Richfield Health Center - Salem
3719 Knollridge Road, Salem, VA 24153 · Non profit - Corporation · 112 certified beds · (540) 380-4500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,465 in federal fines (most recent 2024-12-05)
- about 17% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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.
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 | 22.6% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.3% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.3% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.4% | 18.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.6% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.7% | 15.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 16.1% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.1% | 4.7% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.6% | 21.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.9% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.3% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.5% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.9% | 11.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.22 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.71 | 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.
57.9% 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 526 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.8% 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 219 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 57.9%CMS range 53.2–61.8 | 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 | 10.9%CMS range 8.2–12.9 | 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 | 54.8% | 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 | 50.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 63.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 99.4% | 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 | 1.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 5.2–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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 112 beds and averages 106.5 residents a day — about 95% occupied, or roughly 6 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 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 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 3.49 hrs/resident/day on weekends vs 4.68 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.71 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2024-12-05 · 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 interviews, clinical record review, and facility document review, the facility staff failed to prevent significant medication errors for one (1) of five (5) sampled residents (Resident #1). The findings included: The facility staff failed to administer Resident #1's diabetic medication according to the medical provider's orders. This resulted in the need to administer an injectable medication to increase Resident #1's blood sugar on the morning of 5/16/24, with a subsequent transfer to a local emergency department. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as being able to be understood, and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. Resident #1's diagnoses included Type 2 Diabetes Mellitus, and Congestive Heart Failure. Resident #1's clinical record included an order, for the dates 5/7/24 - 5/16/24, for Tresiba 30 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 · D2024-12-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice related to assessing a resident's change in condition for one (1) of five (5) sampled residents (Resident #1). The findings include: The facility staff failed to ensure Resident #1 had assessments, including reassessments, completed and/or documented according to professional standards of practice. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. Resident #1 had a change in condition which resulted in the need to obtain medical provider orders for oxygen via a nasal cannula for oxygen saturation levels less than 90% on 6/12/24 at 7:48 p.m. Resident #1's condition also resulted in the nurse obtaining an order for 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 · Dcited before2024-12-05 · 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 interviews, clinical record review, and facility document review, the facility staff failed to obtain medical provider ordered laboratory tests for one (1) of five (5) sampled residents (Resident #1). The findings include: The facility staff failed to obtain Resident #1's medical provider ordered laboratory blood test. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. The following information was found in a facility policy titled Telephone Orders (dated 11/2020): Verbal telephone orders must be documented by the nurse receiving the order. The documentation occurs in two locations in the order entry field and in the resident's medical record under progress notes. Resident #1's clinical documentation included the following information, in a nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, clinical record review, and facility document review, the facility staff failed to ensure prompt implementation of a medical provider order for rehabilitative services for one (1) of five (5) sampled residents (Resident #1). The findings include: The facility staff failed to promptly implement a medical provider order for Resident #1 to be assessed for and/or receive lymphatic drainage massage. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. The following information was found in a facility policy titled Telephone Orders (dated 11/2020): Verbal telephone orders must be documented by the nurse receiving the order. The documentation occurs in two locations in the order entry field and in the resident's medical record under progress notes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, facility document review, facility staff failed to ensure the resident was treated with dignity related to toileting for 1 of 23 current residents in the survey sample (Resident #89). Resident #89 was admitted to the facility with diagnoses which included aftercare joint replacement, anemia, hypertension, anticoagulants, abnormal gait, and a history of pulmonary embolism. 