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Riverside Health & Rehab Cntr

2344 Riverside Drive, Danville, VA 24540 · For profit - Corporation · 180 certified beds · (434) 791-3800 Medicare & Medicaid certified

Call the home — (434) 791-3800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Feb 2019Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

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

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)
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 26% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
800 Memorial Dr · (434) 791-4445 · Call to confirm hours
Pharmacy
245 Hairston St Ste B · (434) 483-2503 · Call to confirm hours
Grocery
425 Memorial Dr · (434) 791-2407 · Call to confirm hours
Park
Dan Daniel Riverwalk Trl · Typically dawn to dusk

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 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 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
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 increased10.6%14.9%15.4%better
Long-stay residents who lose too much weight9.5%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.4%1.6%2.0%worse
Long-stay residents with depressive symptoms55.1%18.7%6.5%worse 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 injury3.3%3.6%3.3%typical
Long-stay residents whose ability to walk worsened14.2%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication29.1%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.1%94.0%95.3%typical
Long-stay residents with pressure ulcers5.9%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control17.0%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.2%14.2%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.5%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine80.4%73.6%79.4%typical
Short-stay residents rehospitalized after admission27.3%22.3%22.6%worse
Short-stay residents with an outpatient ER visit16.1%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.001.521.67worse
Long-stay outpatient ER visits per 1,000 resident days2.591.481.80worse

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.

53.6% 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 144 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.6%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
43.0%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 43.0% 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 86 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% 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 SNF53.6%CMS range 41.9–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.5–15.810.7%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 discharge43.0%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 discharge46.5%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 discharge45.4%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 identified99.3%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 setting88.8%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 stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%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 hospitalization6.5%CMS range 3.9–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.451.02Oct 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

0.33
RN hours/ resident / day
1.02
LPN hours/ resident / day
1.61
Aide hours/ resident / day
2.96
Total nurse hours/ resident / day
0.11
RN hoursweekends
53.0%
Total nursing turnover
29.4%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 173.5 residents a day — about 96% occupied, or roughly 6 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 2.96 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.61 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 2.49 hrs/resident/day on weekends vs 3.15 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.42 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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

5
deficiencies at the latest standard inspection (2023-09-07)
5
at the previous standard inspection (2021-03-11)

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

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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

  • Potential for harm · Dcited before2023-09-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview, local ombudsman interview, clinical record review, and facility document review, the facility staff failed to provide care and services to meet the needs of the residents for 2 of 35 current residents in the survey sample, Resident #112 and #114. The findings included: 1. For Resident #112, the facility staff failed to administer the physician ordered antibiotic medication, Cephalexin to treat cellulitis and failed to address the wound specialist's recommendations for lab testing related to concern for cellulitis. Resident #112's diagnosis list indicated diagnoses, which included, but not limited to Hypocalcemia, Aortic Valve Stenosis, Essential Hypertension, Bilateral Open-Angle Glaucoma, Polyosteoarthritis, and Major Depressive Disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 6/26/23 assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. Resident #112'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were obtained/provided to address the urinary catheter needs of 1 of 35 current residents in the survey sample, Resident #145. The findings included: For Resident #145, the facility staff failed to obtain provider orders for an indwelling urinary catheter present on readmission. Resident #145's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Adult Failure to Thrive, and Unstageable Pressure Ulcer of the Right Buttocks. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 8/23/23 coded the resident as rarely/never understood and rarely never understanding others with short-term and long-term memory loss. Resident #145 was coded for the presence of an indwelling catheter. On 8/29/23 at approximately 3:15 PM, surveyor observed…

