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Lakewood Manor

1900 Lauderdale Drive, Richmond, VA 23238 · Non profit - Corporation · 96 certified beds · (804) 740-2900 Medicare only — no Medicaid

Call the home — (804) 740-2900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Apr 2021Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2304 John Rolfe Pkwy · (804) 741-4404 · Call to confirm hours
Pharmacy
11120 Patterson Ave · (804) 740-0238 · Call to confirm hours
Grocery
Food Lion0.8 mi
11272 Patterson Ave · (804) 740-4306 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1900 Lauderdale Dr · (804) 740-2900

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.1%14.9%15.4%worse
Long-stay residents who lose too much weight5.4%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder1.9%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.3%1.6%2.0%worse
Long-stay residents with depressive symptoms2.7%18.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.3%3.6%3.3%better
Long-stay residents whose ability to walk worsened18.5%15.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.7%20.6%18.9%better
Long-stay residents given the seasonal flu vaccine50.8%94.0%95.3%worse
Long-stay residents with pressure ulcers6.4%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control24.0%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.7%14.2%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.8%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine24.9%73.6%79.4%worse
Short-stay residents rehospitalized after admission26.8%22.3%22.6%worse
Short-stay residents with an outpatient ER visit7.1%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.551.521.67typical
Long-stay outpatient ER visits per 1,000 resident days0.941.481.80better

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

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

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

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

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

49.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 276 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.3%U.S. median 51.5%
Got home and stayed home
8.7%U.S. median 10.7%
Went back to hospital
67.2%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 67.2% 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 232 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.3%CMS range 43.0–54.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.7%CMS range 5.9–11.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge69.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.4%CMS range 3.3–9.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.63
RN hours/ resident / day
1.53
LPN hours/ resident / day
2.87
Aide hours/ resident / day
5.03
Total nurse hours/ resident / day
0.33
RN hoursweekends
46.4%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 73.7 residents a day — about 77% occupied, or roughly 22 beds typically open. It usually has some room. 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 5.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 is at or above 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 4.59 hrs/resident/day on weekends vs 5.21 on weekdays — 12% thinner on weekends. RN hours go from 0.76 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

