Dinwiddie Health And Rehab Center
46 Diamond Drive, Petersburg, VA 23803 · For profit - Corporation · 60 certified beds · (804) 518-0780 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)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,278 in federal fines (most recent 2025-09-03)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
- about 19% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.5% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 14.5% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.4% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.5% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.6% | 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 | 3.0% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.7% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 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 | 9.0% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.2% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.5% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.8% | 73.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 18.8% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.4% | 11.5% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.7% 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 227 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.2% 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 88 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% 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 | 58.7%CMS range 51.0–64.4 | 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 | 9.8%CMS range 7.4–12.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 60.2% | 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 | 55.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.1% | 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 | 2.1% | 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 | 4.9% | 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 | 8.0%CMS range 5.0–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.34 hrs/resident/day on weekends vs 4.14 on weekdays — 19% thinner on weekends. RN hours go from 0.55 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide a safe transfer using a mechanical lift resulting in a fall with fractures for one of eight residents in the survey sample (Resident #1).The findings include:Facility staff failed to attach a mechanical lift sling according to facility and manufacturer's recommendations during a transfer of Resident #1 from the bed to a wheelchair. Resident #1 slid out of the sling during the transfer causing fracture of the resident's shoulder (proximal left humerus) and left wrist (harm).Resident #1 (R1) was admitted to the facility with diagnoses that included cerebrovascular accident (stroke), left side hemiplegia, hypothyroidism, chronic pain, mood disorder, major depressive disorder, hearing loss, epilepsy, polyneuropathy, insomnia and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact and as totally dependent upon staff for bed mobility 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 · Dcited before2025-01-15 · 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 staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care regarding wound documentation for one of thirteen residents in the survey sample (Resident #6). The findings include: Facility staff failed to document an assessment for Resident #6's wound that included measurements, appearance, description, and/or status of a wound. Resident #6 (R6) was admitted to the facility with diagnoses that included femur fracture, peripheral vascular disease, diabetes, end stage renal disease, anemia, coronary artery disease, cancer, congestive heart failure, and cerebrovascular accident (stroke). The minimum data set (MDS) dated [DATE] assessed R6 as cognitively intact. R6's closed clinical record documented a care concern form dated 11/23/24 listing that the resident was assessed with a new skin impairment. The form categorized the wound as other and documented unstageable to right lower leg. A nursing note dated 11/23/24 documented,…
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 before2025-01-15 · 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 staff interview, facility document review, and clinical record review, the facility staff failed to perform timely neurological assessments following an unwitnessed fall for one of thirteen residents in the survey sample (Resident #10). The findings include: Resident #10 had no neurological checks initiated immediately following an unwitnessed fall to assess for possible head injury. Resident #10 (R10) was admitted to the facility with diagnoses that included metabolic encephalopathy, depression, dementia with severe agitation, cognitive communication deficit and hypertension. The minimum data set (MDS) dated [DATE] assessed with severely impaired cognitive skills. R10's closed clinical record also documented a nursing note dated 7/8/24 at 11:45 p.m. stating, .resident has been aggressive and agitated all shift . rounded on her q [every] 30 mins [minutes] due to her trying to get out of bed. while in room she was sitting on side of bed with feet on floor and put herself on fall mat . A post-fall…
