Kendal At Lexington
160 Kendal Drive, Lexington, VA 24450 · Non profit - Corporation · 60 certified beds · (540) 463-1910 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (5/5)
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,033 in federal fines (most recent 2024-04-24)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 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 3 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 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 25.2% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.1% | 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 | 4.5% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 18.7% | 6.5% | check this* — see note marked star 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 | 9.9% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.4% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 31.8% | 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 | 4.9% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 19.6% | 21.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.8% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 10.5% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.8% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.71 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.14 | 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.
61.6% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 46 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% 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 | 61.6%CMS range 51.2–72.0 | 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 | 10.7%CMS range 7.5–15.8 | 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 | 67.4% | 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 | 71.7% | 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 | 63.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 3.2% | 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 | 3.2% | 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 | 5.6%CMS range 3.0–10.1 | 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 40.0 residents a day — about 67% 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 4.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.16 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.10 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 4.21 hrs/resident/day on weekends vs 5.15 on weekdays — 18% thinner on weekends. RN hours go from 1.31 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2024-04-24 · 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 document review, and clinical record review, the facility failed to provide staff assistance and supervision for a safe transfer for one of sixteen residents (Resident #1), resulting in a fall with fracture (harm). The findings include: Resident #1 (R1) fell when a privately hired companion/sitter attempted to transfer R1 from the bed to a wheelchair. The private companion did not request facility staff assistance with the transfer and had no prior documented training of facility policies that prohibited private caregivers/companions from performing direct-care activities, including transfers. R1 was diagnosed with a right distal femur fracture, as a result of the fall, and required treatment with immobilization and pain medication. Resident #1 was admitted to the facility with diagnoses that included dementia, hypertension, osteoporosis, urinary tract infection, osteoarthritis, conjunctivitis, gastroesophageal reflux disease, and depression. The minimum data set (MDS -…
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 · Fcited before2024-04-24 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 staff interviews, clinical record review and facility documentation review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections having the potential to affect residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to respond to and implement quarantine and testing measures in accordance with CDC (The Centers for Disease Control and Prevention) recommendations to manage COVID-19 during an outbreak affecting 1 of 2 units. On 4/22/24 at 4:19 p.m., and again on 4/23/24 at 08:35 a.m., interviews were conducted with the facility's infection preventionist (IP). The IP stated that when they have a COVID case they start a line tracking to track exposure. The facility had a COVID outbreak that began on 3/15/24. The IP reported that they conducted staff testing on days 1, 3 and 5-7. Residents were tested on [DATE] and 3/18/24, both instances revealed additional…
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 · E2024-04-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review the facility staff failed to prepare, store, and distribute food in a sanitary manner. The finding included: The dietary staff failed to label open food with an open date and the use by date, failed to dispose of out of date products, failed to ensure metal serving pans were dry before nesting, failed to clean the grill after use, failed to clean trays in the refrigerator after spills occurred, failed to hold proper food temperatures on the steam tables on the units, and failed to ensure beard guards were worn by applicable staff. On 4/22/24 at 10:59 AM, observations were made in the main kitchen during a tour with the dietary manager (other staff #5, OS#5). During the tour of the walk-in refrigerator there was an open bag of tortilla shells with no open or expiration date, 2 bags of unopened tortilla shells out of the original box with no expiration date, 6 quarts of 2% milk that were expired (4/21/24), 3 trays with tan color sour smelling…
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 · E2024-04-24 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review and facility documentation review, the facility staff failed to maintain an antibiotic stewardship program to monitor antibiotic use for three residents (Resident #1- R1, Resident #34- R34, and Resident #27- R27) in a survey sample of 3 residents reviewed for antibiotic use. The findings included: On 4/23/24 at 08:48 a.m., an interview was conducted with the facility's infection preventionist (IP). The IP was asked about the antibiotic stewardship program and was asked to explain the facility's process. The IP reported that she doesn't track any infections other than COVID-19. She also reported that, we do have a PIP (performance improvement plan) in place I just created for UTIs (urinary tract infections), we are going to do education with staff on using McGreer criteria to reduce our UTI's. During the above interview the IP was asked when the PIP was developed and when they identified the deficient practice. The IP reported that it was just created last Tuesday, and the steps had not been taken/implemented yet. When the surveyor…
