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Riverside Lifelong Health & Rehabilitation Sanders

7385 Walker Ave, Gloucester, VA 23061 · Non profit - Corporation · 55 certified beds · (804) 693-2000 Medicare only — no Medicaid

Call the home — (804) 693-2000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 20191 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2019
  • it has 1 actual-harm citation
  • 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
  • about 32% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6530 Main St · (804) 684-5043 · Call to confirm hours
Pharmacy
6819 Waltons Ln · (804) 694-0060 · Call to confirm hours
Grocery
6632 Main St · (804) 693-6500 · Call to confirm hours
Park
Beaver Dam State Park Gloucester Virginia · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 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 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 increased12.4%14.9%15.4%better
Long-stay residents who lose too much weight7.8%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder1.4%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.4%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 injury3.4%3.6%3.3%typical
Long-stay residents whose ability to walk worsened18.9%15.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication4.4%20.6%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers6.8%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control31.1%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.4%14.2%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.4%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine98.8%73.6%79.4%better
Short-stay residents rehospitalized after admission21.8%22.3%22.6%typical
Short-stay residents with an outpatient ER visit16.6%11.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.461.521.67better
Long-stay outpatient ER visits per 1,000 resident days0.921.481.80better

* 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.

63.3% 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 335 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.3%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
57.2%U.S. median 56.6%
Met the expected recovery
0.93U.S. median 0.31
Therapy hours / resident / day
0.42hours / resident / day
Physical therapy
0.42hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 57.2% 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 173 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 0.93 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF63.3%CMS range 59.1–68.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 7.3–12.210.7%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 discharge57.2%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 discharge50.3%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 discharge54.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 stay1.4%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 worsened2.4%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 hospitalization6.0%CMS range 3.7–8.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 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

0.88
RN hours/ resident / day
1.36
LPN hours/ resident / day
2.34
Aide hours/ resident / day
4.59
Total nurse hours/ resident / day
0.36
RN hoursweekends
34.6%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 55 beds and averages 48.2 residents a day — about 88% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 4.02 hrs/resident/day on weekends vs 4.81 on weekdays — 16% thinner on weekends. RN hours go from 1.09 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below 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

3
deficiencies at the latest standard inspection (2023-07-20)
3
at the previous standard inspection (2022-03-03)

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2019-07-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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, clinical record review, and facility documentation review, the facility staff failed to prevent Resident #19 from abusing one resident (Resident #148) in a sample of 21 residents. This is harm. The Findings included: For Resident #148, the facility staff failed to protect him from abuse. Resident #148 was assaulted by Resident #19 resulting in a hip fracture. Resident #148 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #148's diagnoses included Cardiomyopathy and Alzheimer's Disease. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #148 had a Brief Interview of Mental Status Score of 00, indicating severe cognitive impairment. On [DATE], a review of Resident #148's clinical record was conducted, revealing nurses notes. According to the notes, Resident #148 was pushed by Resident #19 and he sustained a fall. Resident #148 was sent to the hospital on [DATE] at 6:30 P.M.,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility policy review, the facility staff failed to properly store, label and date food items, and clean the floors within the facility's main kitchen. This failure had the potential to affect all 51 residents who consumed food prepared from the facility's kitchen. The findings included: 1. Facility staff failed to cover stored food and discard expired milk located in walk-in Refrigerator #4. On 7/18/23 at approximately 10:45 AM, observations during the initial tour of the kitchen revealed 2 clear plastic tubs which held approximately 4 dozen ears of shucked corn on the cob located in walk-in Refrigerator #4. The tubs were labeled and dated, however there was no lid or covering to protect the exposed corn from any potential contaminants. There was also an unopened gallon of milk with an expiration date of 7/16/23 sitting on the shelf with other gallons of milk that were not expired. On 7/18/23 at approximately 11:00 AM, an interview and kitchen tour was conducted with the facility's Dietary Director (DD) who confirmed he was in charge of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-20 · 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

