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August Healthcare At Iliff

8000 Iliff Drive, Dunn Loring, VA 22027 · For profit - Corporation · 130 certified beds · (703) 560-1000 Medicare & Medicaid certified

Call the home — (703) 560-1000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 24% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Urgent care / clinic
2671 Avenir Pl, # A · (571) 623-3770 · Call to confirm hours
Pharmacy
264 Cedar Ln SE · (703) 876-0388 · Call to confirm hours
Grocery
2675 Avenir Pl · (703) 204-0840 · Call to confirm hours
Park
Washington @ Dominion Railroad Trl · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.9%14.9%15.4%better
Long-stay residents who lose too much weight5.4%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms51.1%18.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.1%3.6%3.3%worse
Long-stay residents whose ability to walk worsened16.5%15.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication25.8%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine90.9%94.0%95.3%typical
Long-stay residents with pressure ulcers5.1%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control6.6%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table2.3%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine76.9%73.6%79.4%typical
Short-stay residents rehospitalized after admission35.0%22.3%22.6%worse
Short-stay residents with an outpatient ER visit12.5%11.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days3.751.521.67worse
Long-stay outpatient ER visits per 1,000 resident days1.311.481.80better

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

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

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

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

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

21.4% 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 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

21.4%U.S. median 51.5%
Got home and stayed home
18.3%U.S. median 10.7%
Went back to hospital
68.1%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 68.1% 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 47 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 41% 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 SNF21.4%CMS range 15.5–27.551.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF18.3%CMS range 14.6–21.710.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.1%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 discharge74.5%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 discharge61.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%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 worsened0.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 4.5–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.10
RN hours/ resident / day
1.94
LPN hours/ resident / day
2.54
Aide hours/ resident / day
5.58
Total nurse hours/ resident / day
0.93
RN hoursweekends
21.5%
Total nursing turnover
24.1%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 105.9 residents a day — about 81% occupied, or roughly 24 beds typically open. It usually has some room. 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 5.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.09 hrs/resident/day on weekends vs 5.77 on weekdays — 12% thinner on weekends. RN hours go from 1.17 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% is below 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 (2023-03-23)
4
at the previous standard inspection (2021-03-18)

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 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · G2023-03-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure that a Resident who received a indwelling (Foley) catheter after admission, was assessed for removal of the catheter as soon as possible for 1 Resident (#'s 21) in a survey sample of 35 Residents. This is harm. The findings included: 1. For Resident #21, the facility staff failed reassess the need of an indwelling (Foley) catheter after Resident #21 had one episode of urinary retention. The resident experienced Urinary Tract Infections (UTIs) that required antibiotics. This is harm. On 3/21/23 at 9:25 AM Resident #21 was observed in her bed with eyes closed resting, the Resident had a Foley with a dignity bag cover in place. On 3/22/23 a review of the clinical record revealed the following: 12/28/2022 -4:46 PM-Nursing Progress Note Text: Charge nurse observed patient not voiding throughout this shift. Assessment done. Denied pain, abdomen soft, non-distended. I/O done, collected 550 cc clear urine. MD notified. Gave an order to insert 16F Foley catheter. RP [name…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-07 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a baseline care plan within 48 hours of admission to address skin impairment for one resident (Resident #2) in a survey sample of four residents. The findings included;For Resident #2, the staff failed to develop a baseline care plan within 48 hours of admission to identify and address a skin impairment that was present upon admission. Resident #2 was originally admitted on [DATE]. Diagnoses for Resident #2 included but were not limited to; Post infectious Viral encephalitis and encephalomyelitis, acute cerebral edema, intracranial space occupying lesion, persistent vegetative state, ventilator dependence, and an unstageable coccyx (later called sacrum by staff) pressure sore. Resident #2's admission Minimum Data Set (an assessment protocol) documented the Resident as completely dependent on 1-2 staff members for all Activities of Daily Living care. The Resident was incontinent of bowel 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to treat a pressure sore for one Resident (Resident #2) of the four (4) residents in the survey sample. The findings included;For Resident #2, the staff failed to provide a baseline treatment for what would reveal itself to be an unstageable sacral pressure sore from 12-30-24 through 1-3-25 (5 days). Resident #2 was originally admitted on [DATE]. The Resident was discharged to the hospital on 1-14-25 and did not return. Diagnoses for Resident #2 included but were not limited to; Post infectious acute Viral encephalitis and encephalomyelitis, acute cerebral edema, intracranial space occupying lesion, persistent vegetative state, ventilator dependence, and an unstageable coccyx (later called sacrum by staff) pressure sore. Resident #2's admission Minimum Data Set (an assessment protocol) documented the Resident as completely dependent on 1-2 staff members for all Activities of Daily Living care.…

