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Belvoir Woods Health Care Center At The Fairfax

9160 Belvoir Woods Pkwy, Fort Belvoir, VA 22060 · For profit - Corporation · 56 certified beds · (703) 799-1333 Medicare only — no Medicaid

Call the home — (703) 799-1333 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

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)
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (56%) runs well above the national median (45%)

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

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

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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7740 Gunston Plz · (703) 339-5858 · Call to confirm hours
Pharmacy
7403 Lockport Pl · (571) 642-5262 · Call to confirm hours
Grocery
7205 Lockport Pl · (571) 642-0005 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
9301 Richmond Hwy · (703) 339-6572

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 2 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 increased23.5%14.9%15.4%worse
Long-stay residents who lose too much weight4.2%5.4%5.4%better
Long-stay residents with a catheter left in their bladder3.5%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.6%1.6%2.0%worse
Long-stay residents with depressive symptoms0.0%18.7%6.5%check this — see note marked star 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 on antianxiety or hypnotic medication2.8%20.6%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers3.2%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control18.8%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.7%14.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.6%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine99.6%73.6%79.4%better
Short-stay residents rehospitalized after admission22.9%22.3%22.6%typical
Short-stay residents with an outpatient ER visit7.4%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days0.911.521.67better
Long-stay outpatient ER visits per 1,000 resident days0.861.481.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

67.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 349 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.3%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
62.4%U.S. median 56.6%
Met the expected recovery
0.80U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.38hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 62.4% 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 210 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 0.80 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNF67.3%CMS range 61.8–71.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.6–13.910.7%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 discharge62.4%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 discharge45.2%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 discharge64.3%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%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 worsened0.8%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 hospitalization5.2%CMS range 3.7–8.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.53
RN hours/ resident / day
2.09
LPN hours/ resident / day
2.35
Aide hours/ resident / day
4.96
Total nurse hours/ resident / day
0.46
RN hoursweekends
56.2%
Total nursing turnover
73.7%
RN turnover

How full it usually is: this home is certified for 56 beds and averages 48.3 residents a day — about 86% occupied, or roughly 8 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 4.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 4.66 hrs/resident/day on weekends vs 5.08 on weekdays — 8% thinner on weekends. RN hours go from 0.55 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

14
deficiencies at the latest standard inspection (2026-03-18)
2
at the previous standard inspection (2023-01-11)

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

Inspection deficiencies

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

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · E2026-03-18 · tag F0574 — pattern
    The resident has the right to receive notices in a format and a language he or she understands.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, and staff interview it was determined that the facility staff failed to inform the residents of the location for the contact information for the State Survey Agency and the State Long-Term Care Ombudsman program.The findings include:During an observation of the third floor on 3/11/2026 at approximately 9:30 am, the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was observed to be posted behind the concierge's desk on the wall, inaccessible to the residents. No other signage with the required information was hung on the third floor.During the Resident Council Meeting on 3/11/2026 at approximately 11:07 am, 10 out of 10 residents were unable to identify where the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was located. They were unaware that they had the right to file a complaint with the State…

