Stratford Healthcare Center
508 Rison Street, Danville, VA 24541 · For profit - Limited Liability company · 60 certified beds · (434) 799-4540 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 23.3% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.7% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.6% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.0% | 18.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 34.8% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.7% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.2% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.0% | 14.2% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 61.3% | 73.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.0% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.7% | 11.5% | 12.0% | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
52.6% 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 74 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.6%CMS range 37.6–66.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 9.1–16.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 37.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 29.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 3.9–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 52.7 residents a day — about 88% occupied, or roughly 7 beds typically open. It runs fairly full. 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.01 hrs/resident/day on weekends vs 3.73 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.78 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2025-06-12 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, clinical record review, and facility document review, the facility staff failed to provide a resident with food prepared in a form designed to meet the individual needs for 1 of 6 sampled residents. (Resident #3) The findings include: For Resident #3, the facility staff failed to ensure meat was ground as indicated for a mechanical soft diet as ordered by a medical provider to meet the resident's dietary needs. Resident #3's diagnosis list indicated diagnoses that included, but were not limited to, Congestive Heart Failure, Dysphagia, Transient Cerebral Ischemic Attack, Glaucoma, Anemia, Peripheral Vascular Disease, Chronic Kidney Disease-Stage 3, Unspecified Dementia, and History of Falling. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/2/25, assigned the resident a brief interview for mental status (BIMS) summary score of 7 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Section K (Swallowing/Nutritional Status) was coded in section K0520.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, facility document review, and clinical record review, the facility staff failed to report an incident of visitor-to-resident abuse within two (2) hours of the observed abuse for one (1) of four (4) residents sampled. (Resident #1) The findings were: For Resident #1, facility staff failed to report an incident of visitor-to-resident sexual abuse within two (2) hours of the incident. On 11/10/24 at 3:08 p.m., three (3) staff members observed a visitor (another resident's family member) and resident touching each other inappropriately while together in an alcove off the main hallway. The incident was reported on 11/11/24, over two (2) hours after the incident. Resident #1's diagnoses list included but was not limited to unspecified dementia, major depressive disorder, and cognitive communication deficit. The most recent minimum data set (MDS) with an assessment reference date of 10/16/24 assigned the resident a brief interview for mental status summary score of 03 (three) out of 15 in Section C (Cognitive Patterns) indicating severely impaired cognition.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one (1) of four (4) residents sampled. (Resident #1) The findings were: The facility staff failed to ensure Resident #1's clinical record included a medical resident's evaluation of the resident following an abusive incident observed by staff members which occurred on 11/10/24. Resident #1's diagnoses list included but was not limited to unspecified dementia, major depressive disorder, and cognitive communication deficit. The most recent minimum data set (MDS) with an assessment reference date of 10/16/24 assigned the resident a brief interview for mental status summary score of 03 (three) out of 15 in Section C (Cognitive Patterns) indicating severely impaired cognition. Section GG (Functional Abilities) coded Resident #1 had no impairments for upper or lower extremities and did not use any mobility devices. Resident #1 was coded as independently being able to eat, perform oral hygiene, dress her upper and lower body, and putting on/taking off…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, facility staff failed to administer an an antibiotic medication per provider orders for 1 of 14 sampled current residents (Resident 30). The findings include: Resident 30 was admitted to the facility with diagnoses including type 2 diabetes mellitus, hypertension, cerebral palsy, obesity, spinal stenosis, obstructive uropathy, and benign prostatic hypertrophy. