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Ridgecrest Manor Nursing & Rehabilitation

157 Ross Carter Boulevard, Duffield, VA 24244 · For profit - Corporation · 120 certified beds · (276) 431-2841 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jul 2019Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations
Insights

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

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 citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
121 Advanced Technology Drive · (276) 431-7583 · Call to confirm hours
Pharmacy
134 Cecil D Quillen Dr · (276) 431-2299 · Call to confirm hours
Grocery
2079 Duff Patt Hwy
Park
1420 Natural Tunnel Pkwy · (276) 940-2674 · Typically dawn to dusk
Place of worship
355 Cecil D Quillen Dr · (276) 275-7357

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 3 of 5
Long-stay residentspeople who live here 4 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 improved from 1 to 4 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 rating4★
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 increased11.7%14.9%15.4%better
Long-stay residents who lose too much weight9.7%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 infection0.8%1.6%2.0%better
Long-stay residents with depressive symptoms13.0%18.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%3.6%3.3%better
Long-stay residents whose ability to walk worsened16.7%15.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication34.2%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine90.1%94.0%95.3%typical
Long-stay residents with pressure ulcers4.6%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control18.0%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.7%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine77.5%73.6%79.4%typical
Short-stay residents rehospitalized after admission27.5%22.3%22.6%worse
Short-stay residents with an outpatient ER visit16.0%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.471.521.67better
Long-stay outpatient ER visits per 1,000 resident days3.341.481.80worse

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.

35.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

35.2%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
54.5%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 54.5% 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 22 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF35.2%CMS range 23.4–48.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.5–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.5%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 discharge40.9%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 identified92.3%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 settingnot 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 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 stay2.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%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 hospitalization7.7%CMS range 4.3–15.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 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

0.60
RN hours/ resident / day
1.11
LPN hours/ resident / day
1.88
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.38
RN hoursweekends
37.0%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 104.9 residents a day — about 87% occupied, or roughly 15 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 3.17 hrs/resident/day on weekends vs 3.76 on weekdays — 16% thinner on weekends. RN hours go from 0.69 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% 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

8
deficiencies at the latest standard inspection (2024-02-22)
1
at the previous standard inspection (2022-09-29)

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.

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2019-07-18 · 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, staff interview, and facility document review it was determined the facility staff failed to prevent an accident hazard by ensuring that a bag of medications had been properly secured on 1 of 3 units in the facility. The scope and severity was originally cited at Immediate Jeopardy, Level IV Isolated and was reduced to a Level II Isolated after the facility was cleared of Immediate Jeopardy. The administrator and regional vice president of operations were notified on 7/16/19 that the extended survey process had begun at 9:02 am, as the survey team had identified Immediate Jeopardy & Substandard Quality of Care in the area of Quality of Care. The findings included: The facility staff failed to ensure that a bag of medications had been properly secured on a dementia unit within the facility. The opened bag of medications was left on the floor in the nurse's station that was open and accessible to the wandering residents on the Carter's Fold secured dementia unit, which created an accident…

    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
  • Immediate jeopardy · J2019-07-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to appropriately store medications on 1 of 3 units and failed to label a medication for 1 of 34 residents, Resident # 20. The findings included: 1. The facility staff failed to ensure that a bag of medications had been properly stored on a dementia unit within the facility. The opened bag of medications was left on the floor in the nurse's station that was open and accessible to the wandering residents on the Carter's Fold secured dementia unit, which created the potential for a serious adverse outcome. The scope and severity was originally cited at Immediate Jeopardy, Level IV Isolated and was reduced to a Level II Isolated after the facility was cleared of Immediate Jeopardy. The administrator and regional vice president of operations were notified on 7/16/19 that the extended survey process had begun at 9:02 am, as the survey team had identified Immediate Jeopardy & Substandard Quality of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The sanitizing cycle of the dishwashing machine was not working. The findings included: The sanitizing cycle of the dishwashing machine in the facility kitchen was not working. The test strips did not detect any sanitizing solution. On 02/20/24 at approximately 11:00 a.m., during the initial observation of the facility kitchen Dietary Employee #1 attempted to check the sanitizing solution of the dishwashing machine. Dietary Employee #1 used three different test strips to check the sanitizing solution. None of these test strips changed color. The sanitizing solution bucket was observed to be approximately 2/3 full of solution and the surveyor observed the system that pulled the sanitizer solution into the machine turning. Dietary Employee #1 stated they would call maintenance and would wash dishes by hand. 02/20/24 at 12:15 p.m., the Maintenance Director stated they had checked the dishwashing machine, the sanitizer line in 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 · Dcited before2024-02-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and provider orders for 2 of 21 residents in the survey sample, Residents #34 and #56. The findings included: 1. For Resident #34, the facility staff failed to administer Hydroxychloroquine Sulfate (an oral medication prescribed to treat rheumatoid arthritis) as ordered by the provider on six (6) separate occasions. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/06/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #34's comprehensive person-centered care plan included a focus area stating the resident was at risk for pain and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-22 · 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

    Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to assess a resident's ability to safely smoke for 1 of 21 residents, Resident #64. Facility staff failed to complete a smoking assessment for Resident #64 when resident began smoking after admission. The findings included: For Resident #64 the facility staff failed to complete a safe smoking assessment once the resident began smoking. During entrance conference, surveyor was provided with a list of residents that smoke. Resident #64's name was on this list. Resident #64's face sheet listed diagnoses which included but not limited to bipolar disorder, severe, with psychotic features, chronic obstructive pulmonary disease, and generalized anxiety disorder. Resident #64's most recent minimum data set with an assessment reference date of 12/12/23 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #64's comprehensive care plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the provider orders for 1 of 21 residents in the survey sample, Resident #34. The findings included: For Resident #34, the facility staff failed to administer supplemental oxygen as ordered by the physician. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/06/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #34 was coded as receiving oxygen therapy. Resident #34's comprehensive person-centered care plan included a focus area stating in part .O 2 (oxygen) therapy as ordered with an intervention stating O2 as ordered. On 2/21/24 at 8:58 AM and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-22 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 29 opportunities for a medication error rate of 6.9%. These medication errors affected Resident #12 and/or Resident #57. The findings included: For Resident #12, the facility staff failed to administer Calcium-Vit D-Min Oral Tablet 600-400 mg-unit; this was documented on Resident #12 medication administration record (MAR) to be provided one time a day. On 2/21/24 at 8:18 a.m., Licensed Practical Nurse (LPN) #4 was observed to provide Calcium 500 mg-Vitamin D 5 mcg. On 2/21/24 at 9:58 a.m., LPN #4 confirmed they had provided Resident #12 the Calcium 500 mg tablet. On 2/21/24 at 10:22 a.m., LPN #4 stated they did not have the Calcium 600/Vit D 400 tablet in the medication cart during Resident #12's aforementioned medication administration observation. For Resident #57, the facility staff failed to administer Senna S (sennosides 8.6 mg and docusate 50 mg) as ordered by 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 · Dcited before2024-02-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical record for three (3) of 21 sampled residents (Resident #66, Resident #101, and Resident #154). The findings included: 1. Resident #101's clinical record failed to include documentation of the change in the resident's condition which resulted in an increase in the resident's pain medication dosage. Resident #101's clinical record failed to include documentation of the medical provider notification which had resulted in the medical provider increasing the resident's pain medication dosage. Resident #101's medication orders indicated: - On 11/24/23 at 7:53 p.m., the resident's pain medication Morphine was increased from 0.5 ml every four (4) hours as needed to 1.0 ml scheduled to be provided every four (4) hours. No documentation in Resident #101's clinical record provided information as to the change in the resident's condition which resulted in this change in the medication order. - On 11/25/23 at 10:46 a.m., the resident's pain…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow established infection control guidelines to decrease the potential of and/or risk for infection transmission for 1 of 21 current residents, Resident #96. The findings included: During a surgical wound care observation, the facility staff failed to complete hand hygiene and was observed to touch dressing supplies used to clean the wound with their bare hands. Resident #96's diagnoses included, but were not limited to, fractures, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder. Section C (cognitive patterns) of Resident #96's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/04/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Resident #96's comprehensive care plan included the focus areas, traumatic subluxation of peroneal tendon of left foot. Resident 96's clinical record included a provider order to change dressing to left lower extremity…

