Newport Post Acute
11141 Warwick Blvd, Newport News, VA 23601 · For profit - Corporation · 60 certified beds · (757) 595-3733 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (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 payroll-based staffing rating is low (2/5)
- nursing-staff turnover (71%) runs well above the national median (45%)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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 | 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 held steady at 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.
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 | 1.7% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.4% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.4% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.7% | 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 | 9.6% | 3.6% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.8% | 20.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 2.3% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.2% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.2% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.9% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 19.4% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.90 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.75 | 1.48 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.9% 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 242 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.1% 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 74 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 0.69 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 52.9%CMS range 47.4–60.2 | 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 7.9–13.6 | 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 | 81.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 73.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.7% | 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 | 6.6%CMS range 4.3–9.6 | 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 60 beds and averages 55.4 residents a day — about 92% occupied, or roughly 5 beds typically open. It runs fairly full. 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above 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 2.94 hrs/resident/day on weekends vs 3.57 on weekdays — 18% thinner on weekends. RN hours go from 0.95 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 71% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · E2025-03-19 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and clinical record review, the facility staff failed to ensure that resident care information was not posted to be viewed in their room for 2 of 23 residents (Resident #27 and 36), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 8/29/23 after an acute care hospital stay. The current diagnoses included stroke, dysphagia and adult failure to thrive. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. On 3/12/25 at approximately 4:10 PM a sign was observed above the head of the bed of Resident #27. The sign stated no straws. A review of the physician's orders failed to reveal an order for no straws and a review of the person-centered care plan dated 9/6/2023 - Present failed to identify and have interventions related to no use 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.
- Potential for harm · Ecited before2025-03-19 · tag F0740 — failed to provide behavioral / mental-health care — patternEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 resident interview, staff interview, and clinical record review, the facility staff failed to provide the necessary behavioral health services for 1 of 23 residents (Resident #30), in the survey sample. The findings included: Resident #30 was originally admitted to the facility 8/19/24 after an acute care hospital stay. The admission diagnoses included; congestive heart failure, muscle weakness, pain in left shoulder, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #30's cognitive abilities for daily decision making were intact. On 3/11/25 at 1:50 PM an interview was conducted with Resident #30. Resident #30 stated, How do you think I'm doing? Would you be happy living like this? I lay here every day looking at this ceiling and they do nothing for me. I'm so fucking angry. On 3/12/25 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.
- Potential for harm · D2025-03-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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, and staff interview the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 23 residents (Resident #244), in the survey sample. The findings included: Resident #244 was originally admitted to the facility 3/10/25 after an acute care hospital stay. The admission diagnoses included; spinal stenosis, paroxysmal atrial fibrillation, restless legs syndrome, and essential hypertension. The 5-day scheduled Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/13/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #244's cognitive abilities for daily decision making were intact. On 3/11/25 at 2:10 PM during an observation tour for room [ROOM NUMBER], it was observed that there was a large area on the drywall behind the resident bed headboard that was dirty with flacking paint and gauges in the wall. It was also observed that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and clinical record reviews, the facility staff failed to develop a person-centered comprehensive care plan for 2 of 23 residents (Resident #27 and #34), in the survey sample. The findings included: 1. The facility staff failed to develop a person-centered comprehensive care plan to include to dysphagia for Resident #27. Resident #27 was originally admitted to the facility 8/29/23 after an acute care hospital stay. The current diagnoses included stroke, dysphagia and adult failure to thrive. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/15/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. On 3/12/25 at approximately 4:10 PM a sign was observed above the head of the bed of Resident #27. The sign stated no straws. A review of the physician's orders…
