Westminster At Lake Ridge
12185 Clipper Drive, Lake Ridge, VA 22192 · Non profit - Corporation · 60 certified beds · (703) 643-9017 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2019
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,405 in federal fines (most recent 2026-01-22)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 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 improved from 3 to 5 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 | 18.9% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.1% | 18.7% | 6.5% | better than 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 | 3.9% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.1% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.0% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 21.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.9% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.9% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.1% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.7% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.05 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.17 | 1.48 | 1.80 | worse |
‡ 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.
63.0% 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 294 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.6% 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 141 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 63.0%CMS range 57.1–68.5 | 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 | 12.0%CMS range 9.3–15.1 | 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 | 59.6% | 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 | 54.6% | 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 | 57.5% | 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 | 88.1% | 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 | 92.1% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.1% | 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 | 0.6% | 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 | 7.0%CMS range 4.1–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 60 beds and averages 39.7 residents a day — about 66% occupied, or roughly 20 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.56 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.66 hrs/resident/day on weekends vs 5.33 on weekdays — 13% thinner on weekends. RN hours go from 1.16 to 1.02 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% 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
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-01-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and facility document review, the facility staff failed to maintain a safe environment for one of thirty-seven residents in the survey sample (Resident #1). Four oxygen cylinders were observed unsecured constituting the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity and substandard quality of care. Upon verification of the removal of the IJ, the scope and severity were lowered to Level Two, Isolated. The findings include:On 1/20/26 at 12:46PM, during initial rounds, four oxygen e-tanks were observed stored freestanding in an upright position, not contained in a stand or holder in Resident #1's room on the secured Memory Care Unit. (An E tank (or E-cylinder) is a common medical oxygen cylinder, typically holding around 680 liters (about 23-24 cubic feet) of oxygen, with dimensions of roughly 4.4 inches in diameter and 24-28 inches in height, weighing around 10 lbs. empty, and used for home, travel, and emergency oxygen needs.) On 1/20/26 at 1:00PM, a second observation of Resident #1 was conducted by the survey…
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 · F2026-01-22 · tag F0843 — widespreadHave an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
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 ensure there was a written transfer agreement with a local hospital which had the potential to affect all residents residing on 3 of 3 units. Findings included:On 1/21/2026 at 1:15 p.m. as a part of the extended survey, an interview was conducted with the Administrator who was asked provide evidence of a transfer agreement with the hospital. The Administrator stated he would look for a copy of the agreement. On 1/22/2026 at 9:20 a.m., the Administrator stated he could not find any evidence of a transfer agreement with the hospital. He stated he was sure the facility would have an agreement but could not find it. There was no evidence of a transfer agreement in the facility's documentation.On 1/22/2026 at 10:30 a.m., an interview was conducted with the Clinical Nurse Consultant who stated the Administrator had checked but could not find a transfer agreement. She stated a transfer agreement was necessary and the hospital had been contacted. During the end of day debriefing on 1/22/2026, 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 · E2022-06-23 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
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 develop a procedure for unvaccinated and vaccinated staff who refuse or are unable to be tested for COVID-19 in accordance with the Centers for Disease Control and Prevention (CDC) guidance. The findings included: There were no COVID positive staff nor Residents present in the facility during the course of the survey, from 6-21-22 through 6-23-22. Staff were observed wearing eye protection and face masks during the survey in accordance with community transmission rates, and according to CDC guidance. Staff were interviewed and asked what the procedure was for those staff who are unable or unwilling to be tested. Two direct care staff members, and one house keeping staff member, were interviewed. Each of them stated they did not know, and would ask the Director of Nursing (DON). On 6-22-22 at 10:00 a.m., the DON was asked for policies regarding testing of staff. The document title was Universal COVID-19 Testing Policy. The policy was reviewed and revealed under General Considerations, Staff who…
