Langley Post Acute
1028 Topping Lane, Hampton, VA 23666 · For profit - Corporation · 70 certified beds · (757) 826-4922 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- about 30% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.3% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.4% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 3.3% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.7% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 17.2% | 18.7% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.5% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.7% | 15.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.8% | 20.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.8% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.0% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.4% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.3% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.4% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.3% | 11.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.75 | 1.52 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.01 | 1.48 | 1.80 | worse |
* 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.
58.5% 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 240 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 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 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.5%CMS range 52.8–63.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 7.6–14.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 59.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 64.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 5.2–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 70 beds and averages 66.5 residents a day — about 95% occupied, or roughly 4 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 2.90 hrs/resident/day on weekends vs 3.87 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · E2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The wash cycle of the dish machine was not working properly. The findings include: The facility staff failed to ensure the dish machine was in working order. The wash cycle failed to reach a temperature of 120 degrees. On 10/01/24 at approximately 9:50 a.m., the surveyor observed two dietary staff (dietary employee #1 and #2) running the dish machine in the facility kitchen. The surveyor approached the staff and observed these staff to run the dish machine three additional times. During these observations the wash cycle never went over 112 degrees. The directions on the dish machine read minimum wash cycle 120 degrees. The dietary manager identified this machine as a low temperature machine and stated they would call maintenance and hand wash the dishes. On 10/01/24 at 12:00 p.m., the Maintenance Director (MD) was observed working on the dish machine. The MD stated they had cut the temperature up on the hot water heater 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.
- Potential for harm · Dcited before2024-10-03 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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
Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure that a resident and/or the resident representative had the opportunity to develop an Advanced Directive for 1 of 18 current residents, Resident #16. The findings include: The facility staff failed to provide evidence that they had offered Resident #16 and/or the resident representative the opportunity to develop an Advance Directive. Resident #16's diagnoses included chronic respiratory failure and adult failure to thrive. Section C (cognitive patterns) of Resident #16's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/09/24 included a brief interview for mental status (BIMS) score of 10 out of a possible 15 points. Per the MDS manual a 10=moderate cognitive impairment. During the record review the surveyor was unable to locate any information to indicate this resident and/or the resident representative had been offered the opportunity to develop an Advance Directive. On 10/02/24 at 4:35 p.m., during an end of the day meeting…
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.
- Potential for harm · Dcited before2024-10-03 · tag F0623 — isolatedProvide 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, facility document review, facility staff failed to provide written notice of transfer for 2 of 18 current residents in the survey sample. (Resident #19 and Resident #36). The findings were: 1. For Resident #19, the facility staff failed to provide the resident representative a written notice of transfer when the resident was transferred to the hospital on [DATE] or 09/25/24. The minimum data set assessment with an assessment reference date of 08/25/24 coded the resident a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderately impaired cognition (Section C - cognitive patterns). During a review of Resident #19's clinical record, progress notes read the resident was transferred to a hospital on both 08/02/24 and 09/25/24. A licensed practical nurse (LPN) note dated 08/02/24 at 2:56 a.m. read 911 in to [sic] transport resident to (hospital initials omitted) ER at 2:40 AM. Message was left on (family member name omitted) answering…
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.
- Potential for harm · D2024-10-03 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #19, the facility staff failed to provide the resident representative a written notice which specifies the duration of the bed hold policy when the resident was transferred to the hospital on [DATE] or 09/25/24. The minimum data set assessment with an assessment reference date of 08/25/24 coded the resident a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderately impaired cognition (Section C - cognitive patterns). During a review of Resident #19's clinical record, progress notes read the resident was transferred to a hospital on both 08/02/24 and 09/25/24. A licensed practical nurse (LPN) note dated 08/02/24 at 2:56 a.m. read 911 in to [sic] transport resident to (hospital initials omitted) ER at 2:40 AM. Message was left on (family member name omitted) answering machine asking him to call the facility at his earliest convenience. Another LPN note dated 09/25/24 at 5:10 p.m. read Resident presenting objective Signs [sic] that she may have Sepsis and is Hypotensive…
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.