    Based on observation, interview, record review, and review of facility policy, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions related to pain for one (Resident (R) 6) of two sampled residents reviewed for pain in a total sample of 20. This failure placed the resident at risk of unmet care needs and a diminished quality of life. Findings include: Review of the facility policy titled, Comprehensive Care Planning, dated 07/01/23 revealed, .The facility must work with the resident and their representative, if applicable, to understand and meet the resident's preferences, choices, and goals while they are at the facility. The facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicability quality of life. The facility must develop care plans that describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences. Care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-20 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of the Recreational Therapy Director's job description, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences as identified in the resident assessment for two (Residents (R)39 and R27) of four residents reviewed for activities in a total sample of 20. This failure placed the residents at risk of a diminished quality of life. Findings include: Review of an undated Recreational Therapy Director job description, provided by the Administrator, revealed, .Implements, and evaluates activity programs which provide leisure opportunities that will meet the interests and needs of the resident, adapted to his/her medical limitations .Contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident . 1. Review of a significant change Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR with an Assessment…

    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 · D2022-03-03 · tag F0574 — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, the facility staff failed to provide required postings, including a list of names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible and understandable for the resident population for one of three buildings ([NAME] 2). The findings included: During this surveyor's initial tour of the facility on 3-1-22 observations included all resident rooms and common areas of one of three all inclusive neighborhood buildings. No posting which listed the required names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible and understandable for the resident's could be found. LPN B (Licensed Practical Nurse) was asked where the posting could be found, and she stated it had fallen off of the wall and broken, and it had not as yet been replaced. When asked how long ago that happened, she stated she could not remember, and further stated it was awhile ago. On 3-2-22 the LPN unit Manager was asked about the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-03 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to continue skilled care services following the issuance of a SNF ABN (skilled nursing facility advance beneficiary notice), when the Resident's representative selected to continue services and they would pay for them, for one Resident (Resident #15) in a sample of 3 Residents selected for review of ABN notices. The findings included: Resident #15, was admitted to the facility on [DATE], for skilled care services following hospitalization. On 12/15/21, Resident #15's responsible party (RP) was issued an ABN notice to notify them that skilled care services, to include physical therapy (PT) and occupational therapy (OT), would be ending. This notice also informed Resident #15 that as of 12/18/21, the Resident would no longer qualify for skilled care. The RP for Resident #15 selected option 2 on the ABN. This option read, I want the care listed above. I understand that I may be billed now because I am…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-03 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Observation, staff interview, clinical record review, and facility document review, the facility staff failed to perform handwashing, and gloving during medication pour and pass observations to prevent the spread of infection, for two Residents (Resident #31, and #19) in a survey sample of 15 residents observed receiving medications. The findings included: 1) LPN B filled a syringe and administered oral liquid Morphine pain medication without applying gloves. 2) LPN B did not wash her hands for a sufficient amout of time to prevent the spread of infection, 3) turned off the water faucet of the sink with ungloved bare hands which had been turned on with soiled hands. 4) LPN B then handled the now recontaminated oral syringe with bare hands placing it back in the medication cart and continued to prepare medications for the next resident. Resident #31's diagnoses included; second story fall with Paralysis, pain, and stage 4 pressure ulcer. Resident #19's diagnoses included; Osteoarthritis and pain. Resident #31 was observed on 3-1-22 at 11:30 AM. laying on an alternating…

    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 · E2019-07-11 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to provide a qualified activities director for one of three units. The findings included: 1. For Facility Unit #1, the facility staff failed to provide a qualified activities director and develop an activities program. On 07/11/2019 at approximately 9:35 AM, an interview with Employee K was conducted. When asked about her role, Employee K stated she was a social worker but also planned activities for residents living in Facility Unit #1. On 07/11/19 at 01:07 PM, Employee K verified her credentials as social worker and also stated she has not received any training in activities. A copy of the Activities Department policy was requested and the DON verified there was no Activities policy. On 07/11/2019 at approximately 4:30 PM, the administrator and DON had no further information or documentation to offer.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-07-11 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for four residents (Resident #97, Resident #27, Resident #31, Resident #297) in a sample size of 21 residents. The findings included: 1. For Resident #97, there was an active physician's order for Do not Resuscitate but the code status was listed as Full Code on the baseline care plan and on the Patient Summary page in the electronic health record. Resident #97, an [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to cerebral infarction, generalized muscle weakness, dysphagia, and mild cognitive impairment. Resident #97's admission Minimum Data Set was in progress. On [DATE] at approximately 09:30 AM, Resident #97's clinical record was reviewed. A physician's order dated [DATE] documented, Do Not Attempt Resuscitation. Ensure DNR [do not resuscitate] on file. A Durable Do Not Resuscitate Order…