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 behavior affecting care. During initial tour on 5/13/2024, Resident #89 complained that she was left on the toilet for 2 1/2 hours on 5/12/24. On 5/14/24, the surveyor received the call Alarm History for the resident's room from 5/12/24 at 12:00 AM through 5/13/24 at 12 AM. The log documented a call from the bed active from 10:21:01 through 12:21:41 (duration 120 minutes). The log documented 7 calls from the bathroom starting at 12:41:27 and ending 14:44:48 (duration in minutes 7.55, 9.33, 2.78,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 interview, clinical record review, and facility document review, the facility staff failed to notify and consult with the medical provider following a significant weight loss for 1 of 23 current sampled residents, Resident #69. The findings included: For Resident #69, the facility staff failed to notify and consult with the medical provider following a significant weight loss identified on 3/11/24. Resident #69's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Convulsions, Parkinson's Disease, Lymphedema, Essential Hypertension, and Second-Degree Atrioventricular Block. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/11/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #69 was coded as having had a significant weight loss without a physician-prescribed weight loss regimen. A review of Resident #69's weights revealed a weight of 160.6 on 3/01/24 and a weight of 148.6 on 3/11/24 revealing 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 · D2024-05-15 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification for 1 of 3 residents selected for SNF Beneficiary Notification Review (BNR), Resident #69. The findings included: For Resident #69, the facility staff failed to provide a SNF ABN notification when the resident was discharged from Medicare Part A services with skilled benefit days remaining while continuing to reside in the facility. Resident #69's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Convulsions, Parkinson's Disease, Lymphedema, Essential Hypertension, and Second-Degree Atrioventricular Block. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/11/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #69's clinical record included a social services progress note dated 3/18/24 10:36 AM which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · 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 resident interview, staff interview, and clinical record review, the facility staff failed to accurately complete a minimum data set (MDS) assessment for 2 of 23 residents, Resident #65 and #102. The findings included: 1. The facility staff failed to accurately complete a quarterly MDS assessment. The facility staff failed to mark the resident self-catheterization (intermittent catheterization). Resident #65's diagnoses included, obstructive and reflux uropathy, chronic kidney disease, and diabetes. Section C (cognitive patterns) of Resident #65's quarterly MDS assessment with an assessment reference date (ARD) of 04/10/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Section H (bladder and bowel) was coded always continent of urine. The box beside of intermittent catheterization was left blank (unchecked). On 05/13/24 during initial tour Resident #65 stated they did their own catheterization and had been doing so for a while. Resident #65's clinical record included a provider order dated 05/25/23 that read Resident to self…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive person-centered activity care plan to provide one-to-one activity programming for two (2) of 23 sampled residents (Resident #34 and Resident #26). The findings include: 1. For Resident #34 (R34) the facility staff failed to implement a comprehensive person-centered activity care plan to provide one-to-one activities in her room two times per week. R34's diagnosis list indicated diagnoses that included, but were not limited to, Dementia, Abnormal Posture, Hemiplegia and Hemiparesis, Aphasia following Cerebral Infarction (stroke), Cognitive Communication Deficit, Depression and Epilepsy. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 02/17/24, coded the resident as having modified independence in cognitive skills for daily decision making with short and long-term memory problems. On 05/14/24 at 10:42 AM, surveyor interviewed R34 about activities and she conveyed activity staff do not do anything 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.
- Potential for harm · Dcited before2024-05-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview, and clinical record review, the facility staff failed to review and revise the residents comprehensive care plan (CCP) for 1 of 23 current residents, Resident #65. The findings included: The facility staff failed to review and revise the residents CCP to include their prophylactic antibiotic and their self-catheterization. Resident #65's diagnoses included, obstructive and reflux uropathy, chronic kidney disease, and diabetes. Section C (cognitive patterns) of Resident #65's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/10/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate this resident was always continent of urine. The box beside of intermittent catheterization was left blank (unchecked). On 05/13/24 during initial tour Resident #65 stated they did their own catheterization and had been doing so for a while. Resident #65's clinical record included provider orders to self-cath 4 times a day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review and facility document review the facility staff failed to follow physician's orders for the administration of medications for 2 of 23 residents, Resident #93 and Resident #312. The findings included: 1. For Resident #93 the facility staff failed to administer the medications tramadol and gabapentin per the physician's order. Resident #93's face sheet listed diagnoses which included but not limited to pain in left hip and unspecified dementia. Resident #93's most recent minimum data set with an assessment reference date of 02/17/24 coded the resident as having both long- and short-term memory loss with severely impaired cognitive skills for daily decision making. Resident #93's comprehensive care plan was reviewed and contained care plans for . is at risk for altered levels of pain r/t (related to) a dx (diagnosis) of left hip and vertebrae fx (fracture). She has scheduled and prn (as needed) ordered. Resident #93's clinical record was reviewed and contained a physician's order summary which read in part, tramadol HCl Oral Tablet 50 mg…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