    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 · E2026-03-18 · tag F0575 — pattern
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, and staff interview it was determined that the facility staff failed to post the required State Survey Agency, the State licensure office, and the Office of the State Long-Term Care Ombudsman program information in a place that is accessible to all residents.The findings include:During an observation of the third floor on 3/11/2026 at approximately 9:30 am, the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was observed to be posted behind the concierge's desk on the wall, inaccessible to the residents. No other signage with the required information was hung on the third floor.During the Resident Council Meeting on 3/11/2026 at approximately 11:07 am, 10 out of 10 residents were unable to identify where the list of names, addresses (mailing and email), and telephone numbers of the State licensure office, and the Office of the State Long-Term Care Ombudsman program information was located. They were unaware that they…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-18 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and a review of clinical records, the facility staff failed review and revise the person-centered care plan for 4 for 38 residents (Resident #7, #10, #11 and #43), in the survey sample.1. The facility staff failed to review and revise Resident #7's care plan to include an election of hospice services with an admission to hospice services on 3/8/26.Resident #7 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' current diagnoses included Alzheimer's disease, heart failure, and diabetes. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/22/2025, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident #7's cognitive abilities for daily decision-making were severely impaired. A review of the active care plan, with a target date of 3/26/26, failed to identify a care plan addressing the residents' admission 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-18 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and a review of the clinical record, the facility staff failed to provide the necessary activities of daily living (ADLs) for 4 dependent residents (Resident #16, Resident #67, Resident #49 and Resident #45) of the 38 residents in the survey sample. 1.The facility staff failed to provide at least 2 showers a week and to wash the residents' hair since admission. Resident #16 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included repeated falls and unsteadiness on feet. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/04/26 was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15. This indicated that Resident #16's cognitive abilities for daily decision-making were intact. The resident's personal care plan dated 2/26/26 with a focus on bathing had a Goal specifying resident will gain increased functional ability…

    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 · E2026-03-18 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the Quality Assurance and Performance Improvement (QAPI) program, the facility staff failed to identify failed systems. The findings included:On 3/18/26 at approximately 11:30 AM, an interview was conducted with the Administrator (ADM) regarding any specific care areas or services the committee had identified as not functioning well, or that had failed. Information comes from data collected from the 5-star report, Resident Council meetings, grievances, families, residents, and the Interdisciplinary Team members. The ADM further stated that falls, pressure ulcers, and a newly developed process related to transcription errors were current systems they had identified and were ongoing. The three areas identified during the survey were not identified by the facility's staff and were not presented to the QAPI team. Throughout the survey conducted 3/10/26 through 3/13/26 and 3/16/26 through 3/18/26, three system failures were identified. They were Activities of Daily Living, specifically showers/tub baths, reviews and revisions of person-centered care plans, 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 and interviews, the facility staff failed to ensure that two (2) residents (Resident #18 and Resident #5) in the survey sample of 38 residents lived in a comfortable, homelike environment.The findings include: 1. The facility staff failed to ensure the Resident #18 remained comfortable and warm in her room, room [ROOM NUMBER] B. Resident #18 was originally admitted to the facility on [DATE] after an acute care hospital stay and readmitted on [DATE]. The current diagnoses included: Chronic Kidney DS, stage 3B, and Neuralgia and Neuritis, Unspecified. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/14/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated that Resident #18's cognitive abilities for daily decision making were intact. The resident's personal care plan dated 5/08/25 read that the resident would make their own decisions and have no memory loss. A Goal…

    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 before2026-03-18 · 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 and a review of clinical records, the facility staff failed to accurately transcribe a medication order for 1 of 38 residents (Resident 32) in the survey sample.The findings included: Resident #32 was admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included Right 5th finger osteomyelitis/septic arthritis requiring IV therapy, congestive heart failure, and atrial fibrillation. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/5/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 11 out of 15. This indicated that Resident # 32's cognitive abilities for daily decision-making were moderately impaired. Resident #32 was discharged from the hospital and admitted to the facility on [DATE] with an order for Apixaban Oral Tablet 2.5 MG. Give one tablet by mouth twice daily. A new order was written on 3/13/26 at 3:56 PM for Apixaban Oral Tablet 2.5 MG. Give…

    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 before2026-03-18 · 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 observations, staff interviews, and a review of clinical records, the facility staff failed to provide the necessary care to prevent the development of a sacral stage 3 pressure ulcer in 1 of 38 residents in the survey sample (Resident #7), constituting harm. The findings included: Resident #7 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' current diagnoses included Alzheimer's disease, heart failure, and diabetes. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/22/2025, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident #7's cognitive abilities for daily decision-making were severely impaired. In section GG0130. Self-Care: the resident was coded as requiring set-up assistance with eating and oral hygiene; supervision or touch assistance with personal hygiene; substantial/maximal assistance with toileting, showers/bathes,…