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 · D2025-01-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure one of thirteen residents in the survey sample was free from a significant medication error (Resident #8). The findings include: Resident #8 was administered one dose of oxycodone 30 mg (milligrams) extended-release when the physician's order required an immediate release 20 mg dose. Resident #8 (R8) was admitted to the facility with diagnoses that included diabetes with peripheral angiopathy, below knee amputation, anemia and hypertension. The minimum data set (MDS) dated [DATE] assessed R8 as cognitively intact. R8's closed clinical record documented a physician's order dated 4/22/24 for oxycodone 20 mg every 4 hours as needed for pain (prn). The clinical record documented a physician's order dated 5/17/24 for oxycodone 30 mg extended-release with instructions for one tablet every 12 hours for pain management. R8's medication administration record (MAR) documented licensed practical nurse (LPN)…
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 before2025-01-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to properly store a controlled medication for one of thirteen residents in the survey sample (Resident #7) The findings include: Resident #7 (R7) was admitted to the facility with diagnoses that included chronic kidney disease, atherosclerotic heart disease, hypertension, benign prostatic hyperplasia, and gout. The minimum data set (MDS) dated [DATE] assessed R7 as cognitively intact. R7's closed clinical record documented a physician's order dated 6/9/24 for the medication Tramadol 50 mg (milligrams) with instructions to give two tablets every 6 hours as needed for pain management. Review of a medication error report sheet dated 6/14/24 documented that on 6/13/24, licensed practical nurse (LPN) #3 signed out one tablet of Tramadol for R7. The report documented LPN #3 did not administer the medication to R7 and left the medicine unsecured in the medication cart. The controlled drug count sheet for R7's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-15 · 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 staff interview, facility document review, and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of thirteen residents in the survey sample (Residents #8 and #10). The findings include: 1. There was no documentation in Resident #8's clinical record that the resident was administered an incorrect dose of the medication oxycodone. R8's closed clinical record documented a physician's order dated 4/22/24 for oxycodone 20 mg every 4 hours as needed for pain (prn). The clinical record documented a physician's order dated 5/17/24 for oxycodone 30 mg extended-release with instructions for one tablet every 12 hours for pain management. R8's medication administration record (MAR) documented administration of oxycodone 20 mg on 6/10/24 at 3:40 p.m. for pain rated 8 out of 10 (scale with 0 = no pain, 10 = worst pain). A medication error report dated 6/11/24 documented LPN #3 administered an oxycodone 30 mg extended-release tablet instead of the ordered 20 mg…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow infection control practices during a medication pass observation on one of three units (200 hall). The findings include: On 1/14/25 at 8:00 a.m., a medication pass observation was conducted with licensed practical nurse (LPN) #6 administering medications to Resident #5 (R5). Among the medications administered was a docusate sodium gel cap 100 mg (milligrams). When removing the capsule from the pharmacy packaging, LPN #6 dropped the capsule in the floor. LPN #6 put on gloves, picked up the capsule, placed it in a medicine cup, and stated since the capsule was gel, he would rinse it off with water. LPN #6 took the gel cap to the sink in R5's room, quickly rinsed the capsule with running water, drained remaining water from the cup, and proceeded to administer the docusate sodium gel cap to R5. When questioned, LPN #6 stated that he rinsed the gel cap because there were no over-the counter medications on the cart and the water would not hurt the gel covering.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-07 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review and facility documentation review, the facility staff failed to submit a demand bill, as requested on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #4- R4 and Resident #36- R36) in a survey sample of 3 Residents, reviewed for such notices. The findings included: For R4 and R36, the facility staff failed to continue skilled therapy services and submit a claim to Medicare for a coverage decision, as the resident and/or their representatives requested on the SNF ABN form. On 2/5/24, the facility administration was asked to provide the NOMNC (notice of Medicare non-coverage) and SNF ABN forms provided to R4 and R36. These notices were received and reviewed. Review of the forms and clinical record of each resident revealed the following: 1. According to the clinical record, R4 was receiving skilled therapy services from 11/29/23-12/21/23. On 12/19/23, R4 was issued a NOMNC