3
deficiencies at the latest standard inspection (2023-06-23)
15
at the previous standard inspection (2021-04-01)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2021-04-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to address unplanned significant weight loss; and ensured a comprehensive nutritional assessment was completed upon admission to maintain acceptable parameters of nutritional status for two of seven residents reviewed for nutrition (Resident (R) 83 and R13). This failure had the potential to affect other residents to not receive timely nutritional interventions. Findings include: 1. Review of R83's undated Face Sheet, located in the resident's Electronic Medical Record (EMR), indicated R83 was admitted to the facility on [DATE] with diagnoses which included type two diabetes mellitus (DM2), anemia, and fracture of right pubis. Review of R83's hospital Discharge Summary, dated 03/10/21 located in the hard copy of the medical record, indicated R83 had a right pelvic fracture, was to receive conservative treatment for the fracture, and had a weight of 135 pounds. Review of R83's admission Minimum Data Set (MDS) with an assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-06-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's ice machine, electric mixer, manual can opener, food preparation pans, and a kitchen drawer which housed food preparation equipment clean; failed to cover and date stored foods; and keep the second-floor service kitchen's ice machine clean. This failure had the potential to affect all 84 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated 01/01/23, revealed, Policy: The food service area shall be maintained in a clean and sanitary manner. 2. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair .12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the facility's policy titled, Food Receiving and Storage, dated 01/01/23, revealed, All foods stored in refrigeration or freezer will be covered, labeled, and dated (use by date). 1. Observation during the initial…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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, interview, clinical record review and facility documentation the facility staff failed to provide services as outlined in the comprehensive care plan that meet professional standards of quality for 1 Resident (#50) in a survey sample of 33 Residents. The findings included: For Resident #50 the facility staff failed to accurately transcribe the Registered Dietician and the Wound Care Physician's orders. On 6/21/23 a review of the clinical record of Resident #50 was conducted. Excerpts from the dietician notes are as follows: 12/20/22 at 1:18 PM - Sig change for new wound. Please refer to [Registered Dietician name redacted] regarding new wound. Prostat was added daily x 4 weeks. Recommend adding zinc and vitamin c for healing as well. Resident # 50 was seen by the wound specialist on 12/21/23 who made the following notes: Recommendations: Off-load wound. Reposition per facility protocol. Group 2 mattress; Gel cushion to chair, incontinence protocol with brief check and house barrier ointment applies q shift and prn. Vitamin C 500 mg twice daily, Zinc sulphate…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-04-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods were stored and served under safe and sanitary conditions. Observations on 03/29/21 of the 200-floor kitchen revealed unlabeled and undated foods in the refrigerator. Additionally, observations during the 200-floor meal service on 03/29/21, revealed drinking glasses and dining plates were not handled in a sanitary manor. This deficient practice had the potential to affect 45 of 45 residents who were served meals from the 200-floor kitchen. Findings include: 1. On 03/29/21 at 9:05 AM, during a kitchen observation in the 200-floor kitchen, the following was noted in the refrigerator: 18 individual salads in 6 oz [ounce] Styrofoam bowls were on a large tray, three blueberry pies, one large stainless-steel bowl with salad, and 24 single serving 2 oz ketchup containers. None of the items listed were labeled with date or time of preparation nor expiration dates. In an interview on 03/29/21 at 9:05 AM, with Dietary Aide (DA) 128, DA…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0582 — isolated
    Give 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 interview, record review, and review of the facility's policy, the facility failed to ensure the Resident Representative (RR) for one of three residents reviewed (Resident (R)81) was provided the Notice of Medicare Non-Coverage (NOMNC) at least 48-hours prior to the cessation of services. R81 was notified on 03/24/21 that their skilled services would end on 03/25/21. This failure had the potential for residents and/or their representatives not being informed of potential available services and fees for those services, or the advisement of the ability to appeal the Resident's discharge from Medicare Part A benefits. Findings include: Review of the facility policy titled Advance Beneficiary Notice, revised 02/2020, showed: Purpose Specific Procedures / Requirements: 1. General Guidelines There are two types of required notices: NOMNC - Notice of Medicare Non-Coverage is issued when traditional Medicare or Managed Care plans are ending in the SNF. Notice is only issued if there are days remaining under the covered stay. ABN - Advance Beneficiary Notice is issued only with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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 interviews and record reviews, the facility failed ensure the facility's abuse policy was followed for one of 22 sampled residents (Resident (R) 21). This includes completing a thorough investigation and reporting an injury of unknown origin. This deficient practice had the potential to affect all residents of the facility. Findings include: Review of the facility's policy titled Abuse revised on 11/2020 directs the facility will maintain systems to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, mistreatment .to the administrator or his or her designee .Designated staff