 7/25/22. The following medication order was found on Resident #6's July 2022 MAR: NovoLOG PenFill Solution Cartridge 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously before meals for diabetes Hold Novolog if BS (blood sugar) is less than 200. Documentation 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, facility document review and in the course of a complaint investigation the facility staff failed to properly store and/or label medications. For medication cart A, the facility staff failed to discard expired medication, failed to ensure an insulin pen had a label, failed to ensure medication label contained an expiration date, and failed to place an opened on/use by date on 13 opened insulin pens. For medication cart B, the facility staff failed to dispose of expired medications. The findings included: Surveyor observed medication cart B on 07/24/22 at 2:30 pm. Surveyor observed a medication card of Vitamin D 50,000, containing one capsule. This card had a hand written expiration date of 12/21. Surveyor asked licensed practical nurse (LPN) #2 to look at the medication card and confirm the expiration date. LPN #2 confirmed that the medication had expired on 12/21. Surveyor asked LPN #2 what they were going to do with the medication, and LPN #2 stated they would discard it. Surveyor observed medication cart B on 07/24/22 at 3:00 pm. Surveyor…

    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 · D2022-07-27 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 ensure food was prepared and stored under safe and sanitary conditions in the kitchen and 2 of 2 nourishment rooms. A dietary aide was observed working in the kitchen without a hair restraint, the refrigerators in each nourishment room contained unlabeled and undated items, the 400 Hall nourishment room contained outdated juice, and the 400 Hall ice chest contained an insect within the ice. The findings included: On 7/24/22 at 2:40 pm, surveyor observed a dietary aide standing at a counter near the silverware without a hair restraint in place. Surveyor asked the dietary aide if she was wearing a hair net and she stated no, I don't have mine today. A supply of individually wrapped hair nets were available directly outside of the kitchen entrance. On 7/25/22 at 4:09 pm, the survey team met with the Administrator, Director of Nursing, Regional Director of Clinical Services, and the Regional [NAME] President of Operations and discussed the concern of the observation of the dietary aide…

    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 · D2022-07-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 1 of 19 residents, Resident #59. For Resident #59 the facility staff failed to record the resident's blood sugar and failed to document medications as administered on the medication administration record. The findings included: Resident #59's face sheet included diagnoses which included but not limited to type 2 diabetes mellitus with diabetic polyneuropathy, other specified complication and other circulatory complications, depression, benign prostatic hyperplasia with lower urinary tract symptoms, other seizures, and hypertension. Resident #59's admission minimum data set with an assessment reference date of 06/09/22 assigned the resident a brief interview for mental status score of 15 of 15 in section C, cognitive status. Resident #59's physician's order summary for the month of July 2022 was reviewed and contained orders which read in part, Accuchecks BID (twice daily) two times a day for DM (diabetes mellitus) 2 Notify MD…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 19 residents in the survey sample, Resident #372. For Resident #372, the facility staff failed to follow a physician's order for contact precautions following a report of bed bugs in the resident's room. The findings included: Resident #372's diagnosis list indicated diagnoses, which included, but not limited to Generalized Muscle Weakness, Dementia with Behavioral Disturbance, Dysphagia, Hypothyroidism, Essential Hypertension, Morbid Obesity, Sequelae of Cerebral Infarction, Fracture of Third Thoracic Vertebra, Displaced Fracture of Second Cervical Vertebra, and Displaced Bimalleolar Fracture of Right Lower Leg. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 6/20/22 assigned the resident a brief interview 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.

    Infection Control 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

$8,018 in federal fines across 1 penalty.

  • $8,018 — penalty dated 2024-06-11

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 SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
WEST PIEDMONT HEALTHCARE GROUP INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2009
WWBV HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 09/30/2019
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICERsince 03/01/2019
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
ISABELLE, CHADIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/23/2020

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$8.9M
Net patient revenuemost recent cost report
+3.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 3%Medicare 8%Other / private 90%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$304per resident / day
operating cost
$9,253per month
≈ monthly operating cost
$316per 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 495399. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-21, 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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