- Potential for harm · Dcited before2024-10-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, facility document review, the facility staff failed to ensure narcotics were secured in a permanently affixed compartment on 1 of 2 units, the [NAME] unit. The findings include: The facility staff failed to provide a permanently affixed compartment for narcotics on the [NAME] unit On 10/02/24 at 3:40 p.m., the surveyor and Licensed Practical Nurse (LPN) #3 checked the medication refrigerator on the [NAME] unit. This refrigerator contained a locked black metal box. The surveyor was able to remove this box from the refrigerator and place it on the counter. LPN #3 unlocked the box, and it was observed to contain 5 vials of 1 ml Lorazepam. On 10/02/24 at 4:05 p.m., the [NAME] President of Quality provided the surveyor with a copy of their policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles. This policy read in part, Medications, biologicals, syringes, and needles are stored under proper conditions as directed by state and federal…
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.
- Potential for harm · D2024-10-03 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review, the facility staff failed to assist residents in obtaining dental care from an outside source for 1 of 18 sampled residents, Resident #1. The findings included: For Resident #1, the facility staff failed to obtain a dental consult. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Spastic Hemiplegia Cerebral Palsy, Epilepsy, and Thrombocytopenia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/22/24 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #1's clinical record revealed the following documentation: A nursing progress note dated 5/30/23 at 3:19 PM read Resident [adult child] in facility and said [their] mom's mouth hurts. Writer let PA [physician's assistant] [name omitted] know . Resident #1 was seen by the PA the following day on 5/31/23. The progress note read in part On exam, [his/her] mouth…
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.
- Potential for harm · D2024-10-03 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
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, the facility staff failed to provide evidence of staff education regarding activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, abuse prevention, procedures for reporting incidents of abuse and dementia management for 1 of 5 staff members reviewed, Certified Nursing Assistant (CNA) #5. The findings included: The facility staff were unable to provide evidence of staff education regarding prevention, identification, and procedures for reporting resident abuse and dementia management for CNA #5. On 10/03/24, surveyor requested evidence of CNA #5's staff education completed since hire. CNA #5 had been employed with the facility since September 2023. On 10/03/24 at 2:20 PM, surveyor spoke with the [NAME] President (VP) of Quality and VP of Nursing Services regarding CNA #5's education records. VP of Quality stated they could not locate any training records since hire for CNA #5. VP of Nursing Services stated the CNA…
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.
- Potential for harm · D2024-10-03 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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, the facility staff failed to provide evidence of a minimum of 12 hours of annual training for 1 of 5 sampled Certified Nursing Assistants (CNA), CNA #5. The findings included: The facility staff were unable to provide evidence of at least 12 hours of annual training for CNA #5. On 10/03/24, surveyor requested evidence of CNA #5's staff trainings completed since hire. CNA #5 had been employed with the facility since September 2023. On 10/03/24 at 2:20 PM, surveyor spoke with the [NAME] President (VP) of Quality and VP of Nursing Services regarding CNA #5's training records. VP of Quality stated they could not locate any training records since hire for CNA #5. VP of Nursing Services stated the CNA had been removed from the schedule and could not return to work until all required trainings were completed. Surveyor requested and received the Facility assessment dated [DATE] which read in part .Required in-service training for nurse aides. In-service training…
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.
- Potential for harm · Dcited before2024-10-03 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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, the facility staff failed to maintain a complete and accurate medical record for one of 35 residents in the closed record sample, resident # 311. The findings included: Resident # 311's diagnoses included but were not limited to muscle weakness, osteoarthritis, bradycardia, and dementia. The minimum data set (MDS) with an assessment reference date of 11/29/22 assigned the resident a brief interview for mental status score of 3 out of 15 indicating the resident had severe cognitive impairment. According to the MDS data the resident was dependant for transfers and non-ambulatory without at least extensive assistance. The care plan for resident # 311 was reviewed. A problem statement read, (resident) has a potential to fall (High Risk) R/T: Reduced mobility, History of falls and poor safety awareness, Impulsive behavior, Dementia- cognitive impairment, restlessness. During a review of the progress notes, the following was noted on 1/16/24 at 6:40 AM, resident up through the night and continue to try and get…
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.
- Potential for harm · E2021-04-29 · tag F0657 — failed to keep the care plan current — patternDevelop 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, clinical record review and facility document review, it was determined that facility staff failed to revise the care plan for 3 of 28 residents in the survey sample to reflect that Resident #26 was receiving hospice services; Resident #12's Foley catheter had been discontinued; and Resident #4, acquired left heel pressure ulcer The findings included: 1. The facility staff failed to revise the comprehensive care plan for to reflect hospice services for Resident #26. Resident #26 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, Alzheimer's disease, unspecified dementia with behavioral disturbance, and history of malignant melanoma of the skin. Resident #26's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/5/21. Resident #26 was coded as being severely impaired in the ability to make daily decisions on the Staff Interview for Mental Status…
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.