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- Potential for harm · D2024-05-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 and clinical record review, the facility staff failed to follow up on pharmacy recommendations for 2 of 5 residents chosen for the unnecessary medication task, Residents #7 and #26. The findings included: 1. For Resident #7, the facility staff did not follow up on a pharmacy recommendation dated 03/20/24 until 05/02/24. Resident #7's diagnoses included, but were not limited to, insomnia and major depressive disorder. Section C (cognitive patterns) of Resident #7's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/15/24 included a brief interview for mental status summary score of 13 out of a possible 15 points. On 03/20/24 the pharmacist documented Monthly medication regimen and chart review. Please see pharmacist report for recommendation. The surveyor was unable to find this recommendation in the clinical record. On 05/14/24 at 4:00 p.m., during an end of the day meeting with the Administrator and Director of Nursing (DON) the missing pharmacy recommendation was reviewed. On 05/15/24, the DON provided the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 1 of 23 residents, Resident #93. The findings included: 1. For Resident #93 the facility staff failed to ensure the electronic medication administration record (eMAR) and electronic treatment administration record (eTAR) were complete. Resident #93's face sheet listed diagnoses which included but not limited to pain in left hip and unspecified dementia. Resident #93's most recent minimum data set with an assessment reference date of 02/17/24 coded the resident as having both long- and short-term memory loss with severely impaired cognitive skills for daily decision making. Resident #93's comprehensive care plan was reviewed and contained care plans for . is at risk for altered levels of pain r/t (related to) a dx (diagnosis) of left hip and vertebrae fx (fracture). She has scheduled and prn (as needed) ordered, . has the potential for/impaired skin integrity r/t recent hip fx with limited mobility, dementia and overall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 1 of 5 sampled residents reviewed for immunizations, Resident #99. The findings included: For Resident #99, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 9/22/23 read in part that adults 65 years or older that have never received any pneumococcal vaccine should receive one dose of PCV15 or PCV20. Resident #99's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Traumatic Subdural Hemorrhage, Dementia, Acute Kidney Failure, and Atrial Fibrillation. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/14/24 assigned the resident 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 · E2023-02-08 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy and procedure in regard to screening of new hires for 9 of 25 new hires. The findings included: The facility staff failed to obtain reference checks on new hire #1, #2, #3, #6, #7, #9, #10, #16, and #17 and failed to obtain background checks on new hire #3 and #9 until 02/07/23. 02/07/23, the survey team requested employee files from the facility. 02/08/23, the surveyor reviewed 25 new hire records (employee records). New hire #1, #2, #3, #6, #7, #9, #10, #16, and #17 employee records did not include reference checks. For new hires #3 and #9 background checks were not completed until 02/07/23. New hire #3's date of employment was documented as 11/14/22 and #9's was documented as 08/15/22. A review of the results obtained on 02/07/23 indicated there was no issue with either employees background check. On 02/08/23, the facility staff provided the surveyor with a copy of a document titled, Hiring Process. This document read in part, .All candidates for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-08 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 observation, resident interview, staff interview, clinical record review, and facility policy review, the facility staff failed to provide activity of daily living (ADL) care for 4 of 23 current Residents, Residents #3, #4, #8, and #60. The findings included: 1. For Resident #3, the facility staff failed to provide nail care. Resident #3's fingernails were observed to be long. Resident #3's diagnoses included, but were not limited to, cerebral palsy, diabetes, and apraxia. Section C (cognitive patterns) of Resident #3's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/04/22 included a brief interview for mental status (BIMS) summary score of 15. Section G (functional status) was coded 3/2 for personal hygiene to indicate they required extensive assistance of one person for this task. Resident #3's comprehensive care plan included the focus area has self-care deficits in ADL performance due to decreased mobility, unsteady balance, and communication. Interventions included, but were not limited to, check nail length and trim and clean on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, family interview, staff interview and facility policy review the facility failed to ensure a clean, comfortable, and homelike environment as for 3 of 23 Residents (Resident #26, #8, and #50). The findings included: 1. For Resident #26, facility staff failed to clean the wheelchair the resident used when it was visibly soiled. Resident #26 was admitted to the facility with diagnoses that included paranoid schizophrenia, metabolic encephalopathy, dementia, congestive heart failure, pain, osteoarthritis, hypertension, depression, and a history of falls. On the minimum data set assessment with assessment reference date 1/10/2023, the resident scored 1/15 on the brief interview for mental status and was assessed as psychosis or behaviors affecting care. On 2/6/2023 at 2:30 PM, the surveyor interviewed the resident's family member concerning life in the facility. The family member stated that floors and the wheelchair were often dirty. The family member speculated staff appear to clean once per week. The surveyor observed the wheelchair had dried drips on arm and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, clinical record review the facility staff failed to review and revise the comprehensive care plan for 2 of 26 residents, Resident #38 and Resident #83. The findings included: 1. For Resident #38 the facility staff failed to revise the care plan for COVID status. Resident #38's face sheet listed diagnoses which included but not limited to aphasia, type 2 diabetes mellitus, hypertension, depression and dementia. Resident #38's most recent minimum data set with an assessment reference date of 01/05/23 assigned the resident a brief interview for mental status score of 13 out of 15 in section C, cognitive patterns. This indicates the resident is cognitively intact. Resident #38's comprehensive care plan was reviewed and contained a care plan for . (Resident #38) is positive for COVID-19 This care plan was initiated on 12/29/2022. Goals for this care plan included . care and symptoms will be managed per CDC (Centers for Disease Control) guidelines and facility protocol This goal has a revision date of 01/31/2023. Resident #38's clinical record was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-08 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 interview, and clinical record review the facility staff failed to ensure 1 of 23 residents was free of unnecessary medications (Resident #26). The findings included: Resident #26 was admitted to the facility with diagnoses that included paranoid schizophrenia, metabolic encephalopathy, dementia, congestive heart failure, pain, osteoarthritis, hypertension, depression, and a history of falls. On the minimum data set assessment with assessment reference date 1/10/2023, the resident scored 1/15 on the brief interview for mental status and was assessed as psychosis or behaviors affecting care. The resident weighed 79 pounds. Resident #26 was chosen for medication regimen review. During clinical record review on 2/08/2023, the surveyor found monthly pharmacy reviews were conducted from admission. The recommendation dated 8/17/2022 contained several suggestions including: 5) remains on iron 325 mg every 48 hours for supplement. Non coated iron is very likely to cause GI disturbance /constipation/GI pain. Consider using Slow-FE as this is more gentle on the GI system. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-08 · 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 23 residents in the survey sample, Resident #83. The findings included: For Resident #83, the facility staff failed to obtain a urinalysis with reflex and a complete blood count (CBC) lab test as ordered by the physician on 2/04/23. Resident #83's diagnosis list indicated diagnoses, which included, but not limited to fracture of T9-T10 Vertebra, Paroxysmal Atrial Fibrillation, Neuromuscular Dysfunction of Bladder, Hypertensive Heart Disease, Chronic Kidney Disease, and Pneumonia. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/10/23 assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 indicating Resident #83 was severely cognitively impaired. A review of Resident #83's clinical record revealed physician's orders dated 2/04/23 for a urinalysis with reflex and a CBC lab test; surveyor was unable to locate results for lab…
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 · D2023-02-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and facility document review, the facility staff failed to maintain an infection control and prevention program that ensured a sanitary laundry environment to decrease infection control risk for one (1) of five (5) residential laundry rooms. The findings include: On 2/8/23 at 10:30 a.m., one (1) of the facility laundry rooms (used to wash resident clothing) was observed with the facility's Administrator. A plastic bag containing soiled laundry was observed on the top of one (1) of the washing machines. The Administrator confirmed the aforementioned laundry needed to be washed. The following information was found in a facility document with the subject of Resident Laundry (with an effective date of January 2021): Laundry Room . To remain in an orderly fashion and no dirty linen to be stored on the equipment. On 2/8/23 at 1:10 p.m., the facility's Administrator stated soiled laundry should be kept in a resident's room until it is ready to go into the washing machine. The Administrator reported the soiled laundry should not have been placed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-07-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facility document review, the facility staff failed to prepare, distribute and serve food in a manner that would prevent foodborne illnesses. The findings included: 1. During initial tour of the facility, the surveyor observed food in the active food supply that was opened and exposed. The dry storage room contained honey that had a best by date of March 2021. 07/27/2021 1:33 p.m., the surveyor entered the dietary kitchen on (TRC) the rehab center. The freezer was observed to have one box of chicken fritters and one box of hamburger patties that had been opened, the plastic bag had been ripped open exposing the items inside. The dry storage was observed to contain one jug of honey dated December 2020 and a best by date of March 2021. Dietary personnel #1 stated the honey was crystallized and removed it from the food supply. 07/28/2021 5:15 p.m., the administrator and DON (director of nursing) were made aware of the issues in the dietary kitchen. 07/29/21 6:47 p.m., the administrator provided the survey team with a copy of a policy titled…