    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 before2026-03-18 · 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 an interview with Family Member #1, staff interviews, and a review of clinical records, the facility staff failed to provide adequate assistance during incontinence care to prevent a fall for 1 of 38 residents in the survey sample (Resident #10). The findings included: Resident #10 was admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses included diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care secondary to Fusion of the lumbar spine. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/6/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 5 out of 15. This indicated that Resident #10's cognitive abilities for daily decision-making were severely impaired. An interview was conducted with the Rehabilitation Director on 3/11/26 at 10:00 AM. The Rehab Director stated the resident was unable to tolerate therapy, was resistant…

    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 · D2026-03-18 · 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, resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to provide the resident with a bedside urinal upon request from the resident for 1 resident (Resident #67) out of 38 residents in the survey sample.The findings Include:Resident #67 was initially admitted to the facility on [DATE] due to a right intertrochanteric femur fracture. The residents' current diagnoses included repeated falls and unsteadiness on their feet.The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/8/2026, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of the possible 15. This indicated that Resident #67's cognitive abilities for daily decision making were intact.The resident's personal care plan dated 3/2/2026 read that the resident requires partial/moderate assistance with toilet use and the use of incontinent briefs, and is able to make self-care decisions…

    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 · D2026-03-18 · 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

    Based on information obtained during the medication administration observation, staff interviews, and a review of facility documents, the facility staff failed to ensure that the medication label was not altered from the pharmacy-printed label. The findings included:On 3/12/26 at 1:00 pm, during the medication administration observations with Licensed Practical Nurse (LPN) #3, the label on the Benzonatate 100 mg capsules medication card was noted to have a handwritten 8 covering the previous hourly instructions for administration, such as 4 hours and 12 hours. A review of the physician's order summary revealed that on 2/19/26, an order was received for Benzonatate 100 mg, 1 capsule by mouth every three hours as needed (PRN) for cough. This order was changed on 2/20/26 to Benzonatate 100 mg every eight hours PRN for cough. On 3/11/26, the order was changed to Benzonatate 100 mg, 1 capsule by mouth three times a day for cough for 5 days. The pharmacy instructions further said to use the PRN medication on hand. On 03/12/26 at 1:00 pm, an interview was conducted with LPN #3 regarding…

    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 · D2026-03-18 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 interviews and a review of the clinical record, the facility staff failed to have a hospice-coordinated plan of care for 1 of 38 residents (Resident #5), in the survey sample. The findings included: Resident #5 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included atrial fibrillation and chronic venous insufficiency.The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/9/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 3 out of 15. This indicated that Resident # 5's cognitive abilities for daily decision-making were severely impaired. An interview was conducted with Certified Nursing Assistant (CNA) #6 on 3/13/26 at approximately 12:20 PM. CNA #6 stated she had never seen a hospice aide provide any services to Resident #5. She further stated that a male nurse was observed visiting the resident approximately twice per week. A 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-18 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on information received during the infection control task, and staff interviews, the facility staff failed to document each staff member's COVID-19 information. The findings included:On 3/12/26 at 2:00 pm information for investigation of the staff COVID 19 task was provided by the Human Resource Manager (HRM). The HRM stated that they had no documentation for the employees with longevity, but all new hires initial the Orientation Acknowledgement form that says they were given COVID -19 education. The HRM could not provide the education which was acknowledged by initials for two of two selected new hires. On 3/13/26 at 11:23 am the HR manager provided their Infectious disease COVID-19 preparedness and response plan as the education. Also, the HRM was unable to provide education or documentation that all staff had been offered the COVID-19 vaccine. At 1:00 pm the HRM stated going forward they would institute a new process. The new process would document that all staff received education and would be offered the COVID -19 vaccine. On 3/18/26 at approximately 4:45 pm, a final…

