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Manassas Health And Rehab Center

8575 Rixlew Lane, Manassas, VA 20109 · For profit - Corporation · 120 certified beds · (703) 257-9770 Medicare & Medicaid certified

Call the home — (703) 257-9770 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 20242 actual-harm citations$16,376 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,376 in federal fines (most recent 2024-02-13)

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
8551 Rixlew Ln Ste 140 · (703) 361-4357 · Call to confirm hours
Pharmacy
8386 Sudley Rd · (703) 330-2455 · Call to confirm hours
Grocery
8386 Sudley Rd · (703) 330-5253 · Call to confirm hours
Park
11000 Crestwood Dr · (703) 792-7060 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 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 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.7%14.9%15.4%worse
Long-stay residents who lose too much weight5.1%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%1.6%2.0%better
Long-stay residents with depressive symptoms5.1%18.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.6%3.3%better
Long-stay residents whose ability to walk worsened12.8%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.2%20.6%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.0%95.3%typical
Long-stay residents with pressure ulcers2.5%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control22.7%21.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table23.4%14.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine94.4%73.6%79.4%better
Short-stay residents rehospitalized after admission27.0%22.3%22.6%worse
Short-stay residents with an outpatient ER visit6.9%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days0.871.521.67better
Long-stay outpatient ER visits per 1,000 resident days1.461.481.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

59.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 271 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.5%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
32.9%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 32.9% 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 79 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.5%CMS range 52.8–64.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.8–15.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge32.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge32.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting94.4%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.3–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.54
RN hours/ resident / day
1.14
LPN hours/ resident / day
1.81
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.32
RN hoursweekends
35.2%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 116.4 residents a day — about 97% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.485 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.08 hrs/resident/day on weekends vs 3.65 on weekdays — 16% thinner on weekends. RN hours go from 0.63 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-01-22)
5
at the previous standard inspection (2022-03-10)

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.