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 · D2024-04-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that residents receive adequate assistance devices to prevent accidents for one resident (Resident #103- R103), in a survey sample of 18 residents. The findings included, For R103, who had two recent incidents, the facility staff failed to ensure the resident had a call bell in reach when sitting in the recliner in her room, to prevent further incidents/accidents. On 6/24/24, the facility administrator provided the survey team with a listing of residents who had recently had incidents. R103 was identified on the list to have had 2 incidents of falls on 6/20/24. On 6/25/24, a clinical record review was conducted of R103's chart. According to the nursing note dated 6/20/24 at 17:30, it read in part, Incident time: 16:30, Incident Type: Falls, Reason for Incident: CNA [certified nursing assistant] called this nurse to RR [resident room]. Rsd's [resident's] recliner back/head had…
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 · D2024-04-24 · 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 staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for completion of a criminal background check for a privately hired companion for one of sixteen residents in the survey sample (Resident #1). The findings include: A private companion/sitter working in the facility with Resident #1, had no prior criminal background check as required by the facility's abuse prevention policies. Resident #1 (R1) was admitted to the facility with diagnoses that included dementia, hypertension, osteoporosis, urinary tract infection, osteoarthritis, conjunctivitis, gastroesophageal reflux disease, and depression. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills and required the extensive assistance of two people for bed mobility and transfers. R1's clinical record documented the resident fell on 4/24/24 when a privately hired companion (other staff #3) attempted to transfer the resident from bed to 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 · Dcited before2024-04-24 · 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
Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise the care plan for one resident (Resident #7- R7), in a survey sample of 16 residents. The findings included: For R7, the facility staff failed to review and revise the care plan to include to resident's inability to use a straw in beverages due to the risk of aspiration. On 4/22/24 at the lunch meal, R7 was observed in the dining room and was observed to have several episodes of coughing while eating. The meal/tray ticket for R7 was observed and it was noted that it indicated no straws. A straw was not being used. On 04/22/24 at 03:47 p.m., R7 was visited in their room. It was observed that R7 had a sign in the room that stated, please no straws. I am unable to use straws. R7 was asked about this and reported she can't use a straw because she gets choked. On 04/22/24 at 03:52 p.m., an interview was conducted with CNA #1 (certified nursing assistant). CNA #1 stated that R7 is being evaluated, they think with using a straw…
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 · D2024-04-24 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for one of sixteen residents in the survey sample (Resident #29). The findings include: During a medication pass observation, a medication was not administered and was left in Resident #29's room. The nurse signed off the clinical record indicating administration of the medicine without witnessing that the resident took the medicine. Resident #29 had no assessed ability to safely self-administer the medication. On 4/23/24 at 8:00 a.m., licensed practical nurse (LPN #1) was observed preparing and administering medications to Resident #29 (R29). Medications prepared for R29 included Peroxyl 1.5% oral rinse, 10 milliliters (mls) in a plastic medicine cup. After oral medications were administered, LPN #1 placed the cup of Peroxyl oral rinse on the resident's sink and advised R29 that the rinse was at the sink for use after breakfast and brushing teeth. LPN #1 signed off R29's medication administration record indicating the Peroxyl…
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 · D2024-04-24 · 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
Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide ADL (activities of daily living) assistance for a resident who was dependent on facility staff, affecting one Resident (Resident #7) in a survey sample of 16 Residents. The findings included: For Resident #7 (R7), the facility staff failed to provide assistance with oral care/brushing of teeth. On 4/22/24 at 11:59 a.m., R7 was interviewed in their room. R7 was sitting in a wheelchair at the bedside. It was observed that R7's teeth had a film on them and did not appear clean. R7 was questioned about oral care and R7 reported they had not brushed her teeth. On 4/22/24 at approximately 3:45 p.m., R7 was visited in her room again and it was noted that the teeth still had a visible film on them and R7 reported her teeth had not been brushed. On 4/22/24 at 3:54 p.m., an interview was conducted with CNA #1 (certified nursing assistant). CNA #X reported that oral care is provided daily. When asked about R7, CNA #1 reported that she had not…
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 · D2024-04-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and clinical record review, the facility staff failed to provide respiratory care, consistent with professional standards of practice, for one resident (Resident #187- R187) in a survey sample of 16 residents. The findings included: For R187, the facility staff failed to store the oxygen nasal cannula to prevent contamination and failed to change the tubing and humidification bottle weekly as per physician order and facility protocol. On 04/22/24 at 11:41 AM, R187 was visited in their room. R187 was lying in bed and an oxygen (O2) concentrator was observed at the bedside, not on/running. The O2 humidification bottle was dated 4/9/24, and the nasal cannula was sitting on top of the concentrator, open to air and dated 4/9/24. R187 reported they no longer use oxygen. On 04/22/24 at 03:27 PM, a clinical record review was conducted. It was noted that R187 had a physician order for 3 liters of oxygen per nasal cannula as needed to maintain oxygen saturation levels >90%. There was another order that read, change 02 tubing every Tuesday on night shift…
