Atlantic View Post Acute
540 Aberthaw Avenue, Newport News, VA 23601 · For profit - Corporation · 154 certified beds · (757) 595-2273 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2022
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 21% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 | 11.9% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.3% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.2% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.8% | 18.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.0% | 15.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.7% | 20.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.3% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 21.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.3% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.5% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.7% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.6% | 11.5% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 50.3%CMS range 39.3–58.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.9–15.4 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 92.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.1–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 154 beds and averages 148.5 residents a day — about 96% occupied, or roughly 6 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.546 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 3.45 on weekdays — 14% thinner on weekends. RN hours go from 0.62 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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 3 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2022-12-01 · 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, resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide the necessary treatment and services to prevent development of a sacral pressure ulcer and to promote healing of the sacral pressure ulcer for 1 of 39 residents (Resident #65) which constitued harm. The findings included: On 10/6/22 the sacral pressure ulcer presented as a red, black, and purple wound to the sacrum, measuring 8 cm by 13.0 cm, with a scant amount of drainage and a wound bed with epithelial tissue, which was determined to be an Unstageable - Suspected Deep Tissue (USDT); Injury in Evolution. On 10/10/22 the sacral USDT Injury presented with deterioration; 90% eschar, 10% slough and measured 7.5 centimeters (cm) by 7.0 cm which constituting harm. Resident #65 was originally admitted to the facility 6/14/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a-fib, a pacemaker insertion, benign prostatic…
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 · F2022-12-01 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a complaint investigation, resident and staff interviews, the facility staff failed to ensure sufficient staff were available to carry out the functions of the food and nutrition services. The findings included: The facility failed to have sufficient staff on 04/17/22 to carry out the functions of the food and nutrition services. During an interview on 11/30/22 at 1:37 PM Resident #82 voiced concern about food. Resident voiced concerns about the facility not having enough staff to serve and prepare food. Resident #82 stated the facility served the residents a granola bar, a carton of juice and a cup of fruit for breakfast a few months ago because the facility did not have enough staff. During an interview on 12/01/22 at 9:58 AM Dietary Aide #1 stated on the morning of April 17, 2022 which was Easter Sunday, she was the only dietary staff on duty. Dietary Aide #1 stated she did the best she could to provide a breakfast meal to the residents. The meal consisted of granola bar, a carton of juice and a cup of fruit for those residents on a regular diet. For residents on 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 · F2022-12-01 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, the facility staff failed to ensure menus were followed as pre-planned. The findings included: The facility staff failed to ensure menus were followed as planned on 4/17/22 due to having insufficient staff. During an interview on 11/30/22 at 01:37 PM Resident #82 voiced concern about food. Resident voiced concerns about the facility not having enough staff to serve and prepare food. Resident #82 stated the facility served the residents a granola bar, a carton of juice and a cup of fruit for breakfast a few months ago because the facility did not have enough staff. A review of the facility menu dated 4/17/22 for breakfast indicated: Juice/cranberry PC, Cereal Chex [NAME] PC, Muffin Blueberry RTS, sausage link, 2 each, milk 2% 8 ounces, and 8 ounces of coffee. During an interview on 12/01/22 at 9:58 AM Dietary Aide #1 stated on the morning of April 17, 2022 which was Easter Sunday, she was the only dietary staff on duty. Dietary Aide #1 stated she did the best she could to provide a breakfast meal to the residents. The meal consisted of granola…
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 · F2022-12-01 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and facility staff interview, the facility staff failed to prepare food that conserves nutritive value, flavor and appearance. The findings included: During an interview on 11/30/22 at 9:16 AM Resident #82 voiced concern about his food. Resident #82's concern was how his breakfast food was prepared and presented. Resident #82's breakfast tray was observed to included scrambled eggs, french toast and two sausage patties. The scrambled eggs were observed to be runny and juicy. The sausage patties were observed to be blacken in color. Resident #82 stated the sausage patties were to hard to eat. The French toast sticks were observed to be about 1/4 thick and unrecognizable. During an observation and interview with Resident #99 on 11/30/22 at 9:12 AM, Resident #99 received his breakfast tray with large portion of unseasoned scrambled eggs, one patty of sausage which was black in color and approximately three French toast sticks, one was approximately 1/8 inch thick and unrecognizable. Resident #99's family member was feeding the resident. She stated she…