Show the remaining 14 citations
- Potential for harm · E2021-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observations, clinical record review, staff and resident interviews, the facility staff failed to ensure interventions were in place and operational for 3 out of 28 residents (Resident #41, #355 and #24) to prevent falls. The facility staff failed to ensure Resident #41's and #355's bed/chair alarms were properly positioned and functional. The facility staff failed to ensure Resident #24's call light was within reach and functional; and that her bed was in the lowest position per fall plan of care. The findings included: 1. The facility staff failed to ensure Resident #41's chair alarm was properly positioned and functional to alert staff that the resident has changed position, increasing the risk for falling. Resident #41 was admitted to the nursing home on 5/28/19 with diagnoses that included history of falls with history of displaced right femur fracture, dementia, muscle weakness and high blood pressure. The most recent Minimum Data Set (MDS) assessment was a significant change in status 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.
- Potential for harm · E2021-04-29 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews and facility documentation, the facility staff failed to do a Gradual Dose Reduction (GDR) for 1 of 28 residents (Resident #35) in the survey sample who were receiving a PRN (as needed) psychotropic medication. The findings included: 1. The facility staff failed to ensure a PRN (as needed) psychotropic medication (Ativan) was limited to 14 days for Resident #35. The physician did not do an evaluation of Resident #35 to extend the psychotropic medication pass 14 days without documenting the rational and duration in the resident's medical record. Resident #35 was originally admitted to the facility on [DATE]. Diagnosis for Resident #35 included but not limited to Dementia with behavioral disturbances, Anxiety and Major Depressive Disorder. Resident #35's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 03/10/21 coded Resident #35 a 03 out of a possible score of 15 on the Brief Interview for Mental Status…
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.
- Potential for harm · D2021-04-29 · tag F0574 — isolatedThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and resident interviews the facility staff failed to ensure residents were informed of their rights and given information on how to formally complain to the State Agency and informational agencies about the care they are receiving and ensure residents were educated on where the Ombudsman contact information was posted. The findings included: On 04/28/2021 at approximately 11:00 a.m., a Resident Group Meeting was held with 5 cognitively intact residents present. When asked if they knew where the Ombudsman contact information was posted in the facility, the residents responded, No, what is a Ombudsman? When asked if they were informed of their rights, and given information on how to formally complain to the State Agency if they have a concern about the care they are receiving, the residents stated, No. On 04/28/2021 at approximately 12:00 p.m., an interview was conducted with Director of Activities. When asked was contact information for the Ombudsman and location of where it is posted reviewed with the residents, Director of Activities stated, No, I haven't…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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
Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure 1 of 28 residents (Resident #53) in the survey sample was given the opportunity to formulate an Advance Directive. The findings included: Resident #53 was originally admitted to the nursing facility on 12/16/20. Diagnosis for Resident #53 included but not limited to Heart Failure. Resident #53's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 04/16/21 coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Review of Resident #53's Physician Order Sheet (POS) for April 2021 revealed the following order with a start date of 01/22/21: Do Not Resuscitate (DNR.) The review of Resident #53's clinical record did not show evidence of an Advance Directive. On 04/29/21 at approximately 9:38 a.m., a phone interview was conducted with the Social Worker (SW) and Corporate support. When asked, if Resident #53 had 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.
- Potential for harm · D2021-04-29 · tag F0585 — failed to handle grievances — isolatedHonor 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 staff interview and resident interviews the facility staff failed to ensure residents were informed on how to file a grievance. The findings included: On 04/28/2021 at approximately 11:00 a.m., a Resident Group Meeting was held with 5 cognitively intact residents present. When asked if they had been told how to file a grievance, the residents stated, No. An interview was conducted with the Director of Activities on 04/28/2021 at approximately 12:00 p.m. When asked have the residents been informed on how to file a grievance, the Director of Activities stated, No, have not discussed that with them. Planning to ask the ADON (Assistant Director of Nursing) to go over grievance procedure. When asked should the residents have been informed on how to file a grievance, Director of Activities stated, Yes Ma'am. On 04/29/2021 a copy of the facility policy on Resident Rights was requested and received. The Administrator and Director of Nursing was made aware of the finding at the pre-exit meeting on 04/29/2021 at approximately 6:00 p.m. No further information was provided 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.