    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 · D2022-09-29 · tag F0625 — isolated
    Notify 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 staff interview, clinical record review, and facility document review, the facility staff failed to provide written bed hold policy information to the resident or resident representative prior to transfer for 1 of 4 closed record reviews, Resident #86. For Resident #86, the facility failed to provide the resident written bed hold policy information prior to transfer to an acute care hospital. The findings included: Resident #86's clinical record included the medical diagnoses, diabetes, dependence on respirator, neuromuscular dysfunction of bladder, chronic respiratory failure with hypoxia, and tachycardia. Section C (cognitive patterns) of Resident #86's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/24/22 was coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. The residents clinical record included an interact form dated 06/29/22 indicating the resident was transferred to a local hospital. On 07/11/22 the Social Worker,…

    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 · Fcited before2019-07-18 · 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 a manner that would prevent foodborne illnesses. The facility staff did not complete any hand hygiene prior to obtaining food temperatures. The findings included: The facility staff when obtaining food temperatures allowed the top of the thermometer to touch the food. The top of this thermometer is what the facility staff held while obtaining food temperatures. The facility staff did not have gloves in place, were not observed to wash their hands prior to obtaining the temperatures, and were observed touching the top of the thermometer with their bare hands. On 07/16/19 at 11:41 a.m., the surveyor entered the kitchen to obtain tray line temperatures. Tray aide #1 was working in the kitchen area and stated she would obtain the tray line temperatures. Tray aide #1 did not wash their hands or apply any gloves prior to obtaining these temperatures. Tray aide #1 picked up the thermometer with their bare hands and placed the thermometer into a pan of broccoli. Tray aide #1 did 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-07-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure an infection control program during a medication pass and pour observation and for 4 of 34 residents (Resident 21, Resident #91, Resident #79, and Resident #20). The findings included: 1. The facility staff failed to perform hand hygiene during a medication pass and pour observation on 7/16/19 with licensed practical nurse #2. The surveyor observed a medication pass and pour observation on 7/16/19 beginning at 8:12 a.m. with licensed practical nurse #2. L.P.N. #2 used hand sanitizer before entering the medication cart to begin the medication pass. L.P.N. #2 prepared seven medications for Resident #21 and administered the medications. L.P.N. #2 returned to the medication cart. No hand washing was observed upon exiting Resident #21's room or prior to entering the medication cart. L.P.N. #2 left the medication cart, went to the medication room for two medications for Resident #21, poured…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2019-07-18 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to determine that medication self-administration for 2 out of 34 residents was appropriate (Resident #91 and Resident #95). The findings included: 1. The facility staff failed to assess Resident #91 for medication self-administration of eye drops (Systane Ultra). The clinical record of Resident #91 was reviewed 7/15/19 through 7/18/19. Resident #91 was admitted to the facility 6/13/19 with diagnoses, that included but not limited to sepsis, metastatic colon cancer, type 2 diabetes mellitus, morbid obesity, urogenital implants, chronic urinary retention, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, systemic lupus erythematous, depression, and congestive heart failure. Resident #91's admission minimum data set (MDS) with an assessment reference date (ARD) of 6/20/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15.…