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 · F2022-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 and staff interview, the facility staff failed to store and serve food under sanitary conditions. The findings included: During the kitchen observations on 11/29/22 at 11:27 a.m., the left wall next to the four burner stove and two door oven, was noted to have copious amounts of burnt grease and food particles. Behind the stove was burned food particles and food crumbs. Food and debris was observed behind the standing two part oven. The wall next to the eight burner stove was observed to have a hole that measured an estimated 10 inches long and 3 inches wide. Rust and corrosion was noted on the electrical sockets next to the deep fryer. The wall behind the three compartment sink was observed to have food and debris. The drain hole under the prep severing table was observed to have black like matter. The wall behind the ice machine was observed to have an estimated 8 inch by 3 inch hole. The plaster was observed to be coming off. Trash and debris was observed behind the ice machine. The kitchen floor was noted to have a brown film on it. In the dish wash room…
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 · F2022-12-01 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, and staff interview the facility staff failed to ensure garbage and refuse was disposed properly. The findings included: On 12/01/22 at 2:10 PM two of three outside garbage and refuse containers were observed with open container doors. The area around the refuse containers were observed with trash and debris. Two chairs and a sofa was observed in the area around the dumpster. A dresser drawer was observed in the area along with a pile of old wooden fencing. The area outside the kitchen door was observed to have pools of standing water, leaves, trash and debris. The administrator who accompanied the surveyor during the observations stated, the areas will be cleaned up immediately and the outside service for the dumpers will be called to replace the dumpster due to the doors not closing properly.
- Potential for harm · F2022-12-01 · tag F0886 — failed to test for COVID-19 as required — widespreadPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, document review, policy review and review of Centers for Medicare &Medicaid Services (CMS) Quality, Safety & Oversight (QSO) memo, the facility failed to ensure that contact tracing of residents and staff was conducted, after identifying Licensed Practical Nurse (LPN)7 tested positive for Coronavirus Disease (COVID-19). This deficient has the potential to affect all of the residents in the facility. Findings Include: Review of the CMS QSO-20-38-NH [Nursing Home] revised 09/23/22 revealed, an outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed . Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing . If the facility has the ability to identify close contacts of the individual with COVID-19,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-01 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on deficiencies determined during this survey the QAA (Quality Assessment and Assurance) and Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement corrective plans of action and monitoring to ensure the necessary systems were in place and correct identified quality deficiencies related to a fall on 6/10/22 for one resident (Resident #99) out of a survey sample of 39. The findings included: On 12/01/22 at approximately 4:38 p.m., an interview was conducted with the Administrator, Director of Nursing, [NAME] President (VP) of Operations, [NAME] President (VP) of Nursing and on the phone was the [NAME] President of Quality. The VP of Nursing stated the Quality Assurance Plan is used to ensure systems are evaluated, any quality care concerns are addressed and tracked for improvement. The VP of Operations stated Resident #99 fell out of the Hoyer lift during a transfer on 06/10/22. She stated she did not realize the investigation wasn't completed until information related to the fall was requested by Surveyor #1. She said almost everything…
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 before2022-12-01 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview the facility staff failed to maintain an effective pest control program. The findings included: Resident #35 stated during an interview on 11/29/22 at 2:35 PM that she did not like taking showers in the women's shower room on the Huntington Unit because it had drain flies. Observations made on 11/29/22 at 2:45 PM indicated drain flies were noted in the women's shower room. On 11/30/22 at 9:20 AM two live roaches were observed on the Huntington Unit near room [ROOM NUMBER]. During kitchen observations on 11/29/22 at 11:30 AM, 11/30/22 at 11:48 AM and 12/1/22 at 12: 48 PM, drain flies and gnats were observed in the kitchen. During an interview on 12/1/22 at 1:30 PM the Director of Dining and Nutrition stated that pests were on the list of corrections for the kitchen area. During an interview on 12/1/22 at 4:45 PM the Administrator stated that the pest control company comes out every other week to spray and as needed if called.
