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Falls Run Nursing And Rehabilitation

140 Brimley Drive, Fredericksburg, VA 22406 · For profit - Corporation · 90 certified beds · (540) 752-0111 Medicare & Medicaid certified

Call the home — (540) 752-0111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 28 lower-level deficiencies on record (see below)
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
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • 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.

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
10 Stafford Lakes Pkwy Ste 106 · (540) 370-0295 · Call to confirm hours
Pharmacy
Rite Aid0.8 mi
1095 International Pkwy · (540) 286-0154 · Call to confirm hours
Grocery
Aldi0.7 mi
1030 Warrenton Rd · (855) 955-2534 · Call to confirm hours
Park
Fredericksburg Battlefield · Typically dawn to dusk
Place of worship
2012 International Pkwy · (540) 701-0203

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 5 of 5
Long-stay residentspeople who live here 5 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 held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.0%14.9%15.4%better
Long-stay residents who lose too much weight0.0%5.4%5.4%check this — see note marked star below the table
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 symptoms27.3%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 injury0.9%3.6%3.3%better
Long-stay residents whose ability to walk worsened25.4%15.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.3%20.6%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers0.6%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control26.2%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.9%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine99.5%73.6%79.4%better
Short-stay residents rehospitalized after admission19.2%22.3%22.6%better
Short-stay residents with an outpatient ER visit5.8%11.5%12.0%better

* 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.

59.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 425 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.4%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
74.3%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 74.3% 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 218 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 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.4%CMS range 54.1–62.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 9.7–15.010.7%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 discharge74.3%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 discharge75.7%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 discharge72.0%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 identified98.9%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 setting96.9%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 discharge95.2%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 stay0.4%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 worsened0.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 4.3–8.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

0.80
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.73
Total nurse hours/ resident / day
0.65
RN hoursweekends
48.6%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 87.3 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.89 on weekdays — 15% thinner on weekends. RN hours go from 0.86 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2023-03-16)
9
at the previous standard inspection (2021-08-26)

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

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2023-03-16 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 37 residents in the survey sample, Residents #32, #31, and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to implement the care plan to attempt non-pharmacological interventions as part of the resident's pain management program. A review of R32's physician orders revealed the following order dated 1//17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. A review of R32's March 2023 MAR (medication administration record) revealed the resident received the Oxycodone-Acetaminophen as ordered on 3/2/23, 3/4/23, 3/6/23, 3/11/23, 3/12/23, and 3/14/23. Further review of the clinical record revealed no evidence that non-pharmacological interventions were offered to R32 prior to the administration of Oxycodone-Acetaminophen on all six of the dates in March 2023. A review of R32's 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-16 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #32 and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to offer non-pharmacological interventions and assess for the location of a resident's pain prior to administering an as needed pain medication on multiple occasions in March 2023. A review of R32's physician orders revealed the following order dated 1/17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. A review of R32's March 2023 MAR (medication administration record) revealed the resident received the Oxycodone-Acetaminophen as ordered on 3/2/23, 3/4/23, 3/6/23, 3/11/23, 3/12/23, and 3/14/23. Further review of the clinical record revealed no evidence that non-pharmacological interventions were offered to R32 prior to the administration of Oxycodone-Acetaminophen on all six of these dates…

    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 · Ecited before2023-03-16 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff administered the as needed pain medication, tramadol, outside of the physician's order for pain rated between six to ten on a scale of one to ten (one being least and ten being most) on multiple dates in January 2023 and February 2023. The staff administered tramadol for a pain rating less than six. A review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's January 2023 and February 2023 MARs (medication administration records) revealed the resident was administered as needed tramadol for pain rated less than six on the following dates: 1/3/23 (pain rated as two) 2/4/23 (pain rated as four) 2/20/23 (pain rated as zero) 2/23/23 (pain rated as zero) 2/28/23 (pain rated as three) 2/28/23…

    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 · D2023-03-16 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to initiate a written grievance for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to initiate a written grievance when the resident reported a missing coat. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/2/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. On 3/14/23 at 3:31 p.m., an interview was conducted with R6. The resident stated someone stole their winter coat in November 2022. R6 stated this was reported to multiple staff and the coat was supposed to be replaced but it had not yet been replaced. A review of R6's clinical record failed to reveal documentation regarding R6's missing coat. A review of the November 2022 and December 2022 grievances failed to reveal documentation regarding R6's missing coat. On 3/16/23 at 9:17 a.m., an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide adequate supervision for one of 37 residents in the survey sample, Residents #272. This deficiency is cited as past non-compliance. The findings include: The facility staff failed to have effective interventions implemented to prevent Resident #272 from wandering into other resident rooms. Resident #272 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus, hypertension and adult failure to thrive. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, which indicated the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, hygiene and bathing;…

