Riverside Lifelong Health & Rehabilitation Salud
672 Gloucester Road, Saluda, VA 23149 · Non profit - Corporation · 60 certified beds · (804) 758-2363 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- 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 $71,915 in federal fines (most recent 2026-03-06)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 21% of its spending goes to commonly-owned related companies
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — 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 | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 17.1% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.1% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.6% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.4% | 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 | 2.6% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.8% | 15.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 16.5% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 4.7% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 27.0% | 21.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.1% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.1% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 20.5% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.10 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.56 | 1.48 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.5% 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 40 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 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 57.1%CMS range 44.2–67.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.6–14.3 | 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 | 67.5% | 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 | 52.5% | 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 | 77.5% | 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 | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 6.3%CMS range 3.4–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.62 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 50.2 residents a day — about 84% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.56 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 2.76 hrs/resident/day on weekends vs 3.39 on weekdays — 18% thinner on weekends. RN hours go from 1.10 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
- Immediate jeopardy · K2026-03-06 · tag F0880 — failed to prevent and control infections — patternProvide 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, resident interview, staff interview, clinical record review, and facility document review, the facility failed to maintain an infection prevention and control program to provide a safe sanitary environment and assist in the prevention, development, and transmission of communicable disease and infection for all facility residents and the facility staff failed to utilize appropriate droplet precaution signage for (4) four of (6) six residents identified for droplet precautions, Resident #2, Resident #16, Resident #32, and Resident #48 and the facility staff failed to utilize appropriate personal protective equipment (PPE) for (2) two of (6) six residents on droplet precautions, Resident #16 and Resident #22 and the facility staff failed to utilize appropriate PPE during a medication pass and pour observation, Resident #48. The survey team informed the facility on 3/5/26 at 10:50 AM of the Immediate Jeopardy situation regarding Resident #2 due to the facility failing to: (1) prevent Resident #2 from eating breakfast in a common area with other residents while 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 before2026-03-06 · 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 observation, staff interview, clinical record review and facility document review the facility staff failed to develop a comprehensive care plan that included enhanced barrier precautions for one of 22 current residents in the survey sample, resident #1.The findings included:Resident #1's diagnosis list indicated diagnoses, which include, but not limited to colostomy, Parkinson's Disease and Dementia. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/18/2026, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately cognitive impaired. Section GG revealed functioning level of non-ambulatory, and wheelchair-bound, incontinent and colostomy, requiring assistance with activities of daily living (ADLs). Observation on 3/3/2026 10:40 am revealed an enhanced barrier precautions (EBP) sign posted near the door for Resident #1, along with gloves and gowns to be used during high contact care. Review of revised Care Plan dated 1/9/2026,…