- Potential for harm · Dcited before2021-04-29 · tag F0623 — isolatedProvide 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 record review and staff interview, the facility staff failed to send a notice of discharge to the Ombudsman for 1 resident (Resident #55) in the survey sample of 28 residents. The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses which included sepsis, hypothyroidism, vascular dementia without behavioral disturbance, hypertension, chronic atrial fibrillation, congestive heart failure, COVID-19 and chronic kidney disease. The facility staff failed to send a notice of discharge to the ombudsman. A Nursing Note dated 02/05/21 indicated: Resident #55 was experiencing low Oxygen Saturations. A review of the nursing notes indicated Resident #55 was transferred to the emergency room on [DATE] because resident was hypoxia with oxygen saturation at 89 percent on 3 liters of oxygen. During an interview on 4/29/21 at 5:44 PM with the administrator she stated, The Ombudsman was not sent a notice of discharge to the hospital for Resident #55. The facility staff failed to send a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and resident interview, clinical record review, and facility document review, it was determined that facility staff failed to provide ADL (Activities of Daily Living) services to maintain personal hygiene for 2 of 28 sampled residents, Resident #24 and #35. The findings included: 1. The facility staff failed to ensure Resident #24 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene. Resident #24 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, type two diabetes mellitus, vascular dementia without behavioral disturbance and hemiplegia of the left nondominant side. Resident #24's most recent MDS (Minimum Data Set) assessment was a significant change assessment with an ARD (Assessment Reference Date) of 3/2/21. Resident #24 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #24 was coded as being…
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.
- Potential for harm · D2021-04-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record reviews, staff and resident interview, the facility staff failed to ensure care was provided to prevent and treat pressure ulcers for 1 of 28 residents ( Resident #43) in the survey sample. The findings included: 1. For Resident #43, the facility failed to prevent the development of a facility acquired left heel pressure ulcer, as well as provide consistent offloading to the left medial knee pressure ulcer to ensure continued healing and comfort. Resident #43 was admitted to the nursing facility on 3/24/21 with diagnoses that included closed fractured right femur and pressure ulcers. Resident #43's most recent Minimum Data Set assessment was an admission dated 3/29/21 and coded the resident with a score of 12 out of a total score of 15 which indicated she was moderately impaired in the cognitive skills for daily decision making. Resident #43 was coded always incontinent of bowel and bladder. Resident #43 was assessed to require extensive assistance of 2 for transfers, extensive assistance of 1 for dressing, toilet use, and totally dependent 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.
- Potential for harm · Dcited before2021-04-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 document review, it was determined that the facility staff failed to store narcotics in a double lock compartment; AND failed to ensure one medication room (The Bethel Unit) was free from expired medication. The findings included: On [DATE] at 9:23 a.m., observation of the Bethel Unit medication room was conducted. An unopened 30 ml (milliliter) bottle of Ativan (1) was found in the door of the medication refrigerator behind only one lock to get into the refrigerator. The bottle of Ativan was not stored in a black locked box with the other bottles of Ativan. On [DATE] at 9:24 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2. LPN #2 stated that the Ativan was being stored in the door of the refrigerator because the resident (that the Ativan belonged to) had recently passed. When asked if the Ativan should still be stored in the locked black box or behind a double lock; LPN #2 stated that it should. Upon further review of 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.
- Potential for harm · D2019-03-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, resident and staff interview and clinical record review it was determined the facility staff failed to treat a resident with dignity and respect during her dining experience (Resident #6). Findings: Resident #6 was not treated with dignity and respect during her dining experience. Her clinical record was reviewed on 3/5/19 at 2:00 PM. The resident was admitted to the facility on [DATE]. Her diagnoses included hypertension and dementia, adult failure to thrive, chronic atrial fibrillation and chronic muscle weakness. The latest MDS (minimum data set) assessment dated , 12/17/18, coded the resident with slightly impaired cognitive skills. Her communication ability was unimpaired. The resident required the assistance of at least one staff member for all the ADLs (activities of daily living) with set-up and oversight only to eat. The resident's latest CCP (comprehensive care plan) reviewed and revised on 12/19/18 documented the resident had a potential for weight change due to oral intake. 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.