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 before2024-04-24 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review the facility staff failed to respond to pharmacy recommendations for 2 of 16 residents in the survey sample. (Resident # 22 and Resident # 10). The findings included: 1. The facility staff failed to respond to a pharmacist recommendation to attempt a gradual dose reduction of buspirone for Resident # 22 (R22). R22 had diagnoses that included Alzheimer's Disease, Parkinson's Disease, depression, unspecified dementia, mood disorder, and anxiety disorder. The most current minimum data set (MDS), a quarterly assessment dated [DATE] assessed R22 with severe cognitive impairment. Review of R22 clinical record documented a physician's order dated 12/27/23 for buspirone 5 mg, give 5 mg by mouth three a day as needed for generalized anxiety disorder. On 1/8/24 the physician changed the order to read, give buspirone 5 mg, give 5 mgby mouth 2 times a day for anxiety disorder. On 1/02/24 the consulting pharmacist recommended a gradual dose…
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 12 citations
- Potential for harm · D2024-04-24 · 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
Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 1 of 16 residents in the survey sample were free of unnecessary medications. The findings included: The facility staff failed to attempt a pharmacy recommended gradual dose reduction of Diphenhydramine for Resident #10 (R10). The findings included: R10 Diagnoses for R10 included Insomnia. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/6/24. R10 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R10's pharmacy medication record review (MRR), dated 1/2/24, documented: This resident is receiving Diphenhydramine for control of insomnia. This antihistamine is rarely considered the agent of choice due to its strong anticholinergic properties. Patient is also on melatonin and zolpidem and may be a duplication of therapy. Another MRR, performed by the pharmacy and dated 2/7/24, recommended a gradual dose reduction (GDR) for Dipehnhydramine and melatonin (both medications…
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 · D2024-04-24 · 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
Based on observation, staff interview and facility documentation review, the facility staff failed to store medications appropriately in 1 of 2 medication storage rooms and on 1 of 2 medication carts. Findings were: The facility failed to ensure that expired medications were not available for use and failed to monitor the temperature of the refrigerator where medications were stored to ensure they were maintained at an appropriate temperature. On 04/22/24 at 12:04 PM, a review was conducted of the medication storage room on the 500 unit in the presence of RN #1 (registered nurse). A bottle of Tylenol Extra Strength 500 mg tablets was noted to have an expiration date of 03/2024. RN #1 confirmed the observation and stated that the night shift is to check the room daily and remove expired items. During the above observation, the refrigerator in the 500-unit medication storage room was noted to have not had any record of temperature being checked since 4/20/24. Therefore the staff were unaware if the medications within the fridge were being maintained at an appropriate temperature. RN#1…
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 · D2024-04-24 · 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 observation, staff interview, and clinical record review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #187- R187) in a survey sample of 16 residents. The findings included: For R187, the facility staff failed to maintain accurate documentation with regards to when the oxygen tubing and humidification bottle was changed. On 04/22/24 at 11:41 AM, R187 was visited in their room. R187 was lying in bed and an oxygen (O2) concentrator was observed at the bedside, not on/running. The O2 humidification bottle was dated 4/9/24, and the nasal cannula was sitting on top of the concentrator, open to air and dated 4/9/24. R187 reported she doesn't use oxygen. On 04/22/24 at 03:27 PM, a clinical record review was conducted. It was noted that R187 had a physician order for 3 liters of oxygen per nasal cannula as needed to maintain oxygen saturation levels >90%. There was another order that read, change 02 tubing every Tuesday on night shift and one that read, change O2 humidifier every Tuesday on night shift. According to the electronic…
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 · D2024-04-24 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide education and offer the COVID-19 immunization, to 1 of 5 residents (Resident #34- R34) and failed to offer the spike vaccine booster for the 2023-2024 season for 5 of 5 staff sampled (LPN #1, LPN #4, Other Staff #12, CNA #3, and Admin Staff #1). The findings included: 1. For R34, the facility staff failed to provide education and offer the COVID-19 vaccine. On 4/22/24, in the afternoon, a clinical record review was conducted of R34's chart. It was noted that there was no information recorded with regards to R34's COVID immunization status. On 04/22/24 at 04:19 p.m., an interview was conducted with the facility's infection preventionist (IP). During the interview, the IP reviewed and confirmed the lack of documentation regarding R34's COVID immunization status, within the clinical record. The IP said, I can get them to pull those records for you, we would have to pull it from the VIIS (Virginia…
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 · Ecited before2021-11-17 · 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 observation, staff interview, and clinical record review, the facility staff failed to ensure four of five emergency exit doors were functioning properly; failed to ensure that one of 14 residents had a safety device correctly applied to his wheelchair, Resident # 37; and failed to ensure that physician ordered fall mats were in place for one of 14 residents, Resident #36. Findings were: 1. On 11/17/2021 at approximately 9:30 a.m., Resident #10's medical record was reviewed. Documentation in the clinical record included an elopement that had occurred on 09/08/2021. At approximately 10:00 a.m., the administrator was asked if an investigation had been completed, and if so to provide the information. At approximately 11:00 a.m., the administrator reported that there had not been an investigation regarding the incident. She stated, He went out the door at the CNA (Certified nursing assistant) desk near the dining area (400 unit). He went out into the courtyard that is an enclosed area, his wanderguard…
