The Chesapeake
955 Harpersville Rd, Newport News, VA 23601 · Non profit - Corporation · 52 certified beds · (757) 599-4376 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Jan 2022
- a high number of inspection citations overall (28) — 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 (1/5)
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) | 1 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 | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.4% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.7% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.6% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.8% | 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 | 2.3% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.5% | 15.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 25.2% | 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 | 5.3% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.3% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.5% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.7% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.8% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.2% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.64 | 1.52 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.54 | 1.48 | 1.80 | better |
‡ 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.
58.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.3% 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 104 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 58.2%CMS range 50.7–66.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.1%CMS range 5.0–13.3 | 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 | 66.3% | 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 | 61.5% | 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 | 58.6% | 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 | 97.7% | 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 | 60.5% | 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 | 87.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 3.0% | 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 | 4.9%CMS range 2.9–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 52 beds and averages 45.5 residents a day — about 88% occupied, or roughly 6 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.
Weekend coverage: total nurse staffing is 4.04 hrs/resident/day on weekends vs 5.31 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.51 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · F2025-12-04 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, resident interviews and facility documentation, the facility staff failed to ensure staffing information was posted on one of one unit in a prominent place and readily accessible to all residents, staff and visitors. The findings included:During the initial tour of the facility on 12/2/2025, there was no observation of the daily posting of the nurse staffing information on the nursing unit. On the second day of survey (12/3/2025), no nurse staffing information was observed on the unit. On 12/3/2025 during a medication pass and pour observation, an interview was conducted with an alert resident who stated he did not know how to determine how many staff members were working.On 12/3/2025 at approximately 12:40 p.m. during lunch time, a visitor was interviewed about the nurse staffing. The visitor stated she did not know where that information was located. On 12/3/2025 at 1:00 p.m., a group interview was conducted by another surveyor with five alert and oriented individuals. The surveyor reported that each resident stated that they did not know…
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 · E2025-12-04 · tag F0574 — patternThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and facility documentation, the facility's staff failed to ensure residents were aware of their right to contact the Ombudsman to advocate for them and of their right to file a complaint with the state certification agency. The findings included:On 12/03/25, during the group resident interview, none of the five residents (#2, #11, #21, #31, #43), that attended were aware of what or who the Ombudsman was or how to contact them. Also, none of the five residents in attendance were aware that they could make a complaint with the state agency or where they could find the information to do so. An interview was conducted with the facility's Activities Director (AD) and the Administrator on 12/03/25, at approximately 4:00 PM. The Administrator states that Resident Rights are addressed on admission and discussed in Resident Council Meetings and in the Resident Handbook. An interview was conducted with the admissions coordinator (AC) on 12/04/25 at approximately 11:30 AM. The AC stated it was a collaborative effort by all facility…
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 · E2025-12-04 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible to residents, family members and legal representatives of residents. The findings included:On 12/02/25 at approximately 2:00 PM., during the facility tour, in the main hall leading to the Health Center Unit a sign was observed on the bulletin board that read Survey Book is available upon request in the main office. On 12/03/25, an interview was conducted with the Administrator concerning the survey book accessibility. The administrator stated that they initially had the survey book available to everyone without needing to request access, but it was moved to the office during construction. On 12/03/25, during the end-of-day meeting, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were made aware of the findings, and no further information was provided.