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 before2025-03-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to follow physician's order to ensure an abdominal binder was applied on a resident's abdomen to prevent pulling and or tugging of resident's peg tube for 1 of 23 residents (Resident #34), in the survey sample. The findings included: Resident #34 was originally admitted to the facility 12/27/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Other disorders of plasma protein metabolism. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral care, personal hygiene, toileting hygiene and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, and a clinical record review, the facility staff failed to supervise each resident to prevent avoidable falls for 2 of 23 residents (Resident #36 and 294), in the survey sample. The findings included: 1. Resident #36 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The current diagnoses included spinal stenosis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were intact. The MDS assessment was not coded for toileting transfers due to her medical condition or safety concerns. On 3/13/25 at approximately 2:05 PM an interview was conducted with Resident #36. The resident stated she had a fall in the bathroom after she had completed elimination and washing her hands. The resident stated she turned to get paper towels and lost her balance. She stated Certified Nursing…
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 · D2025-03-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 review of facility documents, the facility's staff failed to ensure an abdominal binder was applied on a resident's abdomen to prevent pulling and or tugging of resident's peg tube for 1 of 23 residents (Resident #34), in the survey sample. The findings included: Resident #34 was originally admitted to the facility 12/27/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Other disorders of plasma protein metabolism. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with oral care, personal hygiene, toileting hygiene and shower/bathe self. 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 · D2025-03-19 · tag F0775 — isolatedKeep complete, dated laboratory records in the resident's record.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on information obtained during the Antibiotic Stewardship task, staff interviews and clinical record review, the facility staff failed to have laboratory reports filed in the resident's clinical record for 1 of 23 residents (Resident #7), in the survey sample. The findings included: Resident #7 was originally admitted to the facility 12/18/23. The current diagnoses included a stroke and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/11/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 1 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were severely impaired. During the Antibiotic Stewardship task, on 3/17/25 at approximately 1:05 PM, it was identified that Resident #7 was diagnosed with a urinary tract infection on 3/10/25 at 11:35 PM, and started on an antibiotic. A further review revealed a nurse's note dated 3/07/25 at 7:58 PM which stated that Resident #7 was observed putting a cheeseburger with ketchup, mustard, and pickle into…
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 before2025-03-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on information obtained during the Antibiotic Stewardship task, staff interviews and clinical record review, the facility staff failed to maintain a medical record which was complete and readily accessible for 1 of 23 residents (Resident #7), in the survey sample. The findings included: Resident #7 was originally admitted to the facility 12/18/23. The current diagnoses included a stroke and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/11/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 1 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were severely impaired. During the Antibiotic Stewardship task, on 3/17/25 at approximately 1:05 PM, it was identified that Resident #7 was diagnosed with a urinary tract infection on 3/10/25 at 11:35 PM, and started on an antibiotic. A further review revealed a nurse's note dated 3/07/25 at 7:58 PM which stated that Resident #7 was observed putting a cheeseburger with ketchup, mustard, and pickle…
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 before2025-03-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure enhanced barrier precautions were followed while providing wound care for 1 of 23 residents to prevent the spread of infection (Resident #10), in the survey sample. The findings included: Resident #10 was originally admitted to the facility on [DATE] and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Pressure Injury of bilateral heels. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. The care plan read that Resident #10 has a bilateral pressure injuries to his heels. Focus: The goal for the resident is that the size of the ulcer…
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 17 citations