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 before2026-03-06 · 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, and facility document review, the facility staff failed to review and revise the comprehensive care plan for 1 of 22 current residents in the survey sample, Residents #48. The findings included: The facility staff failed to review and revise the comprehensive care plan (CCP) when the resident was placed on droplet precautions. Resident #48's diagnoses included dementia, chronic diastolic congestive heart failure, and anxiety. Section C (cognitive patterns) of Resident #48's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/22/25 was coded to indicate the resident had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making. During initial tour Resident #48 was identified by the facility staff as being positive for the flu. A droplet precaution sign and personal protective equipment (PPE) were observed outside of Resident #48's room. Resident #48's clinical record included a progress note transcribed by 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 · D2026-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to follow provider orders for two of 22 residents in the survey sample, resident #3 and resident #31. 1.For Resident #3 the facility staff failed to follow a medical provider order for 1/2 side rails. Resident #3's diagnosis list indicated diagnoses that included, but were not limited to, muscle spasm, psychotic disorder with delusions, insomnia, abnormalities of gait and mobility, abnormal posture, extrapyramidal and movement disorder, difficulty in walking, and repeated falls. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 1/23/26 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #3 was cognitively intact. On 3/4/26 at 10:40 AM, Resident #3's bed was observed to have 1/4 bilateral side rails in place and up on both sides of the bed. A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 medications were available for administration for 2 of 22 current residents in the survey sample, Residents #9 and resident #31. The findings included: 1. For Resident #9, the facility staff failed to ensure the medications Parlodel and Lansoprazole (Prevacid) were available for administration. Resident #9's diagnoses included spastic quadriplegic cerebral palsy, epilepsy and gastro esophageal reflux disease. Section C (cognitive patterns) of Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/21/26 was coded to indicate Resident #9 had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making. Resident #9's clinical record included provider orders for Parlodel give 1.25 mg via J-tube two times a day for dystonia and Lansoprazole oral suspension give 10 ml via J-tube one time a day for heartburn. A J-tube is a type of enteral feeding device placed through 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 · D2026-03-06 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 laboratory results were reported to the provider for 2 of 22 current residents in the survey sample, Residents #6 and #31. The findings included: 1. For Resident #6, laboratory tests obtained on 01/29/26 and 02/06/26 were not reviewed by the provider until 03/05/26. Resident #6's diagnoses included vascular dementia, diabetes, and hyperlipidemia. Section C (cognitive patterns) of Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/21/26 included a brief interview for mental status (BIMS) score of 5, indicating Resident #6 was severely impaired in cognitive skills for daily decision making. Resident #6's clinical record included provider orders dated 01/26/26 for a complete blood count, comprehensive metabolic panel, hemoglobin A1C, vitamin B12, lipid panel, vitamin D, and magnesium. The exact same laboratory tests were ordered again on 01/31/26. During the clinical record review, the surveyor was unable to locate the results for these…
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 · D2026-03-06 · tag F0775 — isolatedKeep complete, dated laboratory records in the resident's record.
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 file provider ordered laboratory test results in the clinical record for 2 of 22 current residents in the sample, Residents #6 and #31. The findings included:1. For Resident #6, the facility staff failed to ensure provider ordered laboratory results were filed in the clinical record. Resident #6's diagnoses included vascular dementia, diabetes, and hyperlipidemia. Section C (cognitive patterns) of Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/21/26 included a brief interview for mental status (BIMS) score of 5, indicating Resident #6 was severely impaired in cognitive skills for daily decision making. Resident #6's clinical record included provider orders dated 01/26/26 for a complete blood count, comprehensive metabolic panel, hemoglobin A1C, vitamin B12, lipid panel, vitamin D, and magnesium. The provider ordered the exact same laboratory tests on 01/31/26. During the clinical record review, the surveyor was unable to find the results for these…