and SNF ABN. R4 selected option 1 which read, I want the care listed above. I want Medicare to be billed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-07 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for 3 Residents (Resident #18- R18, Resident #210-R210, and Resident #211-R211) in a survey sample of 37 Residents and for 2 employees in a sample of 25 staff records reviewed. The findings included: 1. For R18, R210, and R211, all who reported allegations of abuse, the facility staff failed to report the allegations of abuse to the required agencies, failed to have evidence of an investigation being conducted and for R210 and R211, failed to take measures to protect the residents while an investigation is being conducted. On 2/6/24 and 2/7/24, a review was conducted of facility documents to include allegations of abuse. The documents revealed the following: a. On 3/8/23, R18 reported an allegation of verbal abuse from a staff member, CNA #2. On 3/8/23, the facility administrator notified the state survey agency and the ombudsman, but did not notify adult protective services, of the allegation. Once an investigation was conducted, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-07 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 staff interview and clinical record review, the facility staff failed to change insulin administration times as ordered by physician for one of thirty-seven residents in the survey sample (Resident #33). A provider approved pharmacy recommendation to change Resident #33's Humulin insulin administration times was not implemented for over three months. The findings include: Resident #33 (R33) was admitted to the facility with diagnoses that included cerebral infarction, diabetes, congestive heart failure, gastroesophageal reflux disease, chronic kidney disease and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R33 with severely impaired cognitive skills. R33's clinical record documented a physician's order dated 11/21/23 for Humulin 70/30 insulin (100 units/milliliter) with instructions to administer 30 units two times per day for diabetes management. R33's medication administration record (MAR) documented the Humulin was scheduled/administered at 9:00 a.m. and 9:00 p.m. each day.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to report to Adult Protective Services (APS) for 3 Residents (Resident #18- R18, Resident #210-R210, and Resident #211-R211) in a survey sample of 37 Residents. The findings included: For R18, R210, and R211, all who reported allegations of abuse, the facility staff failed to report the allegations of abuse to APS and the results of an investigation. On 2/6/24 and 2/7/24, a review was conducted of facility documents to include allegations of abuse. The documents revealed the following: a. On 3/8/23, R18 reported an allegation of verbal abuse from a staff member, CNA #2. On 3/8/23, the facility administrator notified the state survey agency and the ombudsman, but did not notify adult protective services, of the allegation. Once an investigation was conducted, the administrator again notified the state survey agency and the ombudsman of the findings but didn't report to adult protective services, nor the department of health professions, since the allegation 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.
Show the remaining 19 citations
- Potential for harm · D2024-02-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to invetigate allegations of abuse involving 2 Residents (Resident #210-R210, and Resident #211-R211) in a survey sample of 37 Residents. The findings included: 1. For R210, and R211, all who reported allegations of abuse, the facility staff failed to have any credible evidence of an investigation being conducted. On 2/6/24 and 2/7/24, a review was conducted of facility documents to include allegations of abuse. The documents revealed the following: a. On 3/3/23, R210 reported an allegation of abuse/mistreatment involving CNA #3. The facility had no documented evidence to indicate that an investigation was conducted with regards to R210's report of abuse/mistreatment. b. On 4/24/23, R211 reported an allegation of abuse involving CNA #3. The facility had no credible evidence to indicate an investigation was conducted. On 2/7/24, at 11:03 a.m., Surveyor #1 met with the facility Administrator and Corporate Clinical Specialist (CCS). The Administrator was asked to describe 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 · D2024-02-07 · 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 observation,staff interview and clinical record review the facility failed to develope a baseline care plan for one resident out of 37. The findings included: The facility failed to complete a baseline care plan in the area of nutrition for Resident #160 (R160). R160 was admitted to the facility on [DATE]. Diagnoses for R160 included but not limited to dementia, urinary track infection with sepsis, and hypertension. R160 due to being a new admission in the facility, no Minimum Data Set Assessment (MDS) had been completed On 2/5/24 at 1:15 p.m., interview was conducted with R160 and family was present in the room. The family member had concerns with lack of communication with the staff to know R160 care needs. The family member was concerned with staff sitting the tray down and walking out and not making sure R160 was able to eat. Certified Nursing Assistant (CNA4) was observed picking up R160's meal tray, the family member asked CNA4 if it had been communicated that R160 needed assistance with meals.