will immediately review and investigate all allegation or observations of abuse The results of all investigations…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 interviews, policy review, and record reviews the facility failed to report an injury of unknown origin to the State Agency for one of six sampled residents reviewed for accidents (Resident (R) 21). On 08/04/20, R21 sustained a fracture to her left wrist and the injury was determined to be an injury of unknown origin; however, this was never reported to the State Agency. Findings include: Review of the facility's policy titled Abuse revised on 11/2020 directs the facility will maintain systems to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknow source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .The results of all investigations are to be communicated to the administrator or his or her designated representative and other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident. During…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and staff interview, the facility failed to ensure a thorough investigation was completed for an injury of unknow origin for one of six residents reviewed for accidents (Resident (R) 21). On 08/04/20, R21 received a fracture to her left wrist; however, the cause of the fracture was not known. Findings include: Review of the facility's policy titled Abuse, revised on 11/2020 directs the facility will . maintain systems to ensure that injuries of unknow source .Designated staff will immediately review and investigate . Review of the Profile Face Sheet located in the resident's hard copy medical record, revealed R21was originally admitted on [DATE] and readmitted on [DATE]. Review of the Diagnosis/Procedure form dated 01/18/21 in the EMR revealed the resident had an intertrochanteric fracture and right pelvic fracture. Review of the Minimum Data Set (MDS) with an ARD date of 06/30/20 revealed the resident had a Brief Interview Mental Status (BIMS) score of six,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, the facility failed to ensure that the assessment accurately reflect the resident's status for two of 22 residents (Resident (R) 81 & R78). Review of the residents' comprehensive assessments revealed the residents were not accurately assessed for existing problems. This deficient practice has the potential to affect all residents in the facility. Findings include: 1. Review of CMS's RAI Version 3.0 Manual Section M1040D directs that Open Lesion(s) Other than Ulcers, Rashes, Cuts, Open lesions that develop as part of a disease or condition and are not coded elsewhere on the MDS [Minimum Data Set], such as wounds, boils, cysts, and vesicles, should be coded in this item. Review of R81's Profile Face Sheet in the electronic Medical Record (EMR) under the face sheet tab, revealed the resident was originally admitted [DATE] with a current…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to provide activities of daily living (ADL) care for two of five residents reviewed for ADL, (Resident (R) 70 and R189). Observations revealed both residents had long white hairs on their chins, upper lips, and/or side of their face. This failure has the potential of affecting all dependent residents to not receive assistance with ADLs. Findings include: 1. Review of R70's undated Face Sheet, located in the resident's Electronic Medical Record (EMR), revealed R70 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of R70's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/11/21, located in the EMR under the MDS tab, indicated R70 had significant cognitive impairment, required extensive staff assistance for hygiene, was dependent on staff for personal care, and had no behaviors. Review of R70's Care Plan, located in the resident's EMR under 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, record review, staff and resident interview, and review of the facility's policy, the facility failed to ensure that residents received treatment and care in accordance with the comprehensive person-centered care plan and the residents' choices for one of 22 sampled residents (Resident (R) 81). R81 had a surgical wound on his scalp; however, the facility failed to complete weekly wound assessments. This deficient practice had the potential to place the resident at risk for complications related to wound healing. Findings include: Review of the facility's policy tiled Skin Assessment, dated 10/2017 directs If the area of skin impairment is new (no previous documentation can be located) the Charge Nurse will open up a new skin condition form and document results of the assessment, noting location of wound, wound type, etc. for each area . Each identified area of skin impairment must have a separate entry, a separate-skin condition form for each area. If multiple areas are noted in the same…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2021-04-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure that one (Resident (R) 81) of four residents reviewed for pressure ulcers, received the physician ordered treatment, received complete incontinent care, qualified staff cleansed the wound, and was provided treatment in a correct manner. Findings include: Review of the facility's polity titled Skin Care-Pressure Ulcer Prevention and Treatment Protocol, revised on 02/2016, directs that A skin assessment will be done upon admission by the charge nurse and weekly thereafter by a licensed nurse. The assessment will establish a baseline and identify residents at risk. Preventative and/or treatment measures will be implemented as needed .If an ulcer is present on admission, or when it first occurs, it will be assessed by the licensed nurse who will complete a Skin Condition Form. A complete assessment will be completed including site, size, depth (where appropriate), drainage, odor, and condition 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, record review, staff interview, and facility policy review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of two residents reviewed for urinary catheters (Resident (R) 81). On 03/30/21 during incontinence care, R81's urinary catheter bag was