    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 · Past Non-Compliance
  • Potential for harm · D2023-03-16 · 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, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a urinary catheter for one of 37 residents in the survey sample, Resident #53. The findings include: For Resident #53 (R53), the facility staff failed to secure the resident's urinary catheter bag in a sanitary manner. A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. (1) A review of R53's clinical record revealed a physician's order dated 2/12/23 for a urinary catheter. On 3/15/23 at 8:19 a.m., R53 was observed lying in bed. The resident's urinary catheter bag was secured to the bed frame under the bed and touching the floor. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that if a resident is lying in bed, then their urinary catheter bag should hang on a bar under the bed and should not touch the floor because someone could step on it and because of infection. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per physician orders, for two of 37 residents in the survey sample, Residents #18 and #31. The findings include: 1. For Resident #18 (R18), the facility staff failed to administer oxygen at the physician prescribed rate of four liters per minute. A review of R18's clinical record revealed a physician's order dated 1/22/23 for oxygen at four liters per minute via nasal cannula every shift. R18's comprehensive care plan revised on 1/24/23 documented, Oxygen as needed . On 3/14/23 at 12:40 p.m. and 3/15/23 at 2:31 p.m., R18 was observed lying in bed receiving oxygen via nasal cannula at one and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the one-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-16 · 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 observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to properly store medications for one of 37 residents in the survey sample, Resident #59. The findings include: For Resident #59 (R59), the facility staff failed to secure a bottle of Vitamin D 10000 IU (international units) and one bottle of multivitamins in the resident room. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/21/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. On 3/14/2023 at 1:46 p.m., an observation was made of Resident #59's (R59) room. R59 was not in the room at the time however their family member was in the room. R59's family member stated that the resident was in therapy. Observation of R59's room revealed two bottles of medication on top of the nightstand beside the bed. One bottle was labeled Vitamin D 10000 IU…

    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 · D2023-03-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 37 residents in the survey sample, Resident #26. The findings include: For Resident #26 (R26), the facility staff failed to maintain an accurate ADL (activities of daily living) documentation record for February 2023. On the most recent MDS (minimum data set), a five day admission assessment with an ARD (assessment reference date) of 2/8/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. Section G documented R26 required extensive assistance of one person for bed mobility and limited assistance of one person for transfers, toileting and personal hygiene. The comprehensive care plan for R26 documented in part, At risk for self care deficit severe sepsis and amputation. Date Initiated: 02/05/2023. A review of the ADL documentation for R26 failed to evidence documentation of personal hygiene,…

    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 · Ecited before2021-08-26 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to provide Resident # 14 and the resident's representative written notification of a facility-initiated transfer on 05/19/2021 and 06/22/2021 for Resident # 14. Resident # 14 was admitted to the facility with diagnoses that included but were not limited to: rectal bleeding and diabetes. Resident # 14's most recent MDS [minimum data set], a quarterly assessment with an ARD (assessment reference date) of 05/30/2021, coded Resident # 14 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. The facility's Progress Note for Resident # 14 dated 05/19/2021 at 3:05 p.m., documented in part, Resident currently transferred to [Name of Hospital] for evaluation of possible GI [gastrointestinal (stomach and intestines)] bleed. The facility's Progress Note for Resident # 14 dated 06/22/2021 at 12:31 p.m., documented in part, Resident noted to have blood in her stool x 2 [times two] and has been loosing [Sic.]…

    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
Show the remaining 18 citations
  • Potential for harm · Ecited before2021-08-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure food storage in a safe manner, and failed to clean the kitchen stove. The walk-in refrigerator contained expired milk cartons and pudding. The stove top contained areas of built-up grease that was burned on to the grates, elements, and stove top surface. The stove top also contained ashy material that scraped up easily with a gloved finger. The findings include: On 8/24/21 at 10:50 a.m., observation was made of the facility kitchen. The walk-in refrigerator contained approximately 1 1/2 quarts of a dark brown, thick substance labeled nutritional pudding. The label had an expiration date of 8/23/21. The walk in refrigerator also contained 19 individual cartons of milk, all with expiration dates of 8/22/21. The stove top contained areas of crusty, black debris, which flaked off easily. Some of the debris had the appearance of ash. The loose debris was easily wiped away with a gloved finger. The stove top and grates contained areas of built-up grease. OSM…