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 · D2021-07-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and clinical record review, the facility staff failed to ensure the right to formulate an advanced directive as evidence by the advanced directive in the resident record not completed accurately for one of 30 residents, Resident #93. The findings included: For Resident #93 the facility staff failed ensure a Virginia Department of Health DDNR (durable do not resuscitate) form was complete. Resident #93's face sheet listed diagnoses which included but not limited to chronic kidney disease, dementia, type II diabetes mellitus, dysphagia, depression, hypertension, and hypothyroidism. Resident #93's most recent comprehensive MDS (minimum data set) with an ARD (assessment reference date) of 07/08/2021 assigned the resident a BIMS (brief interview for mental status) score of 3 out 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #93's clinical record was reviewed on 07/28/21. It contained a physician's order summary for the month of July 2021 which read in part, DNR (do not resuscitate). The clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-07-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, and staff interview the facility staff failed to ensure a homelike environment on 1 of 7 units, 3 East. The findings included: The facility staff were using styrofoam plates and cardboard trays on 3 East. 07/27/21 dinner observation on 3 East. The residents on this unit were observed to be using styrofoam plates and cardboard trays. 07/27/21 5:36 p.m., dietary employee #3 stated they were using styrofoam plates and cardboard trays due to a leak in the kitchen in the building. Dietary employee #3 stated the kitchen in this building was no longer in use. 07/28/21 8:05 a.m., dietary employee #4 stated they were using the styrofoam plates and cardboard trays due to COVID-19 precautions and stated a staff person had tested positive that worked this unit. 07/28/21 8:10 a.m., Resident #72 stated they had been using styrofoam for a little while. 07/28/21 8:18 a.m. Resident #68 stated they were not sure how long they had been using styrofoam, they had not been given a reason for using it, but it hadn't been too long. 07/28/21 8:29 a.m., Resident #107…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-07-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and a review of documents, it was determined the facility staff failed to develop and implement a person centered care plan to address the hospice needs for one (1) of 30 sampled residents (Resident #10). The findings include: The facility staff failed to develop a hospice care plan for Resident #10. Resident #10's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 7/16/21, was signed as completed on 7/26/2021. The resident was assessed as sometimes being able to make self understood and as sometimes being able to understand others. The resident's Brief Interview for Mental Status (BIMS) summary score was three (3) out of 15. The resident was assessed as requiring extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The resident was assessed as being dependent on others for toilet use and bathing. Resident #10's diagnoses included, but were not limited to: high blood pressure, dementia, anxiety, and depression. Resident #10 had a provider order dated 11/19/2020 at 1:57 p.m. for hospice. Review 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.
- Potential for harm · Dcited before2021-07-29 · 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 and clinical record review, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 1 of 30 residents in the survey sample, Resident #117. The findings included: For Resident #117, the facility staff failed to follow physician's orders for blood sugar monitoring. Resident #117's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified, Hypothyroidism Unspecified, Spinal Stenosis Lumbar Region without Neurogenic Claudication, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 7/02/21 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 #117 was coded for the diagnosis of Diabetes Mellitus. Resident #117's clinical record included a medication regimen review dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to ensure 2 of 7 units were free of accident hazards, 3 East and Honeysuckle Cottage. The findings included: 1. The surveyor observed three unsecured bottles of the spray disinfectant Avistat-D in the shower room on 3 East. 07/28/21 9:25 a.m., the surveyor observed three opened bottles of the spray disinfectant Avistat-D on a wooden shelf in the shower room on 3 East. The manufacturer label read .KEEP OUT OF REACH OF CHILDREN CAUTION . The shower door was unlocked and the surveyor was able to push open the door and enter. There was no residents observed in the immediate area. 07/28/21 11:51 a.m., rechecked shower room on 3 East. Two bottles of Avistat-D remained on the wooden shelf one bottle was sitting on a stretcher. The door to this shower room was not completely shut. There were no staff or residents in the immediate area. 07/29/21 8:50 a.m., the administrator provided the surveyor with the (MSDS) material safety…
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 · D2021-07-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure a resident with a catheter received the apppropriate services in regards to anchoring the foley catheter for 1 of 30 residents, Resident #19. The findings included: The facility staff failed to anchor Resident #19's foley catheter. Resident #19's face sheet included the diagnoses, benign prostatic hyperplasia, cyst of kidney, and calculus of kidney. The resident was listed as their own responsible party on the face sheet. Section C (cognitive patterns) of the Residents admission (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/03/2021 included a (BIMS) brief interview for mental status summary score of 3 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required extensive assistance of two people for personal hygiene. Section H (bladder and bowel) was coded to indicate the resident had a catheter in place. The residents (CCP) comprehensive care plan included the focus area altered…