    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 · D2019-07-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide a reasonable accommodation by maintaining the breath activated call cord/light within the resident's reach for 1 of 34 residents (Resident #260). The findings included: Resident #260's breath activated call cord was out of reach for twenty-five minutes. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with diagnoses that included but not limited to ventilator associated pneumonia, protein-calorie malnutrition, extradural and subdural abscess, quadriplegia, chronic respiratory failure, pressure ulcer sacral region, stage 2, osteomyelitis of vertebra, lumbosacral region, Hepatitis A, Hepatitis B, Hepatitis C, opioid abuse, hypertension, cocaine abuse, stimulant abuse, tracheostomy status, gastrostomy status, and dependence on ventilator. The admission MDS (minimum data set) assessment had 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, the facility staff failed to provide privacy for 1 of 4 residents observed during a medication pass and pour observation, Resident # S2. The findings included The facility staff failed to pull the privacy curtain to provide privacy while administering medications through a peg tube for Resident # S2. On 9/12/19 at 8:47 am, the surveyor was conducting a medication pass and pour observation with LPN # 1 (licensed practical nurse). The surveyor observed that LPN # 1 did not pull the privacy curtain and Resident # S2 was visible to her roommate as LPN # 1 administered medications to Resident # S2 via peg tube. On 9/12/19 at 10:03 am, the surveyor interviewed LPN # 1. The surveyor asked LPN # 1 why she did not pull the privacy curtain during medication administration for Resident # S2. LPN # 1 stated, I didn't even think about it. Her husband used to be in the room with her, and he used to like to watch her get her medicine. The person that is in there now is usually in therapy when I give her medication, and I didn't…

    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 · D2019-07-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility document review, staff interview and clinical record review, the facility staff failed to report an allegation of abuse to the appropriate agencies for 1 of 12 residents in the survey sample (Resident #209). The findings included: The facility staff failed to report an allegation of abuse to the appropriate agencies for Resident #209. Resident #209 was originally admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, coronary artery disease, high blood pressure, pneumonia, diabetes, arthritis and dementia. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of this resident occurred on 8/23/19. During the clinical record review by the surveyor on 9/11/and 9/12/19, the following documentation was noted on the Admission/readmission Evaluation, which…

    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 · D2019-07-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to immediately start an investigation when 1 of 12 residents in the survey sample alleged abuse by a staff member and failed to report these completed findings within 5 days of the becoming aware of an alleged abuse to a resident in the nursing facility (Resident #209). The findings included: The facility staff failed to immediately investigate an allegation of abuse that was reported to staff by Resident #209 on 8/27/19 at 10:57 am Resident #209 was originally admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, coronary artery disease, high blood pressure, pneumonia, diabetes, arthritis and dementia. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to accurately assess 1 of 34 Residents in the survey sample, Resident # 409. The findings included: The facility staff documented assessments in the clinical record, and created a care plan that reflected that Resident # 409 had a urostomy when Resident # 409 did not have a urostomy. Resident #409 was an [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, urinary tract infection, hypertension, restlessness, and agitation. The clinical record for Resident # 409 was reviewed on 7/16/19 at 10:53 am. At the time of the survey, there were no completed MDS (minimum data set) assessments for Resident # 409. The baseline plan of care for Resident # 409 was initiated on 4/12/19. The facility staff documented a focus area for Resident # 409 as, Resident requires urostomy. Interventions included but were not limited to, Inspect stoma and peristomal skin area with each pouch…

    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 · D2019-07-18 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to provide activities to meet the needs of Residents on 1 of 3 units in the facility and for 3 of 34 Residents in the facility, Resident # 91, Resident # 260, and Resident # 108. The findings included: 1. The facility staff failed to provide group activities for Residents on the [NAME] Fold unit. On 7/15/19 at 4:32 pm, the surveyor was making observations on the [NAME] fold unit. The surveyor observed an activity calendar for July 2019 that was posted on the unit. The surveyor observed that the activity calendar had Coffee Club as an activity that was to be conducted at 4:30 pm. The surveyor did not observe any staff member conducting a group activity with the Residents on the unit. On 7/15/19 at 4:47 pm, the surveyor continued to conduct observations on the [NAME] Fold unit and did not observe any staff member conducting a group activity with the Residents on the unit. On 7/15/19 at 5:02 pm, the surveyor continued 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and clinical record review, the facility staff failed to provided services outline in the comprehensive care plan by following the physician's order in regards to notifying the physician when the resident's weight exceded 3 pounds for 1 of 34 residents, Resident #19. The findings included: The facility staff failed to notify the physician when Resident #19's weight gain exceeded 3 (three) pounds following dialysis. The order read to obtain weight upon return from dialysis and notify the physician of a weight gain greater than 3 (three) pounds (lbs). Resident #19's clinical record was reviewed on 07/16/19 through 07/18/19. The review reveal Resident #19 was initially admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Diagnoses included but were not limited to, congestive heart failure, type 2 diabetes, and chronic kidney disease, stage 4 (severe). Section C (cognitive patterns) of the Residents' quarterly MDS (minimum data set) assessment with an ARD…