    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 before2026-02-05 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record reviews and facility documentation review, the facility staff failed to ensure the professional standards of quality regarding medication administration for one resident (Resident # 2) in survey sample of 6 residents.Findings included:Resident # 2 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's Disease, Atrial Fibrillation/Flutter, Chronic Heart Failure, Type 2 Diabetes and Hypertension. Resident # 2 was discharged from the facility on 4/20/2025.The most recent Minimum Data Set (MDS) Assessment was an admission assessment with an Assessment Reference Date (ARD) of 3/21/2025. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) Score of 13 out of 15 indicating no cognitive impairment. The assessment also coded Resident # 2 as requiring assistance of one to two staff persons with ADLs (activities of daily living.)Review of the closed electronic clinical record was conducted on 2/3/2026…

    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 before2026-02-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure medications were available for administration for 1 Resident (Residents # 2 ) in a survey of 6 residents. Findings included:Resident # 2 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's Disease, Atrial Fibrillation/Flutter, Chronic Heart Failure, Type 2 Diabetes and Hypertension. Resident # 2 was discharged from the facility on 4/20/2025.The most recent Minimum Data Set (MDS) Assessment was an admission assessment with an Assessment Reference Date (ARD) of 3/21/2025. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) Score of 13 out of 15 indicating no cognitive impairment. The assessment also coded Resident # 2 as requiring assistance of one to two staff persons with ADLs (activities of daily living.)Review of the closed electronic clinical record was conducted on 2/3/2026 - 2/5/2026.Review of the Nurses…

    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 · E2023-08-15 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain a clean and safe environment for all of the Resident room floors and common hallway located on the entrance hall of the facility. The findings included: On 8-15-23 at 11:00 a.m., Initial tour of the facility was conducted. Beginning at room [ROOM NUMBER], surveyors found crusted food debris, what appeared to be cracker or cookie crumbs, a pink gelatinous substance, tan droplets, and wet patches lining the entire hallway of Resident's rooms with no wet floor signs deployed. The hallway floor was sticky under foot, and in the individual resident rooms the floors were slick and slippery with a greasy substance which caused the surveyor to slip twice. House keeping carts were noted in the hallway with staff attending them, however, staff were in conversation with each other at the carts, and not engaged in employing the equipment for the purpose of cleaning. Bathrooms were observed to be dirty. Toilets…

    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 · D2023-08-15 · tag F0807 — failed to offer suitable drinks — isolated
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, facility documentation review, clinical record review, the facility staff failed to provide fresh drinking water for two residents (Resident #3, and #4) in a survey sample of 4 residents. For Resident #3, and #4, there was no fresh drinking water in the room from 11:00 a.m., until 3:00 p.m. The findings included: On 8-15-23 during initial tour of the facility, the Resident #3's room was observed, and an attempt to interview the Resident was conducted. The Resident had garbled speech but did shake his head to signify yes and no to questioning. The Resident was not able to ask for water. There was no fresh drinking water in the room for the Resident, and when asked if he was thirsty he signified yes by nodding his head. The room and Resident were observed again at 12:00 p.m., 1:00 p.m., 2:00 p.m., and 3:00 p.m., no fresh drinking water was in the room at any of those times. The Resident's clinical record was reviewed and indicated a swallowing evaluation was conducted by Speech Therapy on 7-25-23, and denoted that the Resident would…

    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 · D2023-03-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain residents' dignity when they failed to ensure one (Resident (R) 14) of 35 sampled residents did not have a thick growth of chin hair and one (R160) of 35 sampled residents' urinary bag was covered. Findings include: 1. An observation on 03/21/23 at 1:00 PM, revealed R14 had a thick growth of hair on her chin. Another observation on 03/22/23 at 1:05 PM, revealed R14 still had a thick growth of facial hair. Review of R14's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R14 was admitted with diagnoses that included but not limited to: dementia, hemiplegia, and hemiparesis affecting the right side. Review of R14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/23, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating R14 had severely impaired cognition. The MDS recorded R14 required extensive assistance with dressing and toileting. During an interview on 03/22/23 at 1:07 PM, Certified…

    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 · D2023-03-23 · 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

    Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Resident (#32) in a survey sample of 35 Residents. The findings included: For Resident #32, the facility staff failed accommodate 1) an electrical outlet or a power strip available on the right side and 2) family pictures where the Resident could view them. On 3/21/23 at approximately 10:00 AM, Resident #32 was observed sitting upright in her bed watching TV. Resident #32 stated that due to physical limitations of her condition she needed to have the electrical outlet or a power strip available on the right side so that she could charge her phone. Resident #32 also stated that the facility put her family pictures up where there were already hooks in the wall; however it was not located where she could view them. When asked if she had asked the facility for assistance with these issues, she stated that she had told them a few weeks ago but had heard nothing about it. On…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview, clinical record review and facility documentation the facility staff failed to provided services that meet professional standards care for 1 Resident (#21) in a survey sample of 35 Residents. The findings included: For Resident #21 the facility staff failed to follow physician orders after a Foley catheter was ordered for 1 week and a voiding trial was to be started the following week. On 3/21/23 at 9:25 AM Resident #21 was observed in her bed with eyes closed resting, the Resident had a Foley catheter with a dignity bag cover in place. On 3/22/23, a review of the clinical record revealed the following: 12/29/22 - 9:00 AM - MD/NP/PA -Progress Note - #Urinary retention: 12/28 resident with urinary retention and Foley inserted. She denies any urinary burning, difficulty urinating, bladder pressure, fever. Stated never had a UTI in the past. Foley draining clear yellow urine. - send urine for U/A & C&S, verbal orders given to nurse. -voiding trial next week. 3/9/23 10:45 AM -…

    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 before2023-03-23 · 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 observation, interview, clinical record review and facility documentation the facility staff failed to ensure that the Residents have an environment free from accident hazards to prevent avoidable accidents for 1 Resident (#20) in a survey sample of 35 Residents. The findings included: For Resident #20 the facility staff failed to identify potential hazard and implement interventions to reduce hazard and monitoring for proper functioning and effectiveness the wander guard bracelet. On 3/21/23 Resident #20 was observed sitting in his wheelchair in his room reading his bible. Attempts to converse with the Resident were unsuccessful in as resident does not speak English and has a diagnosis of dementia. A review of the clinical record revealed an order for checking the placement and function of wander guard every night. Excerpts from the care plan are as follows: INTERVENTIONS Check function of safety device as ordered by physician Reorient/validate and redirect as needed the resident needs activities that minimize the potential to wander while providing diversion 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
Show the remaining 13 citations
  • Potential for harm · D2023-03-23 · 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 record review, the facility failed to ensure tube feeding bags were properly labeled for two of five residents (Resident (R)161 and R15) sampled for tube feeding. Findings include: 1. Review of R161's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R161 was admitted with diagnoses that included tracheostomy and gastrostomy care. Review of R161's Order Summary, located under the Orders tab of the EMR, revealed a physician's order for a tube feeding. During an observation on 03/21/23 at 12:09 PM, the label on the tube feeding bag for R161 was reviewed. The label did not indicate the time the bag was hung, the rate of flow, or the initials of the person who hung the tube feeding bag. Only the first name of the resident and the date were indicated. During an observation on 03/22/23 at 2:37 PM, the label on the tube feeding bag for R161 still lacked the time, rate of flow, and initials of the person who hung the tube feeding. During an interview on 03/22/23 at 3:00 PM, Licensed Practical Nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-23 · 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, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care, consistent with professional standards of practice, for 1 Resident (#104) in a survey sample of 35 Residents. The findings included: For Resident #104 the facility staff failed to label and date and properly store the tubing for her nebulizer. A review of Resident #104's orders revealed the following: 3/14/23 6:00 PM - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML via nebulizer three times a day x 7 days. On 3/21/23 at approximately 10:00 AM, an observation was made of a nebulizer machine on the bedside table. the tubing and mouthpiece were still connected to the machine and it was laying in the open no date on the tubing and it was not in a bag or covered in any way. At that time an interview was conducted with Resident #104 who stated the staff always leave the nebulizer there on the bedside table, when asked if they clean it after each use, she stated that she has never seen them take it apart. On the afternoon of 3/22/23 at 9:30 AM,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-23 · 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

    Based on interview, clinical record review and facility documentation the facility staff failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days for 1 Resident (#'s 13) in a survey sample of 35 Residents. The findings included: 1. For Resident #13 the facility staff failed to ensure that proper evaluation and documentation by physician was obtained for a PRN Ativan order that lasted 6 weeks (4/25/22-6/4/22). On 3/22/23, during clinical record review, it was discovered that Resident #13 had orders for a routine dose of Ativan 0.5 mg twice a day and a PRN order that read: Ativan Tablet 0.5 MG (Lorazepam) - Give 1 tablet by mouth every 4 hours as needed for Anxiety -Start Date 04/25/2022 5:00 PM D/C Date 06/06/2022 9:37 AM A review of the pharmacy recommendations revealed that on 5/20/22 the pharmacy sent a form to the physician that read: Dr [name redacted] -Recommend discontinuing PRN use of Ativan for this resident [#13 name redacted] or REORDER for a specific number of days, per the federal guideline: §483.45(e)(4) PRN orders for psychotropic…