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 · D2021-07-29 · tag F0772 — isolatedHave an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
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 obtain a physician ordered laboratory test for 2 of 30 residents, Resident #19 and #42. The findings included: 1. For Resident #19, the facility staff failed to obtain the laboratory test PT/INR. A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. Resident #19's face sheet included the diagnoses, atrial fibrillation and atherosclerotic heart disease. The resident was listed as their own responsible party on the face sheet. Section C (cognitive patterns) of Resident #19 admission (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/03/2021 included a (BIMS) brief interview for mental status summary score of 3 out of a possible 15 points. On 07/27/21 (LPN) licensed practical nurse #1 documented the following in a progress note in Resident #19's (EHR) electronic health record .NP (nurse practitioner) contacted in regards to not being able 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 · D2021-07-29 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, and facility document review the facility staff failed follow the menu on 1 of 7 units, 3 East. The findings included: The facility staff failed to follow the menu. 07/27/21 5:30 p.m., evening meal observed on 3 East. Resident #107 stated they were supposed to get peanut butter cookies. The surveyor observed peaches on this resident's dinner tray. The tray ticket that accompanied this meal read peanut butter cookies. 07/27/21 5:36 p.m., dietary employee #3 was asked about the missing peanut butter cookies and stated the baker had left early. 07/27/21 (Tuesday) outside of the dining area on 3 East the surveyor observed the menus for Monday 07/26/21 were still posted. There were no menus posted for Tuesday 07/27/21. A review of the menu revealed the regular diet consistency food trays should have contained peanut butter cookies. 07/29/21 11:17 a.m., the (RD) registered dietician stated there was a miscommunication between staff members and management was not notified there was an issue and a need for a substitution. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-29 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, and staff interview, the facility staff failed to maintain essential equipment in the residents bathroom for 1 of 30 residents, Resident #107. The findings included: For Resident #107, the bathroom sink was inoperable. There was a plastic bag placed over the sink in the bathroom and the sink in the nurses station. The face sheet in Resident #107's clinical record included the diagnoses, multiple sclerosis, chronic obstructive pulmonary disease, and type 2 diabetes. Section C (cognitive patterns) Resident #107's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/30/21 included a (BIMS) brief interview for mental status summary score of 15 out of a possible 15 points. Section H (bladder/bowel) had been coded to indicate the resident had a catheter (suprapubic foley catheter). 07/28/21 8:30 a.m., observation in Resident #107's bathroom. A black trash bag was observed to be placed over the bathroom sink. Resident #107 stated the sink did not work and the staff would go to another room to get hot water.…
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
$15,465 in federal fines across 1 penalty.
- $15,465 — penalty dated 2024-12-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRIENDSHIP FOUNDATION INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 10/01/2023 |
| BISHOP, NATHANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| FELDMANN, GREG | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| HOFF, JOSEPH | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| JOHNSON, CYNDA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| LAWSON, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| MITCHELL, CYNTHIA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 10/01/2023 |
| NESTER, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2024 |
| SANDEL, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| SHANNON, CHARLES | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| COMBS, GLEN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| FEINOUR, EDWIN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| GROVE, LUCIAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| OELSCHLAGER, KATHRYN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2023 |
| WILLIAMSON, JOHN | Individual | CORPORATE DIRECTOR | — | since 10/01/2023 |
| VALLEY MANAGEMENT CO INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| CAMPBELL, LUKE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| DUNCAN, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| HIGGINS, BENJAMIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| HUGHES, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2002 |
| LAYELL, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| LOWE, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| NICHOLS, WHITNEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/04/2023 |
| RODGER, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| BROWN, EDWARDS & COMPANY, LLP | Organization | ADP OF THE SNF | — | since 10/01/2023 |
| WALKER & ASSOCIATES PC | Organization | ADP OF THE SNF | — | since 10/01/2023 |
CMS files one row per role, so the 55 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495013. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-15, 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.