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 · D2022-06-23 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 facility documentation review and staff interview, the facility staff failed to implement their abuse policy for screening employees for 8 employees (Employee#1, Employee #4, Employee #5, Employee #8, Employee #9, Employee #10, Employee #16, Employee #23) in a sample size of 25 employees. The findings included: On [DATE], the facility staff provided a copy of their policy entitled, Abuse Prevention Program. In Section 2(a), it was documented, Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has (a) been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . Section 2(b) documented, .had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property . On [DATE] at approximately 10:45 A.M., this surveyor and Employee E, the Human Resources Manager, reviewed 25 employee files which revealed 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 · D2022-06-23 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed within 30 days of admission (prior to admission is being waived due to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency) for 1 resident (Resident #11) in a sample of 19 residents. For Resident #11, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed within 30 days of admission. The Findings included: Resident #11 was admitted on [DATE] with diagnoses including: Schizophrenia, Non-Alzheimer's dementia, and anxiety disorder. On 6-22-22 an observation, Resident interview, and review of Resident #11's record was conducted. Resident #11 was noted to have diagnoses including schizophrenia, and non-Alzheimer's dementia. Geriatric psychiatry notes, resident history, and admission information revealed that the illnesses were long standing. No previous to admission PASARR…
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 · E2019-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to accommodate needs and preferences for 7 residents (Resident #12, Resident #15, Resident #5, Resident #28, Resident #190, Resident #20, Resident #6) in a sample size of 25 residents. 1. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call light was activated. 2. For Resident #15, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 3 of 15 opportunities the call light was activated. 3. Resident #5 was not provided a hoyer lift sling to get out of bed in the morning on 5-14-19 due to lack of equipment. 4. For Resident # 28 the facility staff failed to answer call bells in timely manner for a Resident who requires assistance with transfer and ambulation. 5. For Resident #190 the facility staff failed 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.
- Potential for harm · E2019-05-16 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 and clinical record review the facility staff failed to provide care and services in accordance with professional standards of practice for 3 Residents (Residents # 7, # 190, #5) in a survey sample of 25 Residents. 1a. For Resident #190, the facility staff failed to administer medications per physicians order and; 1b. failed to document that an entry was a late entry. 2. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. The findings include: 1a. For Resident #190, the facility staff failed to administer medications per physicians order and; 1b. failed to document that an entry was a late entry. Resident # 190, a [AGE] year old woman admitted to the facility on [DATE] the Resident had no (Minimum Data Set) MDS information available…
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 · E2019-05-16 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 have sufficient nursing staff to meet the needs of seven Residents (Resident #20, Resident #190, Resident #28, Resident #189, Resident #12, Resident #15, Resident #6) in a survey sample of 25 Residents. 1. For Resident #20, the facility staff failed to have adequate staff to respond to the Resident's call bell and request for assistance for three hours. 2. For Resident #190, the facility staff failed to ensure adequate staff available to answer call bell in a timely manner. 3. For Resident #28, the facility staff failed to ensure adequate staff available to answer call bell in a timely manner. 4. For Resident #189, the facility staff failed to provide sufficient staff to safely lift Resident using Hoyer. 5. For Resident #12, the facility staff failed to answer the call light in a timely fashion to provide needed care and services for 2 of 14 opportunities the call…
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 · E2019-05-16 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to prevent significant medication errors. The facility failed to administer insulin on 5 separate occasions for 3 of 25 sampled residents. 1. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. 2. For Resident # 190 the facility staff omitted giving insulin at 4:30 PM on two consecutive days. 3. For Resident #5, the facility staff failed to ensure insulin was administered on 5-11-19 as ordered by a physician. The findings included: 1. For Resident #7, the facility staff failed to administer 2 consecutive doses of insulin on 05/12/2019 as indicated by sliding scale per physician's orders. Resident #7, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to diabetes, peripheral vascular disease, hypertension, aphasia following cerebral infarction, 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 · E2019-05-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to follow infection prevention protocols. The dietary manager was observed not wearing personal protective equipment (PPE) in the room of a resident on contact isolation for clostridium difficile. The dietary manager then exited the room without washing hands and entered two other resident rooms without performing hand hygiene. The findings included: On 05/16/19 at 08:35 AM, the dietary manager was observed in the room of Resident #92. There was personal protective equipment stationed outside the room door and a Stop sign posted next to the door. The dietary manager was observed standing inside the room talking with Resident #92 (seated in a chair) and a family member (standing next to Resident #92). The dietary manager and the family member were not wearing PPE. The dietary manager was observed shaking the family member's hand then stooped down next to Resident #92, leg touching the side of 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 · D2019-05-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 staff interview facility documentation and clinical record review the facility staff failed to ensure one Residents was free from neglect for 1 of 25 sampled Residents (#34). For Resident #34 who had a recent history of falls with fracture, the facility staff left the Resident on the toilet without supervision, neglecting the Resident's known needs, and the Resident fell. The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including; Dementia, glaucoma, lack of coordination, muscle weakness, and fall with fracture of the tibia, and fibula, and was non-weight bearing at the time of admission from the hospital for surgery related to that fracture on 12-26-18. The Resident was also hard of hearing and wore hearing aids. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive…
