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Raleigh Court Health And Rehabilitation Center

1527 Grandin Road Southwest, Roanoke, VA 24015 · For profit - Limited Liability company · 120 certified beds · (540) 342-9525 Medicare & Medicaid certified

Call the home — (540) 342-9525 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0606) — cited Dec 2022Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0606), cited Dec 2022
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2102 Grandin Rd SW · (540) 777-2481 · Call to confirm hours
Pharmacy
2311 Sanford Ave SW · (540) 524-9983 · Call to confirm hours
Grocery
1319 Grandin Rd SW · (540) 343-5652 · Call to confirm hours
Park
56 Roanoke Ave SW · (540) 777-6325 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased15.0%14.9%15.4%typical
Long-stay residents who lose too much weight3.4%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms84.0%18.7%6.5%worse 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 injury3.8%3.6%3.3%worse
Long-stay residents whose ability to walk worsened13.0%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.4%20.6%18.9%typical
Long-stay residents given the seasonal flu vaccine99.0%94.0%95.3%typical
Long-stay residents with pressure ulcers2.7%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control25.2%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.4%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine84.6%73.6%79.4%typical
Short-stay residents rehospitalized after admission13.8%22.3%22.6%better
Short-stay residents with an outpatient ER visit9.8%11.5%12.0%better

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

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

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

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

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

47.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 140 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.9%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
65.2%U.S. median 56.6%
Met the expected recovery
0.47U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 65.2% 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 89 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 28% 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 SNF47.9%CMS range 40.0–55.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.1–15.710.7%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 discharge65.2%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 discharge53.9%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 discharge66.3%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 identified99.2%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 setting92.2%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 discharge92.3%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 stay0.8%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 worsened0.8%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 hospitalization9.2%CMS range 5.8–14.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.56
RN hours/ resident / day
1.01
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.32
RN hoursweekends
53.4%
Total nursing turnover
58.8%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.4 residents a day — about 94% occupied, or roughly 7 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 3.485 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 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 3.10 hrs/resident/day on weekends vs 3.64 on weekdays — 15% thinner on weekends. RN hours go from 0.66 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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

7
deficiencies at the latest standard inspection (2024-08-15)
17
at the previous standard inspection (2022-12-19)

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 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.

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2020-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 28 residents (Resident #99) was free of accident hazards as evidenced by failure to ensure the resident was transferred with the correct size sling when using the mechanical lift, which resulted in resident injury. The findings included: Resident #99 was transferred with the incorrect sling when being transferred with the Hoyer lift. This resulted in the sling breaking and the resident fell to the floor. Resident #99 was evaluated at a local hospital and was diagnosed with a closed reduction (dislocation) left shoulder. This was a closed record review due to an FRI (facility reported incident) that was reported to the OLC (Office of Licensure and Certification). The face sheet in the EHR (electronic health record) included the diagnoses cerebral infarction, essential (primary) hypertension, and morbid (severe) obesity. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/12/2019…

    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 · Past Non-Compliance
  • Potential for harm · E2024-08-15 · 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