- Potential for harm · E2025-12-04 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and facility documentation, the facility's staff failed to ensure residents were aware of how to file a grievance or complaint. The findings included:On 12/03/25, during the group resident interview, none of the five residents (#2, #11, #21, #31, #43), that attended, were aware of the availability, or how to file a grievance or complaint. An interview was conducted with the facility's Activities Director (AD) and the Administrator on 12/03/25, at approximately 4:00 PM. The Administrator stated that Resident Rights, including how to file a grievance or complaint, are addressed on admission and discussed in Resident Council Meetings and in the Resident Handbook. An interview was conducted with the admissions coordinator (AC) on 12/04/25 at approximately 11:30 AM. The AC stated it was a collaborative effort of all facility staff and leadership to inform residents on where to find information regarding their rights and that it is addressed on admission and at Resident Meetings. The facility's policy titled Resident's Rights, was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care consistent with professional standards of practice for 3 Residents (#19, #1 and #42) in a survey sample of 24 Residents. The findings included:1. The facility staff failed to ensure oxygen nasal canula and concentrator tubing were changed according to the physician's order for Resident #19. Resident #19 was admitted to the facility originally on 06/22/2022 and most recently readmitted on [DATE]. On 12/02/2025 at 01:15 PM, an observation was made of Resident #19's oxygen nasal canula and concentrator tubing dated 11/23/2025; the humidification bottle attached to the oxygen concentrator was not dated. A review of the clinical record revealed that the orders for oxygen read: Clean oxygen concentrator and filter, change tubing weekly (every (Q) 7 days). The MAR (Medication Administration Record) was signed off as changed on 11/16/2025 and 11/23/25. On 12/2/25, an interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-04 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, and staff interview, the facility's staff failed to offer and provide snacks at bedtime. The findings included:There were no observations during this survey from 12/02/2025-12/04/2025 of snacks being offered or provided to residents. On 12/03/2025, during the resident group meeting/interview, five Residents (#2, #11, #21, #31, #43) stated that they did not receive nor are they offered snacks mid-day or bedtime regularly. The residents said that it is rare to receive snacks at bedtime. The residents also stated that when they do get snacks, it is in connection with a planned activity. An interview was conducted with the Dietary Manager (DM) on 12/03/25. The DM stated snacks are available to all units and residents, but is unsure about the distribution. On 12/04/2025, an interview was conducted with the Administrator, who stated they have snacks available but agreed that snacks are not offered consistently. On 12/04/25, at approximately 5:00 PM, the above findings were shared with the Administrator, Director of Nursing, and Assistant Director…
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 · D2025-12-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review, and review of facility documents, the facility staff failed to cover the catheter bag for 1 of 24 residents (Resident #48), in the survey sample. The findings included:Resident #48 was originally admitted to the facility 8/29/23. The current diagnoses included; urinary tract infection, multiple sclerosis, type 2 diabetes mellitus without complications, major depressive disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/10/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #48's cognitive abilities for daily decision making were intact.On 12/2/25 at 3:30 PM during an observation tour it was observed that the catheter bag for Resident #48 was not covered with a privacy bag. On 12/2/25 at 3:35 PM a second observation tour was conducted with the Director of Nursing (DON). The DON observed Resident #48's catheter bag uncovered and stated, there should be a cover…
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 · D2025-12-04 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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, the facility failed to ensure the resident's right to personal privacy and confidentiality of her personal and medical record. Personal privacy includes accommodation, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. The resident has a right to secure confidential personal and medical records. Findings include:The facility failed to ensure privacy and confidentiality of the medical record for 1 resident in survey sample of 24 residents. Resident #49.On 12/2/25, during a clinical record review for Resident #18, a progress note revealed an entry containing the name of another resident, Resident #49. 11/29/2025 21:56 NOTE TEXT: While working at admin desk M.A stated resident (#18) was seated on opposite side of the counter talking with Resident #49 (name redacted). M.A noticed a motion out of corner her eye with the W/C tipping forward. Resident #18 (name redacted) was reaching out towards Resident #49 (name…
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 · D2025-12-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and clinical record review, the facility staff failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for one (1) of 24 residents (Resident #18) in the survey sample. The findings included: On 12/3/25 during a clinical record review, it was discovered that Resident #18 did not have a baseline care plan. The first care plan was created on 11/10/25, seven (7) days after admission.Resident #18 was admitted to the facility on [DATE] with diagnoses to include but not limited to rhabdomyolysis (a rare muscle injury where severely damaged or injured skeletal muscles rapidly breakdown), displaced fracture of the first cervical vertebra, pulmonary hypertension, history of pneumonia, depression, heart failure, cognitive communication deficit and osteoporosis. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/25…
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 · D2025-12-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and clinical record review, the facility staff failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for three (3) of 24 residents (Residents #14, #2, and #18) in the survey sample.Findings include: 1. 1. For Resident #14, the facility staff failed to update her comprehensive care plan to reflect her speaking more Italian and her use of an elbow extension splint. Resident #14 was admitted on [DATE] with diagnosis including but not limited to non-traumatic intracerebral hemorrhage, major depressive disorder, hypertensive chronic kidney disease, contracture, iron deficiency anemia, pain, unspecified, vascular dementia, neuromuscular dysfunction of the bladder and cerebrovascular disease. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/28/25 Section C0500 coded the resident as having a BIMS (Brief Interview 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.
