Franklin Health And Rehabilitation Center
720 Orchard Avenue, Rocky Mount, VA 24151 · For profit - Limited Liability company · 120 certified beds · (540) 489-3467 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- 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 (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
- about 17% of its spending goes to commonly-owned related companies
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 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 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.8% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.4% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.8% | 1.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 20.1% | 18.7% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.4% | 15.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 37.9% | 20.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.0% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.5% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 11.6% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.8% | 11.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.69 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.07 | 1.48 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 238 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.9% 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 126 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 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.4%CMS range 54.6–66.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 8.8–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 38.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 88.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 4.2–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 115.4 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.81 hrs/resident/day on weekends vs 3.50 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 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.
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.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · Gcited before2026-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remained free of accident hazards as is possible for (1) one of (3) three current sampled residents, Resident #1, resulting in harm. While operating a motorized wheelchair in the facility parking lot on 4/03/26, Resident #1 struck a curb which caused the motorized wheelchair to tilt resulting in Resident #1 falling from the motorized wheelchair. Resident #1 sustained bilateral subdural hematomas, first/second cervical vertebral fractures, a scalp laceration, multiple abrasions, and a hematoma of the scalp resulting in transfer to a higher level of care and surgical intervention. The findings included: Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, Parkinson's disease, unspecified hearing loss - bilateral, spinal stenosis, osteoarthritis, spondylosis, anxiety disorder, weakness, depression, nondisplaced fracture of first cervical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-22 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, facility staff failed to ensure the privacy and confidentiality of medical information in oral communication for 1 of 30 current residents in the survey sample, Resident #51. Resident #51 was admitted to the facility with diagnoses that included peripheral vascular disease and renal failure. On the Minimum Data Set assessment with Assessment Reference Date 7/12/23, the resident scored 10/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident was unaware that staff were shouting details about the resident's clinical condition in the hall. On 9/19/23 at 9:20 AM, CNA#5 yelled down the hall to LPN #1 you got any Foleys on that hall? LPN #1 replied there's no one named Foley on this hall. CNA #5 then yelled Foley catheters. LPN #1 replied [Resident #1 name] has a Foley. CNA #5 then yelled down the other hall [nurse name] you got any Foley on that hall? The nurse replied that she didn't know and would have to let her know later. F-583 guidance states that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to accurately code a minimum data set (MDS) assessment for 1 of 3 closed records reviewed, Resident #112. The findings were: The facility staff failed to code Resident #112's discharge status to an assisted living facility (ALF). The discharge MDS coded the resident as discharged to an acute hospital when Resident #112 was discharged to an ALF. Resident #112's admission record listed diagnoses to include but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety. Section A (Identification Information) of the most recent MDS, with an assessment reference date of 08/30/23, coded the resident's discharge status as being discharged to an acute hospital. During a review of Resident #112's clinical record, a licensed practical nurse (LPN) progress note written on 08/30/23 at 1:52 p.m. read the resident was discharged the same day via wheelchair in stable condition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
2. For Resident #96, the facility staff failed to ensure fall prevention and safety measures were in place per the resident's comprehensive person-centered care plan. Resident #96's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Non-traumatic Subarachnoid Hemorrhage, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Cirrhosis of the Liver. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/05/23 coded the resident as moderately impaired in cognitive skills for daily decision making with short-term memory problems. Resident #96 was coded as requiring extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene and being totally dependent on staff for transfers. Resident #96's most recent Fall Risk Scoring Tool dated 9/11/23 scored the resident as being at high risk for falls. Resident #96's current comprehensive person-centered care plan documented the resident as being at risk for falls related to weakness, impaired range of motion, recent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that the resident environment remained as free of accident hazards as is possible as evidenced by the presence of unsecured oxygen cylinders located in 2 of 30 resident rooms in the survey sample, Resident #267 and #271. The findings included: 1. For Resident #267, the facility staff failed to secure an oxygen cylinder located beside the resident's bed. Resident #267's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, and Schizophrenia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/07/23 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. On 9/18/23 at 8:02 PM, surveyor entered Resident #267's room and observed an unsecured oxygen cylinder located at the head of the bed on the left. Resident #267 was sitting in a wheelchair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure that a resident who needs respiratory care is provided such care consistent with the comprehensive person-centered care plan for 1 of 30 residents in the survey sample, Resident #40. The findings included: For Resident #40, the facility staff failed to turn on the oxygen cylinder to deliver oxygen support. Resident #40's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Parkinson's Disease, Paroxysmal Atrial Fibrillation, and Bipolar Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/05/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #40's current comprehensive person-centered care plan included a focus area stating the resident was at risk for respiratory complications secondary to wheezing, cough, shortness of breath, and allergies with interventions including in part, to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review, facility document review and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5 %. There were three errors in 36 opportunities for a medication error rate of 8.3%. These errors affected Resident # 40. The findings included: For resident # 40 the facility staff failed to administer a lidocaine pain patch and lidocaine cream as ordered. Resident # 40's demographic sheet lists diagnoses including but not limited to, multiple sclerosis, generalized anxiety disorder, major depressive disorder, unspecified polyneuropathy, low back pain and spinal stenosis. Resident # 40's care plan has a problem statement for pain with an intervention reading, administer medications per order. On 9/19/23 at 9:35 AM this surveyor conducted a medication pass and pour observation on Licensed Practical Nurse (LPN) # 1. LPN # 1 administered by mouth medications and fluticasone nasal spray, one spray each nostril, to resident # 40. Surveyor did not observe LPN # 1 apply any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and clinical record review, the facility staff failed to ensure medications were secure and stored in locked compartments for 1 of 30 residents in the survey sample, Resident #264. The findings included: For Resident #264, the facility staff failed to ensure a bottle of Tylenol Arthritis 650 mg was secure and stored in a locked compartment. The bottle of Tylenol Arthritis was located on the resident's bedside table. Resident #264's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/14/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. On 9/18/23 at approximately 8:15 PM, surveyor observed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-22 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 provide laboratory services to meet the needs of the resident for 1 of 30 residents in the survey sample, Resident #267. The findings included: For Resident #267, the facility staff failed to obtain lab tests as ordered by the physician on 9/06/23. Resident #267's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, and Schizophrenia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/07/23 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. A review of Resident #267's clinical record revealed a physician's order dated 9/01/23 for a CBC (complete blood count), CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), and CRP (c-reactive protein) on 9/06/23 and then weekly. Surveyor was unable to locate evidence of the lab tests being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 30 residents in the survey sample, Resident #264. The findings included: For Resident #264, the facility staff failed to document treatment provided to a diabetic ulcer to the left great toe. Resident #264's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/14/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #264 was coded for the presence of a diabetic foot ulcer. Resident #264's current comprehensive person-centered care plan included the focus area of a diabetic ulcer to the left great toe with interventions including treatment per treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility document review, the facility staff failed to maintain an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of COVID-19 on 1 of 2 nursing units, Unit 2. Facility staff failed to follow facility policy and procedure and CDC (Centers for Disease Control and Prevention) guidance related to source control mask use during a COVID-19 outbreak. At the time of the survey on 9/21/23, there was a current facility total of 40 COVID-19 positive residents and 27 COVID-19 positive staff members. Unit 2 had a total of 18 COVID-19 positive residents. The findings included: On 9/20/23 at 2:05 PM, surveyor observed registered nurse (RN) #4 in Resident #22's room on Unit 2 without wearing a mask while speaking with the resident. Resident #22's room was not identified as requiring COVID-19 precautions and the resident was not identified as COVID-19 positive at the time of observation. The observation was also witnessed by the facility staff development coordinator (SDC) who…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2021-07-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 1 of 26 residents in the survey sample, Resident #74. The findings included: For Resident #74, the facility staff administered a Vitamin C tablet instead of the physician ordered Cyanocobalamin (Vitamin B12) tablet. Resident #74's diagnosis list indicated diagnoses, which included, but not limited to Unspecified Diastolic (Congestive) Heart Failure, Hypothyroidism