    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 · D2019-07-18 · 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, facility document review and clinical record review, the facility staff failed to ensure that the resident received services and assistance to maintain continence by assuring that there was a physician order for the size of the indwelling Foley catheter and balloon for 1 of 34 residents (Resident #79). The findings included: The clinical record of Resident #79 was reviewed 7/15/19 through 7/18/19. Resident #79 was admitted to the facility 5/2/19 and readmitted [DATE] with diagnoses that included but not limited to pneumonia, persistent vegetative state, adult failure to thrive, severe sepsis with septic shock, neuromuscular dysfunction of the bladder, dysphagia, hypothyroidism, acute respiratory failure, dependence on respirator, tracheostomy status, unspecified coma, and non-traumatic intracerebral hemorrhage. Resident #79's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/3/19 assessed the resident to be in a persistent vegetative…

    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 · D2019-07-18 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, the facility staff failed to provide appropriate care and services in regards to gastrostomy tube for 1 of 4 residents observed during a medication pass and pour observation, Resident # S2. The findings included The facility staff failed to appropriately check gastrostomy tube placement and residual for Resident # S2. On 9/12/19 at 8:47 am, the surveyor conducted a medication pass and pour observation with LPN # 1 (licensed practical nurse). The surveyor observed LPN # 1 as she applied a syringe to Resident # S2's gastrostomy tube and pulled the syringe plunger back. The surveyor observed a small amount of dark yellow liquid residual return into the syringe. The surveyor observed LPN # 1 as she pushed down on the plunger and returned residual the contents to Resident # S2. The surveyor observed LPN # 2 as she removed the plunger from Resident # S2's peg tube, pulled back on the plunger, and replaced the plunger into Resident # S2's gastrostomy tube. The surveyor then observed LPN # 1 place her stethoscope on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 pain management services through non-pharmacological interventions for pain management prior to the use of pain medication for 3 of 34 residents (Resident #67, Resident #81, and Resident #260). The findings included: nter 1. The facility staff failed to provide non-pharmacological pain interventions prior to the use of pain medication for Resident #67. The clinical record of Resident #67 was reviewed 7/15/19 through 7/18/19. Resident #67 was admitted to the facility 5/10/19 and readmitted [DATE], 6/17/19 and 7/3/19 with diagnoses that included but not limited to dependence on respirator, type 2 diabetes mellitus, chronic atrial fibrillation, hypertension, cardiac pacemaker, anemia, cirrhosis of the liver, gastrostomy tube, acute viral hepatitis, sedative, hypnotic, or anxiolytic dependence, opioid dependence, pyothorax without fistula, nicotine dependence, anxiety, and depressive episodes.…

    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 · D2019-07-18 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, staff interview, and facility document review failed to determines that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled by completing the shift verification of controlled substances record on the special care unit for 15 opportunities. The findings included: During the survey from 7/15/19 through 7/18/19, the surveyor observed three medication carts on each of the three units. On 7/16/19 at 2:24 PM, the Special Care Unit medication cart was checked with licensed practical nurse #1. The surveyor and L.P.N. #1 checked the shift verification of controlled substances for June 2019 and July 2019. The surveyor identified the following areas where there was not a signature from the on-coming nurse or a signature from the off-going nurse: On 6/28/19 Day shift, there was not a signature by the off-going nurse. On 6/30/19 Day shift, there was not a signature by the off-going nurse. On 7/3/19 Day shift, there was not a signature by the on-coming nurse. On 7/3/19 Night shift, there is…