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 11 citations
- Potential for harm · D2019-05-16 · 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 and clinical record review, the facility staff failed to notify the ombudsman of transfer to the hospital for two Residents (Resident #339, Resident 89) in a survey sample of 25 Residents. 1. For Resident #339, the facility staff failed to notify the ombudsman of transfer to the hospital on two occasions. 2. For Resident #89, the facility staff failed to notify the ombudsman of transfer to hospital. The findings included: 1. For Resident #339, the facility staff failed to notify the ombudsman of transfer to the hospital on two occasions. Resident #339, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: other symptoms and signs involving musculoskeletal system, lack of coordination, muscle weakness, unsteadiness on feet, dysphagia and cognitive communication deficit. Resident #339's most recent MDS (minimum data set) (an assessment tool), was coded as an admission assessment, with an ARD (assessment reference date) of 11/21/18. Resident…
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 · D2019-05-16 · 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 Based on staff interview and clinical record review, the facility staff failed to notify the resident of bed hold policy before transfer to the hospital for one Resident (Resident #339) in a survey sample of 25 Residents. For Resident #339, the facility staff failed to notify the resident of the bed hold policy before transfer to the hospital on two occassions. The findings included: Resident #339, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: other symptoms and signs involving musculoskeletal system, lack of coordination, muscle weakness, unsteadiness on feet, dysphagia and cognitive communication deficit. Resident #339's most recent MDS (minimum data set) (an assessment tool), was coded as an admission assessment, with an ARD (assessment reference date) of 11/21/18. Resident #339, had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognition. Resident #339, was coded that extensive assistance of two staff members…
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 · D2019-05-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 develop a care plan for 2 of 25 sampled residents. 1. For Resident # 91, the facility staff failed to develop a care plan for a renal diet. 2. For Resident #34, the facility staff failed to develop a comprehensive care plan for hearing deficits. The Findings included: 1. For Resident # 91, the facility staff failed to develop a care plan for a renal diet. Resident #91 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #91's diagnoses included Hypertension, Chronic Kidney Disease, Stage 4 Type 2 Diabetes without Complications, Hyperlipidemia, and Obesity. On 5/14/19 at 3:15 P.M., an interview was conducted with Resident #91 and her son. Resident #91 was concerned that her diet order wasn't being followed. She stated that the facility served her canned peaches that morning, and continued to serve her orange juice for breakfast. She stated, and her son agreed that…
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 · D2019-05-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 staff interview and clinical record review, the facility staff failed to review and revise a careplan for one Resident (Resident #341) in a survey sample of 25 Residents. For Resident #341, the facility staff failed to review and revise the careplan after the Resident was diagnosed with a superficial vein thrombosis and was started on an anticoagulant. The findings included: Resident #341, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: fracture of left humerus, fracture of left pubis, muscle weakness, lack of coordination, anemia, syncope and collapse, gastrointestinal hemorrhage, hypertension, hyperlipidemia, and gastro-esophageal reflux disease. Resident #341's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/30/19 was coded as an admission assessment. Resident #341, had a BIMS (brief interview for mental status) score of 13, which indicated the resident was cognitively intact. She was coded as…
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 · D2019-05-16 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 observation, Resident representative interview, clinical record review, and facility document review, the facility staff failed to ensure treatment services to maintain hearing were afforded one Resident, (Resident #34) in a sample of 25 Residents. For Resident #34, who was hard of hearing, and wore hearing aids, the facility staff failed to provide timely cerumen removal as ordered by a physician, to maintain hearing. The findings included; Resident #34 was admitted to the facility on [DATE] with diagnoses including; Dementia, glaucoma, lack of coordination, muscle weakness, fall with fracture of the tibia, and fibula, and was hard of hearing with hearing aid devices. Resident #34's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3-20-19. Resident #34 was coded with a Brief Interview of Mental Status score of 7, indicating moderate cognitive impairment. Resident #34 was extensively dependant on one staff member for assistance with…