not placed below the resident's bladder for proper urinary drainage. This deficient practice had the potential to affect all residents who had a urinary catheter. Findings include: Review of the facility's policy titled, Special Needs - Suprapubic Catheter, dated 06/2015, directs to .Always keep the bag below the bladder level to ensure good drainage . Review of the facility's policy titled, Urinary Change in Continence Catheters and Prevention of Urinary Tract Infections, dated 07/2014, directed .Securing the catheter to facilitate urine flow and to prevent the catheter from being pulled…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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, record review, staff interview, and facility policy review, the facility failed to ensure the intravenous (IV) dressings were changed as ordered by the physician and failed to ensure the resident's Peripherally Inserted Central Catheter (PICC) was flushed for one of one resident reviewed for parenteral fluids (Resident (R) 66). This deficient practice had the potential to cause infection at the IV insertion site. Findings include: Review of the facility's policy titled, Special Needs: IV [intravenous] CVAD [Central Venous Access Device] PICC, dated 11/2016, directs that PICC= Peripherally Inserted Central Catheter - inserted in the arm with tip in the SVC [Superior Vena Cava] . Dressing changes for PICC's. Dressing changes are weekly .Inspect the site for -s/s [signs and symptoms] of infection, sutures/anchor (if needed) in place, catheter has not been pulled outward .Potential Complications with PICC's .Bleeding from the site .Bruising at the insertion site .inflammation, edema, tenderness…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to clean and air-dry nebulizer equipment between uses for one of 22 sampled residents (Resident (R) 81). This failure had the potential to cause pulmonary infections for the 14 residents in the facility that receive nebulizer treatments. Findings include: Review of R81's undated Face Sheet, located in the resident's Electronic Medical Record (EMR) Face Sheet revealed R81 was readmitted to the facility on [DATE] with medical diagnoses that included pneumonia. Review of R81's physician Orders, located in the EMR under the physician orders tab revealed a physician's order, dated 03/15/21, for DuoNeb (inhalation solution) nebulizer treatments three times a day for pneumonia. Observation on 03/30/21 at 1:05 PM, during R81's nebulizer breathing treatment, revealed a nebulizer at R81's bedside and breathing treatment medication cup, tubing, and mask were out of the plastic bag, connected, and sitting on top 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one of five sampled residents reviewed for unnecessary medications were free from unnecessary medications (Resident (R) 67). R67 was ordered an antipsychotic medication; however, the facility failed to monitor for side effects of the medication; and failed to monitor for specific behaviors related to the indication of use for the medication. This failure had the potential to affect any resident who received an antipsychotic medication. Findings include: Review of R67's undated Face Sheet, located in the resident's electronic medical record (EMR), under the face sheet tab, revealed the resident was admitted to the facility on [DATE]. Review of R67's Diagnoses, located in the resident's EMR under the diagnoses/procedure tab the resident's diagnoses included vascular dementia without behaviors, senile degeneration of the brain, anxiety disorder, and major depressive disorder. Review of R67's admission…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, interview, record review, and facility policy review, the facility failed to ensure one newly admitted resident (Resident (R)189) out of eight newly admitted residents reviewed for isolation was placed in isolation with Transmission Based Precautions (TBP) for 14 days per the facility's policy. This failure had the potential to spread possible infections to other residents and staff of the facility. The findings include: Review of R189's undated Face Sheet, located in the resident's Electronic Medical Record (EMR) revealed R189 was admitted to the facility on [DATE]. Review of R189's Physician Orders, located in the EMR under the Physician Orders tab, did not include an order for isolation. Review of R189's Comprehensive Care Plan, located in the resident's EMR under the care plan tab, revealed the resident was care planned for Risk for Exposure to and/or Transmission of Covid-19 Care Plan dated 03/23/21 and included: monitor for signs/symptoms of respiratory infection (i.e. (new or change…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-08-16 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 documentation review, and clinical record review, the facility staff failed, for 1 resident of 29 residents (Resident #66) to document the administration of medication. For Resident #66, the facility staff failed to document the administration of medications for Depression, and Bowel Management. The Findings Included: Resident #66 was a [AGE] year old, admitted to the facility on [DATE]. Resident #66's diagnoses included constipation, depression, and age-related physical debility. The Minimal Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 7/12/18 coded her as having a Brief Interview of Mental Status Score of 6, indicating severe cognitive impairment. On 8/15/18 at 9:00 A.M. an observation was conducted of Resident #66 who was asleep in her room. On 8/15/18 a review was conducted of Resident #66's clinical record, revealing the following signed physician orders: 1. 6/1/18 - Senna 8.6 MG Tablet By Mouth 4 Times Daily 2. 