    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 · D2023-09-07 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, facility staff failed to ensure that a resident diagnosed with dementia received the appropriate treatment and services by monitoring targeted behaviors associated with the use of an antipsychotic medication for 1 of 21 residents in the survey sample, Resident #75. The findings were: The facility staff failed to monitor behaviors for Resident #75 who had a dementia diagnosis. Resident #75's facesheet listed diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, epilepsy, stage 4 sacral pressure ulcer, dementia, adult failure to thrive, and bipolar disorder. The resident's minimum data set with an assessment reference date of 07/30/23 coded the resident's brief interview for mental status a 99 which indicated the resident was unable to complete the interview. The resident was coded to have both short and long-term memory problems and severely impaired cognitive skills for daily decision making. A provider order for Behaviors - monitor 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the attending physician reviewed the pharmacists recommendations for 3 of 35 current sampled residents, Resident #57, 75, and 128. The findings include: For resident #57, the facility staff failed to ensure the physician reviewed the pharmacists recommendations for the months of May 2023 and July 2023. #57's diagnoses included but was not limited to the following; dementia, anxiety, major depressive disorder, post traumatic stress disorder, bipolar disorder and hypertension. The most recent minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/26/23, assigned resident #57 a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. The clinical record for resident #57 was reviewed 9/6/23. There was a Consultant Pharmacist Medication Regimen Review dated 5/31/23 that read in part, See report for any noted irregularities and/or recommendations. The surveyor was unable to locate the report in the 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 each resident's drug regimen was free from unnecessary drugs for 1 of 35 current residents in the survey sample, Resident #128. The findings included: For Resident #128, the facility staff failed to obtain a stop date for the antibiotic medication, Macrobid which resulted in the medication being administered for greater than four (4) weeks. Resident #128's diagnosis list indicated diagnoses, which included, but not limited to Rheumatoid Arthritis, Essential Hypertension, Major Depressive Disorder, Atrial Fibrillation, and History of Falling. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/17/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating Resident #128 was cognitively intact. Resident #128's order history included an order dated 5/22/23 for Macrobid 100 mg by mouth two times a day for cellulitis related urinary tract infection. The Macrobid order did not include a duration…

    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 · E2021-03-11 · tag F0886 — failed to test for COVID-19 as required — pattern
    Perform COVID19 testing on residents and staff.
    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 consistently document in the resident's clinical records that COVID-19 testing was offered, completed (as appropriate to the resident's testing status), and the results of each test for 26 residents. The findings included: The facility staff failed to consistently document that COVID-19 testing was offered to the residents of the facility and failed to document the results of each test in the resident's clinical records. During the record reviews, the survey team were unable to locate results of COVID-19 tests for negative residents. On 03/11/2021 at 1:45 p.m., the administrator, (DON) director of nursing, and (RNC) regional nurse consultant were interviewed regarding the missing COVID-19 testing results. The DON stated they printed off the facility census, identified if anyone was positive and that was marked on the census. They did not mark the negative test results on this census and only documented in the clinical record if the resident was positive. The DON stated they…

    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 · D2021-03-11 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and the review of documents, it was determined the facility staff failed to develop a base-line care plan to address indwelling urinary catheter needs at the time of admission for one (1) of 28 sampled residents (Resident #83). The findings include: The facility staff failed to develop a base-line care plan, within 48 hours of the resident's admission, to address Resident #83's indwelling urinary catheter. Resident #83 was admitted to the facility with an indwelling urinary catheter in place. Resident #83's minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/21 had the resident assessed as able to make self understood and as able to understand others. Resident #83's Brief Interview for Mental Status (BIMS) summary score was documented as 13 out of 15. Resident #83 was documented as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #83 was assessed as having an indwelling urinary catheter. Resident #83's diagnoses included, but were not limited to: cardiac dysrhythmias,…

    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 · D2021-03-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, Resident interview, staff interview and clinical record review the facility staff failed to provide ADL (activities of daily living) care for dependent residents for 2 of 28 residents, Resident #49 and Resident #144. The findings included: 1. For Resident #49 the facility staff failed to provide assistance with oral care. Resident #49's face sheet listed diagnoses which included, but not limited to non-displaced fracture to body of scapula, chronic obstructive pulmonary disease, congestive heart failure, hypertension, rheumatoid arthritis, atrial fibrillation and anemia. Resident #49's admission MDS (minimum data set), with an ARD (assessment reference date) of 01/09/21 assigned the resident a BIMS (brief interview for mental status) score of 15 of 15 in section C, cognitive patterns. Section G, functional status, coded the resident as needing extensive assistance of one person physical assist in the area of personal hygiene. Personal hygiene is listed as combing hair, brushing teeth, shaving, applying make-up, and washing/drying face and hands. Resident #49's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-11 · 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 interviews and the review of documents, it was determined the facility staff failed to follow medical provider orders for treatment and/or care for two (2) of 28 sampled residents (Resident #65 and Resident #83). The findings include: 1. The facility staff failed to ensure Resident #83's blood glucose levels were monitored according to medical provider orders. Resident #83's minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/21 had the resident assessed as able to make self understood and as able to understand others. Resident #83's Brief Interview for Mental Status (BIMS) summary score was documented as 13 out of 15. Resident #83 was documented as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #83 was assessed as having an indwelling urinary catheter. Resident #83's diagnoses included, but were not limited to: cardiac dysrhythmias, heart failure, high blood pressure, hemiplegia/hemiparesis, respiratory failure, and urinary retention. Review of Resident #83's clinical record revealed an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-11 · 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

    Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure medical provider orders were obtained/provided to address the urinary catheter needs of one (1) of 28 sampled residents (Resident #83). The findings include: Facility staff members failed to ensure Resident #83's clinical record included medical provider orders for an indwelling urinary catheter and medical provider orders for the care of an indwelling urinary catheter. Resident #83's minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/3/21 had the resident assessed as able to make self understood and as able to understand others. Resident #83's Brief Interview for Mental Status (BIMS) summary score was documented as 13 out of 15. Resident #83 was documented as requiring assistance with bed mobility, dressing, toilet use, personal hygiene, and eating. Resident #83 was assessed as having an indwelling urinary catheter. Resident #83's diagnoses included, but were not limited to: cardiac dysrhythmias, heart failure, high blood pressure,…

    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 12 citations
  • Potential for harm · F2019-02-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 and staff interview the facility staff failed to prepare, distribute and serve food in accordance with professional standards for food service safety. Findings: On 2/19/19 at 4:15 PM the surveyor observed [NAME] I taking the trayline temperatures on the kitchen. The DM (dietary manager) was assisting by wiping the thermometer hub with an alcohol wipe between dishes. Cook I was observed to take the temperatures in two separate chicken dishes by inserting the hub of the thermometer down into the juices beside the whole pieces of the chicken in the pan. The thermometer hub was not inserted into the deepest portion of the meat to obtain the temperature. The surveyor asked if this was the usual manner to to check the juices in the pan rather than check the actual internal meat temperature. The DM said NO they always checked the inside of the meat and took the thermometer from [NAME] I and inserted it into a chicken thigh. The DM did not have on gloves and she fumbled with the greasy thermometer and her right knuckle slipped onto the surface of the chicken. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-21 · 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 accurately complete a DDNR (durable do not resuscitate) order form for one of 37 Residents, Residents #142. The findings included: The facility staff failed to accurately complete the Residents DDNR. The boxes on this form had been left unchecked. The clinical record review revealed that Resident #142 had been admitted to the facility 10/26/18. Diagnoses included, but were not limited to, dementia, anxiety, diabetes, hypertension, and muscle weakness. Section C of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/02/19 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The Residents clinical record included a physicians order indicating the Residents code status was a DNR (do not resuscitate). On 02/19/19 at 3:13 p.m., the unit manager provided the surveyor with a DDNR order form from the Virginia Department of Health that had been signed by the Residents physician and authorized representative. This…

    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 · D2019-02-21 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility document review, the facility staff failed to ensure that employee background checks were obtained within a timely manner upon hire to the facility for 2 of 25 newly hired employees. The findings included: The facility staff failed to ensure that employee background checks were completed within 30 days of hire for 2 newly hired employees. On 2/20/19 at 1:32 pm, the surveyor reviewed employee records for 25 newly hired employees. During the employee record review, the surveyor observed that Employee # 1 had a hire date of 3/6/18 and criminal background check was completed on 2/19/19. Employee # 2 had a hire date of 2/20/18 and criminal background check was completed on 10/26/18. On 2/20/19 at 2:00 pm, the surveyor spoke with the facility human resources manager. The surveyor asked the facility human resources manager to verify the dates of hire and employee background checks for Employee # 1 and Employee # 2. On 2/20/19 at 2:15 pm, the facility human resources verified that the hire dates and criminal background check dates for Employee # 1 and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement the CCP (comprehensive care plan) for one of 37 Residents, Resident #41. The findings included: The resident's CCP stated that the resident's smoking supplies were stored at the nurse's cart when in fact the resident kept them in his room. The clinical record review revealed that Resident #41 had been admitted to the facility 04/13/18. Diagnoses included, but were not limited to, hypertension, diabetes, multiple myeloma, difficulty in walking, and cerebral infarction. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/07/18 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required supervision with set up help only for locomotion on and off the unit. The resident was coded as using a wheelchair for mobility and as not having any impairment in the upper or…