    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 · E2019-07-11 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility documentation review, the facility staff failed to have quarterly QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance/Performance Improvement) meetings for 3 of a possible 4 quarters The findings include: On 07/11/19 at 12:06 PM, a review of the facility's QAA/QAPI program was conducted. When asked for the attendance logs of QAPI meetings since the last survey, the administrator presented two attendance records. One document was dated 05/30/2019 and the other was dated 06/26/2019. The administrator verified he did not have attendance logs or meeting minutes as evidence QAA/QAPI meetings were held quarterly. Also, the attendance log dated 05/30/2019 did not have the Medical Director in attendance. The facility provided a copy of their policy entitled, Quality Management Systems. In Section III, Part (a), under the header, Facility on page 5, it was documented, Conduct quarterly facility-specific Quality and Performance Improvement meetings. On 07/11/2019 at approximately 4:30 PM, the administrator and the DON had no further…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to maintain dignity for one resident (Resident #97) in a sample size of 21 residents. The findings included: For Resident #97, a facility staff member was standing over him in the dining room while coaching him to eat his breakfast on 07/10/2019. Resident #97, an [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to cerebral infarction, generalized muscle weakness, dysphagia, and mild cognitive impairment. The Minimum Data Set was in progress. On 07/10/19 at 08:07 AM, Resident #97 was observed sitting in his wheelchair in the dining room receiving assistance to eat breakfast. Employee C, a speech therapist, was standing to the left of Resident #97 and coaching him throughout the mealtime. On 07/10/19 at 08:22 AM, an interview with Employee C was conducted. When asked if it was her routine process to stand next to residents when assisting them through mealtimes, she stated.…

    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 12 citations
  • Potential for harm · D2019-07-11 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure safety and clinical appropriateness for self-administration of medication for 1 resident (Resident #297) in a survey sample of 21. The findings included: For Resident #297, the facility staff failed to properly determine the safety and clinical appropriateness for self-administration of an Albuterol inhaler. Resident #297, an [AGE] year old male, was admitted to the facility on [DATE]. On 07/09/19 at approximately 12:35 PM, during the course of an interview, an Albuterol inhaler with a spacer was observed in Resident #297's dresser drawer. Resident #297 stated, my wife brought that up here to me yesterday from home for me to start using and further stated, the nurse saw it out on my bed yesterday when my wife brought it up here and told me just to stick it in my dresser drawer, I only use it if I feel like I need to. On 07/09/19 at approximately 1:05 PM, the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0578 — failed to honor advance directives / code status — isolated
    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 documentation review and clinical record review the facility staff failed to uphold a Resident's desire to formulate an Advance directive for one Resident (Resident #27) in a survey sample of 21 Residents. The findings include: For Resident #27 the facility staff failed to notify the physician of the Resident's desire to execute a Do Not Resuscitate (DNR) and indicate in the Resident's record, this wish. Resident #27 was admitted to the facility on [DATE] with a recent readmission date of [DATE]. On [DATE] at 9:43am review of Resident #27's clinical chart revealed a signed DNR (do not resuscitate) signed on [DATE] by both of Resident #27's daughters, who are Medical Power of Attorney. The physician had not signed the form. On [DATE] at 9:43am, it was observed that on the spine of Resident #27's chart there were colored dots, yellow and red. During a staff interview to explain the dots the staff indicated that a purple dot indicates the person is a DNR (which was not present),…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · 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 interviews and clinical record review, the facility staff failed to notify the Resident and Resident's representative of the reason for and location of transfer, and failed to notify the ombudsman for one Resident (Resident #14) in a survey sample of 21 Residents. The findings included: For Resident #14 the facility staff failed to provide written notification of transfer/discharge to the Resident and/or Resident Representative; and failed to notify the ombudsman of the discharge. Resident #14 was admitted to the facility on [DATE] with a readmission date of 4/24/19. On 7/11/19 a review of Resident #14's clinical record revealed that Resident #14 was sent to the hospital on 4/22/19. Review of the entire clinical record revealed no indication that the Resident or Resident Representative had been provided a notice of transfer in writing. There was no indication that the ombudsman being notified of the transfer. On 7/11/19 at 12:34PM an interview was conducted with LPN C. When asked about…