    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 · F2021-03-18 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of the facility policy, the facility failed to ensure garbage was properly disposed of and contained in closed dumpsters. Bagged garbage was left out and not immediately placed in a container. Unsanitary conditions and/or uncontained trash increases the likelihood of pest infestations and had the potential to affect all 81 residents residing in the facility at the time of the survey. Findings include: A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 10/2019, stated, It is the center policy all garbage and refuse will be collected and disposed in a safe and efficient manner. In addition, the policy stated, The Dining Services Director will ensure proper practice for handling garbage and refuse including: Garbage and refuse is removed from the kitchen area routinely during the day and at the end of the workday. The policy further stated, The Dietary Services Director will be responsible for appropriate recycling practices are in place as outlined by local authorities. On 03/15/21 at 9:55 AM, observations were…

    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 before2021-03-18 · 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 observations, interviews, and review of facility policies, the facility failed to store food under sanitary conditions. Specifically, one of two nourishment refrigerators located at the nursing stations in the facility was not clean and contained unlabeled and undated foods. This failure had the potential to affect 51 out of 81 residents in the facility who might consume food stored in the refrigerator on the North Unit. Findings include: Review of the facility's policy titled, Nursing Services Space, dated 08/15/20, stated, If a refrigerator is provided in a nursing station, it will meet the following standards: a. Be located in a clean area not subject to contamination by human waste; and e. If foods are retained in the refrigerator, they will be covered and clearly identified as the contents and date initially covered. On 03/15/21 at 10:30 AM, observations were conducted at the nursing station on the North Unit of the facility. Observation of the nourishment refrigerator revealed unlabeled and open food and drink containers in the refrigerator. Two plastic containers 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-18 · 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 interview, record review, and review of facility policies and documentation, the facility failed to ensure one of 18 sampled residents (Resident (R) 235) received the care necessary to prevent falls. Specifically, the facility failed to put interventions in place to prevent further accidents after R235 fell on [DATE]. Findings include: Review of R235's Electronic Health Record (EMR) Profile revealed R235 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, dementia, repeated falls, and disorientation. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/07/20, revealed R235 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R235's cognitive status was intact at the time of admission. The admission MDS documented R235 required extensive assistance of one person for mobility and ambulation, had an unsteady gait and used a wheelchair for mobility. The MDS assessment indicated R235 received physical…

    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 · D2021-03-18 · 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 interview, observation, material from the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility failed to ensure two staff members followed transmission-based precautions (TBP) to prevent the potential for spread of COVID-19 for one (Resident (R) 183) of 37 residents reviewed for infection control. Staff failed to wear the appropriate personal protective equipment (PPE) when entering the room of the resident, who was on quarantine due to being a new admission to the facility with unknown COVID status. Findings include: Observation on 03/15/21 at 9:45 AM revealed the facility had four quarantine rooms to be used for newly admitted residents whose COVID status was unknown. Each room had four signs on the door. One identified the room as a quarantine room with a large capital Q. The second sign had two stop signs and stated, Droplet Precautions .Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room…