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 before2021-11-17 · 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 observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 14 residents in the survey sample, Resident # 37. Resident # 37's care plan was not updated to include the use of anti-rollback devices on the wheelchair. Findings include: Resident # 37 was admitted to the facility 10/2/21 with diagnoses to include, but were not limited to: urinary retention, right femur fracture, COPD, GERD, high blood pressure, and gait abnormality. The most recent MDS (minimum data set) was a significant change assessment dated [DATE]. Resident # 37 was coded as having impairment in long term and short term memory, and moderately impaired in cognition. Resident # 37 was observed throughout the survey from 11/16/21-11/17/21, with anti-rollback devices applied to the back of the wheelchair. The clinical record was reviewed and the care plan for falls did not include the intervention for the anti-rollback devices. The care plan, initiated…
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 before2021-11-17 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 review and staff interview, the facility staff failed to ensure a monthly pharmacy review was conducted for one of fourteen residents, Resident #26. There was no pharmacy review done for the month of June 2021. Findings were: Resident #26 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Stroke with hemiparesis, hypertension, diabetes mellitus, major depressive disorder and dementia. The a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 10/20/2021, assessed Resident #26 as moderately impaired with a cognitive summary score of 11. The clinical record was reviewed on 11/17/2021 at approximately 9:30 a.m. There was no documentation in the clinical record of any pharmacy medication regimen reviews from April 2021 to the time of the survey. The DON (director of nursing) was interviewed at approximately 9:45 a.m., regarding the reviews. She looked at the electronic record and was also unable to locate 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 · Ecited before2019-04-04 · 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 resident interview, group interview, staff interview and clinical record review, the facility staff failed to invite and/or encourage participation in care plan meetings for two of 14 residents in the survey sample. Residents #3 and #23 were not invited to participate in their quarterly care plan meetings. Eight residents during the resident council group interview stated they had not been invited to participate in the quarterly care plan meetings. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included anemia, high blood pressure, GERD (gastroesophageal reflux disease) and depression. The minimum data set (MDS) dated [DATE] assessed Resident #23 as cognitively intact. On 4/2/19 at 3:00 p.m., Resident #23 was interviewed about quality of life and care in the facility. During this interview, Resident #23 stated she had not been invited to care plan meetings since she had been in the facility. When asked about her participation in the meetings, 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 · D2019-04-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 a medication pass and pour observation, staff interview, and facility document review, the facility staff failed to follow a physician's order for medication administration for one of 14 residents in the survey sample, Resident #244. The facility staff failed to ensure Resident #244 was administered Miralax 17 grams per the physician's order during a medication pass and pour observation. Finding include: Resident #244 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: Constipation, high blood pressure, osteoporosis, high cholesterol, and dry eyes. No MDS (minimum data set) information was completed for this resident at the time of the survey. During a medication pass and pour observation on 04/03/18 at 08:25 AM, LPN (Licensed Practical Nurse) # 1 prepared medications for Resident #244. The medications included, Colace 100 mg soft gel capsule (two capsules), Calcium 600 plus D 3 (600/200) (one tablet), Atenolol 25 mg (one tablet), and Artificial Tears…
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 · D2019-04-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide proper care and treatment of a pressure ulcer for one of 14 residents in the survey sample. Resident #94 was observed without a physician ordered dressing in place on his coccyx pressure ulcer. Nursing staff failed to follow infection control practices during a dressing application to Resident #94's pressure ulcer. No hand hygiene was performed after removal of gloves and no glove change and/or hand hygiene was performed after cleansing the wound and prior to applying a clean dressing. The findings include: Resident #94 was admitted to the facility on [DATE] with diagnoses that included left hip joint replacement, atrial fibrillation, COPD (chronic obstructive pulmonary disease), coccyx pressure ulcer and insomnia. The minimum data set (MDS) dated [DATE] assessed Resident #94 as cognitively intact. This MDS assessed the resident as always incontinent of bowel and frequently incontinent…
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 before2019-04-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during a dressing application for one of 14 residents in the survey sample and failed to follow infection control protocols during a medication pass observation. 1. Resident #94 was observed without a physician ordered dressing in place on his coccyx pressure ulcer. Nursing staff failed to follow infection control practices during a dressing application to Resident #94's pressure ulcer. No hand hygiene was performed after removal of gloves and no glove change and/or hand hygiene was performed after cleansing the wound and prior to applying a clean dressing. 2. During a medication pass observation, an oral medication that dropped onto unclean bed linens, was handled by the nurse without use of gloves and then administered to a resident. The findings include: 1. Resident #94 was admitted to the facility on [DATE] with diagnoses that included left hip joint…
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.