    Based on observation, staff interview, and facility document review, facility staff failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings were: Facility staff stacked food storage containers one on top of each other after being washed and remained wet. Facility staff left the ice scoop inside the ice machine. On 08/11/24 at 1:15 p.m. during the initial tour of the kitchen, three (3) stacks of food storage containers were observed wet. A dietary aide who accompanied the surveyor during the tour acknowledged the containers had been washed and stacked, one on top of the other, to dry. The dietary aide unstacked the containers to dry separately. The ice scoop was observed inside the ice machine. The dietary aide removed the scoop, placed it in the holder attached to the wall beside the ice machine and stated, They know not to do that. On 08/14/24 at 4:32 p.m. during an end of day meeting with the assistant administrator, administrator, regional director of clinical services, assistant director of nursing, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, clinical record review, and facility document review, facility staff failed to notify the resident representative of a change in condition requiring transfer for 1 of 4 closed records reviewed for the survey (Resident #113) The findings were: The facility staff failed to notify Resident #113's resident representative of the resident's change in condition. The resident was unresponsive and required a transfer to an acute care hospital. The minimum data set with an assessment reference date of 06/15/2023 assigned Resident #113 a brief interview for mental status score a 15 out of 15. The admission record listed the resident was his own responsible party and a family member as the emergency contact #1. The clinical record contained a licensed practical nurse (LPN) change of condition progress note dated 07/11/23 at 9:09 p.m. which read, pt. (patient) notice [sic] to be unresponsive to voice by writer, who attempted sternal rub with no response. vs (vital signs) 101/69 97.8 temp, 106 bpm (beats per minute), and 94% O2 (oximeter). md (medical doctor) 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, facility document review, and clinical record review, the facility staff failed to develop a comprehensive care plan which addressed hypotension for one (1) of 23 sampled current residents (Resident #74). The findings include: Review of Resident #74's comprehensive care plan, on the morning of 8/14/24, fail to reveal evidence the resident was care planned to address low blood pressure (hypotension). Resident #74's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/9/24, was signed as completed on 5/16/24. Resident #74 was assessed as able to make self understood and as able to understand others. Resident #74's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #74's clinical record included a medical provider order for midodrine 5 mg tablet dated 6/24/24. This order indicated the resident was to receive one (1) tablet two times a day for low blood pressure. This order indicated the medication should not be administered if 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, and clinical record review, facility staff failed to provide adequate supervision to ensure the resident environment remained free of accident hazards for 2 of 23 current residents in the survey sample (Resident #107 and #62). The findings were: 1. For Resident #107, the facility staff failed to maintain the resident's cigarettes and lighters. The most recent minimum data set with an assessment reference date of 07/17/24 assigned Resident # 107 a brief interview for mental status score a 10 out of 15. The care plan included a focus area which read the resident was a smoker, the goal read the resident will smoke safely. For interventions, the care plan read educate on facility smoking policy, OT referral as needed, smoking apron, smoking assessment as needed. During the initial tour on 08/11/24 at 3:10 p.m., Resident #107 was lying in bed with the overbed table beside the bed. The surveyor observed one (1) pack of cigarettes and two (2) blue lighters on the overbed table. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure one (1) of 23 sampled current residents was free from unnecessary medications (Resident #74). The findings include: The facility staff failed to hold Resident #74's midodrine according to the medical provider's ordered parameters. Midodrine is a medication used to treat low blood pressure (hypotension). Midodrine works by constricting blood vessels to increase an individual's blood pressure. Resident #74's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/9/24, was signed as completed on 5/16/24. Resident #74 was assessed as able to make self understood and as able to understand others. Resident #74's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #74's clinical record included a medical provider order for midodrine 5 mg tablet dated 6/24/24. This order indicated the resident was to receive one (1) tablet two (2) times a day for low…

    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 before2024-08-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents are free of any significant medication errors for 1 of 23 sampled residents, Resident #105. The findings included: For Resident #105, the facility staff failed to follow provider orders for the administration of the medication, Cephalexin four times a day for two days as indicated. Cephalexin is indicated for the treatment of patients with certain infections caused by bacteria such as urinary tract infections. Resident #105's diagnosis list indicated diagnoses, which included, but not limited to, Traumatic Subdural Hematoma, Muscle Weakness, Urinary Tract Infection (UTI), Delirium, End Stage Renal Disease, and Dependence on Renal Dialysis. Resident #105's most recent minimum data set (MDS) with an assessment reference (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident is moderately cognitively impaired. A provider's order dated 6/7/24, read in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, family report, and ombudsman interview, facility staff failed to treat the resident with dignity and respect as evidenced by failure to answer calls for assistance within an hour for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview on 5/21/2024, the ombudsman reported investigating a family concern about call bells dating from 2/9 through 2/11/2024. The ombudsman stated that 2 of the 169 calls from the resident's room over that period were answered after more than an hour. This statement was corroborated by the family report dated 5/9/2024 stating that the resident waited over 1 hour 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-22 · 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 — the official record, unedited, may be distressing