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and clinical record review, the facility failed to meet professional standards of practice for one of 37 residents. The facility failed to accurately implement tube feeding physician order for Resident #7 (R7). The Findings Include: Diagnoses for R7 included Dysphasia, cerebral infarction, dementia, and feeding tube. The most current MDS (minimum data set) was a 5-day assessment with an ARD (assessment reference date) of 1/26/24. R7 was assessed with a cognitive score of 3 indicating severely cognitively impaired. On 2/5/24 at 11:15 AM an observation of R7 was made. R7 was lying in bed, feeding tube apparatus (IV pole and feeding tube pump) was noted besides the bed but not being used at this time. When asked about the feeding tube, R7 said that the facility used it but was uncertain how long it had been in use and did not give any other information. Review of R7's physician order dated 1/24/24 documented: Give isosource 1.5 60cc/hr [60 cubic centimeters per hour] over 20 hrs [hours] or until 1200cc is delivered. On 2/5/24 at 4:00 PM R7 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 · D2024-02-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and clinical record review, the facility failed to maintain nutritional parameters via a feeding tube for one of 37 residents. Resident #7 (R7) was not receiving the proper amount of tube feeding as ordered. The Findings Include: Diagnoses for R7 included Dysphasia, cerebral infarction, dementia, and feeding tube. The most current MDS (minimum data set) was a 5-day assessment with an ARD (assessment reference date) of 1/26/24. R7 was assessed with a cognitive score of 3 indicating severely cognitively impaired. On 2/5/24 at 11:15 AM an observation of R7 was made. R7 was lying in bed, feeding tube apparatus (IV pole and feeding tube pump) was noted besides the bed but not being used at this time. When asked about the feeding tube, R7 said that the facility used it but was uncertain how long it had been in use and did not give any other information. Review of R7's physician order dated 1/24/24 documented: Give isosource 1.5 60cc/hr [60 cubic centimeters per hour] over 20 hrs [hours] or until 1200cc is delivered. Review of the clinical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 document review, the facility staff failed to ensure the medication error rate was less than 5 %. There were 2 medication errors in 32 opportunities, resulting in an 6.25% error rate. The findings included: On 2/5/24 at 4:03 PM, licensed practical nurse #4 (LPN #4) was observed during the medication administration. LPN #4 pulled pantoprazole 40 mg tablet delayed release from the med cart, crushed it and administered it to resident # 39 (R39). R39's clinical record documented a physician's order dated 1/24/24 for pantoprazole sodium oral tablet delayed release 40 mg, give 1 tablet 2 times a day for treatment of gastroesophageal reflux disease. On 2/5/24 at 4:32 PM, LPN #4 was questioned if pantoprazole should be crushed or taken whole. LPN #4 stated that she crushed the pantoprozole because there was a note to crush all meds for R39, then stated that it should be taken whole due to pantoprozole being delayed release. On 2/6/24 at 10:22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-07 · 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 observation, facility documentation and staff interview the faciliy failed to remove expired biologicals in one of two medication rooms. Findings were: The facility failed to ensure that expired biologicals were not available for use. During a medication storage room review conducted on [DATE] at 11:12 a.m., the medication room on 100 unit was reviewed with license practical nurse( LPN#5, LPN5). A biological product (Liquid Urine Controls) had expired on [DATE] that was being stored in the refrigerator. LPN5 also reviewed the biolologcial product, expiration date and verbalized that it had expired. LPN5 then removed the biological product from the the medication storage room. A facility policy titled, Medication Storage, read in part Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . On [DATE] at 4:32 p.m., the above information was presented to the Director of Nusing, Administrator and the Nurse Consultant. No further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-07 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and facility documentation review the facility staff failed to store food properly in the main kitchen. The findings included: The dietary staff failied to label food products with an open date and the use by date label. On 2/5/24 at 11:00 a.m., obersavations were made in the main kitchen and a tour of the main kitchen was conducted with the dietary manager (other staff #7, OS7). In the dry ingredient storage