    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 · D2026-03-18 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, and staff interviews, the facility's staff failed to ensure that the call bell was accessible to one (1) of 38 residents in the survey sample (Resident #72). The findings include: Resident #72 was originally admitted to the facility 3/04/26 and after an acute care hospital stay and readmitted on [DATE]. The current diagnoses included; Wedge compression fracture of fourth lumbar vertebra and Subsequent encounter for fracture with routine healing.The 5-day assessment Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/11/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #72's cognitive abilities for daily decision making were intact.On 3/12/26 at approximately 10:45 am, an interview was conducted with Resident #72 concerning his care. The resident was observed lying in bed with his head raised slightly to approximately 45 degrees; his call bell was…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 22 residents in the survey sample was free of unnecessary medications, Resident #34 (R34). The findings include: For R34, the facility staff failed to ensure an antidepressant medication was administered for an appropriate diagnosis. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/7/2022, the resident was coded as having both short- and long-term memory difficulties, and being moderately impaired for making daily cognitive decisions. The physician order dated 12/14/2022, documented, Mirtazapine (Remeron) Tablet (used to treat depression) (1) 7.5 MG (milligrams); Give 1 tablet by mouth at bedtime for appetite stimulant. This order was written by the nurse practitioner. The comprehensive care plan dated 12/2/2022 and revised on 12/15/2022, documented in part, Focus: (R34) is at risk for compromised nutritional status and weight loss r/t (related to) cancer, hx (history) 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 · D2023-01-11 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, it was determined the facility staff failed to secure hair in a hair restraint in one of two kitchens in the facility. The findings include: Observation was made on 1/10/2023 at 10:56 a.m. of OSM (other staff member) #1, the food and beverage director, walking through the kitchen. There was a staff member making food on the prep tables where she walked by. OSM #1 did not have any type of hair covering on her head. When asked if she had a hair restraint on, OSM #1 stated she usually wore a cap. When asked if she was supposed to have one on while in the kitchen, OSM #1 stated, yes. The facility policy, Uniforms and Personal Hygiene for Food Service documented in part,, Approved Hair Restraints are hair nets, (facility name) logo baseball caps, solid black or white skull caps, or white toques .Hair is neat and clean, and worn pulled away from the face. An approved hair restraint is worn at all times while preparing or plating food. ASM (administrative staff member) #1, the administrator, and ASM #2, the director 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 · Ecited before2021-08-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the treatment as ordered by the physician to promote healing of a pressure ulcer for one of 25 residents in the survey sample, (Resident #21). Resident #21 was admitted to the facility on [DATE] with a readmission on [DATE], with an unstageable pressure ulcer (1) on the sacrum/buttocks. The physician's orders for treatment to the pressure ulcer documented the treatment was to be completed on day and evening shift however, the facility staff transcribed the scheduled time for the treatment as day shift only resulting in Resident #21 receiving the treatment only once a day and not twice a day as ordered by the physician from 8/4/21 through 8/10/21. The findings include: 1. Resident #21 was admitted to the facility with diagnoses that included but were not limited to diabetes (2), heart failure (3) and end stage renal disease (4). Resident #21's most recent…

    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 · D2021-08-11 · 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 staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure resident rights by accommodating the needs of one of 25 residents in the survey sample, Resident #9. The facility staff failed to ensure accommodation of Resident #9's need for a thick wheelchair cushion. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: acute respiratory failure (inability of the heart and lungs to maintain an adequate level of gas exchange) (1), diabetes mellitus (inability of insulin to function normally in the body) (2), below the left knee amputation [LBKA] (surgical removal of the limb-below the left knee) (3) and pneumonia (inflammation of the lungs usually caused by infection with bacteria) (4). Resident #9's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 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 · D2021-08-11 · 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 observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for the use of fall mats for one of 25 residents in the survey sample, Resident # 17; and for the provision of pressure ulcer treatment per physician orders for one of 25 residents in the survey sample, Resident # 21. The findings include: 1. The facility staff failed to implement Resident # 17's comprehensive care plan for the use of fall mats while in bed. Resident # 17 was admitted to the facility with diagnoses that included but were not limited to: hypertension [1], fracture of the right Ilium [2] and muscle weakness. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was…