    Based on staff interview and clinical record review, facility staff failed to administer a medication for managing blood pressure (BP) as ordered by the physician/surrogate for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor obtained the Medication Administration Audit report for 2/10/2024. The report indicated the resident's Midodrine HCl oral tablet 5 mg give 1 tablet three times a day for hypotension, hold for BP above 140/90 scheduled for 9 AM was administered to the resident at 11:07 AM. The administrator and corporate clinical consultant were notified of the concern during a summary meeting on 5/22/2024.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-22 · tag F0776 — isolated
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, facility staff failed to obtain a radiological test ordered by the physician/surrogate for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor interviewed the nurse practitioner (NP) on 5/21/2024. The NP reported having entered the order for the Computed tomography (CT) scan and stated the scheduler confirmed the order had been entered. Record review revealed the NP entered an order for a CT of the abdomen on 11/10/2023. During that interview, the administrator stated that the scheduler was no longer working for the facility due to issues with record-keeping, among others.…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 6 residents, Resident #2. The findings included: For Resident #2 the facility staff failed to include an order for oxygen on the physician's order summary and failed to correctly document a physician's order in the nurse's progress notes. Resident #2's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, unspecified systolic (congestive) heart failure, and major depressive disorder. Resident #2's most recent minimum data set with an assessment reference date of 08/22/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Section O, Special Treatment, Procedures and Programs coded the resident as receiving oxygen therapy while both a resident of the facility and not a resident of the facility. Resident #2's comprehensive care plan was reviewed and contained a care plan for the resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · E2022-12-19 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to provide activities of daily living care for 4 of 24 residents, Residents #109, #79, #100, and #209. The findings included: 1. For Resident #109, the facility staff failed to complete activity of daily living (ADL) care for a dependent care resident. This was a closed record review. Resident #109's diagnoses included, but were not limited to, plantar fascial, fibromatosis, obstructive sleep apnea, diabetes, chronic pain, pain in right foot, non-displaced fracture of proximal phalanx of right great toe, and morbid obesity. The clinical record included an admission Assessment/Screening dated 05/08/21 that indicated the resident was alert and orientated to person, place, time, and situation. The portion of the admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/15/21 did not include a cognitive score. Section G (functional status) was coded 3/3 (extensive assist of two persons) for personal hygiene and 4/2 (totally…

    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 · Ecited before2022-12-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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

    Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 1 of 24 residents, Resident's #209 and failed to initiate physician orders following an office visit for 1 of 24, Resident #100. The findings included: 1. The facility nursing staff failed to administer Resident #209's Miramax powder per the providers order. Resident #209's diagnoses included, but were not limited to, diabetes and muscle weakness. There was no completed minimum data set assessment on this resident. The clinical record included an admission/readmission nursing collection tool completed on 12/09/22 that indicated Resident #209 was orientated to person, place, time, and situation. Resident #209's clinical record included a provider order for Miralax powder 17 grams give 1 scoop by mouth one time a day for constipation. Date of order 12/09/22. The scheduled time for administration was documented as 9:00 a.m. 12/14/22 8:15 a.m., the surveyor observed Licensed Practical Nurse (LPN) #4 prepare and administer Resident #209's morning…