there was a package of buttermilk pancake mix that was wrapped in plastic wrap and on the shelf with no open date or used by date label on the item. In the bread storage there were hot dog buns in a ziploc bag without a label showing the open date or use by date on the item. In the stand alone cooler there were 3 cups filled, covered with a lid and on a tray and the items had no labeling to indicate the product, date prepared, date opened or a use by date. OS7 identified the items as a cup of skim milk and 2 cups of whole milk. On 2/5/24 at 11:35 a.m., OS7 was interviewed about the unlabeled items and stated that per policy it should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-07 · 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 and clinical record review, the facility staff failed to document a complete and accurate clinical record for one of thirty-seven residents in the survey sample (Resident #22). Resident #22's dialysis communication form was incomplete. The findings include: Resident #22 (R22) was admitted to the facility with diagnoses that included end stage renal disease with hemodialysis, anemia, benign prostatic hyperplasia, diabetes, chronic kidney disease, and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R22 as cognitively intact. On 2/5/24 at 2:45 p.m., R22 was interviewed about quality of life/care in the facility. R22 stated during the interview that he went out to dialysis twice per week. R22 stated he took a communication book with him to/from dialysis at each visit. R22's dialysis communication sheet dated 2/6/24 documented the resident left the dialysis center on 2/6/24 at 12:55 p.m. The facility's portion of this 2/6/24 communication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facility documentation review, the facility staff failed to follow infection control practices for hand hygiene on 1 of 3 nursing units, unit 3. The findings included: The facility staff failed to adhere to standard precautions and perform hand hygiene between residents during medication administration. On 2/5/24 at 4:03 PM observations of medication administration and blood glucose testing were conducted with licensed practical nurse #4 (LPN #4). The following was observed: LPN #4 prepared medication for one resident, administered the medication, assisted the resident with water to drink then returned to the medication cart. No hand hygiene was performed. LPN #4 then applied gloves (without performing hand hygiene) went into a different resident room and performed blood glucose testing. After the testing was complete LPN #4 removed gloves and applied alcohol-based hand sanitizer. On 2/5/24 at 4:32 PM, LPN #4 was questioned about hand hygiene between resident contact, LPN #4 stated that she usually uses alcohol hand rub but didn't this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-07 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident interview, facility staff interview, and facility documentation review, the facility staff failed to ensure a call bell which relays the call to a centralized work area was present for one Resident (Resident #3- R3) in a survey sample of 37 Residents. The findings included: For R3, the facility staff failed to ensure the call bell at the bedside was functional. On 2/5/24 at 11:53 a.m., an interview was conducted with R3. R3 was sitting in a wheelchair at the side of the bed in their room. R3 was asked to engage the call bell, which they did. However, observations revealed that when pressed the call bell did not illuminate the light outside of the room door and gave no auditory signal to the staff. The surveyor pressed the call bell with the same result. On 2/5/24 at 3:06 p.m., an interview and observations were conducted with R3 again. R3 was again noted to be sitting in a wheelchair at the bedside. R3 was asked to press the call bell, when this was done the call bell again gave no visual or auditory signal to staff. The surveyor pressed the call bell…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-23 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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, facility document review and clinical record review, the facility staff failed to follow physician orders for two of sixteen residents in the survey sample. Resident #10 had elastic tubular bandages in use for over two weeks without a physician's order. Resident #212 was not administered a medication as ordered by the physician. The findings include: 1. Resident #10 was admitted to the facility with diagnoses that included lymphedema, pneumonia, peripheral venous insufficiency, obesity, hypertension, congestive heart failure, COPD (chronic obstructive pulmonary disease) and respiratory failure. The minimum data set (MDS) dated [DATE] assessed Resident #10 as cognitively intact. On 6/21/22 at 2:35 p.m., Resident #10 was observed seated in a wheelchair in his room. The resident's lower legs were wrapped with elastic gauze dressings. There were red/brownish stains scattered near the bottom of the wraps. Dry, scaly skin was visible on the toes of both feet.…