- No harm found · B2021-11-17 · tag F0732 — patternPost nurse staffing information every day.
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 post daily nurse staffing in a prominent area visible for visitors and residents in the facility. Findings include: On 11/16/21 beginning at 9:00 a.m upon entrance and during initial tour of the facility, a posting of nurse staffing data was not observed. The posting was not observed on either units. On 11/17/21 beginning at 11:50 a.m. the DON(director of nursing) was asked about the nurse staffing posting. The DON stated The number of residents on the units is posted at the nursing station. he posting of which staff is working which unit is posted in the break room. At the back of each unit the DON stated, There is the posting. The postings were located behind the nursing stations in a frame. The DON was asked if she thought the information was readily accessible to visitors and residents, she stated No, probably not. The DON further stated that staffing information including which staff were working which unit was posted in the employee breakroom. The administrator, vice president of operations, and charge…
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
$10,033 in federal fines across 1 penalty.
- $10,033 — penalty dated 2024-04-24
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 KENDAL — 5 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 | 4 of 5 | 4.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 3.6 | -1.6 vs chain |
| Staffing | 5 of 5 | 4.6 | +0.4 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 4 homes this chain runs (chain average 4.4★, 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 |
|---|---|---|---|
| BAKER, PRISCILLA | Individual | CORPORATE DIRECTOR | since 07/27/2017 |
| BRANNER, ELIZABETH | Individual | CORPORATE DIRECTOR | since 05/18/2023 |
| BROOKE, GEORGE | Individual | CORPORATE DIRECTOR | since 05/16/2024 |
| GOSSE, THOMAS | Individual | CORPORATE DIRECTOR | since 05/15/2025 |
| GRIZZLE, JAMES | Individual | CORPORATE DIRECTOR | since 05/21/2020 |
| HARE, RANDOLPH | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/20/2022 |
| HENTZ, MICHELE | Individual | CORPORATE DIRECTOR | since 05/16/2024 |
| HERRICK, DIANNE | Individual | CORPORATE DIRECTOR | since 05/16/2024 |
| HUCH, ROBERT | Individual | CORPORATE DIRECTOR | since 05/21/2020 |
| KEELEY, MARK | Individual | CORPORATE DIRECTOR | since 05/18/2023 |
| LUECKE, PAMELA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/20/2021 |
| MOLITERNO, VALERIE | Individual | CORPORATE DIRECTOR | since 05/15/2025 |
| REID, COLIN | Individual | CORPORATE DIRECTOR | since 05/15/2025 |
| ROSS, BENNETT | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/19/2022 |
| SUMMERS, BRUCE | Individual | CORPORATE DIRECTOR | since 07/27/2017 |
| WALSH, NATASHA | Individual | CORPORATE DIRECTOR | since 05/23/2019 |
| WARNER, HARRY | Individual | CORPORATE DIRECTOR | since 05/16/2024 |
| WILDER, LINDA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/18/2023 |
| BUSH, FELICIA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2010 |
| DAY, ADAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/02/2025 |
| BAROCO, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2023 |
| BRYD, VASSAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2024 |
| FELDBAUER, ADAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/06/2023 |
| GUILL, NOELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/16/2025 |
CMS files one row per role, so the 35 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $671K 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 495034. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-24, 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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