    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 · D2021-08-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a call bell within reach for one of 28 residents in the survey sample, Resident #8. The facility staff failed to maintain Resident #8's call bell within reach on 8/24/21. Resident #8 was lying in bed and the resident's call bell was on the floor under the bed. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to diabetes, major depressive disorder and a history of falling. Resident #8's quarterly minimum data set assessment with an assessment reference date of 5/17/21, coded the resident's cognition as moderately impaired. Section G coded Resident #8 as requiring limited assistance of two or more staff with bed mobility and as requiring extensive assistance of one staff with transfers. On 8/24/21 at 12:04 p.m. and 12:47 p.m., Resident #8 was observed lying in bed watching television.…

    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 before2021-08-26 · 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 and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 28 current residents in the survey sample, Resident #430. The facility failed to develop a baseline care plan to address the physician prescribed anticoagulant medication Warfarin and monitoring for the medication for Resident #430 upon admission. The findings include: Resident #430 was admitted to the facility on [DATE]. Resident #430's diagnoses included but were not limited to: congestive heart failure 'CHF' (circulatory congestion and retention of salt and water by the kidneys) (1), heart block (conduction disorder of the heart whereby electrical impulses are slowed either partially or completely) (2), pacemaker (electrical device used to maintain a normal heart rhythm by stimulating the heart muscle to contract) (3) and chronic kidney disease (decreased function of the kidneys) (4). Resident #430's most recent MDS (minimum data set) assessment, a 5 day Medicare…

    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 before2021-08-26 · 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, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #8. The facility staff failed to implemented Resident #8's comprehensive care plan for maintaining the resident's call bell within reach. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to diabetes, major depressive disorder and a history of falling. Resident #8's quarterly minimum data set with an assessment reference date of 5/17/21, coded the resident's cognition as moderately impaired. Section G coded Resident #8 as requiring limited assistance of two or more staff with bed mobility and as requiring extensive assistance of one staff with transfers. Resident #8's comprehensive care plan dated 2/16/17 documented, Self-care deficit. Resident has dx (diagnosis) Muscle Weakness, Gait Abnormality, CAD…

    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 before2021-08-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services in a sanitary manner for two of 28 residents in the survey sample, Resident #130 and Resident #72. 1. Resident #130's nebulizer mask and medication delivery tank was observed on separate occasions uncovered when not in use and the residents oxygen tubing was observed uncovered and wrapped around the top of an oxygen tank on the back of the resident's wheelchair. 2. The facility staff failed to store oxygen equipment in a sanitary manner for Resident #72. Nasal cannula tubing was observed uncovered and wrapped around the top of the tank that was not in use, located on the back of Resident #72's wheelchair. The findings include: 1. Resident #130 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, chronic obstructive pulmonary disease (COPD -general term for chronic, nonreversible lung…

    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 · D2021-08-26 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on employee record review and staff interview, it was determined that the facility staff failed to perform an annual performance review for one of five CNA (certified nursing assistant) records reviewed. The findings include: On 8/24/2021 at 4:15 p.m., a review of the facility's CNA annual training and performance review was conducted. Review of five CNA transcripts revealed one of five CNAs selected for review did not have an annual performance review. Review of CNA #2's transcript documented a hire date of 6/1/2018. Further review of the transcript documents provided dated 6/1/2020 through 6/1/2021 failed to evidence documentation of an annual performance review. On 8/24/2021 at approximately 4:45 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the annual performance review for CNA #2. ASM #1 stated that CNA #2's annual performance review had not been completed. ASM #1 stated that CNA #2 only worked prn (as needed) and they were not sure when they had last worked. A request was made to ASM #1 for documentation verifying CNA #2's…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one the drug regime for one of 28 residents in the survey sample, Resident #72, was free of unnecessary pain medications. The facility staff administered Tylenol prescribed for Resident #72, for pain scale ratings above below the physician ordered parameters of 1-4 and administered Tramadol HCL for a pain rating 4, for which the physician prescribed Tylenol. The findings include: Resident #72 was admitted to the facility on [DATE] with the diagnoses of but not limited to benign prostatic hyperplasia (an enlarged prostate) (1), high blood pressure, atrial fibrillation (a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria)(2), sepsis,(your body's overactive and extreme response to an infection) (3), spinal stenosis, (Spinal…