    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 · E2022-12-19 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review and facility document review, the facility staff failed to consistently have pharmacy recommendations available for review, and failed to ensure pharmacy recommendation were followed up on by the provider for 1 of 5 resident's sampled for unnecessary medications. Resident #54. The findings included: 1. The facility staff failed to ensure pharmacy recommendations were consistently available for review. During the clinical record review, the surveyors were unable to consistently locate pharmacy recommendations in the clinical record. On 12/19/22 at 1:03 p.m., Regional Nurse Consultant (RNC) stated the pharmacy recommendations should have been uploaded into the clinical record and it was ultimately the responsibility of the Director of Nursing (DON) to ensure they were addressed and uploaded. On 12/19/22 at 3:00 p.m., the facility provided the surveyor with a copy of their policy titled, Medication Regimen Review, effective 08/20/20. This policy read in part, .The consultant pharmacist reviews the medication regimen of each resident 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility document review, the facility staff failed to dispose of expired medications on 1 of 2 units (unit 2) ,and failed to secure medications on 2 of 2 units (unit 1 and 2). The findings included: The facility staff failed to dispose of expired medication in the medication room on unit 2 and failed to secure medications in the medication room and on a medication cart on unit 1. 12/13/22 3:05 p.m., the surveyor and Licensed Practical Nurse (LPN) #3 checked the medication room on unit 2. This medication room contained a medication refrigerator that was unlocked. Inside the refrigerator the surveyor observed a clear narcotic box that was unlocked and opened. This narcotic box contained a 30 ml bottle of Lorazepam (ativan). LPN #3 identified the residents name on the bottle as a resident that had been discharged from the facility. A review of the clinical record revealed this resident had been discharged on 12/09/22. 12/13/22 3:20 p.m., the surveyor and LPN #1 checked the medication room on unit 1. This medication room included 12 bags 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on family interview, clinical record and staff interview the facility staff failed to honor the legal Power of attorney (POA) for one of 24 residents sampled (Resident #85). On the Minimum Data Set assessment with assessment reference date 9/14/22, the Resident #85 scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident's diagnoses included chronic venous insufficiency, cerebral infarct, diabetes mellitus with peripheral angiopathy, atrial fibrillation, heart failure, chronic kidney disease, essential hypertension, morbid obesity, bacterial pneumonia, and chronic pain. On 12/19 at 9:30 AM, the surveyor interviewed the resident's Power of Attorney (POA) at his request. The POA stated that the administrator has said that the POA was not empowered to make decisions for the resident. The POA is not always notified when changes occur in the resident's status and the resident has been sent to medical appointments without the POA's knowledge. The POA is not notified when the resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on family interview, staff interview, and clinical record review, facility staff failed to notify the RP and/or physician with significant changes to resident status for one of 24 current residents in the survey sample (Resident #85). On the Minimum Data Set assessment with assessment reference date 9/14/22, Resident #85 scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The residents' diagnoses included chronic venous insufficiency, cerebral infarct, diabetes mellitus with peripheral angiopathy, atrial fibrillation, heart failure, chronic kidney disease, essential hypertension, morbid obesity, bacterial pneumonia, and chronic pain. On 12/19 at 9:30 AM, the surveyor interviewed the residents' Power of Attorney (POA) at his request. The POA stated that the administrator said that the POA was not empowered to make decisions for the resident. The POA is not always notified when changes occur in the residents' status and the resident has been sent to medical appointments without the POAs…

    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 · D2022-12-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and resident interview the facility staff failed to maintain a clean and homelike environment in one of two shower rooms (Unit 1 Shower Room). The findings: On 12/19/22 at approximately 1:00 p.m., a resident, who was not included in the sample, reported the shower room on Unit 1 had black mold in the shower. LPN #1 (licensed practical nurse) accompanied one surveyor to the Unit 1 Shower room for observation 12/19/22 at 1:08 p.m. A black substance was noted in the grout, not on the tile, of the shower. There was no odor noted. LPN #1 applied a glove and attempted to scratch one of the discolored areas on the grout. The nurse's glove remained clean after attempting to scratch the black substance. LPN #1 stated she would notify maintenance. The Regional Nurse Consultant who was acting in place of the director of nursing (DON) as well as acting in place of the administrator due to both of their absences during the survey, was informed of the shower room observation on 12/19/22 at 1:15 p.m. At approximately 2:30 p.m. on 12/19/22, the maintenance…

    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 · D2022-12-19 · tag F0606 — failed to not employ staff found guilty of abuse — isolated
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on personnel record review, facility staff failed to obtain a criminal background check prior to employment for one of 25 staff members reviewed. Facility Policy Number 702 titled Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training states under PROCEDURE: 1. Criminal background and reference checks are performed on all employees. The surveyor reviewed the employment records of 25 employees hired since the last standard survey. One non-clinical employee's record did not contain a criminal background check. The surveyor informed the regional nurse consultant (acting as director of nursing and administrator) of the issue on 12/16/22. A background check dated 12/19/22 revealed several convictions. The surveyor reviewed the convictions with the nurse consultant and concluded none were barrier offences. On 12/19/22 at 3:25 PM, the surveyor reported the concern to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator).