Show the remaining 18 citations
- Potential for harm · D2025-12-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
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 follow physician orders for oxygen administration for one (1) of 24 residents in the survey sample, Resident #42.The findings include: The facility staff failed to follow the physician's orders regarding the oxygen flow rate and to monitor it for Resident #42. Resident #42 was admitted to the facility originally on 10/09/25 and most recently readmitted on [DATE]. The current diagnoses included a displaced Intertrochanteric fracture of the left Femur. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/14/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #42's cognitive abilities for daily decision making were intact.A review of the Medication Administration Record (MAR) revealed the following: Oxygen at 2L via Nasal Cannula (NC) every shift…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations of the kitchen, interviews, and facility document review, the facility staff failed to maintain an effective infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections among facility residents.Findings included: On 12/2/25 at 11:40 AM, during an initial tour of the main kitchen, the Assistant Administrator of Culinary Services (ADM# 6) was observed in the main kitchen area without a hairnet, and another employee with a blue uniform top was observed walking through the kitchen without a hairnet. According to the Director of Culinary (ADM# 8) the female observed walking through the kitchen was a server from the Independent Living community. When asked what his expectation was for donning hairnets in the kitchen area, he stated, Everyone should wear hairnets, but she is a server from the independent living area and doesn't work in the health care center, I don't know her nameOn 12/2/25, while exiting the kitchen area, a white bed blanket and a white…
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 · D2022-01-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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
Based on clinical record review, staff interview and facility documentation review, the facility staff failed to ensure 1 of 25 residents (Resident #46) in the survey sample was given the opportunity to formulate an Advance Directive. The findings included: Resident #46 was admitted to the nursing facility on 11/04/20. Diagnosis for Resident #46 included but not limited to Cerebral Infarction (stroke) and Chronic Atrial Fibrillation. Resident #46's Minimum Data Set (MDS-an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 12/27/21 coded a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Review of Resident #46's Physician Order Sheet (POS) for January 2022 revealed the following order: Do Not Resuscitate (DNR) starting on 11/04/20. The review of Resident #46's clinical record did not show evidence of an Advance Directive. On 01/06/22 at approximately 1:47 p.m., an interview was conducted with the Social Worker, who stated, The process for obtaining…
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 · D2022-01-06 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, facility documentation review and clinical record review, it was determined that the facility staff failed to notify a state agency of misappropriation of stolen property in a timely manner for one of 25 residents in the survey sample, Resident #4. The findings include: Resident #4 was originally admitted to the nursing facility on 02/09/2017. Diagnosis for Resident #4 included but not limited to Muscle Weakness and Type 2 Diabetes Mellitus. Resident #4's Minimum Data Set an Annual assessment with an Assessment Reference Date (ARD) of 10/11/21 coded Resident #4 a 9 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS),This indicated Resident #4 cognitive abilities for daily decision making were moderately impaired. The facility staff failed to provide personal care to include showers for Resident #4 in the survey sample who was unable to independently carry out Activities of Daily Living (ADL's). In addition, the MDS coded Resident #4 requiring physical help of one person with bathing. Requiring extensive assistance of one person…
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 before2022-01-06 · tag F0622 — isolatedNot 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 staff interviews, clinical record review and facility documentation review, the facility staff failed to send a copy of one resident's care plan (Resident #23) after being transferred to the hospital for 1 of 25 residents in the survey sample. The findings included: The facility staff failed to send Resident #23's care plan to include their goals when discharged and admitted to the hospital on [DATE]. Resident #23 was originally admitted to the nursing facility on 10/02/19 and readmitted to the facility on [DATE]. Diagnosis for Resident #23 included but not limited to Cognitive Communication Deficit. Resident #23's Minimum Data Set (MDS-an