    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 · D2021-08-26 · 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, facility document review and clinical record review, it was determined that the facility staff failed to implement infection control practices for one of eight residents in the medication administration observation, Resident #281. The facility staff failed to administer medication in a sanitary manner to Resident #281 on 8/25/21. LPN (Licensed practical nurse) #1 touched and administered a dropped pill to Resident #281 with gloved hands that were worn while touching the medication cart and vital sign machine. The findings include: Resident #281 was admitted to the facility on [DATE]. Resident #281's diagnoses included but were not limited to heart failure, muscle weakness and high blood pressure. Resident #281's admission minimum data set assessment with an assessment reference date of 8/18/21, coded the resident as being cognitively intact. On 8/25/21 at 8:34 a.m. LPN #1 was observed preparing Resident #281's medications with gloved hands. LPN #1 touched the medication…

    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 · E2019-09-06 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the Advanced Directives policy to ensure periodic reviews with resident and/or responsible party, were provided to formulate Advance Directives, or, if applicable, make changes to their existing Advance Directives or maintain them as written, for seven of 40 residents in the survey sample, Residents #22, #15, #30, #20, #57, #36, and #14. The findings include: 1. Resident #22 did not have any Advance Directives, the facility staff failed to conduct a periodic review to determine if the resident or responsible party wished to develop Advance Directives later. Resident #22 was admitted to the facility on [DATE]. Diagnoses included but are not limited to stroke, aphasia, high blood pressure, diabetes, gastrostomy, quadriplegia, dysphagia, adult failure to thrive, and contractures. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/15/19 coded the resident as severely…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2019-09-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in the main kitchen freezer. In the main freezer a box of frozen green beans and lima beans were observed not closed and sealed exposing the food to the environment. The findings include: On 9/4/19 at 11:11 AM to 11:20 AM a tour of the kitchen was conducted with OSM #3 (Other Staff Member) the Assistant Dietary Manager. The following was identified: • A box of frozen green beans was found in the freezer, with the lid not securely closed and the bag inside was not sealed. The food was exposed to environment of the freezer. • A box of frozen lima beans was found in the freezer, with the lid not securely closed and the bag inside was not sealed. The food was exposed to environment of the freezer. On 9/4/19 at approximately 11:15 AM, OSM #3 stated it should be sealed. On 9/4/19 at approximately 11:17 AM, OSM #2, the Dietary Manager, was notified of the concern. A review of the facility policy, Storage of Frozen Foods documented, .11.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-06 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review it was determined facility staff failed to protect confidentiality of the medical record for one of 40 residents in the survey sample, Resident #25. The findings include: Resident #25 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #25's diagnoses included but were not limited to chronic obstructive pulmonary disease (1) and hyperlipidemia (2). Resident #25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/01/19, coded Resident #25 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. On 9/04/19 at 4:39 p.m., LPN (licensed practical nurse) #8 was observed administering medication to Resident #25. LPN #8 pushed the medication cart to the hallway opposite the doorway to Resident #25's room. LPN #8 prepared one Omeprazole (3) 40 mg (milligram) tablet into a medication cup…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-06 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — 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 document review, it was determined that the facility staff failed to evidence that any of the required documentation was provided to the receiving health care institution on transfer to the hospital for one of 40 residents in the survey sample, Resident #43. The findings include: Resident #43 was admitted on [DATE]; diagnoses included but are not limited to Alzheimer's disease, high blood pressure, dysphagia, anxiety disorder, and adult failure to thrive. The quarterly/5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/25/19 coded the resident as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; and extensive care for transfers, mobility, dressing, eating, toileting and hygiene. A review of the nurse's notes dated 7/14/19 documented, Around 4:15 a.m. resident observed with large amounts of coffee ground emesis on his clothing, mouth, and blankets.…