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · 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 staff interview, clinical record review and facility document review; the facility staff failed to implement written policies and procedures regarding the investigation and reporting of an allegation of resident abuse for one of 24 residents in the survey sample, Resident # 17. The findings include: For Resident #17, the facility staff failed to investigate and report an allegation of rape reported by the resident on 3/16/22. Resident #17's diagnoses Included, but was not limited to Alzheimer's disease, generalized anxiety disorder, major depressive disorder, bipolar disorder, pseudobulbar affect, and unspecified macular degeneration. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/9/22, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15, indicating severe cognitive impairment. Resident #17's clinical record included a nursing progress note dated 3/16/22 at 3:20 pm which read, this writer spoke with resident's daughter and RP (responsible party) in regards to resident making a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · 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 staff interview, clinical record review and facility document review, facility staff failed to report an allegation of resident abuse for one of 24 residents within the survey sample, Resident #17. The finding included: For resident #17, the facility staff failed to report an allegation of rape reported on 3/16/22. Resident #17 diagnosis include, but are not limited to, Alzheimer's disease, generalized anxiety disorder, cognitive communication deficit, major depressive disorder, bipolar disorder, pseudobulbar disorder and macular degeneration. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/9/22 assigned the resident a brief interview for mental status (BIMS) summary score of 3, indicating severe cognitive impairment. Resident #17's clinical record included a nursing progress note dated 3/16/22 at 3:20 pm which read, this writer spoke with resident's daughter and RP (responsible party) in regards to resident making a statement of being raped. Per (daughter) I feel like I spoke with someone before about this a few months back. I…

    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 · D2022-12-19 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, facility document review and staff interview, the facility staff failed to ensure that 1 of 24 residents in the survey sample had a Level II PASARR, Resident #1. The findings include: For resident #1, the facility staff failed to refer the resident for a level II PASARR (Preadmission Screening and Resident Review) evaluation and determination. Resident #1's diagnosis included but were not limited to spastic hemiplegic cerebral palsy, other seizures, severe intellectual disability, schizoaffective disorder, dementia and major depressive disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/9/22 assigned the resident a brief interview for mental status (BIMS) summary score of 99 indicating the resident was unable to complete the interview. Resident #1's clinical record included a level I PASARR dated 9/16/2010 indicating the recommendation for a Level II evaluation and determination, MR (mental retardation) or related condition was checked under section 5 Recommendation. Surveyor was unable to locate a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, facility documentation review, and staff and resident interview, the facility staff failed to develop and implement a person-centered baseline care plan and failed to provide the resident with a summary of the baseline care plan for one of 24 residents in the survey sample, Resident #357. The findings include: For resident #357, the facility staff failed to develop a baseline care plan that addressed his Foley catheter, peripherally inserted central catheter (PICC) line, urinary tract infection, intravenous (IV) antibiotics, and failed to give resident #357 a copy of his baseline care plan. Resident #357 was admitted to the facility 12/08/22 with diagnosis including but not limited to urinary tract infection (UTI), acute kidney failure and type 2 diabetes. Resident #357 was alert and listed in the clinical record as his own responsible party. On 12/14/22 at 8:53 am, the surveyor entered resident #357's room and noted an IV pole at the bedside and a PICC line in the right arm. There was a Foley catheter bag attached to the bed. The resident reported…

    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 · D2022-12-19 · 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

    Based on resident interview, staff interview, and clinical record review, facility staff failed to provide wound care as ordered for one of 24 residents sampled (Resident #79). Resident #79 was admitted to the facility with diagnoses which included multiple sclerosis, local infection of skin, right hip pressure ulcer, hypertension, and major depression. On the quarterly Minimum Data Set assessment with assessment reference date 11/17/22, the resident scored 12/15 on the brief interview for mental status, indicating the resident's cognitive status was essentially intact, and was assessed as being without signs of delirium, psychosis, or behaviors affecting care. The resident required the extensive assistance of 1 person for personal hygiene and was totally dependent on 1 person for bathing. During the initial tour on 12/13/22, the resident reported to the surveyor that the facility was chronically short of staff. The staff shortage resulted in long waits for incontinence care, not being bathed, and missed wound treatments. The resident was concerned that missed wound treatments would…

    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 · D2022-12-19 · 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