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the brief interview for mental status and was assessed without signs of delirium or psychosis. The resident exhibited rejecting care 1-3 days of the week prior to the assessment. Clinical record review for antibiotic use revealed a provider order dated 9/20/24 for urinalysis with culture and sensitivity and Ceding 300 mg twice per day for 7 days. On 9/27/24, the laboratory results revealed lactose fermenting gram negative rods. The provider ordered Ertapenem 1 gram intramuscularly daily for 5 days. An Infection control Infection tracker note dated 10/2/24 indicated provider made aware resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 medical provider documented the action and/or rationale for the action on a pharmacy recommendation, as part of a medication regimen review for (1) one of (5) five residents sampled for medication regimen reviews, Resident #9. The findings included: Resident #9's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's disease, hyperlipidemia, essential (primary) hypertension, chronic respiratory failure, chronic obstructive pulmonary disease, hypothyroidism, atrial fibrillation, schizophrenia, anxiety disorder, major depressive disorder, and bipolar disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. Progress notes within Resident #9's clinical record indicated a drug regimen review was completed on 6/12/24 with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0839 — isolatedEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and facility document review the facility staff failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one agency staff member working in the facility. The findings include: On 10/11/24, surveyors requested employee records of a selection of facility employees and contracted staff for review for compliance with regulations. On 10/15, the administrator reported that staff pulled the licenses of contracted nursing staff over the weekend and discovered that one contracted licensed practical nurse's license (LPN 1) was revoked by the board of nursing on 8/9/2024. The nurse had not notified the facility. A facility investigation was conducted over the weekend. The nurse will not return to the facility. The administrator stated that the company would no longer use that agency as it had not fulfilled requirements of the contract to only provide licensed staff to the facility. The nurse had worked 11 shifts after the license was revoked. Staff interviewed and assessed each resident on the nurse's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, family interview, and clinical record review, the facility staff failed to ensure the highest practicable physical well-being for 1 of 4 Residents (Resident #2). The facility staff failed to identify an injury of unknown origin. The findings included: The facility staff failed to identify an injury of unknown origin. Resident #2's family member identified injuries to the residents lower extremities when visiting and brought it to the attention of the facility nursing staff. Resident #2 was sent to a local hospital and a CT scan identified a mildly displaced acute right intertrochanteric femur fracture. The facility was unable to determine how this injury occurred. Resident #2's diagnoses included, but were not limited to, muscle weakness, cognitive communication deficit, edema, depressive disorder, anxiety disorder, restless leg syndrome, and other chronic pain. The only completed minimum data set (MDS) assessment for Resident #2 was a discharge assessment with an assessment reference…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-17 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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, Resident interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 4 out of 12 residents, Resident #8, Resident #14, Resident #28 and Resident #37. For Resident #8 the facility staff failed to document blood sugar levels and the administration of insulin on one occasion and failed to document a weekly ordered weight on one occasion. For Resident #14 the facility staff failed to document the administration of the medications Prevacid and Neurontin for one occasion and failed to document tube feeding water flushes for one occasion. For Resident #28 the facility staff failed to document the administration of the medications Levothyroxine and Prilosec on one occasion, and failed to document blood sugar levels and insulin administered on two occasions. For Resident #37 the facility staff failed to document the administration of the medication Ascorbic Acid on one occasion, the medication iron tablet on two occasions, the nutritional supplements Magic cup and Pro Stat AWC for one occasion each. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 12 residents in the survey sample, Resident #22. For Resident #22, the facility staff failed to secure the resident's cigarettes and lighter. The findings included: Resident #22's diagnosis list indicated diagnoses, which included, but not limited to Dementia with Behavioral Disturbance, Anxiety Disorder, Osteoarthritis of Hip, Thoracic, Thoracolumbar and Lumbosacral Intervertebral Disc Disorder, Peripheral Vascular Disease, History of Falling, Muscle Weakness, and Nicotine Dependence. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 2/02/22 assigned the resident a BIMS (brief interview for mental status) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Resident #22 was coded as being independent with bed mobility, transfers, walking, bathing and required supervision…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-05-31 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure the highest practicable well-being for 7 of 22 Residents, Resident #43, #31, #19, #34, #4, #40, and #22. The findings included: 1. For Resident #43, the facility staff failed to administer the Residents medication per the physician's orders. The medication renvela was not administered with meals or any food item. The clinical record review revealed that Resident #43 had been admitted to the facility 09/29/16 and was readmitted [DATE]. Diagnoses included, but were not limited to, hypertension, end stage renal disease, gout, gastro-esophageal reflux disease, cognitive communication deficit, and metabolic encephalopathy. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/15/19 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. The Residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · E2019-05-31 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 6 of 22 residents were free of an unnecessary psychotropic medication (Resident #6, Resident #40, Resident #154, Resident #19, Resident #53, and Resident # 7). The findings included: 1. The facility staff failed to identify and monitor resident specific target behaviors and identify non-pharmacological interventions for the administration of prn Ativan for Resident # 154. The clinical record of Resident #154 was reviewed 5/29/19 through 5/31/19. Resident #154 was admitted to the facility 5/22/19 with diagnoses that included but not limited to fracture of parts of lumbosacral spine and pelvis, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, anxiety, major depressive disorder, age-related osteoporosis, rheumatoid arthritis, hypertension, Vitamin D deficiency, kyphosis, atherosclerotic heart disease, and chronic pain. Resident #154's admission minimum data set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-31 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 [NAME] F tag 760 E Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 2 of 22 residents were free of a significant drug error (Resident #40 and Resident #22). The findings included: 1. The facility staff failed to administer physician ordered insulin to Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to ensure the Virginia Department of Health Durable Do Not Resuscitate (DDNR) form was complete for 1 of 22 residents (Resident #154). The findings included: The facility staff failed to ensure the Virginia Department of Health DDNR was accurate for Resident #154. The clinical record of Resident #154 was reviewed 5/29/19 through 5/31/19. Resident #154 was admitted to the facility 5/22/19 with diagnoses that included but not limited to fracture of parts of lumbosacral spine and pelvis, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, anxiety, major depressive disorder, age-related osteoporosis, rheumatoid arthritis, hypertension, Vitamin D deficiency, kyphosis, atherosclerotic heart disease, and chronic pain. Resident #154's admission minimum data set (MDS) had not been completed. The clinical record contained a Virginia Department of Health Durable Do Not Resuscitate form dated 5/22/19. Section 1 and Section 2 were blank. Section 1 of the DDNR read in part, I further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure a clean and comfortable homelike environment for 1 of 22 residents (Resident #41). The findings included: The facility staff failed to ensure Resident #41's privacy curtain and air conditioning unit were clean. Resident #41 was admitted to the facility 1/26/18 with diagnoses that included but not limited to frostbite, anxiety, depression, and dementia. Resident #41's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/15/19 assessed the resident with a BIMS (brief interview for mental status) as 9/15. The surveyor interviewed Resident #41 on 5/29/19 at 11:34 a.m. Resident #41 was observed sitting up in bed during the interview. The surveyor sat in a folding chair and the privacy curtain was pulled to separate Resident #41 from the roommate. When the surveyor sat down, a large orange stain was observed at the end of the curtain as well as dark marks throughout the remainder of the curtain. At the end of the interview, Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure the PASSARs (Pre-admission Screening and Resident Review) were complete for 2 of 22 residents (Resident #45 and Resident #7). The