    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 before2019-07-11 · 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a comprehensive care plan for one Resident (Resident #19) in a sample size of 21 residents. The findings included: For Resident # 19, the facility staff failed to develop a comprehensive Behavioral Care Plan to include mental health and psychosocial services after Resident #19 assaulted another resident, resulting in a hip fracture. Resident #19 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #19's diagnoses included Major Depressive Disorder, and Generalized Anxiety Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 11/28/18 coded Resident # 19 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On 7/9/19 a review was conducted of facility documentation, revealing a Facility Reported Incident follow-up report dated 2/25/19. In summary, on 2/17/19 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0657 — failed to keep the care plan current — isolated
    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 observation, staff interview, facility documentation review, and clinical record review the facility staff failed to develop a careplan to include the respiratory diagnosis and use of respiratory equipment for one Resident (Resident #31) in a survey sample of 21 Residents. The findings included: 1. For Resident #31 the facility staff failed to revise the careplan to include the diagnoses of Chronic Respiratory Failure and use of a Bi-Pap with oxygen. The care plan status was marked completed. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Chronic Respiratory Failure. Observations on 7/9/19 and 7/10/19 revealed the following: On 07/09/19 at 12:39 PM Resident #31's bi-pap was on the bedside table and an oxygen concentrator was at the bedside. On 07/09/19 at 04:33 PM the bi-pap was on the bedside table and an oxygen concentrator was at the bedside. On 07/10/19 at 09:23 AM the bi-pap was on the bedside table and an oxygen concentrator was at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · 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 observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow professional practice standards for medication and treatment administration for three Residents (Residents #16 #97, and #297) in a survey sample of 21 Residents. The staff stated their professional standard for nursing was Mosby. The findings included: 1. For Resident #16, the facility staff failed to ensure medications and treatments were not left at bedside unattended. Resident #16, was initially admitted to the facility on [DATE]. Diagnoses included; Alzheimer's type dementia, dysphagia, fractured humerus, and hand contracture. Resident #16's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-14-19 was coded as an annual full assessment. Resident #16 was coded as having severe cognitive impairment, and was not able to make her own daily life decisions. The Resident was coded as requiring extensive to total assistance of one to two staff members 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 · Dcited before2019-07-11 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to provide an activity program for two Residents (Resident #27, Resident #97) in a survey sample of 21 Residents. The findings included: 1. For Resident #27 the facility staff failed to provide a program to support the Resident's interests. Resident #27 was admitted to the facility 8/28/15. On 7/9/19 at 11:50am Resident #27 was observed in her room, in bed, with no stimulation being provided such as a radio or television on. No supplies for independent activities was observed in the room of Resident #27. On 07/09/19 at 03:18 PM Resident #27 was observed in her room, in bed with no stimulation provided. No supplies for independent activities was observed. On 7/10/19 during multiple observations throughout the day, from 9am-5pm, Resident #27 was observed in her room, in bed looking up at the ceiling. No form of stimulation was provided, such as a radio, television or any supplies for independent activities was observed. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility staff failed to mitigate an accident hazard for 1 (Resident #297) of 21 sampled residents. The findings include: For Resident #297, the facility staff failed to properly repair the handles on 3 dresser drawers that are located in his room and being accessed by him for storage of personal belongings. Resident #297, an [AGE] year old male was admitted to the facility on [DATE]. On 07/09/19 at approximately 12:35 PM, during initial tour of the facility, Resident #297 shared concerns regarding sharp objects in his dresser drawers and stated, I am afraid my hand may catch on the screw that is sticking out and scratch me, I have asked numerous times for them to come look at it and fix it. Three drawers in his dresser revealed the heads of screws protruding approximately 2 centimeters on the inside of the drawer. Sharp edges existed around the circumference of the screw heads. The screws were holding the outside dresser drawer handles in place.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide appropriate treatment and services for 1 resident (Resident #39) with a clinically-justified indwelling urinary catheter in a survey sample of 21 residents. The findings included: For Resident #39, the facility staff failed to secure the tubing of the indwelling urinary catheter in a manner that would reduce the risk for a traumatic dislodgement from the Resident's bladder. Resident #39, a [AGE] year old female, was admitted to the facility on [DATE] with diagnoses including but not limited to stroke and urinary retention. On 7/10/19 at approximately 1:20pm, RN C was observed changing an incontinence brief for Resident #39 who has a clinically-justified indwelling urinary catheter which was unsecured. RN C responded, it [urinary catheter tubing] should be secured to her leg, otherwise it can catch on stuff and be pulled out accidentally, that can cause trauma to her urethra.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review the facility staff failed to ensure one Resident, Resident #27, was served the correct therapeutic diet in a survey sample of 21 Residents. The findings include: Resident #27 was admitted to the facility on [DATE] with a recent readmission date of 3/13/19. Resident #27 has diagnoses of bipolar disorder, muscle weakness, impaired gait, stiffness of left hand, paresthesia, carpal tunnel syndrome left upper limb, Lewy body dementia, anxiety, multiple sclerosis, mild cognitive impairment, and hypertension. On 7/9/19 at 12:47pm Resident #27 was observed in bed being fed by staff. She had one bowl containing of pureed chicken, one single serving of applesauce and 120cc of juice. On 07/11/19 at 08:55 AM, Resident # 27 received a bowl of eggs, a single serving container of yogurt and 120cc of cranberry juice. Note: The facility does not use meal tickets. The resident diet listing read, puree, nectar liquids, allergic to lemon per…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to ensure that a multi dose vial of TB (tuberculosis) Test medication was dated after being accessed via needle puncture for 1 of 2 sampled units and failed to safely secure an Albuterol inhaler for 1 of 21 sampled residents. The Findings included: On 7/9/19 at 12 Noon, an observation was conducted of the Rehabilitation Unit's medication storage room. Licensed Practical Nurse G (LPN G) was present. She unlocked the refrigerator, and handed the surveyor a 50% empty bottle of Aplisol 10 Test (TB Test with 10 doses). When asked why the bottle had not been dated when opened, LPN G stated, They should have dated it when it was opened. It looks like two doses are missing. On 7/11/19 at 9:45 A.M. an interview was conducted with the corporate nurse (Employee E). She stated that when the bottle is unopened, it contains 10 doses. On 7/12/19 a review of facility documentation was conducted. The Medication Ordering 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-11 · 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, facility documentation review, and clinical record review the facility staff failed to maintain respiratory equipment in a manner to prevent infections for one Resident (Resident #31) in a survey sample of 21 Residents. The findings included: For Resident #31 the facility staff failed to store the Bi-Pap tubing in a manner to prevent the development of infection. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Chronic Respiratory Failure. Observations on 7/9/19 and 7/10/19 revealed the following: On 07/09/19 at 12:39 PM Resident #31's bi-pap tubing was noted in floor behind the oxygen concentrator. On 07/09/19 at 04:33 PM the bi-pap tubing was noted in floor behind the oxygen concentrator. On 07/10/19 at 09:23 AM the bi-pap tubing was noted in floor behind the oxygen concentrator. On 07/10/19 at 01:13 PM the bi-pap tubing was noted in floor behind the oxygen concentrator. Review of Resident #31's physician…