    Based on clinical record review and staff interview, the facility failed to act on a medication regimen recommendation by the pharmacist for one of five residents sampled for unnecessary medications (Resident #54). The findings were: The facility staff failed to ensure that pharmacy recommendations for a gradual dose reduction (GDR) were reviewed, and that the attending physician documented what, if any, action was to be taken regarding Lorazepam 0.5mg tid (three times a day) for Resident #54. Resident #54's admission record listed diagnosis information to include myocardial infarction, type 2 diabetes mellitus, Cushing's syndrome, major depressive disorder, anxiety disorder, and Crohn's disease. On the minimum data set with an assessment reference date of 11/21/2022, the resident scored a 12 out of 15 on the brief interview for mental status. A document titled, Consultant Pharmacist Recommendation to Physician signed by the consultant pharmacist and dated 11/28/2022 was provided by the Regional Nurse Consultant who was acting in place of the facility's director of nursing (DON),…

    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 before2022-12-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, facility staff failed to administer the intravenous antibiotic vancomycin per physician orders for 1 of 24 sampled residents (Resident #209). Resident #209 was admitted to the facility with diagnoses including acute osteomyelitis, orthopedic surgical aftercare, rheumatoid arthritis, type 2 diabetes mellitus, chronic ulcer of foot, hypertensive heart disease with heart failure, and Charcot's joint, ankle, and foot. Facility staff had not completed a Minimum Data Set assessment at the time of the survey. Surveyors determined the resident was capable of answering questions concerning care. Review of the residents' clinical record revealed an order for Vancomycin HCl 1.25 gm intravenously at bedtime for wound infection related to osteomyelitis right ankle and foot. The medication administration record for 12/15/22 and 12/16/22 was marked 5= hold. The nursing progress note dated 12/15/22 read Received call from lab this shift with critical vancomycin trough 34.9. Results faxed to Pharmacy and call placed by this nurse at 2200 and spoke…

    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 before2022-12-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 24 residents, Resident #15. The findings included: The facility staff failed to accurately complete a Durable Do Not Resuscitate Order form. Section #1 and #2 had been left blank. Resident #15's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes, and anxiety. Section C (cognitive patterns) of the admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/28/22, included a brief interview for mental status (BIMS) score of 8 out of a possible 15 points. Resident #15's electronic health record (EHR) included the provider order Do Not Resuscitate (DNR) dated 03/23/22 and a Durable Do Not Resuscitate (DDNR) Order Form from the Virginia Department of Health dated 03/22/22. Section 1 of the DDNR order form read in part, I further certify [must check 1 or 2]: 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-08-15 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility document review, the facility staff failed to ensure the posting of the required daily nurse staffing information. The findings include: On 8/13/24 at approximately 10:25 a.m., the surveyor observed the posted daily nurse staffing information did not include the facility's census. The Assistant Administrator was informed the posting did not include the census. The form used to post the daily nurse staffing information was titled DAILY NURSE STAFFING SUMMARY. This form included the following statements: - Post this document in a prominent place; accessible to patients and visitors. Complete at the beginning of each shift; update any changes to information as needed. - Retain Nursing Staffing Data for 18 months. On 8/13/24 at 10:44 a.m., the surveyor reviewed the facility's retained documentation of posted daily nurse staffing information with the Administrator. These documents were kept in a binder but were not organized by date. The surveyor noted multiple documents were missing some of the required information. The following…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-12-19 · tag F0555 — widespread
    Honor the resident's right to choose his or her attending physician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility document review, the facility staff failed to ensure the residents and/or resident representative(s) were informed of a change in the physician/provider responsible for his or her care. The findings included: The facility staff failed to notify the residents and/or resident representative when there was change in the medical director and/or provider(s). 12/16/22 10:10 a.m., the survey team received a phone call from former employee #1 who stated the facility had failed to inform the residents and/or resident representative of a change in provider(s). 12/16/22 11:32 a.m., the Regional Nurse Consultant (RNC) stated the previous Medical Director chose to terminate their contract and a new letter was not sent out to the families and/or representatives when this change occurred. The RNC stated the [NAME] President of Operations is going to take care of this today. 12/19/22 10:26 a.m., the RNC provided the surveyor with a Notice of Termination of Attending Physician Agreement dated 07/12/22 that stated they would terminate their agreement with 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.

    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.