findings included: 1. The facility staff failed to ensure the PASSAR was complete for Resident #45. The clinical record of Resident #45 was reviewed 5/29/19 through 5/31/19. Resident #45 was admitted to the facility 10/1/18 and readmitted [DATE] with diagnoses that included but not limited to schizophrenia, osteomyelitis in ankle and foot, type 2 diabetes mellitus, morbid obesity, obstructive and reflux uropathy, hypertension, hyperlipidemia, peripheral vascular disease, and chronic kidney disease, stage 3. Resident #45's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 5/16/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. During the survey process, the record review asked if a Level II PASSAR had been completed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop care plans for psychotropic medication (Zyprexa and Restoril) and insomnia for 1 of 22 residents (Resident #40). The findings included: The facility staff failed to develop a care plan for the use of psychotropic medications, failed to develop a care plan for insomnia, and failed to develop a care plan for diabetes for Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to review and revise the comprehensive plan of care for 2 of 22 Residents in the survey sample, Resident # 31 and Resident # 7. The findings included 1. The facility staff failed to review and revise the plan of care for Resident # 31 to reflect refusal of insulin. Resident # 31 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], with a readmission date of 1/21/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, hypertension, anemia, and heart failure. The clinical record for Resident # 31 was reviewed 5/30/19 at 3:38 pm. The most recent MDS (minimum data set) assessment for Resident # 31 was an annual assessment with an ARD (assessment reference date) of 5/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 31 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 31…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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, clinical record review, staff interview, Resident interview, and facility document review, the facility staff failed to provide services to prevent urinary tract infections for 1 of 22 Residents in the survey sample, Resident 34. The findings included The facility staff failed to ensure that Foley catheter tubing for Resident # 34 was secured. Resident # 34 was an [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of 7/19/18. Diagnoses included but were not limited to; obstructive and reflux uropathy, chronic kidney disease, hypertension, and type 2 diabetes mellitus. The clinical record for Resident # 34 was reviewed on 5/29/19 at 11:44 am. The most recent MDS (minimum data set) assessment for Resident # 34 was a quarterly assessment with an ARD (assessment reference date) of 5/9/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 34 had a BIMS (brief interview for mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to utilize non-pharmacological interventions prior to the use of pain medication for 1 of 22 residents (Resident #154). The findings included: The facility staff failed to utilize non-pharmacological interventions prior to the use of pain medication for Resident #154. The clinical record of Resident #154 was reviewed 5/29/19 through 5/31/19. Resident #154 was admitted to the facility 5/22/19 with diagnoses that included but not limited to fracture of parts of lumbosacral spine and pelvis, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, anxiety, major depressive disorder, age-related osteoporosis, rheumatoid arthritis, hypertension, Vitamin D deficiency, kyphosis, atherosclerotic heart disease, and chronic pain. Resident #154's admission minimum data set (MDS) had not been completed. Resident #154's careplan initiated 5/23/19 identified actual pain as a focus area r/t (related to) decreased…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and staff interview, the facility staff failed to dispose of expired medications on two of two halls. The findings included: The facility staff failed to dispose of expired medications. On 05/29/19 at 9:35 a.m., the surveyor checked medication cart #2 on the 100 hall with LPN (licensed practical nurse) #1. This cart included an opened bottle of 1000-tablet multivitamins with an expiration date of 03/19 and a victoza (insulin) flex pen with an open date of 04/14/19. The label on this flex pen read to discard after 30 days. LPN #1 checked the medications with the surveyor, confirmed they were out of date disposed of the flex pen, and returned the bottle of multivitamins to the medication room to be returned to the pharmacy. On 05/29/19 at 10:10 a.m., the surveyor checked medication cart #1 on the 200 hall with LPN #2. This cart included an opened bottle of 100-tablet zinc sulfate 220 mg with a use by date of 09/18 and a victoza flex pen dated 04/28/19. The label on this flex pen read to discard after 30 days. LPN #2 checked the medications with the 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.