    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 · D2018-06-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Staff Interview and Clinical Record Review, the facility staff failed to accurately document an assessment for one Resident, #95, in a sample of 33 Residents. For Resident #95, facility staff coded her discharge in the Minimum Data Set assessment as an unplanned discharge to the hospital, when she was instead discharged home. The Findings included: Resident #95, a [AGE] year old female, was admitted on [DATE]. Her diagnoses included but were not limited to: muscle weakness, adult failure to thrive, pneumonia, dysphagia, wheezing, and gastro-esophageal reflux disease. Her most recent Minimum Data Set (MDS) Assessment was a discharge assessment with an Assessment Reference Date (ARD) of 4/17/18. The Brief Interview for Mental Status coded Resident #95 as a 12, indicating minor impairment. Resident #95 required extensive assistance of 1 staff member for ambulation, dressing, eating, and personal hygiene; and required total assistance of 2 or more staff members for bathing. On the morning of 6/21/18, a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-06-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed, for 1 resident (Resident #82) in the survey sample of 33 residents, to implement the care plan. For Resident #82, the facility staff failed to implement the care plan by positioning devices to prevent pressure over bony prominences (float heels). The Findings included: Resident #82 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #82's diagnoses included Encounter for Attention to Tracheostomy, Congenital Cerebral Cysts, Generalized Muscle Weakness, Presence of Cerebrospinal Fluid Drainage Device, Osteoporosis, Gastro-Esophageal Reflux Disease, Seizure Disorder, Cerebral Palsy, Dependence on Respirator (Ventilator) Status, and Severe Intellectual Disabilities. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 6/8/18, coded Resident #82 as requiring the extensive physical assistance of at least 2 persons for bed mobility and transfers. In addition, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-06-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to, for two residents (Resident #79 and Resident #47) in a survey sample of 33 residents, to provide a safe environment. 1. Resident #79 did not have on non skid shoes or socks. The resident had a recent fall. 2. For Resident #47, medications were left on the over bed table when the nurse left the room. In addition, the nurse left medications unattended on the medication cart. The findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses of depression, anxiety, dementia and osteoarthritis. Resident #79's most recent MDS (minimum data set) with an ARD (assessment reference date) of 6/6/18 was coded as a quarterly assessment. Resident #79 was coded as having a BIMS (brief interview of mental status) of 6 out of a possible 15, or moderate cognitive impairment. Resident #79 was also coded as requiring extensive assistance of one to two staff members to perform activities 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-06-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — 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 ensure a system of prompt identification of potential diversion of controlled medications and provide safekeeping of hard scripts for all controlled medications for 2 residents (Residents #31 and #79) in a survey sample of 33 residents. 1. For Resident #31, the facility staff failed to send a hard copy script dated 6/5/18 for Lorazepam (for anxiety) 0.5 milligrams to the Pharmacy. 2. For Resident #79, the facility staff failed to send a hard copy script dated 6/5/18 for Oxycodone 2.5 milligrams to the Pharmacy. Oxycodone is an opioid narcotic pain medication. The findings included: 1. For Resident #31, the facility staff failed to send a hard copy script dated 6/5/18 for Lorazepam (for anxiety) 0.5 milligrams to the Pharmacy. Resident #31, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included hyperlipidemia, hypothyroidism, paranoid schizophrenia, bipolar disorder, dementia, and diabetes. 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 · D2018-06-21 · 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, staff interview and clinical record, the facility staff failed to ensure 1 resident (Resident #195) of 33 residents in the survey sample was free from significant medication errors. For Resident #195, blood pressure medication was not administered with a meal and was administered late. The findings included: Resident #195, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included cataract, congestive heart failure, a fib, anxiety, edema and orthostatic hypotension (low blood pressure). As Resident #195 was new to the facility, a Minimum Data Set assessment had not been competed. A medication pour and pass observation was conducted with Registered Nurse D (RN D) on 6/20/18 at 9:00 a.m. RN D reported that Resident #195's blood pressure was 114/60. RN D stated that she needed to hold the medication midodrine due to the blood pressure reading. Resident #195 had a physician order dated 6/18/18 for midodrine. The order read, Midodrine HCl Tablet 2.5 mg (milligram) Give 2…

    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 before2018-06-21 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and facility documentation review, facility staff failed to store food in a clean and sanitary environment. The walk in refrigerator had vegetable matter stuck to the floor under shelving units. On 6/19/18 at 11:45a.m., a tour of the facility kitchen was conducted with Employee B, a cook in dining services. When examining the walk-in fridge, vegetable scraps were found underneath the left-hand shelving unit nearest the door. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 6/20/18. On the morning of 6/21/18, Surveyors were provided with a copy of the facility Food and Nutrition Services Cleaning Standards policy. This policy included a document entitled Dining Services Cleaning Schedule [name of facility] Nursing Center. A review of this document reveals that the Walk-Ins are to be cleaned daily by the PM Cook. The policy provided also included the cleaning procedure for the walk in refrigerator. It notes that the unit should be emptied and the floor mopped and walls washed, among other steps. The cleaning…

    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

“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 AUGUST HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.0≈ chain avg
Health inspection 3 of 53.3-0.3 vs chain
Staffing 4 of 52.2+1.8 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 5 homes this chain runs (chain average 3.0★, per CMS)

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
ILIFF VA HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/01/2024
COHEN, ITAMARIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2024
DELIMBA, KATHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2024
PATEL, PIYUSHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2024

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$20.8M
Net patient revenuemost recent cost report
+3.2%
Operating marginrevenue minus expenses
$4.9M
Related-party expense24% of expenses
Who pays — share of resident-days
Medicaid 46%Medicare 10%Other / private 44%

This home reported $4.9M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$510per resident / day
operating cost
$15,501per month
≈ monthly operating cost
$527per day
avg. revenue, all payers

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

What families pay in VA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495205. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-03-23, 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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