Part of a chain

This home belongs to LIFEWORKS REHAB — 64 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 →

RatingThis homeChain avg
Overall 4 of 52.1+1.9 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 5 of 53.9+1.1 vs chain
The other 63 homes this chain runs (chain average 2.1★, per CMS)
1 of 5APPOMATTOX HEALTH & REHABILITATiON CENTERAppomattox, VA 1 of 5Alamance Health Care CenterBurlington, NC 1 of 5Bayside Health & Rehabilitation CenterVirginia Beach, VA 1 of 5Cabarrus Health and Rehabilitation CenterConcord, NC 1 of 5Charlotte Health & Rehabilitation CenterCharlotte, NC 1 of 5Chesapeake Health And Rehabilitation CenterChesapeake, VA 1 of 5Colonial Heights Rehabilitation And Nursing CenterColonial Heights, VA 1 of 5Elkton Nursing And Rehabilitation CenterElkton, MD 1 of 5Greenville Health and Rehabilitation CenterGreenville, NC 1 of 5Guilford Health Care CenterGreensboro, NC 1 of 5Harrisonburg Hlth & Rehab CntrHarrisonburg, VA 1 of 5Largo Nursing And Rehabiliation CenterGlenarden, MD 1 of 5Layhill Nursing And Rehabilitation CenterSilver Spring, MD 1 of 5Lenoir Health and Rehabilitation CenterLenoir, NC 1 of 5Lynchburg Health & Rehabilitation CenterLynchburg, VA 1 of 5Norfolk Health Care CenterNorfolk, VA 1 of 5Oxford Health and Rehabilitation CenterOxford, NC 1 of 5Parham Health Care & Rehab CenterRichmond, VA 1 of 5Salem Health & RehabilitationSalem, VA 1 of 5University Health and Rehabilitation CenterDurham, NC 1 of 5Virginia Beach Healthcare And Rehab CenterVirginia Beach, VA 1 of 5Westport Rehabilitation And Nursing CenterRichmond, VA 1 of 5White Oak Rehabilitation And Nursing CenterHyattsville, MD 1 of 5Williamsport Health And Rehabilitation CenterWilliamsport, MD 2 of 5Adelphi Nursing And Rehabilitation CenterAdelphi, MD 2 of 5Albemarle Health & Rehabilitation CenterCharlottesville, VA 2 of 5Beaufont Health And Rehabilitation CenterRichmond, VA 2 of 5Belaire Health Care CenterGastonia, NC 2 of 5Charlottesville Health & Rehabilitation CenterCharlottesville, VA 2 of 5Cherrydale Health & Rehabilitation CenterArlington, VA 2 of 5Culpeper Health & Rehabilitation CenterCulpeper, VA 2 of 5Fairfax Rehabilitation And Nursing CenterFairfax, VA 2 of 5Glenburnie Rehab & Nursing CenterRichmond, VA 2 of 5Hanover Health And Rehabilitation CenterMechanicsville, VA 2 of 5Lexington Health Care CenterLexington, NC 2 of 5Litchford Falls Health and Rehabilitation CenterRaleigh, NC 2 of 5Pike Creek Nursing & Rehabilitation CenterWilmington, DE 2 of 5Regency Health And Rehabilitation CenterYorktown, VA 2 of 5Shady Grove Nursing And Rehabilitation CenterRockville, MD 2 of 5The Nursing And Rehab Center At Stadium PlaceBaltimore, MD

Showing 40 of 63; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
RALEIGH COURT HOLDINGS I LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/28/2021
CHARLES 1994 & FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
CHARLES 1994 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
CHARLES 1994 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
EDWARD 1998 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
EDWARD 1998 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
KSS 2000 FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
ML 2000 FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
REDROCK WEST LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
SAUL 2012 FAMILY GRANTOR TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
SAUL 2012 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/28/2021
FLANNAGAN, KORIEIndividualW-2 MANAGING EMPLOYEEsince 09/13/2023
RCZBM WEST MANAGER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/28/2021

12 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.

$14.9M
Net patient revenuemost recent cost report
-6.0%
Operating marginrevenue minus expenses
$2.9M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 7%Other / private 22%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.9M 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$395per resident / day
operating cost
$12,011per month
≈ monthly operating cost
$373per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

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.

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 495209. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-15, 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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