- Potential for harm · D2022-12-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self reported documentation, family and staff interviews, the facility staff failed to ensure one resident (Resident #41) was free from physical abuse to include having a bruise on her right lower extremity and failed to protect one resident, Resident #99 who was reviewed for neglect, in the survey sample of 39 residents. The findings included: 1. Resident #41 was admitted to the facility on [DATE] from an acute care facility with a diagnosis of Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long- and short-term memory problems as well as severely impaired for daily decision making. Resident #41 requires total dependence of one person with dressing, grooming, eating, toileting, and personal hygiene, requires and bathing. The care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-01 · 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 record review, facility self report documentation, family and staff interviews, the facility staff failed to implement their policies and procedures to report and investigate an abuse allegation involving two residents, Resident #41 and Resident #15 (the perpetrator), a closed record resident in the survey sample of 39 residents. The findings included: 1. For Resident #41 the facility staff failed to report and investigate a physical abuse allegation that resulted in the resident having a bruise on her right lower extremity to the Resident Representative, Administrator/ designee, APS (Adult Protective Services) or to the State certification and certification agency. The incident occurred on 11/12/22 but was not reported until 11/14/22. Resident #41 was admitted to the facility on [DATE] from an acute care facility with diagnosis Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded 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.
Show the remaining 16 citations
- Potential for harm · D2022-12-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility self report document, family and staff interviews, the facility staff failed to ensure appropriate abuse training was implemented to include reporting an abuse allegation involving two residents, Resident #41 and Resident #15 (the perpetrator), a closed record resident, and they failed to timely report an allegation of neglect for one resident, Resident #99 in a survey sample of 39 residents. The findings included: 1. For Resident #41 the facility staff failed to report a physical abuse that resulted in resident having a bruise on her right lower extremity in a timely manner (Within 2 hours) that occurred on 11/12/22 until 11/14/22 . Resident #41 was admitted to the facility on [DATE] from an acute care facility with diagnosis Alzheimer's disease with late onset and Major Depressive Disorder. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/02/22 coded the resident as not having the ability to complete the Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self report document, family and staff interviews, the facility staff failed to thoroughly investigate and take appropriate action as a result of investigation findings surrounding an abuse allegation involving two (2) residents. Resident #41 and Resident #15 (the perpetrator), a closed record resident and failed to thoroughly investigate an allegation of neglect for one (1) resident Resident #99, in a survey sample of 39 residents. The findings included: 1. For Resident #41 the facility staff failed to report and investigate a physical abuse allegation that resulted in the resident having a bruise on her right lower extremity to the Resident Representative, Administrator/ designee, APS (Adult Protective Services) or to the State survey and certification agency. The incident occurred on 11/12/22 but was not reported until 11/14/22. Resident #41 was admitted to the facility on [DATE] from an acute care facility with diagnosis Alzheimer's disease with late onset and Major Depressive…
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 before2022-12-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, the facility staff failed to ensure that 1 of 39 residents (Resident #51) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS). The findings included: Resident #51 was originally admitted to the nursing facility on 03/25/19. Diagnosis for Resident #51 included but are not limited to anxiety and depression. The most recent (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 09/10/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 05 out of a possible score of 15, which indicated severe cognitive impairment for daily decision-making. Under section P (under restraints/alarms) was coded for the use of a wander/elopement alarm. A review of the quarterly assessment with an ARD date of 06/10/22 under section P (under restraints/alarms) was not coded for the use of a wander/elopement alarm. Resident #51's comprehensive care plan with a revision 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.