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 · D2022-06-23 · 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 observation, resident interview, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of sixteen residents in the survey sample. Resident #10 had no care plan regarding chronic lower extremity edema and use of support hose and/or wraps for management of lymphedema. The findings include: Resident #10 was admitted to the facility with diagnoses that included lymphedema, pneumonia, peripheral venous insufficiency, obesity, hypertension, congestive heart failure, COPD (chronic obstructive pulmonary disease) and respiratory failure. The minimum data set (MDS) dated [DATE] assessed Resident #10 as cognitively intact. On 6/21/22 at 2:35 p.m., Resident #10 was observed seated in a wheelchair in his room. The resident's lower legs were wrapped with elastic gauze dressings. Dry, scaly skin was visible on the toes of both feet. Resident #10 stated at this time that the wraps helped with swelling in his legs and he had experienced swelling in his…
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 · D2022-06-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to perform skin assessments for 1 of 16 residents in the survey sample, Resident #9. Resident #9 who was identified as being at risk for the development of pressure ulcers did not have a weekly skin assessment completed. The findings include: Resident #9 was admitted to the facility with diagnoses that included stage 4 pressure ulcer to the buttock, adult failure to thrive, GERD, vitamin d deficiency, type 2 diabetes, stage 2 chronic kidney disease, aphasia, and enteral feeding (tube feeding). The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #9 as severely impaired for daily decision making with a score of 4 out of 15. Under Section G - Functional Status, the MDS assessed Resident #9 as total dependent with one personal physical assistance for transfers, dressing, hygiene, bathing, locomotion, and toileting and extensive assistance with one person physical assistance for eating and bed…
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 before2022-06-23 · 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 observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of sixteen residents in the survey sample. Resident #10's clinical record documented use of TED support hose for over two weeks when the hose were not in use. The findings include: Resident #10 was admitted to the facility with diagnoses that included lymphedema, pneumonia, peripheral venous insufficiency, obesity, hypertension, congestive heart failure, COPD (chronic obstructive pulmonary disease) and respiratory failure. The minimum data set (MDS) dated [DATE] assessed Resident #10 as cognitively intact. On 6/21/22 at 2:35 p.m., Resident #10 was observed seated in a wheelchair in his room. The resident's lower legs were wrapped with elastic gauze dressings. Dry, scaly skin was visible on the toes of both feet. Resident #10 stated at this time that the wraps helped with swelling in his legs and he had experienced swelling in his feet/legs for a long time.…
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 before2022-06-23 · 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 document review, the facility staff failed to follow infection control protocols during meal distribution on one of three units and failed to follow infection control practices during a medication pass on one of three units. A staff person failed to perform hand hygiene between residents during meal distribution on unit 2. A nurse failed to follow infection control practices during medication preparation on unit 1. The findings include: 1. Meal distribution was observed on 6/21/22 starting at 12:23 p.m. on unit 2. A temporary nurse aide (TNA #1) was observed distributing trays from the meal cart to residents in their rooms. TNA #1 entered room [ROOM NUMBER] and moved resident items from the bed table, handled the bed remote, unwrapped the utensils and then exited the room. Without any hand hygiene, TNA #1 prepared and served the next tray to room [ROOM NUMBER]. TNA #1 moved this resident's personal items from the bed table, opened food items and touched 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 · D2022-06-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 the infection control influenza/pneumococcal immunization review, clinical record review, staff interview and facility document review, the facility staff failed to follow policies and procedures to ensure one of five residents (Resident #8) was offered the influenza vaccine during the 2021-2022 flu season. Findings include: Resident #8's diagnoses included, but were not limited to: Diabetes Mellitus, morbid obesity, anxiety, chronic kidney disease and major depressive disorder. The most recent MDS (minimum data set) for Resident #8 was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. In Section O0250. C. If influenza vaccine not received, state reason: documented that the vaccine was Not offered. On 06/22/22 at approximately 9:00 AM, a review was conduced of the facility's infection control influenza/pneumococcal immunization program. Five resident's were selected for review. 