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 · D2026-03-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure the clinical record was complete and accurate for 1 of 22 current residents in the survey sample resident #10. The findings included:For resident #10 the facility staff failed to ensure the Durable Do Not Resuscitate (DDNR) order was complete and accurate in the medical record.Resident #31's diagnoses included but were not limited to vascular dementia, cerebral infarction, venous insufficiency, heart failure, and hypertension.The admission minimum data set (MDS) assessment with an assessment reference date of 2/20/26 assigned the resident a brief interview for mental status score of 7/15 indicating the resident was severely cognitively impaired. The MDS also indicated that resident #10 had a condition or chronic disease that may result in life expectancy of less than 6 months and resident was receiving hospice services.The physician's orders were reviewed. Resident #10 had an active order for do not resuscitate documented.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-06 · 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 education for the declination of a pneumococcal vaccine for (1) one of (5) five residents sampled for immunization review, Resident #57. The findings included:Resident #57's diagnosis list indicated diagnoses, which included, but not limited to atherosclerosis of native arteries of extremities with rest pain, right leg, allergic rhinitis, polyneuropathy, and encounter for surgical aftercare following surgery on the circulatory system. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/28/26, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of Resident #57's pneumococcal vaccination history disclosed the resident received the Prevnar 13 vaccine on 05/16/2022. No evidence could be located on the clinical record that Resident #57 was offered a PCV20 (Prevnar 20) or PCV21 (21-valent Pneumococcal Conjugate…
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 · E2022-12-20 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, facility documentation review and clinical record review, the facility staff failed to provide privacy for 4 Residents (Resident #31, 20, 1, 29) in a survey sample of 26 Residents. The findings included: 1. For Resident #31, the facility staff failed to protect his personal privacy by leaving him unclothed and visible from the hallway wearing only an incontinence brief. On 12/13/22 at 12:03 PM, during tour, Surveyor C observed Resident #31 from the hallway. Resident #31 was observed lying in bed, no clothes on, wearing an incontinence brief and a urinary catheter was noted. Upon entry of the room, Resident #31 was interviewed but did not respond to Surveyor C. On 12/14/22, on numerous occasions throughout the day, Resident #31 was observed lying in bed with no clothes on and no covers. He was able to be observed from the hallway to have only an incontinence brief on. On 12/16/22 at 11:30 AM, Resident #31 was observed lying in bed with a blanket covering him. Upon further review, it was noted that there was no privacy curtain that could be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-20 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, facility documentation and clinical record review, the facility staff failed to follow standards of nursing practice affecting 4 Residents (Resident #1, 20, 41 and 262) in a survey sample of 26 Residents. The findings included: 1. For Resident #1 the facility staff crushed an extended-release medication that is not to be crushed. On 12/16/22 at 7:54 AM, RN D, the nursing supervisor, was observed during medication administration of Resident #1's medication. RN D removed a Venlafaxine ER capsule 150 mg and a Venlafaxine ER capsule 75 mg from the pharmacy bag which was labeled and indicated Do Not Crush. RN D opened both capsules emptying the contents into a plastic bag along with other medications for Resident #1 and crushed them all. RN D then mixed the crushed medications into apple sauce and entered the room of Resident #1 and administered the medications. Following the medication administration observation, Surveyor C asked RN D how she knew which medications to crush…
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 20 citations
- Potential for harm · D2022-12-20 · 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 Resident and staff interviews, facility documentation review and clinical record review, the facility staff failed to notify the doctor and Resident representative timely of a Resident change in condition for 1 Resident (Resident #51) in a survey sample of 26 Residents. The findings included: For Resident #51, who reported visual hallucinations, the facility staff failed to notify the doctor and resident representative until the following day. On 12/13/22 at 12:23 PM, Resident #51 reported to Surveyor C that she is having visual hallucinations. Resident #51 presented to be alert, oriented and an accurate historian. Resident #51 said that the hallucinations started over the weekend and they are really bad. Resident #51 described that she is seeing building and people but can't touch them. The Resident denied any auditory hallucinations and reports she notified the nurse. On 12/13/22 at approximately 12:30 PM, Surveyor C went to LPN B, who was the assigned nurse for Resident #51, and made her aware that Resident #51 was reporting visual hallucinations. LPN B stated that she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-20 · 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, staff interview, and facility documentation review the facility staff failed to maintain a comfortable and homelike