assessment protocol) an admission assessment with an Assessment Reference Date (ARD) of 11/23/21 coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Review of Resident #23's admission MDS assessment with an ARD of 11/23/21, under Section G (Functional Status) was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-06 · 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 ensure that 1 of 25 residents (Resident #30) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS). The findings included: The facility staff failed to ensure the significant change MDS with an Assessment Reference Date (ARD) of 12/02/21 under Section M (skin conditions) for the number of stage III pressure ulcers that were present upon admission/reentry into the facility was accurate for Resident #30. Resident #30 was originally admitted to the nursing facility on 03/07/04 with a readmission date of 07/04/14. Diagnosis for Resident #30 included but not limited to stage III pressure ulcer of the sacral region. Resident #30's Minimum Data Set (MDS-an assessment protocol) significant change MDS with an ARD of 12/02/21 coded a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The comprehensive care plan with a revision date of 11/29/21documented Resident #30 has a stage three…
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 · D2022-01-06 · 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
Based on observation, family interview, staff interviews, and clinical record review, the facility staff failed to ensure the most appropriate pressure reducing bed surface was afforded to a vulnerable immobile resident with a history of Moisture Associated Skin Damage (MASD) to avoid further progression of the area to a stage III pressure ulcer and deterioration to a stage IV for 1 of 25 residents (Resident #15), in the survey sample. The findings included: Resident #15 was originally admitted to the facility 9/10/20, was discharged from the facility 9/23/20, return anticipated and returned to the facility 9/26/20. Resident #15's diagnoses included; recent stroke on 9/6/20 with hemiparesis (inability to move on one side) and aphasia (speech/communication problems), diabetes and dementia. The quarterly Minimum Data Set (MD'S) assessment with an assessment reference date (AR) of 12/17/20 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…
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 · F2020-01-15 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of nurse staffing and staff interviews, the facility staff failed to have a Registered Nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week. The findings included: Review of RN coverage from October 1, 2019 through January 12, 2020 revealed there was no RN for at least 8 consecutive hours on 10/19/19. On 1/14/20 at 1:30 p.m., during an interview with the Assistant Director of Nursing (ADON), she verified they were absent an RN on 10/19/19 for at least 8 hours within a 24 hour timeframe. On 1/14/20 at 5:30 p.m., an interview was conducted with the Director of Nursing (DON). She stated the facility did not have a staffing policy related to RN coverage within a 24 hour period, but she was aware of the requirement. On 1/14/20 at 5:45 p.m., the aforementioned issue was reviewed with the Administrator and no further information was provided prior to survey exit on 1/15/20.
- Potential for harm · E2020-01-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and staff interviews, the facility staff failed to handle, prepare and store food in a manner to prevent food borne illness potentially affecting most residents in the facility. The findings included: During the initial kitchen inspection at 11:30 A.M. on 01/13/20 a male staff member was observed in the kitchen and dish washing area without a beard guard. On 01/14/20 at 11:15 A.M. a male staff member was observed in the kitchen and dish washing area without a beard guard. On 01/15/20 at 9:45 A.M. a male staff member was observed in the kitchen and dish washing area without a beard guard. During an interview on 01/13/20 at 12:30 P.M. with the Dietary Manager she stated, all staff in the kitchen are aware that hair nets and beard guards must be worn at all times.
- Potential for harm · E2020-01-15 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility staff failed to ensure garbage and refuse were disposed of properly. The findings included: During the outside garbage and refuse observation at 12:45 P.M. on 01/14/20 the following were observed in the outside area: one discarded wheelchair, one discarded merry walker PCV pipe frame, 14 pallets, one bed side dresser, one cabinet, and copious amounts of card board boxes, paper, trash and debris. The area around the grease disposal container was noted to have copious amounts of spillage on the concrete flooring with trash and debris. During an interview with the Dietary Manger on 01/14/20 at 1:05 P.M. she stated, it was the Maintenance Department responsibility to maintain the refuse and garbage area. She would have them to clean the area immediately.