- Potential for harm · D2019-05-31 · tag F0770 — failed to provide lab services — isolatedProvide 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, the facility staff failed to obtain a physician ordered laboratory test for 1 of 22 residents (Resident #40). The findings included: The facility staff failed to obtain a CMP (comprehensive metabolic panel) for Resident #40. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #40 was not interviewable. The surveyor reviewed the March 2019 physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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, the facility staff failed to obtain a physician order prior to obtaining laboratory tests for 1 of 22 residents (Resident #40). The findings included: The facility staff failed to obtain a physician order before obtaining an albumin level, a urine and urine for culture and sensitivity, and a CBC (complete blood count) for Resident #40 on 3/4/19. The clinical record of Resident #40 was reviewed 5/29/19 through 5/31/19. Resident #40 was admitted to the facility 2/28/19 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, insomnia, muscle weakness, hypertension, atherosclerotic heart disease, unspecified dementia with behavioral disturbances, cerebrovascular disease, anxiety disorder, major depressive disorder, hyperlipidemia, type 2 diabetes mellitus, and unspecified psychosis. Resident #40's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/15/19 assessed the resident with a BIMS (brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to clean scissors before use or after use for 1 of 22 residents (Resident #45). The findings included: The facility staff failed to clean the scissors used in wound care for Resident #45. The clinical record of Resident #45 was reviewed 5/29/19 through 5/31/19. Resident #45 was admitted to the facility 10/1/18 and readmitted [DATE] with diagnoses that included but not limited to schizophrenia, osteomyelitis in ankle and foot, type 2 diabetes mellitus, morbid obesity, obstructive and reflux uropathy, hypertension, hyperlipidemia, peripheral vascular disease, and chronic kidney disease, stage 3. Resident #45's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 5/16/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. Section K Skin Conditions assessed the resident with a surgical wound and surgical wound care. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-05-31 · tag F0622 — widespreadNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — the official record, unedited, may be distressing
Based on clinical record review and staff interview, the facility staff failed to ensure that comprehensive care plan goals were sent with facility residents upon transfer for 7of 22 residents. The findings included: The facility staff failed to ensure that comprehensive care plan goals were sent with facility residents upon transfer. During the course of the survey that was conducted 5/29/19 through 5/31/19, the survey team identified the following Residents did not have comprehensive care plan goals sent upon transfer, Resident # 6, Resident # 12, Resident # 19, Resident # 31, Resident # 32, Resident # 40, and Resident # 43. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings as stated above, and agreed that it had not been a facility practice to send comprehensive care plan goals with Residents upon transfer. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/31/19.
- No harm found · C2019-05-31 · tag F0623 — widespreadProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of transfer/discharge to include the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman and documentation in the medical record that the notice was sent to the Ombudsman for 3 of 22 residents (Resident #45, Resident #40, and Resident #6). The findings included: 1. The facility staff failed to provide written notice of transfer to the resident and the resident representative when the resident was transferred to the hospital, failed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2019-05-31 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interview, and facility document review, the facility staff failed to provide written notice of bed hold upon transfer or discharge for 8 of 22 residents The findings included The facility staff failed to provide documentation that a written notice of bed hold was issued to facility residents upon transfer or discharge. During the course of the survey that was conducted 5/29/19 through 5/31/19, the survey team identified the following Residents did not have documentation that a written notice of bed hold was issued upon transfer or discharge, Resident # 6, Resident # 12, Resident # 19, Resident # 31, Resident # 32, Resident # 40, Resident # 43, and Resident #45. The Discharge/Transfer Letter Policy, contained documentation that included but was not limited to; .4. A copy of the completed bed hold notice will be scanned into PCC under document manager and filed in business file with certified receipt attached if applicable, with copy of the discharge/transfer letter. On 5/31/19 at 6:30 pm, the administrative team was made aware of the findings…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 5 of 5 | 2.6 | +2.4 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 4.0 | -2.0 vs chain |
The other 125 homes this chain runs (chain average 2.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WWBV HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 09/30/2019 |
| SHELOR, THOMAS | Individual | W-2 MANAGING EMPLOYEE | — | since 08/24/2022 |
| VOLPE, BENJAMIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| WEISBERG, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2019 |
| NICOLUZAKIS, GREGORY | Individual | CORPORATE OFFICER | — | since 03/01/2019 |
| SABER GOVERNANCE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2019 |
| DAVIS, MITCHELL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/04/2018 |
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.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $822K paid to related parties — landlords or management companies under common ownership — equal to about 13% 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495166. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-16, 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 →
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