- Potential for harm · E2021-04-22 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff interviews and facility document review the facility staff failed to ensure that 5 of 24 residents in the survey sample were allowed to participate in and/or formulate an advance directive upon admission, Residents #180, #181, #230, #231 and #26. The findings included: 1. Resident #180 was admitted to the facility on [DATE] with diagnoses to include but not limited to Right Femur Fracture, Hypertension and Spina Bifida. Due to Resident #180 being a new admission the Minimum Data Set was not scheduled to be started until 4/20/21 therefore a current Brief Interview for Mental Status was not available. However, based on nursing notes and an initial interview with Resident #180 she was determined to be alert and oriented. During a review of Resident #180's electronic medical record I was unable to locate an Advance Directive or documentation to show the facility discussed or helped to formulate an Advance Directive for the resident. Resident #180's Physician Orders were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-04-22 · tag F0742 — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to ensure a resident displaying mental health concerns received the care and services to address identified concerns (staying in a totally dark room most of the time, social isolation, no interest and withdrawal) for 1 of 24 residents (Resident #16), in the survey sample. The findings included: Resident #16 was originally admitted to the facility 3/15/21 and had never been discharged from the facility. The current diagnoses included; severe anxiety, depression and dementia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/22/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #16's cognitive abilities for daily decision making were intact. In section D0200 (Mood) the resident was coded as having little to no interest, depressed, little energy and trouble concentrating 12-14 days out of 14 days; sleeping too much 7-11 days out of 14 days,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-04-22 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for 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 record review, staff interview and facility policy. The facility staff failed to assist one resident Resident #5 in the survey sample of 24 residents with making arrangements for dental services. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease, Ataxia, hypertension, acute peptic ulcer, type II diabetes, mental disorder due to known physiological condition, anxiety disorder, vascular dementia with behavioral disturbance, insomnia, and abnormal weight loss. The facility staff failed to provide Resident #5 with dental services. A Quarterly Minimum Data Set, dated [DATE] assessed this resident in the area of Cognitive Impairment (Brief Interview of Mental Status) BIMS as a (0). In the area of Activities of Daily Living this resident was assessed in the area of eating as a (1-1) requiring set up help only. In the area of Pain Management this resident was assessed as receiving PRN (as needed pain medication. In the area 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.
- Potential for harm · D2021-04-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
Based on resident interview, staff interview, and clinical record review the facility's staff failed to inform the resident representative of an acute condition and the necessity start a new treatment for 1 of 24 residents (Resident 24), in the survey sample. The findings included: Resident #24 was originally admitted to the facility 4/1/21 and had never been discharged from the facility. The current diagnoses included; cognitive impairment and right wrist pain. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/6/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #24's cognitive abilities for daily decision making were moderately impaired. In sectionG (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one with walking in room, dressing and toileting, limited assistance of one with transfers, locomotion, personal hygiene and supervision of one with eating. On 4/20/21 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.
- Potential for harm · D2021-04-22 · 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 observations, staff interviews and clinical record review the facility staff failed to ensure for 1 of 24 residents in the survey sample, Resident #13, that the residents status was accurately reflected in the Resident Assessment. The findings included: Resident #13 was originally admitted to the facility on [DATE]. Resident #13 was discharged to another nursing home on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to Parkinson's Disease and Dementia with Lewy Bodies. Resident #13's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 03/08/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 00 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #13 as requiring extensive assistance of 1 for eating and extensive assistance of 2 for bed mobility and toilet use and total dependence of 1 for dressing and personal hygiene and total dependence of 2 for transfer and bathing. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation review the facility staff failed to provide physician ordered wound treatment to 1 of 24 residents in the survey sample, Resident #13. The findings included: Resident #13 was originally admitted to the facility on [DATE]. Resident #13 was discharged to another nursing home on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to Parkinson's Disease and Dementia with Lewy Bodies. Resident #13's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 03/08/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 00 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #13 as requiring extensive assistance of 1 for eating and extensive assistance of 2 for bed mobility and toilet use and total dependence of 1 for dressing and personal hygiene and total dependence of 2 for transfer and bathing. On 04/21/2021 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.