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 before2019-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview facility documentation and clinical record review the facility staff failed to provide supervision for 2 of 25 sampled Residents (#189 and #34). 1. For Resident #189 the facility staff failed to utilize proper amount of staff while transferring a resident via Mechanical Lift. 2. For Resident #34 who had a recent history of falls with fracture, the facility staff left the Resident on the toilet without supervision, and the Resident fell. The findings included: 1. For Resident #189, the facility staff failed to utilize the proper amount of staff while transferring a resident via Mechanical Lift. Resident #189, a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Hypertension, Diabetes, Hypothyroidism, Chronic ischemic heart disease, Congestive heart failure, and abnormal posture. Resident #189's most recent (Minimum Data Set) MDS a quarterly with an ARD date of 3/16/19 codes Resident #189 as having a (Brief Interview of 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 · D2019-05-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain nutritional status. 1. For Resident #91, the facility staff failed to maintain nutritional status, resulting in an increased potassium level which required pharmacological intervention. 2. For Resident #290, the facility staff failed to provide a therapeutic diet as ordered by the healthcare provider on 05/14/2019. The Findings included: 1. For Resident #91, the facility staff failed to maintain nutritional status, resulting in an increased potassium level which required pharmacological intervention. Resident #91 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #91's diagnoses included Hypertension, Chronic Kidney Disease, Stage 4 Type 2 Diabetes without Complications, Hyperlipidemia, and Obesity. On 5/14/19 at 3:15 P.M., an interview was conducted with Resident #91 and her son. Resident #91 was concerned that her diet order wasn't being followed.…
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 · D2019-05-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain an accurate record for a controlled medication. Facility staff failed to account for the receipt of a controlled medication from the pharmacy. The Findings included: On 05/15/2019 at approximately 10:30 AM, an inventory of refrigerated controlled medications was conducted with LPN C in the medication storage room. A partial bottle of lorazepam oral concentrate [syrup] 2mg/ml, prescription #9981672, contained 20 ml [millilters] but was documented as 24.50 ml on the individual inventory sheet. LPN C stated, I don't know how that happened, I see 20 in the bottle but the sheet is 24.5. Two unopened bottles of lorazepam suspension 2mg/ml, prescription #10018839 and #10073360, each containing 30 ml, were observed with seals intact, however there was no record of either bottle on inventory. LPN C had no response when asked about the accounting for the bottles. At approximately 10:40, the Assistant Director of Nursing (ADON, Employee C) and Employee P were informed of 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 · D2019-05-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview facility documentation and clinical record review the facility staff failed to ensure Residents are free from unnecessary medications for 1 Resident (#25) in a survey sample of 25 Residents. For Resident #25 the facility staff administered Tylenol 650 mg on three occasions when Resident has pain rating of 0/10. The findings include: Resident #25 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia with behavioral disturbance, Hypertension, Use of Anti-Coagulants, diabetes and stage 3 chronic kidney disease, osteoporosis and feeding difficulties. Resident #25's most recent (Minimum Data Set) MDS was dated 4/3/19 and it was an annual. According to the most recent MDS Resident # 25 had a (Brief Interview of Mental Status) BIMS score of 00/15 indicating severe cognitive impairment. On 5/14/19 during clinical record review it was noted that Resident # 25 had received Tylenol 650 (milligrams) mg without indication for use on three separate…
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 · D2019-05-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 staff interview and clinical record review, the facility staff failed to ensure resident's are free from unnecessary psychotropic medication use for one Resident (Resident #19) in a survey sample of 25 Residents . For Resident #19, the facility staff failed to ensure the medication regime was free from unnecessary psychotropic medications. The findings included: Resident #19, was admitted to the facility on [DATE]. The Resident's diagnoses included but were not limited to: UTI, retention of urine, unspecified lack of coordination, cognitive communication deficit, dysphagia, extend spec beta lactamase resistance, parkinsons, unspecified dementia without behavioral disorder, hypotension, and unspecified OA (osteoarthritis). Resident #19's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19 was coded as a quarterly assessment. Resident #19 was coded as having a BIMS (brief interview for mental status) score of 11, which indicated moderately impaired…
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 · D2019-05-16 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 provide an appropriate alternative to accommodate a food allergy for 1 resident (Resident #290) in a sample size of 25 residents. For Resident #290, the facility staff failed to provide any alternative dessert at the lunch meal on 05/14/2019 to accommodate her food allergies. The Findings included: Resident #290, a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease (COPD), shortness of breath, acute respiratory failure, and malnutrition. Resident #290's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/03/2019 was coded as admission from an acute hospital. A comprehensive MDS is pending and the physician's admitting assessment read, Cognition WNL (within normal limits), AOX4 (alert and oriented to person, place, time, and situation),…
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
$8,405 in federal fines across 1 penalty.