- Potential for harm · D2022-12-01 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 39 residents (Resident #4) in the survey sample received the services needed to meet their dental needs. The findings included: The facility staff failed to follow-up with a dental visit recommended by the dentist on 07/31/22 for Resident #4. Diagnosis for Resident #4 included but not limited to Major Depressive Disorder. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 9/01/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. The MDS coded Resident #4 supervision with oversight, encouragement or cueing with eating. Under section L0200 (Dental), nothing was coded for Resident #4. An interview was conducted with Resident #4 on 11/30/22 at approximately 11:10 a.m. She said that she had two bad teeth in the back of her mouth that needed to be pulled. She also said that a dentist…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-01 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 and review of facility documents, the facility's staff failed to have an appropriate call bell accessible and functional for a resident with bilateral contractured hands for 1 of 39 residents (Resident #226) in the survey sample. Resident #226 was originally admitted to the facility on [DATE] from the community. The current diagnoses included; Quadriplegia and Contracture Right and Left Hands. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/29/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long- and short-term memory problems as well as severely impaired for daily decision making. In section G(Physical functioning) the resident was coded as total dependence of one person for bathing, dressing, eating, toilet-use, personal hygiene and bathing. Functional Status G0400: Functional Limitation In Range of Motion: 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 · E2019-04-18 · tag F0622 — patternNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 interviews and facility documentation review, the facility staff failed to convey the summary of goals of the comprehensive plan of care upon transfer/discharge for 6 of 46 residents (Resident #134, #52, #81, #80, #106 and #50) in the survey sample. 1. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving provider the resident's comprehensive care plan goals at the time of discharge to the local hospital on 3/8/19 and 3/28/19 or as soon as possible to the actual time of transfer for Resident #134. 2. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 2/8/19 or as soon as possible to the actual time of transfer for Resident #52. 3. The facility staff failed to include in the transfer summary indication that the facility staff conveyed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-04-18 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and facility documentation, the facility staff failed to issue a written notice of the bed hold policy upon transfer to the local hospital for 7 of 46 residents (R #134, #52, #81, #80, #106, #54 and #50) in the survey sample. 1. The facility staff failed to ensure Resident #134 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 3/8/19 and on 3/28/19. 2. The facility staff failed to ensure Resident #52 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 2/8/19. 3. The facility staff failed to ensure Resident #81 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 3/15/19 and to the emergency department (ED) on 3/20/19. 4. The facility staff failed to ensure Resident #80 or RR was issued a written notice of the bed hold policy upon transfer to the local hospital on 4/6/18 and on 5/22/18.…
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 before2019-04-18 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 complaint investigation, group interview and resident interviews, the facility staff failed to maintain an effective pest control program so that it is free of pests. The findings included: A complainant that involved Resident #80, a current resident, filed a complaint to the State survey and certification agency dated 3/4/19 that indicated cockroaches were seen in the resident's room, bathroom on the floors and ceilings. Although the complainant could not be reached via telephone, the resident was interviewable and stated during an interview on 4/17/19 at 8:50 a.m. that the complainant showed him the roaches that were in the bathroom and stated he had seen others in the room and throughout the facility. Resident #80 was admitted to the nursing facility on 3/16/18 with diagnoses that included kidney failure, high blood pressure history of stroke and left sided hemiplegia. Resident #80's most recent Minimum Data Set (MDS) assessment was a quarterly dated 3/6/19 and coded the resident with a score of 14…