- Potential for harm · D2020-01-15 · 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
Based on observations, resident interview, staff interviews, and clinical record review the facility staff failed to ensure a resident wheel chair was in good repair, for 1 of 24 residents (Resident #11), in the survey sample. Resident #11's wheel chair had a torn pressure relief cushion and a broken right arm rest. The findings included: Resident #11 was originally admitted to the facility 5/3/19 and had never been discharged from the facility. The current diagnoses included; mini stroke, arthritis and dementia. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/24/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident 11's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 with transfers and walking in the corridor, extensive assistance of 1 person with bed mobility, locomotion, dressing, toileting, and personal hygiene. Resident #11…
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 before2020-01-15 · tag F0622 — isolatedNot 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 a resident interview, clinical record review, staff interviews, and facility documentation review, the facility staff failed to covey the resident's comprehensive care plan goals to the receiving facility for 1 of 24 residents (Resident #36) in the survey sample. The findings included: Resident #36 was originally admitted to the facility 11/4/19 and readmitted [DATE]. The current diagnoses included anemia and diabetes. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/11/19 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. In section G (Physical functioning) the resident was coded as requiring total care of 1 person with bathing, extensive assistance of 2 people with bed mobility and toileting, extensive assistance of 1 person with transfers, dressing, and personal hygiene and supervision after…
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 · D2020-01-15 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of three hospital discharges for 1 of 24 residents (Resident #36) in the survey sample. The findings included: Resident #36 was originally admitted to the facility 11/4/19 and readmitted [DATE]. The current diagnoses included; anemia and diabetes. An interview was conducted with Resident #36 in the resident's room on 12/13/19 at approximately 11:15 a.m. The resident stated an appointment was scheduled for an off site physician's visit because of a problem with anemia requiring transfusions. The resident further stated there were recent hospitalizations for treatment of severe anemia. Review of the clinical record revealed the resident was discharged to a local hospital on [DATE], 11/22/19, and the resident was also discharged to the hospital 11/30/19, for lethargy and only non-verbal responses to painful stimuli.…
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 · D2020-01-15 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to complete a Preadmission Screening and Resident Review (PASARR) for one (Resident #19) of 24 residents in the survey sample. The findings included: Resident #19 was admitted to the facility on [DATE]. The latest diagnoses included, but not limited to, Parkinson's disease; generalized anxiety disorder; major depressive disorder, single episode; and, psychotic disorder with hallucination due to known physiological condition. Resident #19's most recent MDS (Minimum Data Set) assessment was a Quarterly Review Assessment with an ARD (Assessment Reference Date) of 11/07/2019. Resident #19 scored as cognitively intact, scoring a 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. A review of Resident #19's clinical record was conducted on 1/14/2020 yielding no results of a PASARR (Preadmission Screening and Resident Review) assessment. During an interview conducted with the Social Worker, Other Administrative Staff #4 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 · D2020-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident interview, staff interviews, and clinical record review the facility staff failed to maintain a resident's wheel chair in a condition to prevent accident hazards for 1 of 24 residents (Resident #11), in the survey sample. The findings included: Resident #11 was originally admitted to the facility 5/3/19 and had never been discharged from the facility. The current diagnoses included; mini stroke, arthritis and dementia. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/24/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident 11's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 with transfers and walking in the corridor, extensive assistance of 1 person with bed mobility, locomotion, dressing, toileting, and personal hygiene. Resident #11 was observed on 1/14/20 at approximately 12:45 p.m., seated in 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 · D2020-01-15 · 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 inspection of 2 out of the facility's 4 medication carts and staff interview, four expired cards of the medication Tylenol, were in use. The findings include: On 1/13/20 at 12:55 p.m., during inspection of one of the unit's medication carts on the [NAME] hall, Licensed Practical Nurse (LPN) #2 identified two cards of 30 Tylenol 325 milligrams in use had an expiration date of 12/31/19. The LPN removed the Tylenol and stated the medication would be reordered. On 1/13/20 at 1:38 p.m., during inspection East hall medication cart, LPN #3 identified two cards of Tylenol 325 mg in use that had an expiration date of 12/31/19. The LPN stated the process to determine if all expired medications are removed from the cart included checking all medications in the medication cart on the night shift and removing them and reorder if necessary, but that any nurse can remove expired medications and reorder them. On 1/14/20 at 5:30 p.m., the Administrator was made aware of the aforementioned issue. No further information was provide prior to survey exit on 1/15/20. The facility's policy 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.