    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 before2019-02-21 · 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 2. The facility staff failed to assess blood pressures for Resident # 85 prior to the administration of blood pressure medications to assure physician orders were followed. Resident # 85 was an [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 3/22/18. Diagnoses included but were not limited to, hypertension, dementia, anxiety, and anemia. The clinical record for Resident # 85 was reviewed on 2/20/19 at 10:22 am. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/4/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 85 had a BIMS score (brief interview for mental status) of 7 out of 15, which indicated that Resident # 85's cognitive status was severely impaired. The current plan of care for Resident # 85 was reviewed and revised on 2/11/19. The facility staff documented a focus area for Resident # 85 as, The resident has…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-21 · 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, clinical record review, and staff interview, the facility staff failed to ensure that 1 of 37 Residents in the survey sample remained free of accident hazards, Resident # 85. The findings included: The facility staff failed to ensure that a door chime that was in place as a fall intervention for Resident # 85 was turned on. Resident # 85 was an [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 3/22/18. Diagnoses included but were not limited to, hypertension, dementia, anxiety, and anemia. The clinical record for Resident # 85 was reviewed on 2/20/19 at 10:22 am. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/4/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 85 had a BIMS score (brief interview for mental status) of 7 out of 15, which indicated that Resident # 85's cognitive status was severely…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to ensure that oxygen equipment was stored in a safe manner for 1 of 37 Residents in the survey sample, Resident # 100. The findings included The facility staff failed to ensure that portable oxygen cylinders were stored securely in Resident # 100's room. Resident # 100 was an [AGE] year-old- male who was originally admitted to the facility on [DATE], with a readmission date of 1/5/19. Diagnoses included but were not limited to, malignant neoplasm of prostate, COPD (chronic obstructive pulmonary disease), anxiety, and type 2 diabetes mellitus. The clinical record for Resident # 100 was reviewed on 2/19/19 at 3:44 pm. The most recent MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 1/12/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 100 had a BIMS (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-21 · 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility staff failed to dispose of an expired medication on 1 of 3 units (the South unit). The findings included: The facility staff failed to dispose of expired medication. The #1 cart on the south hall included expired vitamin D. On [DATE] at 7:30 a.m., the surveyor and LPN (licensed practical nurse) #2 checked the medication cart on the south unit. This cart included 1 bottle of vitamin D with an expiration date of 01/19. After checking the expiration date LPN #2 disposed of the vitamin D in the sharps container. The administrative staff were notified of the above during a meeting with the survey team on [DATE] at 4:34 p.m. and again on [DATE] at 1:00 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-02-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to follow up on pharmacy recommendation for 1 of 37 Residents, Resident #49. Findings included: For Resident #49, the facility failed to follow up on a pharmacy recommendation dated 01/26/19. Resident #49 was admitted to the facility on [DATE]. Diagnoses included, but not limited to unspecified dementia with behavioral disturbance, hypertension, muscle weakness, and depression. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/12/18 coded the Resident 06 of 15 in section C, cognitive patterns. On 02/21/19 at 11:00am the ADON (assistant director of nursing) provided the surveyor with a copy of a pharmacy recommendation dated 01/26/19. Under the section titled Recommendation which read in part: Please discontinue sucralfate. The attending medical doctor that the recommendation was addressed to had checked under the section titled Physician's Response and the selection read in part: I accept 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 · D2019-02-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to ensure that 1 of 37 Residents in the survey sample were free of unnecessary psychotropic medications, Resident # 58. For Resident #58, facility staff failed to ensure that the psychotropic medication Haldol was discontinued when ordered. Resident #58 was admitted to the facility on [DATE]. On the On the admission Minimum Data Set assessment with assessment reference date 12/20/18, the resident scored 4/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, and behaviors affecting care. Diagnoses included fractured humerus with orthopedic aftercare, Alzheimer's disease, diabetes mellitus, depression, anxiety, and unspecified psychosis. During clinical record review, the surveyor noted the resident had a PRN (as needed) order dated 12/13/18 for Haldol injectable 2 mg (milligrams) IM (intramuscular) Q6H PRN anxiety. The order was written on admission, discontinued on 12/17, then restarted…