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2024-02-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, family interview, clinical record review, and facility document reviews, it has been determined that the facility staff failed to ensure that a resident was free from neglect when they neglected to properly assess, monitor, treat, and consult a physician or practitioner for 1 of 15 residents (Resident #15, closed record review) in the survey sample who was unresponsive and presented with respiratory distress, which constituted harm. The findings include: For Resident #15, the facility neglected to properly administer supplemental oxygen, assess, and monitor during signs and symptoms of respiratory distress for approximately two (2) hours before calling 911. Resident #15 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was discharged from the nursing facility, admitted to the local hospital on [DATE], and did not return to the nursing facility. Resident #15 diagnoses included dementia, left lower leg cellulitis, anxiety, and allergic rhinitis.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-02-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, Emergency Medical Service (EMS) report, facility document review, and clinical record review, it was determined that the facility staff failed to assess, monitor, and appropriately treat an unresponsive resident who presented with respiratory distress for 1 of 15 residents (Resident #15, closed record review) in the survey sample, which constituted harm. The findings include: For Resident #15, the facility failed to properly administer supplemental oxygen, assess, and monitor an unresponsive resident including vital signs and signs and symptoms of hypoxia for approximately 2 hours before calling 911. Resident #15 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was discharged from the nursing facility, admitted to the local hospital on [DATE], and did not return to the nursing facility. Resident #15 diagnoses included dementia, left lower leg cellulitis, anxiety, and allergic rhinitis. The quarterly Minimum Data Set (MDS) assessment with an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-22 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain a clean dumpster area during the facility task- kitchen observation 1/20/26 at 11:50 AM. The findings include: On 1/20/26 at 11:50 AM, an observation was conducted in the dumpster area outside of the kitchen. On the left side of the dumpster on the ground there were blue and white gloves and plastic straw.An interview was conducted on 1/20/26 at 1:10 PM with OSM #1, the dining services director. When asked about the findings, OSM #1 stated, we only wear black gloves. I will talk with housekeeping about it. It sounds like trash from the facility.On 1/21/26 at 11:00 AM ASM (administrator staff member) #1, the administrator was informed of the above concerns.The facility does not have a policy related to the dumpster.No further information was provided prior to exit.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-22 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for two of 43 residents in the survey sample, Resident #6 and Resident #35.The findings include:1. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to administer pain medication as ordered. Pain level parameters for the administration of Hydromorphone (1) were not followed during administration during dates in December 2025 and January 2026. The comprehensive care plan for R6 documented in part, Patient has pain or potential for pain. Date Initiated: 11/07/2025. Under Interventions it documented in part, Administer pain medication as ordered. Report s/s (signs/symptoms) potential negative side effects. Date Initiated: 11/07/2025 . Report breakthrough pain and/or unrelieved pain for further assessment and treatment. Date Initiated: 11/07/2025.On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-22 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical review, the facility staff failed to provide activities to promote the highest level of wellbeing for three of 43 residents in the survey sample, Residents #24, #17, and #72.The findings include:1. For Resident #24 (R24), the facility staff failed to provide activities to promote the resident's highest level of wellbeing in December 2025 and January 2026.On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/2/25, R24 was coded as having both short term and long term memory problems. She was coded as preferring the following activities: snacks between meals, reading books/newspapers/magazines, listening to music, and doing things with groups of people. On 1/20/26 at 12:57 p.m., R24 was observed sitting up in bed in her room on the memory care unit. The resident was being fed by a staff member who was seated in a chair next to the bed. On 1/20/26 at 2:43 p.m., R24 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The findings include: On 1/20/26 at 10:55 AM, an observation was conducted in the kitchen with the following findings: walk-in refrigerator #1, opened and undated five-pound bag of hash browns; walk-in refrigerator #2, one half chicken salad sandwich dated (prep 1/16/26 at 1:39 PM, expires 1/18/26 at 1:39 PM). An interview was conducted with OSM #1, the dining services director as the tour was being conducted, asked about opened and undated hash browns as well as the expired chicken salad sandwich OSM #1 stated, they should not be in there. I am throwing both of them out now. On 1/21/26 at 11:00 AM ASM (administrator staff member) #1, the administrator was informed of the above concerns.A review of the facility's Safe Food and Supply Storage policy revealed, Leftover prepared foods must be stored in approved containers, zip lock bags or wrapped with plastic wrap, be labeled as to contents and dated with a 'Use By' date.