- Potential for harm · Dcited before2021-04-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
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 facility staff failed to to provide oxygen at the correct prescribed rate for one of 24 residents in the survey sample; Resident #230. The findings included: Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sepsis, acute and chronic respiratory failure with hypoxia, chronic heart failure, morbid obesity, and high blood pressure. Resident #230 did not have a completed MDS (Minimum Data Set) assessment at this time. Resident #230 was documented as being alert and cognitively intact. Review of Resident #230's current physician orders documented the following order: Oxygen 2 L (liters)/min (minute) per nasal cannula. On 4/20/21 through 4/21/21 observations of Resident #230 were conducted. The following was observed: On 4/20/21 at 2:06 p.m., Resident #230's oxygen was set to 2.5 liters. Resident #230 was laying in the bed at this time, not within reach of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-22 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interviews, and clinical record review, the facility's staff failed to investigate underlying causes of the resident's anxiety and depression, address, review and revise the resident's behavioral health care plan and create an environment conducive for a resident with known mental health disorders who voiced a suicide attempt while hospitalized for 1 of 24 residents (Resident #130), in the survey sample. The findings included: Resident #130 was originally admitted to the facility 4/8/21 and readmitted had not been discharged from the facility. The current diagnoses included; a bipolar disorder, an anxiety disorder and chronic pain syndrome. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #130's cognitive abilities for daily decision making were intact. In section D0200 (Mood) of the MDS assessment the resident was coded as having hopelessness,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-22 · 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 observations, staff interview and facility documentation review the facility staff failed to remove expired medication from 1 of 2 medication carts (Cart A). The findings included: On [DATE] at 11:30 a.m., during inspection of Medication Cart A observed Advair Diskus box and on the outside of the box the date [DATE] was written. Requested to see Advair Diskus box. When asked what does the date [DATE] indicate, Licensed Practical Nurse (LPN) #1 stated, That was when it was opened. Review of the label on the box revealed the following: Advair Diskus AER 250/50 60 AEPB [DATE] 1 PUFF BY MOUTH TWICE A DAY - RINSE MOUTH AFTER EACH USE DISCARD WHEN COUNTER READS 0 OR 30 DAYS AFTER FOIL POUCH IS OPENED, WHICHEVER COMES FIRST. Requested that LPN #1 remove the Advair Diskus from the box. Observed that the Advair Diskus was not in a foil pouch and [DATE] was written on the diskus. Requested that LPN #1 review the label on the Advair Diskus box. When asked when should the Advair Diskus have been discarded, LPN #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-22 · tag F0779 — isolatedKeep signed and dated reports of x-rays and other diagnostic services in the residents record.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, and clinical record review the facility's staff failed to file in the resident's clinical record signed and dated x-ray reports dated 4/13/21 and 4/19/21 for 1 of 24 residents (Resident 24), in the survey sample. The findings included: Resident #24 was originally admitted to the facility 4/1/21 and had never been discharged from the facility. The current diagnoses included; cognitive impairment and right wrist pain. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/6/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #24's cognitive abilities for daily decision making were moderately impaired. In sectionG (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one with walking in room, dressing and toileting, limited assistance of one with transfers, locomotion, personal hygiene and supervision of one with eating. On 4/20/21 at approximately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to document that one of 24 residents; Resident #231 received a bed bath on 4/16/21 and 4/17/21. The findings included: Resident #231 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, cerebral palsy, high blood pressure, stroke, and altered mental status. Resident #37 did not have a completed MDS (Minimum Data Set) assessment at this time. On 4/20/21 through 4/21/21 this writer had several interactions with Resident #231. Resident #231 had periods of confusion during these interactions. On 4/20/21 at 1:17 a.m., an interview was conducted with Resident #231. When asked if she received showers, Resident #231 stated, Don't know. I am not sure when I am supposed to get showers. When asked if she received bed baths, Resident #231 stated that sometimes staff provided bed baths. Review of Resident #231's ADL…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-04-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility documentation review the facility staff failed to maintain infection control practices for 2 residents in the survey sample, (Resident #8 and #231. The findings included: 1. Staff failed to clean over bed table after removing metal tray. 1. Resident #8 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Anxiety Disorder and Hypertension. Resident #8's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 02/25/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 01 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #8 as requiring limited assistance of 1 for eating and personal hygiene, limited assistance of 2 for dressing, extensive assistance of 1 for toilet use, extensive assistance of 2 for bed mobility and transfer and total dependence of 1 for bathing. On 04/21/2021 at 10:07 a.m., standing at treatment cart in hallway and observed Assistant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-05-31 · tag F0697 — failed to manage pain — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to maintain a complete pain management program consistent with professional standards of practice and the comprehensive person centered care plan for two of 23 residents in the survey sample, Resident #6 and #22. 1. For Resident #6, facility staff failed to document the location of pain prior to administering pain medications on several occasions in May 2019. 2. For Resident #22, facility staff failed to document the location of pain prior to administering pain medication on two occasions in May of 2019. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, atrial fibrillation, high blood pressure, and adult failure to thrive. Resident #6's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/15/19. Resident #6 was coded as being severely impaired 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.