- Potential for harm · D2019-03-06 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 and staff interview and clinical record review it was determine the facility staff failed to accommodate a resident's choice of seating in the dining room (Resident #6). Findings: The facility staff failed to accomodate Resident #6's choice of seating in the dining area. Her clinical record was reviewed on 3/5/19 at 2:00 PM. The resident was admitted to the facility on [DATE]. Her diagnoses included hypertension and dementia, adult failure to thrive, chronic atrial fibrillation and chronic muscle weakness. The latest MDS (minimum data set) assessment dated , 12/17/18, coded the resident with slightly impaired cognitive skills. Her communication ability was unimpaired. The resident required the assistance of at least one staff member for all the ADLs (activities of daily living) with set-up and oversight only to eat. The resident's latest CCP (comprehensive care plan) reviewed and revised on 12/19/18 documented the resident had a potential for weight change due to oral intake. 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.
- Potential for harm · D2019-03-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to coordinate care with the dialysis facility, for 2 of 20 Residents, Residents #29 and #262. The findings included: 1. For Resident #29, the facility staff failed to obtain information related to the Residents dialysis treatment from the contracting dialysis facility. The clinical record review revealed that Resident #29 had been admitted to the facility 11/17/17. Diagnoses included, but were not limited to, chronic kidney disease, malignant neoplasm, diabetes, dementia, depressive disorder, and dysphagia. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/20/19 included a BIMS (brief interview for mental status) summary score of 11 out of a possible 15 points. Section O (special treatments, procedures, and programs) had been checked to indicate the Resident received dialysis. The Residents comprehensive care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-03-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 2 of Residents, Resident #10 and Resident #2. The findings included: 1. For Resident #10 the facility staff failed to determine the Resident's wishes related to an Advance Care Plan. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hemiplegia, dysphagia, aphasia, apraxia, encephalopathy, atrial fibrillation, hypertension, hyperlipidemia, gastroesophageal reflux disease, constipation and hyperglycemia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/31/18 coded the Resident as having both long and short term memory loss with severely impaired cognitive skills for daily decision making. This is a quarterly MDS. Resident #10's clinical record was reviewed on 03/06/19. It contained an Advance Care Plan dated 10/23/12, which read in part Quality of Life: I want my doctors to help me…
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.
- Potential for harm · D2019-03-06 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, facility document review, and during a medication pass and pour observation, the facility staff failed to follow established infection control guidelines on 1 of 2 units the Bethel unit. The findings included: The facility staff failed to perform any hand hygiene prior to or after preparing and administering medications to 2 different Residents. On 03/06/19 beginning at approximately 7:49 a.m., the surveyor observed LPN (licensed practical nurse) #1 prepare and administer unsampled Resident #44's medications. During this observation, Resident #44 declined to drink all of their miralax. LPN #1 discarded the remainder of the miralax in the Residents bathroom. LPN #1 was not observed to complete any hand hygiene. After exiting the bathroom, LPN #1 pushed a wheeled B/P (blood pressure) machine into this same room to obtain unsampled Resident #20's B/P. LPN #1 stated the machine was dead exited the room and went down the hall and obtained a different B/P machine and entered the Residents room and obtained Resident #20's B/P. After obtaining, the Resident's B/P…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LANGLEY HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/10/2025 |
| VA HOLDINGS GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 09/10/2025 |
| KAHANOW, AVIVA | Individual | INDIRECT OWNERSHIP INTEREST | — | since 09/03/2025 |
| ROKEACH, FRAIDE | Individual | INDIRECT OWNERSHIP INTEREST | — | since 09/03/2025 |
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST | — | since 09/03/2025 |
| BUCKLEY, ERIK | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2025 |
| DICK, JENNIFER | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/02/2026 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 09/03/2025 |
| HEALTHCARE SERVICES GROUP INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2025 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2025 |
| VIRGINIA HEALTH REHABILITATION AGENCY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2025 |
| HAJIMOMENIAN, AMIR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2025 |
| POSEN, MINDEE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/03/2025 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 08/22/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 08/22/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 08/26/2025 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| QUINTO NEXGEN LLC | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| SK NEXGEN TR | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/03/2025 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| UKR NEXGEN LLC | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| YK NEXGEN TR | Organization | ADP OF THE SNF | — | since 09/15/2025 |
| YR NEXGEN TR | Organization | ADP OF THE SNF | — | since 09/15/2025 |
CMS files one row per role, so the 33 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
15 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.
This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 30% 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
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
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.
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 495367. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-03, 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.