6/1/18 -…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-08-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed for one Resident (Resident #18) in a survey sample of 29 residents, to ensure physician ordered pressure relieving boots were in place. The findings Included: Resident #18 was admitted to the facility on [DATE]. Diagnoses included: Congestive heart failure, urinary obstruction and chronic obstructive pulmonary disease (COPD). Resident #18's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-17-18 was coded as a quarterly assessment. Resident #18 was coded as having a BIMS (brief interview of mental status) of 15 out of a possible 15, or no cognitive impairment. Resident #18 was also coded as requiring extensive to total assistance of one to two staff members to perform activities of daily living such as mobility and toileting. There were no pressure ulcers during the seven day lookback. On 8/14/18 at 12:49 PM,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-08-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 2 residents (Resident #81, 68) of 29 residents in the survey sample were free from unnecessary psychotropic medications. 1. For Resident #81, a stop date was not indicated on the PRN (as needed) Lorazepam. 2. For Resident #68, a stop date was not indicated on the PRN (as needed) Lorazepam. The findings included: 1. For Resident #81, a stop date was not indicated on the PRN (as needed) Lorazepam (Ativan). Resident #81, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included coronary artery disease, rheumatoid arthritis, depression and anxiety. The most recent Minimum Data Set assessment was a comprehensive assessment with an assessment reference date of 7/26/18. The resident had Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. She required extensive assistance with activities of daily living. Resident #81 had a physician order dated 3/10/18 for Lorazepam 2…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-08-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 perform hand hygiene between two residents during medication administration. LPN (licensed practical nurse) A did not perform hand hygiene between Resident #80 and Resident #39 and Resident #45. The findings included: On 08/15/18 at 7:45 AM, Medication pass was observed for three residents. After preparing and administering medications for Resident #80, the LPN (licensed practical nurse-A) did not clean her hands. After preparing and administering medications to Resident #39, the LPN (A) did not clean her hands prior to administering medications to Resident #45. Review of the facility's policy on Hand washing technique revealed: Wash hands before pouring medications and after passing medications. On 8/16/18 at 10:24 AM An interview was conducted with the facility Infection Control nurse (RN-registered nurse-B) was conducted. She stated, Handwashing, we can use hand sanitizer or wash hands if contact with fluids, etc. Monthly audits are performed without any issues. On 8-16-18 at…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-06-23 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to make the results of their most recent survey conducted by Federal or State surveyors accessible for residents, family members, and legal representatives of residents to review. This failure had the potential to affect all 84 residents who resided in the facility. Findings include: A group interview was conducted on 06/21/23 at 1:30 PM with eleven residents whom the facility identified as reliable historians. During the meeting, eleven of the eleven residents (Resident (R)5, R7, R19, R30, R32, R41, R51, R54, R58, R190, and R191) who participated were unaware where the facility's previous survey results conducted by Federal and State surveyors could be located and reviewed in the facility. An observation on 06/21/23 from 3:15 PM to 3:45 PM of the facility's first, second, and third floors revealed the facility's previous survey results could not be located and there was no posted information which notified residents, family members, and legal representatives of residents where the facility's previous survey results could 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
RUSNAK, HEATHERIndividualW-2 MANAGING EMPLOYEEsince 03/08/2021
BALES, JAMESIndividualCORPORATE DIRECTORsince 01/01/2019
BROOKS, SHARONIndividualCORPORATE DIRECTORsince 01/01/2021
BROWNING, HERBERTIndividualCORPORATE DIRECTORsince 02/01/2018
CARTER, VALERIEIndividualCORPORATE DIRECTORsince 02/01/2018
CAVE, RIndividualCORPORATE DIRECTORsince 12/31/2021
FRANKS, TIFFANYIndividualCORPORATE DIRECTORsince 01/01/2020
HARRIS, CHARLESIndividualCORPORATE DIRECTORsince 02/01/2018
JUNG, JOHNIndividualCORPORATE DIRECTORsince 01/01/2021
KECK, MICHAELIndividualCORPORATE DIRECTORsince 04/01/2009
MARCHELLO, SALLIEIndividualCORPORATE DIRECTORsince 01/01/2018
OAKEY, SAMUELIndividualCORPORATE DIRECTORsince 02/01/2018
OWENS, ARNEIndividualCORPORATE DIRECTORsince 01/01/2020
POATS, JIMIndividualCORPORATE DIRECTORsince 01/01/2022
POMA, JOHNIndividualCORPORATE DIRECTORsince 01/01/2021
SCOTT, MATTHEWIndividualCORPORATE DIRECTORsince 02/01/2018
THOMSON, GARYIndividualCORPORATE DIRECTORsince 01/01/2022
ALBRITTON, TRACEYIndividualCORPORATE OFFICERsince 12/01/2021
CARLTON, DANIELIndividualCORPORATE OFFICERsince 12/31/2021
COOK, JONATHANIndividualCORPORATE OFFICERsince 05/01/2016
HAWTHORNE, LISAIndividualCORPORATE OFFICERsince 06/14/2021
MARKWITH, CHRISTOPHERIndividualCORPORATE OFFICERsince 01/31/2018
MORAN, CHRISTINEIndividualCORPORATE OFFICERsince 03/31/2021
ROBINSON, JOHNIndividualCORPORATE OFFICERsince 05/01/2016
VIRGINIA BAPTIST HOMES INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 04/01/2009

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

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$39.0M
Net patient revenuemost recent cost report
+0.5%
Operating marginrevenue minus expenses
$2.6M
Related-party expense7% of expenses

This home reported $2.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$200per resident / day
operating cost
$6,080per month
≈ monthly operating cost
$201per day
avg. revenue, all payers

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

What families pay in VA

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Virginia Medicaid page for homes that do.

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495403. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-06-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

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

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