environment for 1 Resident (Resident #31) in a survey sample of 26 Residents. The findings included: For Resident #31, the facility staff failed to maintain a comfortable and homelike environment by not repairing the baseboard in the room that was pulled away from the wall. On 12/13/22 at 12:03 PM, during tour, Surveyor C observed Resident #31's room. It was noted that on the left side of the Resident, along the entire wall the cove base molding was peeling away from the wall exposing unfinished sheetrock that was not painted and in poor condition. Resident #31 was asked about it and how long it had been that way, but he didn't respond. On 12/15/22 at 11:30 AM, an interview was conducted with CNA B, who was assigned to Resident #31. CNA B was asked about the baseboard molding, and she said it had been that way a while. She couldn't define a while but said she had let maintenance know. On 12/15/22 at 12:35 PM, an interview was conducted with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, staff interview and clinical record review the facility staff failed to provide assistance to a Resident who was dependent upon staff assistance with activities of daily living for one Resident (Resident #29) in a survey sample of 26 Residents. The findings included: For Resident #29, the facility staff failed to assist the Resident when she requested a shower. On 12/13/22 at 3:25 PM, Surveyor C observed Resident #29 in the hallway at the nursing station and asked if she could be showered. Resident #29 stated, I haven't had a shower since Monday before last and my body stinks. CNA C was at the nursing station and responded to Resident #29 by saying, I'm here tomorrow on women's day and will try to get you in there then. Today is men's day and you don't want to be in there with stinky men. Resident #29 responded, At this point I don't really care. CNA C said, I promise I will try to get you in there first thing tomorrow, I promise. Review of Resident #29's clinical record revealed a care plan initiated 12/6/22, that indicated the Resident required staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-20 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident and staff interviews, facility documentation review and clinical record review, the facility staff failed to provide vision services for 2 Residents (Resident #25 and #44) in a survey sample of 26 Residents. The findings included: 1. For Resident #25 the facility staff failed to 1) arrange for repair of the Resident's glasses which were broken and 2) failed to make an appointment for evaluation of cataract removal as recommended for over a year. On 12/14/22 at 11:32 AM, Resident #25 was visited in his room. Resident #25 presented as being alert and oriented. Surveyor C observed that Resident #25's glasses were broken. The left side stem was taped, despite the tape the stem of the glasses was hanging downside of the Resident's face/cheek and his glasses were sliding down to the tip of his nose as a result. When asked, Resident #25 reported they had been broken for a while but they were working to get him Medicaid so they can get them fixed. Resident #25 reported this has been going on for 3 months. On 12/19/22 at 2:17 PM, Resident #25 was visited again.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to apply palm protectors to prevent the development of skin breakdown for one (1) Resident (Resident #31) in a survey sample of 26 Residents. The findings included: On 12/13/22 at 12:02 PM, Resident #31 was observed lying in bed. Resident #31 was noted with bilateral hand and wrist contractures and no splinting or device to prevent the development of wounds was noted. Resident #31 would not verbally respond to Surveyor C's questions. On 12/14/22 at approximately 10 AM, Resident #31 was observed lying in bed, no palm protector devices were noted. On 12/16/22 at 11:30 AM, Resident #31 was observed in bed, without a palm protector on. CNA B, who was assigned to Resident #31 was asked about splints or palm protectors and CNA B was able to find one palm protector in the chest of drawers. CNA B stated that Resident #31 will frequently refuse them. Resident #31 was asked about the palm protector and the Resident said, Please put it on. CNA B…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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, the facility failed to provide medications as ordered by a physician for one Resident (Resident #262) in a sample of 26 residents. The findings included: For Resident #262, the facility staff failed to administer four medications as ordered because they were not available. Resident #262 was admitted to the facility on [DATE]. A review of Resident #262'S clinical record was conducted. This review revealed the following excerpts from the progress notes: i. Note dated 12/09/2022 at 16:41, read, hydralazine HCL Tablet 50 MG, Give 1 tablet via G-Tube every 8 hours for HTN. Pharmacy has not delivered, new admission. ii. Note dated 12/10/2022 at 09:53, read, levetiracetam Solution 100 MG/ML. Give 5 ml via G-Tube every morning and at bedtime for Seizure disorder. None available. iii. Note dated 12/10/2022 at 