    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 before2021-08-11 · 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 interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for the administration of medication for one of 25 residents in the survey sample, Resident # 17; and failed to follow professional standard for the provision of pressure ulcer treatment per physician's orders for one of 25 residents, Resident # 21. The findings include: 1. The facility staff failed to accurately transcribe the physician's order of metoprolol [1] for Resident # 17. Resident # 17 was admitted to the facility with diagnoses that included but were not limited to: hypertension [2], fracture of the right Ilium [3] and muscle weakness. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions.…

    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 before2021-08-11 · 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 observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide assistive devices and failed to ensure an environment free from accident hazards for one of 25 residents in the survey sample, Resident # 17. The facility staff failed implement physician ordered fall mats on the floor while Resident #17 was in bed. The facility staff failed to place fall mats on the floor to the right and left sides of Resident #17's bed, while the resident was lying in bed. The findings include: Resident # 17 was admitted to the facility with diagnoses that included but were not limited to: hypertension [1], Fracture of the right Ilium [2] and muscle weakness. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one…

    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 · D2021-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services consistent with professional standards of practice for one of 25 residents in the survey, Resident #235. The facility staff failed to obtain an order for Resident #235's use of an incentive spirometer and failed to ensure the spirometer was stored in a sanitary manner. The findings include: Resident #235 was admitted to the facility on [DATE]. Resident #235's diagnoses included but were not limited to: heart failure (inability of the heart to pump enough blood to maintain normal body requirements) (1), atrial fibrillation (random and rapid contractions of the atria of the heart) (2) and fracture of the left femur (break in the left thighbone) (3). Resident #235's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 7/20/21, coded the resident as scoring 15 out of 15 on the BIMS…

    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 · D2021-08-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer medications in a sanitary manner for 1 of 3 residents in the Medication Administration task; Resident #93. The findings include: Resident #93 was admitted to the facility on [DATE] with the diagnoses of but not limited to osteoporosis, Barrett's esophagus, cardiac arrhythmia, high blood pressure, heart failure, atrial fibrillation, infection of right hip prosthesis, and macular degeneration. The admission MDS had not been completed as of survey. The admission BIMS (Brief Interview for Mental Status) assessment dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions. The admission nursing assessment dated [DATE] documented the resident as requiring extensive assistance for bed mobility, transfers, dressing, toileting, hygiene and bathing; and independent for eating. On 8/10/21 at 8:52 AM, LPN #2 (Licensed Practical…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HEALTHPEAK PROPERTIES, INC. — 15 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 53.5-0.5 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 4 of 54.3-0.3 vs chain
Quality measures 4 of 53.9+0.1 vs chain
The other 14 homes this chain runs (chain average 3.5★, 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 / managerTypeRoleSince
HCP S-H SUNRISE OPCO HOLDCO LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2020
HCP S-H 2014 MEMBER LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/02/2024
HCP S-H OPCO TRS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2020
HEALTHPEAK OP LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/06/2020
HEALTHPEAK PROPERTIES INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2020
S-H 2014 OPCO TRS INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 12/02/2024
SUNRISE SENIOR LIVING MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/20/2025
BOWN, KEITHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
CARTER, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2010
COELHO, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
DABBENIGNO, PETERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
FALCO, DENISEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
FRANTZ, EDWARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
HARRIS, TONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
KESSLER, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
O'RIORDAN, DAMIENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
PAINTER, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
ROYAL, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/02/2024
SEKEL, WENDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
THOMPSON, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
WELLS, ANJAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
CHENG, PATRICKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/28/2025
JOHNSTON, SHAWNIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/28/2025
RUSSO, FRANKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/28/2025

CMS files one row per role, so the 45 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

7 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.

$33.2M
Net patient revenuemost recent cost report
-13.9%
Operating marginrevenue minus expenses

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$234per resident / day
operating cost
$7,098per month
≈ monthly operating cost
$205per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Virginia Medicaid page for homes that do.

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 495197. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-18, 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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