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure dignity for one of 43 residents in the survey sample, Resident #133. The findings include:For Resident #133 (R133), the facility staff failed to ensure the resident's incontinence brief was not exposed and visible from the hall. R133 was admitted to the facility on [DATE]. A nursing admission assessment signed by a nurse on 1/13/26 documented R133 was only oriented to self. On 1/20/26 at 12:45 p.m., R133 was observed lying in bed, only wearing an incontinence brief. The resident was visible from the hall. On 1/20/26 at 2:25 p.m., 1/21/26 at 3:55 p.m., and 1/22/26 at 10:41 a.m., R133 was observed lying in bed with a gown pulled above the resident's waist. The resident's incontinence brief was exposed and visible from the hall. On 1/22/26 at 10:54 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #8 (the CNA caring for R133). CNA #8 stated she had pulled the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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, staff interview and facility document review, it was determined that the facility staff failed to ensure all discharge needs were met prior to discharge from the facility for one of 43 residents in the survey sample, Resident #136.The findings include:For Resident #136 (R136), the facility staff failed to ensure needed durable medical equipment (DME), a bedside commode, was delivered to the residents home prior to discharging them from the facility to reside independently in a multi-level home with a bathroom located up 13 steps on the second level when they were unable to negotiate stairs. On the admission minimum data set (MDS), with an assessment reference date (ARD) of 12/12/2023, R136 was assessed as requiring partial/moderate assistance for bathing, upper body dressing, and standing from a sitting position, requiring substantial/maximal assistance of a helper for toileting and lower body dressing. Toilet transfers and walking were not attempted due to medical condition or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of 43 residents in the survey sample, Resident #133. The findings include:For Resident #133 (R133), the facility staff failed to dress the resident in clothes on 1/20/26, 1/21/26, and 1/22/26. R133 was admitted to the facility on [DATE]. A nursing admission assessment signed by a nurse on 1/13/26 documented R133 was only oriented to self. On 1/20/26 at 12:45 p.m., R133 was observed lying in bed, only wearing an incontinence brief. The resident was visible from the hall. On 1/20/26 at 2:25 p.m., 1/21/26 at 3:55 p.m., and 1/22/26 at 10:41 a.m., R133 was observed lying in bed with a gown pulled above the resident's waist. The resident's incontinence brief was exposed and visible from the hall. On 1/22/26 at 10:54 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #8 (the CNA caring for R133). CNA #8 stated she had pulled…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement interventions to prevent a decrease in mobility for one of 43 residents in the survey sample, Resident #35.The findings include:For Resident #35 (R35), the facility staff failed to ambulate as recommended by physical therapy and care plan interventions to prevent a decrease in mobility.On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 10/24/2025, the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The assessment documented use of a wheelchair and walking not attempted due to the residents medical condition or safety concerns. It documented no therapy services received during the assessment period.On 1/20/2026 at 2:05 PM, an interview was conducted with R35 who stated that they had recently been discharged from physical therapy (PT). R35 stated that their…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-22 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 43 residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to follow pain level parameters for the administration of hydromorphone (1). On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 12/17/2025, the resident 14 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. Section J documented R6 receiving scheduled and as needed pain medication and having almost constant pain.On 1/20/2026 at 2:57 PM, an interview was conducted with R6 who stated that they had chronic pain and took medication every four hours as needed. R6 stated that the medication helped when they had knee pain. The physician orders for R6 documented in part, Hydromorphone HCl Tablet 4 MG (milligram) Give 1 tablet by…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and clinical record review the facility staff failed to honor a Family Member/Responsible Party's verbalized choice for a transfer from the facility to the hospital or to another facility for 1 of 3 resident's (Resident #13) reviewed for participation in treatment options which resulted in the responsible party physically removing the resident from the facility. The findings included: Resident #13 was originally admitted to the facility 8/30/23 for rehabilitation services after a left hip fracture and surgical repair. The admission diagnoses included; fracture of left femur and a stroke with left hemiparesis. The resident was transferred from the facility on 8/31/23 therefore a closed record review was conducted. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 8/30/23. The tool revealed the resident was oriented to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-02-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 staff interview, facility document review, and clinical record, it was determined that the facility staff failed to notify the on-call practitioner of a resident's change in condition including shortness of breath, difficulty breathing, and unresponsiveness for approximately 2 hours, and the decision to transfer from the facility to the emergency room for 1 of 15 residents in the survey sample, Resident #15 (a closed record resident). The findings include: For Resident #15, the facility staff failed to notify the on-call practitioner of a resident's change in condition and the decision to transfer from the facility to the hospital emergency room. Resident #15 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was discharged from the nursing facility and admitted to the local hospital on [DATE]. The resident did not return to the nursing facility. Resident #15 diagnoses included dementia, anxiety, and allergic rhinitis and a primary re-admission diagnosis of left…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide two-person assistance while transferring Resident #13, which resulted in a fall for 1 of 3 residents reviewed for falls in the survey sample. The findings included: Resident #13 was originally admitted to the facility 8/30/23 for rehabilitation services after a left hip fracture and surgical repair. The admission diagnoses included; fracture of left femur and a stroke with left hemiparesis. The resident was transferred from the facility on 8/31/23 therefore a closed record review was conducted. The resident's Minimum Data Set (MDS) was not completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 8/30/23. The tool revealed the resident was oriented