    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 · D2019-07-18 · 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 staff interview, facility document review, and clinical record review, the facility staff failed to ensure 1 of 34 residents was free of an unnecessary psychotropic medication (Resident #260). The findings included: The facility staff failed to identify and monitor resident specific target behaviors and identify non-pharmacological interventions associated with the use of Klonopin and Ativan for Resident #260. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with diagnoses that included but not limited to ventilator associated pneumonia, protein-calorie malnutrition, extradural and subdural abscess, quadriplegia, chronic respiratory failure, pressure ulcer sacral region, stage 2, osteomyelitis of vertebra, lumbosacral region, Hepatitis A, Hepatitis B, Hepatitis C, opioid abuse, hypertension, cocaine abuse, stimulant abuse, tracheostomy status, gastrostomy status, and dependence on ventilator. The admission…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, clinical document review, and during a medication pass and pour observation, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were three (3) errors in thirty-one (31) opportunities resulting in a medication error rate of 9.68%. The findings include: Medication errors were observed while completing the Medication Administration Task. There were three (3) errors in thirty-one (31) opportunities resulting in a medication error rate of 9.68%. On 7/12/19 at 8:48 a.m., LPN (licensed practical nurse) #11 was observed administering medications to Resident #20. LPN #11 reported that two (2) of Resident #20's medications, which were ordered for 9:00 a.m., were not found in the medication cart. These medications were Allopurinol and Lantus Insulin. LPN #11 looked in the unit's medication storage area and reported the two (2) medications were not available to be administered to Resident #20. After the medications were discovered to not be available, LPN #11 contacted the provider and obtained orders 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to ensure that 1 of 4 Residents observed during a medication pass and pour observation were free of significant medication errors, Resident # S1. The findings included: The facility staff failed to appropriately administer Lantus via insulin pen to Resident # S1. Resident # S1 was a [AGE] year-old- female who was originally admitted to the facility on [DATE], with a readmission date of 6/17/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, obesity, hypertension, and anemia. Resident # S1 had orders that included but were not limited to, Lantus Solution 100 unit/ML (milliliter) Inject 20 unit subcutaneously two times a day for dm (diabetes mellitus). On 9/12/19 at 9:29 am, the surveyor observed LPN # 2 (licensed practical nurse) administer medications to Resident # S1. The surveyor observed LPN # 2 as she administered 20 units of Lantus via insulin pen to Resident # S1 on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-18 · 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 clinical record review and staff interview, the facility staff failed to ensure an accurate clinical record for 1 of 34 Residents in the survey sample, Resident # 86. The findings included: The facility staff failed to ensure that complete advanced directive documentation was in the clinical record for Resident # 86. Resident # 86 was a [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, cognitive communication deficit, hypertension, Alzheimer's disease, and Type 2 diabetes mellitus. The clinical record for Resident # 86 was reviewed on 7/16/19 at 9:44 am. The most recent MDS (minimum data set) assessment for Resident # 86 was a significant change assessment with an ARD (assessment reference date) of 6/12/19. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 86's cognitive status was moderately impaired. The current plan of care for Resident # 86 was reviewed and revised on 3/7/19.…

    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
  • No harm found · C2024-02-22 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview the facility staff failed to ensure the daily staff posting contained the required information. The findings included: On 02/21/24 surveyor observed the daily staff posting located in the lobby of the facility. The daily staff posting for dates prior to 02/21/24 did not contain the actual hours worked for any licensed staff for either shift. Surveyor spoke with the director of nursing and administrator on 02/21/24 regarding the missing information on the staff posting, and administrator stated they would fix it, but did not offer an explanation as to the reason it was not included on the forms. The concern of not including actual staff hours worked on the daily staff posting was discussed with the administrator, director of nursing, assistant director of nursing and regional director of clinical services on 02/22/24 at 12:45 PM. No further information was provided prior to exit.

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

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 4 of 52.6+1.4 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
WWBV HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 09/30/2019
JONES, STEVENIndividualW-2 MANAGING EMPLOYEEsince 08/01/2022
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2019
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICERsince 03/01/2019
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
DAVIS, MITCHELLIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/04/2018

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$12.4M
Net patient revenuemost recent cost report
+10.7%
Operating marginrevenue minus expenses
$1.3M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 5%Other / private 11%

About 84% 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$312per resident / day
operating cost
$9,472per month
≈ monthly operating cost
$349per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in VA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495134. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-22, 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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