09:53, read, Famotidine Tablet 20 MG. Give 20 mg via G-Tube one time a day for Ulcer prevention. None available. iv. Note 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 · Dcited before2022-12-20 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 2 medication errors (medications crushed that are not to be crushed) in 32 opportunities, resulting in an 6.25% error rate. The findings included: On 12/16/22 at 7:54 AM, RN D, the nursing supervisor, was observed during medication administration of Resident #1's medication. RN D removed a Venlafaxine ER capsule 150 mg and a Venlafaxine ER capsule 75 mg from the pharmacy bag which was labeled and indicated Do Not Crush. RN D opened both capsules emptying the contents into a plastic bag along with other medications for Resident #1 and crushed them all. RN D then mixed the crushed medications into apple sauce and entered the room of Resident #1 and administered the medications. On 12/16/22 at 8:07 AM, RN D was observed during her medication administration of Resident #20's medications. RN D proceeded to remove Resident #20'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 · D2022-12-20 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Resident and family interviews, facility documentation review and clinical record review, the facility staff failed to provide dental services for one Resident (Resident #44) in a survey sample of 26 Residents. The findings included: For Resident #44, the facility staff failed to arrange for dental services to obtain dentures following extraction of his teeth. On 12/14/22 at 10:03 AM, during an interview with Resident #44, a nurse entered the room to provide the Resident with medication. One of the pills was chewable and Resident #44 was having difficulty chewing the pill. Resident #44 mentioned that he had his teeth removed and keeps waiting for dentures. On 12/14/22, an interview was conducted with the spouse of Resident #44. The spouse said that they have been waiting and waiting for him to get his dentures taken care of, but nothing seems to be happening. A clinical record review was conducted of Resident #44's chart. This review revealed the following: i. A progress note written by the registered dietician on 8/4/22, read, .Dental: Resident reports he has a DDS follow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a pneumococcal and/or influenza vaccine for 2 residents, Resident #53 and Resident #258, out of 5 residents reviewed for pneumococcal and influenza immunization. The findings include: 1. The facility staff failed to provide pneumococcal immunization for Resident #53. On 12/14/22, clinical record review was performed for Resident #53 and revealed a document entitled, Pneumococcal Vaccine Informed Consent, dated 11/8/22, signed by Resident #53, with a check mark placed next to the statement which read, The undersigned does authorize the Center to administer the pneumococcal vaccine. There was no further documentation that indicated whether or not Resident #53 had received a pneumococcal vaccine. Resident #53 was admitted to the facility on [DATE]. On 12/14/22, an interview was conducted with the facility Director of Nursing (DON), also serving as the facility's Infection Preventionist (IP), 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.
- Potential for harm · D2022-12-20 · tag F0886 — failed to test for COVID-19 as required — isolatedPerform COVID19 testing on residents and staff.
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 clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 1 resident, Resident #258, in a sample of 5 Residents reviewed for COVID-19 testing. The findings included: For Resident #258, facility staff failed to conduct a COVID-19 test on 12/2/22 and 12/4/22, following her admission to the facility on [DATE]. On 12/14/22, a clinical record review was conducted and revealed facility staff performed a COVID-19 test for Resident #258 on 11/29/22. There was no evidence of COVID-19 testing on Day 3 post-admission, 12/2/22, or Day 5 post-admission, 12/4/22. The COVID-19 Community Transmissibility Level for the facility was HIGH for the week 11/24/22 through 11/30/22. On 12/14/22, a group interview was conducted with the Director of Nursing (DON) who also serves as the facility's Infection Preventionist (IP) and the Corporate Director of Education, Employee…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-20 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 documentation review, the facility staff failed to provide COVID-19 immunization for 1 resident, Resident #53, in a survey sample of 5 residents reviewed for COVID-19 immunization. The findings included: The facility staff failed to provide evidence that Resident #53 was offered, educated, and provided/or declined COVID-19 vaccination. On 12/14/22, clinical record review was performed for Resident #53, admitted to the facility on [DATE]. Resident #53 had no documentation with regard to COVID-19 immunization, to include the resident's current COVID-19 vaccination status, offer to provide immunization against COVID-19 infection, or documentation of resident refusal or medical contraindication. On 