- Potential for harm · Dcited before2019-05-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, clinical record review and facility documentation the facility staff to develop one of 23 residents (Resident #34) comprehensive personal centered care plans in the survey sample. The facility staff failed to develop a person-centered care plan to include the following: *Atrial Fibrillation with the use of anticoagulation, *Psychosis and Major depressive disorder with the use of antipsychotic medication use. The findings included: Resident #34 was originally admitted to the nursing facility on 04/30/19. Diagnoses for Resident #34 included, but not limited to, Atrial Fibrillation, Unspecified Psychosis and Major Depressive Disorder. The current Minimum Data Set (MDS) a 14-Day PPS with an Assessment Reference Date (ARD) of 05/14/19 coded the resident with a 15 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The residents MDS was coded for the usage of antipsychotic and anticoagulation. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 interviews and clinical record review, the facility staff failed to ensure 1 of 23 residents (Resident #27) in the survey sample who was unable to carry out activities of daily living, received the necessary services to maintain toenail care. The facility staff failed to provide podiatry services for Resident #27. The findings included: Resident #27 was originally admitted to the facility on [DATE]. The current diagnoses included: Hypotension, Major Depressive Disorder, Difficulty in walking and Type II Diabetes Mellitus. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/07/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as being a two person physical assist with transfers and one person physical assistance with dressing,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
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 facility staff failed to provide respiratory services consistent with professional standards of care and the comprehensive person-centered care plan for one of 23 residents in the survey sample, Resident #22. For Resident #22, facility staff failed to administer oxygen at the correct liters per minute per order and comprehensive care plan. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, adult failure to thrive, vascular dementia, respiratory failure and osteoporosis. Resident #22's most recent MDS (minimum data set) assessment was an annual assessment with an ARD (Assessment Reference Date) of 4/24/19. Resident #22 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #22 was coded in section O (Special treatments,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-05-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation during the inspection of the medication room, staff interviews and the facility's policy review, the facility staff failed to ensure a Schedule II medication was secured in a permanent affixed locked cabinet. The facility staff failed to ensure a multi-dose vial of Morphine was secured in a permanently affixed locked medication cabinet. The findings included: On 05/30/19 at approximately 2:15 p.m., an inspection of the medication room was made with License Practical Nurse (LPN) #2. The facility only had one medication room. Located inside the medication room was a locked cabinet. The LPN unlocked the cabinet, which contained a large gray stat box. The surveyor asked the LPN, Can the stat box be removed from the cabinet she replied, Yes. The LPN removed the stat box from the cabinet then placed it back inside the cabinet then locked the cabinet back. The stat box was not permanently affixed inside the locked cabinet. The surveyor reviewed the content of the stat box. The stat box contained a one (1) multi-dose vial of Morphine 20 mg/ml oral solution (Roxanol); 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.
“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 | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 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 | Share | Since |
|---|---|---|---|---|
| NEWPORT OPERATOR HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/10/2025 |
| KAHANOW, AVIVA | Individual | INDIRECT OWNERSHIP INTEREST | — | since 09/10/2025 |
| ROKEACH, FRAIDE | Individual | INDIRECT OWNERSHIP INTEREST | — | since 09/10/2025 |
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST | — | since 09/10/2025 |
| LAW, JOSEPH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 09/10/2025 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 09/10/2025 |
| 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 |
| BERCZEK, STEPHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/11/2025 |
| MASON, MACKENZIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2025 |
| POSEN, MINDEE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/10/2025 |
| WOLF, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/10/2025 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/08/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/08/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/08/2025 |
| 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 25 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $1.2M 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 495368. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-19, 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.