- No harm found · C2020-01-15 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, facility documentation review, and review of Certified Nursing Assistant (CNA) training, the facility staff failed to ensure 23 CNA's (CNA #1 through CNA #23) received 12 hours of nurse aide training per year by their anniversary date . The findings included: The facility staff did not have a system in place to capture the in-service training of the 23 CNA's employed by the nursing facility. On 1/13/20 at approximately 1:00 p.m., a request was made to provide CNA training records to determine compliance with the 12 hours of training per their anniversary date. The Director of Nursing (DON) returned on 1/14/20 at 4:30 p.m. and stated, I know they had the skills fair that was at least 8 hours and that the newly hired CNA's would have at least the same with orientation, but we can't come up with how we are tracking the 12 hours. We would need to go through sign in sheets to find their names and what the topics were, as well as add up some of their computer training. I am not sure how we have been doing it and this has never been asked to produce. I am going to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2020-01-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the facility's Infection Control Program and staff interviews, the facility staff failed to ensure they conducted an annual review of its Infection Prevention Control Program (IPCP). The findings included: On 1/14/20 at 3:45 p.m., during review of the facility's IPCP with the Registered Nurse (RN) in charge of the IPCP, it was discovered that the last full annual review of the program as approved was dated 2009. She stated, I worked on different components of the program, for example Antibiotic Stewardship and the immunizations program and updated them in 2019. I should have reviewed the entire program at the same time. I will know to do this going forward. On 1/14/20 at 5:30 p.m., the aforementioned issue was brought to the attention of the Administrator. No further information was provided prior to survey exit.
“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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| LOOP, DAVID | Individual | W-2 MANAGING EMPLOYEE | since 02/01/2018 |
| BALES, JAMES | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| BROOKS, SHARON | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| BROWNING, HERBERT | Individual | CORPORATE DIRECTOR | since 11/28/2006 |
| CARLTON, DANIEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/01/2018 |
| CARTER, VALERIE | Individual | CORPORATE DIRECTOR | since 02/01/2018 |
| CAVE, R | Individual | CORPORATE DIRECTOR | since 12/31/2021 |
| FRANKS, TIFFANY | Individual | CORPORATE DIRECTOR | since 01/01/2020 |
| HARRIS, CHARLES | Individual | CORPORATE DIRECTOR | since 02/01/2018 |
| JUNG, JOHN | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| KECK, MICHAEL | Individual | CORPORATE DIRECTOR | since 11/28/2006 |
| MARCHELLO, SALLIE | Individual | CORPORATE DIRECTOR | since 01/01/2018 |
| OAKEY, SAMUEL | Individual | CORPORATE DIRECTOR | since 11/18/2003 |
| OWENS, ARNE | Individual | CORPORATE DIRECTOR | since 01/01/2020 |
| POATS, JIM | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| POMA, JOHN | Individual | CORPORATE DIRECTOR | since 01/01/2021 |
| SCOTT, MATTHEW | Individual | CORPORATE DIRECTOR | since 02/01/2018 |
| THOMSON, GARY | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| ALBRITTON, TRACEY | Individual | CORPORATE OFFICER | since 12/01/2021 |
| COOK, JONATHAN | Individual | CORPORATE OFFICER | since 12/31/2014 |
| HAWTHORNE, LISA | Individual | CORPORATE OFFICER | since 06/14/2021 |
| MARKWITH, CHRISTOPHER | Individual | CORPORATE OFFICER | since 01/31/2018 |
| MORAN, CHRISTINE | Individual | CORPORATE OFFICER | since 03/31/2021 |
| ROBINSON, JOHN | Individual | CORPORATE OFFICER | since 02/01/2018 |
| VIRGINIA BAPTIST HOMES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/17/1969 |
CMS files one row per role, so the 26 rows in the source record cover these 25 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.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495397. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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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