12/14/22, an interview was conducted with the Director of Nursing (DON), who was also the facility's Infection Preventionist (IP). The DON/IP verified the findings for Resident #53 and stated the COVID-19 immunization status should have been assessed at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-03-19 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain resident dignity and privacy for 4 residents (Resident #18, Resident #250, Resident #23, Resident #24) in a sample of 27 residents. The findings included: 1. For Resident #18, the facility staff failed to get permission to enter his room on 03/16/2021 resulting in a breach of Resident #18's privacy and devaluing his private space. Resident #18, an [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to cerebral infarction, hypertension, and muscle weakness. Resident #18's most recent Minimum Data Set with an Assessment Reference Date of 01/12/2021 was coded as an annual assessment. The brief interview for mental status was coded as 14 out of possible 15 indicative of intact cognition. Functional status for transfers was coded as requiring extensive assistance from staff with 2+ persons physical assistance 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 · E2021-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to mitigate accident hazards for 5 Residents (Resident #18, #23, #24, #27, #35) in a survey sample of 27 Residents. The facility staff failed to respond timely to Resident #18, #23, #24, #27, and #35's call for assistance, using the Resident call bell system. The findings included: On 3/16/21, during initial tour of the facility, multiple Residents (Resident #18, #23, #24, #27) expressed concerns of having to wait extended periods of time, (over an hour) for staff to respond to their calls for assistance. During the survey from 3/16/21 until 3/19/21, several occurrences of Resident's engaging their call bell were observed while Surveyor A was in the room with the Resident. Surveyor A observed the call bells to go off in excess of 15 minutes on each occurrence before the facility staff responded. On 03/17/21 02:30 PM, during a Resident Council group interview, multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to accurately complete an assessment for 1 Resident ( Resident # 1) in a survey sample of 27 residents. Findings included: For Resident # 1, the facility staff failed to accurately code Section L for Oral/Dental Status on the Minimum Data Set Assessments. Resident #1 , a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic pain syndrome, cerebral infarction, dysphagia, anxiety disorder, hypokalemia, dysarthria, pain in left shoulder and vascular dementia. Resident #1's most recent MDS (Minimum Data Set) with an Assessment Reference Date of 03/2/2021 was coded as a Quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicating no cognitive impairment. Functional status for bed mobility, transfers, toileting, dressing, and personal hygiene were coded as requiring extensive to total assistance from one to two staff persons. For eating,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a comprehensive care plan for one resident (Resident # 1) in a survey sample of 27 residents. The findings included: For Resident # 1, the facility staff did not develop a comprehensive care plan to include plans for (A) limited range of motion and (B) did not develop measurable goals for the care area of dentition. Resident #1, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic pain syndrome, cerebral infarction, dysphagia, anxiety disorder, hypokalemia, dysarthria, pain in left shoulder and vascular dementia. Resident #1's most recent Minimum Data Set with an Assessment Reference Date of 03/2/2021 was coded as a Quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicating no cognitive impairment. Functional status for bed mobility, transfers, toileting, dressing, and personal hygiene were coded as requiring extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, facility documentation review, the facility staff failed to review and revise the care plan for 1 resident (Resident # 1) in a survey sample of 27 residents. The findings included: For Resident # 1, the care plan was not reviewed and revised with the creation of a dental care plan until 3/3/2021 (9 days after the resident experienced the spontaneous loss of three teeth on 2/22/2021 and continued with sporadic pain.) The interdisciplinary care plan meeting was held on 3/11/2021. Resident #1, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic pain syndrome, cerebral infarction, dysphagia, anxiety disorder, hypokalemia, dysarthria, pain in left shoulder and vascular dementia. Resident #1's most recent Minimum Data Set with an Assessment Reference Date of 03/2/2021 was coded as a Quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary service associated with wound care for 1 resident (Resident #23) in a sample size of 27 residents. The findings included: For Resident #23, the facility staff failed to arrange for transportation to a wound clinic appointment on 03/16/2021. As a result, Resident #23's appointment for an evaluation by a wound