to person, place, and situation. In section GG (Usual Performance Admission) the resident was coded as requiring substantial/maximal assistance with chair/bed-to-chair transfer and the resident was coded dependent with toilet transfers. A fall risk…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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, Emergency Medical Service (EMS) report, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the licensed nurses and other nursing personnel have the knowledge, competencies, and skill sets to provide care and respond to emergencies for a resident who was unresponsive with breathing difficulties for 1 of 15 residents (Resident #15, a closed record review) in the survey sample. The findings include: Resident #15 was originally admitted to the facility on [DATE] and re-admitted on [DATE].The resident was discharged and admitted to the local hospital on [DATE]. The resident did not return to the nursing facility. Resident #15 diagnoses included dementia, left lower leg cellulitis, anxiety, and allergic rhinitis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-03-10 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 46 residents in the survey sample, Residents #45, #24, # 64, #56 and # 103. The findings include: 1. The facility staff failed implement Resident # 45's comprehensive care plan to administer oxygen at two liters per minute. Resident # 45 was admitted to the facility with diagnoses that included but were not limited to: chronic obstructive pulmonary disease (COPD). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 45 for Oxygen Therapy while a resident. On 03/08/22 at approximately 1:36 p.m., an observation of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-10 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis [1] program for three of 46 residents in the survey sample, Residents # 24, # 64 and # 56. The findings include: 1. The facility staff failed to maintain accurate communication regarding Resident #24's care with the dialysis center for January 2022 through March 2022. Resident # 24 was admitted to the facility with diagnoses included but were not limited to: end stage renal disease [2]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/23/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 24 as having received dialysis while a resident. The physician's order sheet for Resident # 24 documented in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to place a call bell within reach for one of 46 residents in the survey sample, Resident #103. The findings include: The facility staff failed to place Resident #103's call bell within reach. Resident #103 was admitted to the facility on [DATE] with diagnoses that include pneumonia and neuropathy. Resident #103's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 2/24/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G coded the resident as requiring extensive staff assistance with bed mobility, transfers, dressing, hygiene; total dependence for bathing. Section H coded the resident as frequently incontinent for bowel and for bladder. A review of the comprehensive care plan dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory services according to the physician's orders for one of 46 residents in the survey sample, Resident # 45. The findings include: Facility staff failed to maintain Resident # 45's oxygen flow rate at 2 liters per minute according to the physician's orders. Resident # 45 was admitted to the facility with diagnoses that included but were not limited to: chronic obstructive pulmonary disease (COPD). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 45 for Oxygen Therapy while a resident. On 03/08/22 at approximately 1:36 p.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-10 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, clinical record review, facility document review and staff interviews it was determined that the facility failed to maintain a complete and accurate clinical record for one of 46 residents in the survey sample, Resident #42. The findings include: The facility staff failed to maintain a complete and accurate ADL (activities of daily living) record for Resident #42. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/15/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section G documented Resident #42 requiring extensive assistance of two or more persons for bed mobility and one person for dressing and personal hygiene. On 3/8/2022 at 10:00 a.m., an interview was conducted with Resident #42. Resident #42 stated that the facility staff used a mechanical lift to get him out of bed to take him to the shower. Resident #42 stated that he was scheduled for showers on Tuesdays and Fridays and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-03-05 · tag F0770 — failed to provide lab services — widespread
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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, it was determined that the facility staff failed to dispose of laboratory vaccutainers upon expiration date in three of three medication storage rooms, (Evergreen, Magnolia and Dogwood medication storage rooms). Expired laboratory vaccutainer tubes were observed available for use in Evergreen, Magnolia and Dogwood medication storage rooms. The Evergreen medication storage room contained 17 expired laboratory (lab) vaccutainer tubes, Magnolia medication storage room contained 18 expired lab vaccutainer tubes and Dogwood medication storage room contained seven expired lab vaccutainer tubes. The findings include: During the medication storage and labeling facility task on [DATE] at 8:14 AM with LPN (licensed practical nurse) #2, the unit manager a review of the Evergreen and Magnolia medication storage rooms was conducted. During the observation and review with LPN #2, the following expired laboratory supplies were observed: -In the Evergreen medication storage…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-03-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in the kitchen and in one of three nourishment rooms in accordance with professional standards for food service safety. The findings include: 1. The facility failed to properly store opened, available for use dry goods in the kitchen and failed to dispose of dry goods that were past their expiration date. On 3/2/21 at approximately 11:20 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #7, the dietary manager. Observation of the kitchen's dry storage area revealed a gallon sized zipper