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 · D2021-03-11 · 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, staff interview and clinical record review, the facility staff failed to ensure a clean, homelike environment in one of fifteen rooms on the 300 hall. The room, occupied by Residents #21 and #31, had trash, lint, residue, and accumulated debris in the floor in addition to soiled and damaged furniture. The findings include: On 3/10/21 at 8:42 a.m., the room occupied by Residents #21 and #31 was inspected. There was accumulation of lint under Resident #21's bed along with straw papers, crumbs, paper trash/debris, a used napkin and a top to a plastic cup. A pink Sweet'n Low packet was in the floor in front of the wardrobe. A towel was in the floor in the corner behind Resident #21's wardrobe. Resident #21's bedside table was not positioned near the bed but was stored against the opposite wall. The drawers were facing the wall and not accessible with the back panel facing the room. Trash, lint and rubber/plastic medical tubing caps were observed on the floor along the wall under the clock.…
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 before2021-03-11 · 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 staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 19 residents in the survey sample, Resident #296. Resident #296s electronic health record failed to indicate the resident's code status. The findings include: Resident #296 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, respiratory failure, oxygen dependent, anxiety disorder, hypertension and delirium. The most recent minimum data set (MDS) dated [DATE] was the discharge assessment and assessed Resident #296 as having modified independent for daily decision making. Resident # 296's clinical record was reviewed on 03/10/2021. Observed on the March medication administration record (MAR) was the following: Advance Directive Full Code (discontinued as of 03/05/2021 18:37) Observed on the care plans was the following: [Resident #296] has Full Code Status. Revision Date: 02/12/2021 . 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.
- No harm found · C2022-06-23 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and facility document review, the facility staff failed to ensure waste was properly disposed of in garbage and refuse containers located outside of the main kitchen. Findings include: On 06/21/22 at 11:00 AM, a tour of the dumpster refuse area outside of the main kitchen was toured with the DM (dietary manager). The facility had two sets of dumpsters. Two for trash and two for cardboard boxes. The two dumpsters for trash were located in an enclosed area. These two dumpsters were observed with their lid/door opened. The DM closed the lid/door to each dumpster. In the enclosed area scattered on the ground, were six plastic gloves and a large piece of a black trash bag laying on the ground. The DM picked them up and stated that housekeeping is responsible for the dumpster area. The other two dumpsters (for cardboard/boxes) were then observed (not enclosed). Observed on the ground around the dumpster was a surgical mask, scattered pieces of paper and debris and small plastic cup. On 06/21/22 at approximately 3:00 PM, the administrator was asked for…
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
$8,278 in federal fines across 1 penalty.
- $8,278 — penalty dated 2025-09-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMMONWEALTH CARE OF ROANOKE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.6 | -1.6 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.7 | -1.7 vs chain |
| Quality measures | 3 of 5 | 4.2 | -1.2 vs chain |
The other 11 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BDSHEFFER LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/09/2008 |
| GOODALL, LURY | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/09/2008 |
| STALLARD, PATRICIA | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/03/2020 |
| PETRINE, JAMES | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 04/03/2020 |
| SHEFFER, BRADY | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | since 01/09/2008 |
| ALESANTRINO, JOE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 06/01/2019 |
| PETRINE, DEBORAH | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 07/15/2020 |
| TUCKER, DAVID | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 02/11/2026 |
| COMMONWEALTH CARE OF ROANOKE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/14/2007 |
| OVERSTREET, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2022 |
| SEVIER, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2012 |
| WILLIAMS, TY'SHANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/17/2025 |
| DJ PETRINE LLC | Organization | ADP OF THE SNF | since 07/15/2020 |
| HAMIDI, ADAM | Individual | ADP OF THE SNF | since 12/02/2025 |
CMS files one row per role, so the 26 rows in the source record cover these 14 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.
3 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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 495398. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-07, 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.