    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 · D2019-02-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to sustain an accurate clinical record for 1 of 37 Residents, Resident #72. Findings included: For Resident #72, the facility failed to ensure accurate code status on physician's progress notes and medication administration record. The Resident was a DNR (Do Not Resuscitate) and the documentation indicated she was a full code. Per clinical record review Resident #72 was admitted to the facility on [DATE]. Diagnosis included, but were not limited to dysphagia, encephalopathy, Alzheimer's disease, adult failure to thrive, and anemia. Section C (cognitive patterns) of the Residents most recent MDS (Minimum Data Set) assessment with an ARD (assessment reference date) of 12/31/18 coded the Resident as having memory problems with short term and long-term memory. On 02/20/19 at 9:12am the surveyor reviewed Resident 72's clinical record. The Resident's clinical record included a DDNR (durable do not resuscitate) order form dated 01/09/19 from…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-02-21 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolated
    Have policies on smoking.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow their policy and procedure regarding the Residents smoking supplies for one of 37 Residents, Resident #41. The findings included: The facility policy/procedure stated that Residents smoking paraphernalia must be kept locked in the appropriate unit's medication room. Resident #41 kept his smoking supplies in his room. The clinical record review revealed that Resident #41 had been admitted to the facility 04/13/18. Diagnoses included, but were not limited to, hypertension, diabetes, multiple myeloma, difficulty in walking, and cerebral infarction. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/07/18 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required supervision with set up help only for locomotion on and off the unit. The resident was coded as…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFEWORKS REHAB — 64 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.1+0.9 vs chain
Health inspection 4 of 52.0+2.0 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 2 of 53.9-1.9 vs chain
The other 63 homes this chain runs (chain average 2.1★, per CMS)
1 of 5APPOMATTOX HEALTH & REHABILITATiON CENTERAppomattox, VA 1 of 5Alamance Health Care CenterBurlington, NC 1 of 5Bayside Health & Rehabilitation CenterVirginia Beach, VA 1 of 5Cabarrus Health and Rehabilitation CenterConcord, NC 1 of 5Charlotte Health & Rehabilitation CenterCharlotte, NC 1 of 5Chesapeake Health And Rehabilitation CenterChesapeake, VA 1 of 5Colonial Heights Rehabilitation And Nursing CenterColonial Heights, VA 1 of 5Elkton Nursing And Rehabilitation CenterElkton, MD 1 of 5Greenville Health and Rehabilitation CenterGreenville, NC 1 of 5Guilford Health Care CenterGreensboro, NC 1 of 5Harrisonburg Hlth & Rehab CntrHarrisonburg, VA 1 of 5Largo Nursing And Rehabiliation CenterGlenarden, MD 1 of 5Layhill Nursing And Rehabilitation CenterSilver Spring, MD 1 of 5Lenoir Health and Rehabilitation CenterLenoir, NC 1 of 5Lynchburg Health & Rehabilitation CenterLynchburg, VA 1 of 5Norfolk Health Care CenterNorfolk, VA 1 of 5Oxford Health and Rehabilitation CenterOxford, NC 1 of 5Parham Health Care & Rehab CenterRichmond, VA 1 of 5Salem Health & RehabilitationSalem, VA 1 of 5University Health and Rehabilitation CenterDurham, NC 1 of 5Virginia Beach Healthcare And Rehab CenterVirginia Beach, VA 1 of 5Westport Rehabilitation And Nursing CenterRichmond, VA 1 of 5White Oak Rehabilitation And Nursing CenterHyattsville, MD 1 of 5Williamsport Health And Rehabilitation CenterWilliamsport, MD 2 of 5Adelphi Nursing And Rehabilitation CenterAdelphi, MD 2 of 5Albemarle Health & Rehabilitation CenterCharlottesville, VA 2 of 5Beaufont Health And Rehabilitation CenterRichmond, VA 2 of 5Belaire Health Care CenterGastonia, NC 2 of 5Charlottesville Health & Rehabilitation CenterCharlottesville, VA 2 of 5Cherrydale Health & Rehabilitation CenterArlington, VA 2 of 5Culpeper Health & Rehabilitation CenterCulpeper, VA 2 of 5Fairfax Rehabilitation And Nursing CenterFairfax, VA 2 of 5Glenburnie Rehab & Nursing CenterRichmond, VA 2 of 5Hanover Health And Rehabilitation CenterMechanicsville, VA 2 of 5Lexington Health Care CenterLexington, NC 2 of 5Litchford Falls Health and Rehabilitation CenterRaleigh, NC 2 of 5Pike Creek Nursing & Rehabilitation CenterWilmington, DE 2 of 5Regency Health And Rehabilitation CenterYorktown, VA 2 of 5Shady Grove Nursing And Rehabilitation CenterRockville, MD 2 of 5The Nursing And Rehab Center At Stadium PlaceBaltimore, MD

Showing 40 of 63; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
RIVERSIDE HOLDINGS I LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/28/2021
CHARLES 1994 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
CK 2008 FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
DRM SOUTH LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
EDWARD 1998 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
LAUREN 2020 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
NORMAN 5571 & FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
RL 2008 FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
ROBIN 2008 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
SAUL 2012 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
SPRINGROCK SOUTH LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
WILEY, ADAMIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 01/23/2024
RSBRM SOUTH MANAGER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/28/2021

CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

12 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.

$22.8M
Net patient revenuemost recent cost report
+3.4%
Operating marginrevenue minus expenses
$5.7M
Related-party expense26% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 7%Other / private 11%

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $5.7M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$353per resident / day
operating cost
$10,722per month
≈ monthly operating cost
$365per 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 495295. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-09-07, 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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