closure plastic bag containing two 1.41-pound bags of dry chicken gravy. One package was observed unopened and the other was observed opened. OSM #7 confirmed that the package of dry chicken gravy was opened inside of the plastic bag and was not dated. OSM #7 stated that staff were to date any item that was opened with the date it was opened and a use by date. Further…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-05 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the physician of a change in peritoneal dialysis status for one of 46 residents in the survey sample, Resident #245. The facility staff failed to notify the physician when Resident #245 did not complete peritoneal dialysis on 2/28/21 and 3/1/21. The findings include: Resident #245 was admitted to the facility on [DATE] with diagnoses including, but not limited to infected leg wound and ESRD (end stage renal disease) (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/5/21. Resident #245 was coded as moderately cognitively impaired, scoring seven out of 15 on the BIMS (brief interview for mental status). He was coded as receiving dialysis in the facility during the look back period. Resident #245 was observed lying on his back in bed, with his eyes closed, on the following dates and times: 3/02/21 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility document review and clinical record review, it was determined the facility staff failed to develop and / or implement the comprehensive care plan for two of forty six residents, Resident #53 and Resident #61. The facility staff failed to develop and implement a comprehensive care plan to address the use of an incentive spirometer for Residents #53 and # 61. The findings include: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: bipolar (mental disorder characterized by periods of mania and depression) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and angina (severe pain in the chest accompanied by a choking feeling) (3). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 1/24/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is cognitively…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for three of 46 residents in the survey sample, Residents #90, #65 and #194. The facility staff failed to review and revise the comprehensive care plans for Resident #90, Resident #65 and Resident #194 to address the residents' use of bed rails. The findings include: 1. Resident #90 was admitted to the facility on [DATE]. Resident #90's diagnoses included but were not limited to muscle weakness, dementia and difficulty swallowing. Resident #90's admission MDS (minimum data set) assessment, with an ARD (assessment reference date) of 2/15/21, coded the resident's cognition as severely impaired. On 3/2/21 at 4:33 p.m., Resident #90 was observed lying in bed with bilateral one half bed rails raised in the upright position. Review of Resident #90's clinical record failed to reveal a physician's order for bed rails. Resident #90's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care, consistent with professional standards of practice, for three of 46 residents in the survey sample, Residents # 61, # 64 and #53. The facility staff failed to store Resident #61 and # 53's incentive spirometers and Resident #64's C-PAP [continuous positive airway pressure] mask in a sanitary manner. The findings include: 1. The facility staff failed to store Resident # 61's incentive spirometer [1] in a sanitary manner. Multiple observations revealed Resident #61's incentive spirometer on the bedside table uncovered when not in use. Resident # 61 was admitted to the facility with diagnoses that included but were not limited to: chronic obstructive pulmonary disease [2]. Resident # 61's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/26/2021, coded Resident # 61 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-05 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for three of 46 residents in the survey sample, Residents #90, #65 and #194. 1. The facility staff failed to assess Resident #90 as requiring the use of bed rails and failed to obtain consent for the use of bed rails. On 3/2/21, the resident was observed lying in bed with bed rails in the upright position. 2. The facility staff failed to assess Resident #65 as requiring the use of bed rails. On 3/2/21 and 3/3/21 Resident #65 was observed lying in bed with bed rails in the upright position. 3. The facility staff failed to assess Resident #194 for the use of bed rails and failed to obtain consent for the use of bed rails. On 3/2/21 Resident #194 was observed lying in bed with bed rails in the upright position. The findings include: 1. The facility staff failed to assess Resident #90 as requiring the use of bed rails and failed to obtain…

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

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

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

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

Fines & penalties

$16,376 in federal fines across 2 penalties.

  • $8,188 — penalty dated 2024-02-13
  • $8,188 — penalty dated 2024-02-13

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 COMMONWEALTH CARE OF ROANOKE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.6-0.6 vs chain
Health inspection 3 of 53.3-0.3 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 4 of 54.2-0.2 vs chain
The other 11 homes this chain runs (chain average 3.6★, 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 / managerTypeRoleSince
WHITTINGTON, KATELYNIndividualW-2 MANAGING EMPLOYEEsince 11/05/2017
ALESANTRINO, JOEIndividualCORPORATE OFFICERsince 06/01/2019
PETRINE, DEBORAHIndividualCORPORATE OFFICERsince 10/08/2006
COMMONWEALTH CARE OF ROANOKE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/05/2005

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$16.8M
Net patient revenuemost recent cost report
+1.8%
Operating marginrevenue minus expenses
$959K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 11%Other / private 20%

This home reported $959K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$407per resident / day
operating cost
$12,380per month
≈ monthly operating cost
$415per day
avg. revenue, all payers

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

What families pay in VA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495038. 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 →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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