- $8,405 — penalty dated 2026-01-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to INGLESIDE ENGAGED LIVING — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 5.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 5 of 5 | 5.0 | ≈ chain avg |
| Quality measures | 5 of 5 | 5.0 | ≈ chain avg |
The other 1 home this chain runs (chain average 5.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WESTMINSTER INGLESIDE KING FARM RETIREMENT COMMUNITIES INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2011 |
| BARTELS, BRUCE | Individual | CORPORATE DIRECTOR | since 03/04/2015 |
| CECCHINE, MARGARET | Individual | CORPORATE DIRECTOR | since 04/01/2023 |
| COX, SALLY | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| GLECKMAN, HOWARD | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| HAUGE, JENNIFER | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| JOHNSON, GREGG | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| KATZ, RUTH | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| KEARNEY, JONATHAN | Individual | CORPORATE DIRECTOR | since 02/01/2025 |
| KREUTZER, JOHN | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| KUHN, NANCY | Individual | CORPORATE DIRECTOR | since 10/07/2015 |
| MAGIDSON, PHILLIP | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| MASSETTI, AMANDA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/11/2020 |
| MASSEY, NATHANIEL | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| ORTIZ, ELIZABETH | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| WAGNER, STEVEN | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| ALLEY, TRACI | Individual | CORPORATE OFFICER | since 08/02/2021 |
| CLARK, DALE | Individual | CORPORATE OFFICER | since 01/01/2021 |
| DELOVSKA-TRAJKOVA, DUSANKA | Individual | CORPORATE OFFICER | since 01/01/2013 |
| MOUR, CHRISTINE | Individual | CORPORATE OFFICER | since 08/24/2015 |
| O'CONNOR, LYNN | Individual | CORPORATE OFFICER | since 07/01/2010 |
| SILVERBLOOM CONSULTING, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2021 |
| ARMSTRONG, TOMMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/17/2025 |
| CHASM, ALEXIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/29/2023 |
| GREEN, LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2024 |
| JAMES, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/20/2023 |
| JOHNSON, ZENOBIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/12/2023 |
| WOOTEN, KERA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/13/2020 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | since 01/01/2015 |
| BAKER TILLY US LLP | Organization | ADP OF THE SNF | since 01/01/2015 |
| FLAGSHIP REHABILITATION, INC | Organization | ADP OF THE SNF | since 01/01/2015 |
| JUDY WILHIDE MDS CONSULTING, INC. | Organization | ADP OF THE SNF | since 01/01/2024 |
| MARSH & MCLENNAN COMPANIES | Organization | ADP OF THE SNF | since 01/01/2015 |
| RICHTER AND ASSOCIATES | Organization | ADP OF THE SNF | since 11/10/2015 |
| NGUYEN, UY | Individual | ADP OF THE SNF | since 12/01/2025 |
| TESFAY, AKBERT | Individual | ADP OF THE SNF | since 12/05/2023 |
CMS files one row per role, so the 46 rows in the source record cover these 36 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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 495280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, 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 →
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