Unspecified, Unspecified Dementia without Behavioral Disturbance, and Pulmonary Hypertension Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/22/21 assigned the resident a BIMS (brief interview for mental status) score of 7 out of 15 in section C, Cognitive Patterns. On 7/21/21 at 8:41 am, during a medication pass and pour observation, surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #74's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-22 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to ensure that residents were free of significant medication errors for 1 of 26 residents in the survey sample, Resident #50. The findings included: For Resident #50, the facility staff failed to follow physician's orders for the administration of Novolog (a rapid-acting insulin) on 21 separate occasions. Resident #50's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus with Other Diabetic Ophthalmic Complications, Chronic Diastolic (Congestive) Heart Failure, Polyneuropathy Unspecified, and Chronic Pain Syndrome. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/08/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #50 was coded for the diagnosis of Diabetes Mellitus. Resident #50's current physician's orders included the following orders each dated 11/30/20: Novolog Solution 100 unit/ml inject 38 units…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2018-09-20 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, pharmacy staff failed to submit irregularity reports to the facility director of nursing and medical director for action for 4 of 34 residents sampled (Resident #57, 72, 95, and 101). The Findings Included: 1. For resident #57, pharmacy staff failed to submit a pharmacy irregularity report recommending laboratory testing. Resident #57 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, heart failure, hypertension, gastroesophageal reflux, thyroid disorder, arthritis, osteoporosis, fracture leg, malnutrition, anxiety, depression, and insomnia. On the comprehensive admission minimum data set assessment with assessment reference date 8/7/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting others. During medication regimen review on 9/20/18, the surveyor noted a pharmacy note dated 8/21/18 at 14:37…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-09-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 34 residents (Resident #9). The findings included: The facility staff failed to code the use of the wander guard on Resident #9's quarterly minimum data set (MDS) with assessment reference date (ARD) of 9/13/18. The clinical record of Resident #9 was reviewed 9/18/18 through 9/20/18. Resident #9 was admitted to the facility 3/9/18 with diagnoses that included but not limited to pneumonitis, dysphagia, hypertension, hyperlipidemia, major depressive disorder, insomnia, Type 2 diabetes mellitus, constipation, traumatic subarachnoid hemorrhage, mild cognitive impairment, anxiety disorder, dementia with behavioral disturbances, and bipolar disorder. The quarterly MDS with an ARD of 9/13/18 assessed the resident with a BIMS (brief interview for mental status) as 9 out of 15. Resident #9's current comprehensive care plan had the focus area that the resident was a wander risk r/t (related to) history of attempts to leave facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-09-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a complete and accurate clinical record was maintained for 1 of 34 residents (Resident #6). The findings included: The facility staff failed to document clinical information of Resident # 6's respiratory status and the reason for testing on 8/21/18. The facility staff also failed to document clinical information concerning a follow-up chest x-ray preformed (sic) on 9/3/18. The clinical record of Resident #6 was reviewed 9/18/18 through 9/20/18. Resident #6 was admitted to the facility 4/18/17 and readmitted [DATE] with diagnoses that included but not limited to displaced intertrochanteric fracture of femur, dysphagia, atrial fibrillation, major depressive disorder, Vitamin B12 deficiency, age-related physical debility, hypertension, convulsions, dry eye syndrome, benign prostatic hypertrophy and shortness of breath. Resident #6's quarterly minimum data set (MDS) assessment 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.0 | +1.0 vs chain |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 3.9 | +1.1 vs chain |
The other 63 homes this chain runs (chain average 2.1★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRANKLIN HOLDINGS I LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/28/2021 |
| AK 2003 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| AL 2003 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| AMERICA WEST LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| CHARLES 1994 & FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| CHARLES 1994 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| CHARLES 1994 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| EDWARD 1998 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| EDWARD 1998 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| KSS 2000 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| ML 2000 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| MRV WEST LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| REDROCK WEST LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SAS 1998 FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SAUL 2012 FAMILY GRANTOR TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| SAUL 2012 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/28/2021 |
| RAJCHENBACH, MOSHE | Individual | CORPORATE OFFICER | — | since 05/28/2021 |
| SPIEGEL, HINDY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/28/2021 |
| RCZBM WEST MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/28/2021 |
CMS files one row per role, so the 20 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
17 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495207. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-09-22, 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.