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

RatingThis homeChain avg
Overall 5 of 53.3+1.7 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 5 of 53.2+1.8 vs chain
Quality measures 3 of 53.7-0.7 vs chain
The other 5 homes this chain runs (chain average 3.3★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
RIVERSIDE HEALTHCARE ASSOCIATION, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/10/2003
RECTOR & VISITORS OF THE UNIVERSITY OF VIRGINIAOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST5%since 07/10/2023
RIVERSIDE INTEGRATED SERVICES INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST95%since 07/10/2023
ALEWYNSE, JOYCEIndividualCORPORATE DIRECTORsince 03/01/2022
BATES, JAREDIndividualCORPORATE DIRECTORsince 03/01/2022
HAYWOOD, BARBARAIndividualCORPORATE DIRECTORsince 01/01/2016
SMITH, CONWAYIndividualCORPORATE DIRECTORsince 01/01/2010
SMITH, KIRBYIndividualCORPORATE DIRECTORsince 06/01/2007
TILLER, BROOKEIndividualCORPORATE DIRECTORsince 03/01/2022
VERSER, JOSEPHIndividualCORPORATE DIRECTORsince 03/01/2022
ZEIDLER, JEANNEIndividualCORPORATE DIRECTORsince 01/01/2019
AUSTIN, WALTERIndividualCORPORATE OFFICERsince 07/02/2012
DACEY, MICHAELIndividualCORPORATE OFFICERsince 01/01/2019
DOWNEY, WILLIAMIndividualCORPORATE OFFICERsince 06/01/2007
HECKLER, EDWARDIndividualCORPORATE OFFICERsince 01/01/2019
HOUSER, JASONIndividualCORPORATE OFFICERsince 01/01/2019
NELSON, LINWOODIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025

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

Follow the money — this home’s finances

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

$9.9M
Net patient revenuemost recent cost report
-17.2%
Operating marginrevenue minus expenses
$3.8M
Related-party expense32% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 12%Other / private 88%

This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 32% 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. 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

$343per resident / day
operating cost
$10,415per month
≈ monthly operating cost
$292per 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 495383. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-07-20, 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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