    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 before2019-09-06 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident representative upon a hospital transfer for two of 40 residents in the survey sample, Residents #43 and #22. The findings include: 1. The facility staff failed to provide Resident #43 or the resident representative with written notification of a hospital transfer on 7/14/19. Resident #43 was admitted on [DATE], with diagnoses including but not limited to Alzheimer's disease, high blood pressure, dysphagia, anxiety disorder, and adult failure to thrive. The quarterly/5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/25/19 coded the resident as severely cognitively impaired in ability to make daily life decisions. A review of the nurse's notes dated 7/14/19 documented, Around 4:15 a.m. resident observed with large amounts of coffee ground emesis on his clothing, mouth, 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-06 · 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 2. The facility staff incorrectly coded Resident #15's quarterly MDS dated [DATE] for the administration of insulin. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to peripheral vascular disease, intervertebral disc disorders, ischemic heart disease, diabetes, depression, bladder dysfunction, osteoporosis, high blood pressure, and anxiety. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19 coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for mobility, transfers, dressing, hygiene, and toileting; limited assistance for bathing; and supervision for eating. A review of the above MDS revealed in Section N Medications the resident was coded as having received insulin injections for seven days of the seven-day look back period. Record the number of days that insulin injections were received during the last 7 days or since…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-06 · 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 40 residents in the survey sample, Residents #67 and #222. The facility staff failed to develop Resident #67's baseline care plan to include the use of an incentive spirometer and staff failed to develop a baseline care plan related to the use of bed rails for Resident #222. The findings include: 1. The facility staff failed to develop Resident #67's baseline care plan to include the use of an incentive spirometer (1). Resident #67 was admitted to the facility on [DATE]. Resident #67's diagnoses included but were not limited to difficulty swallowing, tremor and surgical aftercare following surgery on the circulatory system. Resident #67's most recent MDS (minimum data set), a 14 day Medicare assessment with an ARD (assessment reference date) of 8/30/19, coded the resident as being cognitively intact.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-06 · 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, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement the plan of care for two of 40 residents in the survey sample, Residents #222 and #57. Resident #222 and Resident #57 were observed receiving oxygen at a rate that was not prescribed by the physician. The findings include: 1. The facility staff failed to implement Resident #222's comprehensive care plan to administer oxygen at the physician-ordered rate. Resident #222 was admitted to the facility on [DATE] with diagnoses including, but not limited to cancer of the esophagus and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/26/19, Resident #222 was coded as having mild cognitive impairment for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as receiving oxygen in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, the comprehensive person-centered care plan, for three of 40 residents in the survey sample, Residents #222, #57, and #67. The facility staff failed to administer oxygen at the physician-ordered rate during multiple observations conducted for Resident #222 and #57, and failed to obtain a physician's order for Resident #67's use of an incentive spirometer. The findings include: 1. During multiple observations the facility staff failed to administer oxygen to Resident #222 at the physician-ordered rate. Resident #222 was admitted to the facility on [DATE] with diagnoses including, but not limited to cancer of the esophagus and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-06 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for two of 40 residents in the survey sample, Residents #61 and #222. The facility staff failed to assess Resident #61 and Resident #222 for the use of bed rails, and staff failed to review risks and benefits for use of bed rails, and failed to obtain informed consent for the resident's use of bed rails. The findings include: 1. The facility staff failed to evidence that Resident #61 was assessed for the use of bed rails and staff failed to review the risks and benefits and obtain informed consent for the resident's use of bed rails. Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included but were not limited to heart failure, seizures and history of heart attack. Resident #61's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/21/19, coded the resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
VOLPE, BENJAMINIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
WEISBERG, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 03/01/2019
NICOLUZAKIS, GREGORYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/01/2019
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
KULP, JEFFREYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/09/2017
BUNDLE TENANT LLCOrganizationADP OF THE SNFsince 02/05/2026
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 09/22/2010
MS STAFFORD, L.P.OrganizationADP OF THE SNFsince 08/01/2015
SABER GOVERNANCE LLCOrganizationADP OF THE SNFsince 09/01/2019
SABER HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 10/21/2010
TCF NATIONAL BANKOrganizationADP OF THE SNFsince 07/19/2019
WALKER & ASSOCIATES PCOrganizationADP OF THE SNFsince 09/22/2010
AHMAD, IMRANIndividualADP OF THE SNFsince 01/08/2026

CMS files one row per role, so the 21 rows in the source record cover these 13 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.

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

Follow the money — this home’s finances

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

$12.2M
Net patient revenuemost recent cost report
+11.5%
Operating marginrevenue minus expenses
$1.5M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 6%Medicare 18%Other / private 76%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$370per resident / day
operating cost
$11,252per month
≈ monthly operating cost
$418per day
avg. revenue, all payers

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

What families pay in VA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495407. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-03-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

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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