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 before2019-04-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, staff interview and facility documentation the facility staff failed to assure that 1 of 46 residents (Resident #84) in the survey sample received a complete and accurate assessment. The facility staff failed to ensure the MDS with an Assessment Reference Date (ARD) of 03/08/19 under Section N (Medications) for the use of an antipsychotic medication (Seroquel) was coded correctly for Resident #84. The findings included: Resident #84 was admitted to the facility 3/01/19. Diagnosis for Resident #84 included but not limited to *Vascular Dementia with behavior disturbances. Resident #84's quarterly MDS with an Assessment Reference Date (ARD) of 03/08/19 coded resident with a BIMS score of 02 out of a possible 15 indicating severe cognitive impairment. Review of Resident #84's quarterly MDS with an ARD of 03/08/19 was coded one (1) for receiving Antipsychotic medications. Section N on the MDS under medications received read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, enter 0 if medication was 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 · D2019-04-18 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure a person-centered baseline care plan was developed within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 46 residents (Resident #440) in the survey sample. Resident #440, a newly admitted stroke resident, had difficulty at times communicating her needs to the nursing staff (expressive aphasia). The facility staff failed to ensure communication needs were included in the 48 hour baseline care plan. This failure resulted in resident frustration during episodes of her inability to communicate verbally or through gestures. The findings included: Resident #440 was admitted to the nursing facility on 4/12/19 with a diagnosis of atrial fibrillation and history of cerebral infarction (stroke) with left sided hemiplegia. The resident's Minimum Data Set (MDS) assessment was not due. The 48 hour baseline 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.
- Potential for harm · D2019-04-18 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the necessary person-centered care and services were provided for 1 of 46 residents (Resident #440) in the survey sample. Resident #440, a newly admitted stroke resident, had difficulty at times communicating her needs to the nursing staff (expressive aphasia). The facility staff failed to have the appropriate communication devices as needed when the resident was unable to verbally find the right words or gesture to enable the staff to understand her, which caused her extreme distress and frustration. The findings included: Resident #440 was admitted to the nursing facility on 4/12/19 with a diagnosis of atrial fibrillation and history of cerebral infarction (stroke) with left sided hemiplegia. The resident's Minimum Data Set (MDS) assessment was not due. The 48 hour baseline care plan dated 4/12/19-4/14/19 identified the resident had the potential for impaired quality of life related to a new environment and change in health status. The goal…
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 · D2019-04-18 · 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 clinical record review, staff interview and facility documentation, the facility staff failed to ensure a PRN (as needed) psychotropic medication (Ativan) order was limited to 14 days and failed to re-evaluate the resident for appropriateness of the medication for one resident (Resident #84) of 46 residents in the survey sample who was receiving a PRN (as needed) psychotropic medication. The facility staff failed to ensure a PRN (as needed) psychotropic medication (Ativan) order was limited to 14 days. The physician did not do an evaluation of Resident #84 to extend the psychotropic medication passed 14 days and did not document the rational and duration in the resident's medical record. The findings included: Resident #84 was admitted to the facility 3/01/19. Diagnosis for Resident #84 included but not limited to *Vascular Dementia with behavior disturbances. Resident #84's MDS with an Assessment Reference Date (ARD) of 03/08/19 coded resident with a BIMS score of 02 out of a possible 15 indicating severe cognitive impairment. In addition, the MDS with an ARD of 03/08/19,…
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 · D2019-04-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on general observation of the nursing facility, staff interviews, the facility failed to ensure medications were stored in accordance with currently accepted professional principles in 1 out of 9 facility medication carts. The facility staff failed to ensure one eye drop (Latanoprost) was removed from medication cart once expired on Unit (M). The eye drops in its original box had an open date of 03/04/19 with a do not use date after 04/04/19. The findings included: Resident #41 was originally admitted to the facility on [DATE]. Diagnosis for Resident #41 included but not limited to *Glaucoma. Resident #41's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 02/07/19 coded Resident #41 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. On 04/18/19 at approximately 1:35 p.m., the medication cart on Unit (M) with License Practical Nurse (LPN) #2 was inspected. During the inspection of the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-18 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the specialized rehabilitation services were provided for 1 of 46 residents (Resident #440) in the survey sample. Resident #440, a newly admitted stroke resident, had difficulty at times communicating her needs to the nursing staff (expressive aphasia). The facility staff failed to ensure speech therapy recommended the appropriate communication devices as needed and relayed information to the nursing staff. Failure to take these steps resulted in the nursing staff's failure to provide alternate communication devices to foster appropriate communication to and from the resident in order to avoid episodes of distress and frustration. The findings included: Resident #440 was admitted to the nursing facility on 4/12/19 with a diagnosis of atrial fibrillation and history of cerebral infarction (stroke) with left sided hemiplegia. The resident's Minimum Data Set (MDS) assessment was not due. The 48 hour baseline care plan dated 4/12/19-4/14/19…
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 · D2019-04-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, facility documentation review the facility failed to implement appropriate infection control practices during medication administration for 1 (Resident #42) of 46 residents in the survey sample. The facility staff failed to discard a pill that was dropped on Resident #42's bed during medication observation. The License Practical Nurse (LPN) placed the pill in the resident's left hand; the pill fell on the residents bed. The nurse retrieved the pill off of the bed with her bare hand and placed the pill in the resident's left hand. Resident #42 consumed the pill with a sip of water. The findings included: Resident #42's current Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date (ARD) of 02/08/19 coded the resident a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. During the medication observation on 04/16/19 at approximately 4:28 p.m. LPN #1 pulled the following medications from the medication cart for Resident #42: Aspirin 81 mg…
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 · D2017-09-14 · tag F0441 — isolatedHave a program that investigates, controls and keeps infection from spreading.
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, clinical record review and staff interviews the facility staff failed to maintain an infection control program to provide a safe, sanitary environment to prevent the development and transmission of disease and infection for 1 of 25 residents (Resident #17) and in the survey sample. The findings included: The facility staff failed to use a barrier and disinfect the over bed table after being used to check Resident #17's blood sugar and administering insulin. Resident #17 was originally admitted to the facility on [DATE]. Diagnoses for Resident #17 included but not limited to Type 2 Diabetes (1). Resident #17's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/2017 coded the resident with a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), moderate cognitive impairment. In addition, the MDS coded Resident #17 requiring total dependence of one with dressing and bathing, extensive assistance to two with transfers, extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BRIGHTON HOLDCO LLC | Organization | DIRECT OWNERSHIP INTEREST | since 09/10/2025 |
| KAHANOW, AVIVA | Individual | INDIRECT OWNERSHIP INTEREST | since 09/10/2025 |
| ROKEACH, FRAIDE | Individual | INDIRECT OWNERSHIP INTEREST | since 09/03/2025 |
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST | since 09/10/2025 |
| BUCKLEY, ERIK | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 09/22/2025 |
| GUZIK, STACY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/10/2025 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 09/03/2025 |
| HEALTHCARE SERVICES GROUP INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/08/2025 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/08/2025 |
| VIRGINIA HEALTH REHABILITATION AGENCY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/08/2025 |
| HAJIMOMENIAN, AMIR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/10/2025 |
| POSEN, MINDEE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/03/2025 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/18/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/18/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/20/2025 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | since 09/15/2025 |
| QUINTO NEXGEN LLC | Organization | ADP OF THE SNF | since 09/15/2025 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/15/2025 |
| SK NEXGEN TR | Organization | ADP OF THE SNF | since 09/15/2025 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/15/2025 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | since 09/15/2025 |
| UKR NEXGEN LLC | Organization | ADP OF THE SNF | since 09/15/2025 |
| YK NEXGEN TR | Organization | ADP OF THE SNF | since 09/15/2025 |
| YR NEXGEN TR | Organization | ADP OF THE SNF | since 09/15/2025 |
CMS files one row per role, so the 32 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.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495286. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-12-01, 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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