physician was delayed by 13 days. Resident #23, Resident #23, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to heart failure and neurogenic bladder. Resident #23's most recent minimum data set with an assessment reference state of 01/19/2021 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, transfers, dressing, and personal hygiene were coded as requiring extensive assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the medication pour and pass observation error rate was less than 5% for 1 Resident (Residents #29) in a sample size of 27 residents. There were 2 medication errors (wrong dose and expired medication administered) in 34 opportunities resulting in an 5.88% error rate. The findings included: Resident #29 was admitted to the facility on [DATE]. Diagnoses for Resident #29 included but were not limited to: atrial fibrillation, congestive heart failure, glaucoma, and late onset Alzheimer's. On [DATE] at 9:59 AM, LPN B was observed to prepare and administer medications to Resident #29. Medications administered included: Cartia, Forosemide, metoprolol, potassium chloride, Cosopt eye drops, acetaminophen, UTI stat, and Vitamin D3. During the medication administration observation, LPN B prepared the medications and provided Resident #29 with one Vitamin D3 tablet from the bottle. Surveyor B read…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure Residents are free to significant medication errors for 3 Residents, (Resident #38, #16, and #13) in a survey sample of 27 Residents. 1. For Resident #38, the facility staff administered expired insulin [DATE]-[DATE]. 2. Resident #16 received expired insulin three times daily from [DATE]-[DATE], and once on [DATE]. 3. The facility staff failed to ensure Resident #13 did not receive expired insulin. The findings included: 1. Resident #38 was administered expired insulin from [DATE]-[DATE]. Resident #38 was admitted to the facility on [DATE]. Diagnoses for Resident #38 included but were not limited to: cerebral infarction, encephalopathy, aphasia, type 2 diabetes, and atrial fibrillation. On [DATE] at 2:15 PM, during medication storage review the following were identified: * A multi-dose vial of LISPRO, which was labeled as Resident #38's had an open date of [DATE]. This medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-03-19 · 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
Based on observation, staff interview and facility documentation review, the facility staff failed to date medications after opening them. Two medications were found to be opened, undated, and available for administration to Residents #38, and #13. The Findings included: On 3/17/21 at 1:57 P.M., a review was conducted of medication storage. Surveyor B was accompanied by LPN A. A vial of Tuberculin Purified Protein Derivative was opened and undated. Licensed Piratical Nurse A (LPN A) was asked about the importance of knowing the date it was opened. She stated, It's important to know when opened and if expired, we are supposed to date when we open it and initial it. On 3/17/21 at approximately 2:15 P.M., an audit was conducted of Medication Cart B. Resident #38's LISPRO insulin was opened and undated. LPN A stated, Insulin is good 45 days from opening date. The medication vial had a label on it that read, store using directions provided throw away any medication that remains 28 days after first use. When asked if she could locate the date that it was opened, LPN A stated, No ma'am I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$71,915 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $71,915 — penalty dated 2026-03-06
- Medicare payment denial — starting 2026-06-06 for 6 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to RIVERSIDE HEALTH SYSTEM — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 3.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 3.7 | +0.3 vs chain |
The other 5 homes this chain runs (chain average 3.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RIVERSIDE HEALTHCARE ASSOCIATION, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/03/2010 |
| RECTOR & VISITORS OF THE UNIVERSITY OF VIRGINIA | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 07/10/2023 |
| RIVERSIDE INTEGRATED SERVICES INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 95% | since 07/10/2023 |
| ALEWYNSE, JOYCE | Individual | CORPORATE DIRECTOR | — | since 03/01/2022 |
| BATES, JARED | Individual | CORPORATE DIRECTOR | — | since 03/01/2022 |
| HAYWOOD, BARBARA | Individual | CORPORATE DIRECTOR | — | since 01/01/2016 |
| SMITH, CONWAY | Individual | CORPORATE DIRECTOR | — | since 06/01/2008 |
| SMITH, KIRBY | Individual | CORPORATE DIRECTOR | — | since 06/01/2008 |
| TILLER, BROOKE | Individual | CORPORATE DIRECTOR | — | since 03/01/2022 |
| VERSER, JOSEPH | Individual | CORPORATE DIRECTOR | — | since 03/01/2022 |
| ZEIDLER, JEANNE | Individual | CORPORATE DIRECTOR | — | since 01/01/2019 |
| AUSTIN, WALTER | Individual | CORPORATE OFFICER | — | since 07/02/2012 |
| DACEY, MICHAEL | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/01/2019 |
| DOWNEY, WILLIAM | Individual | CORPORATE OFFICER | — | since 06/01/2008 |
| HECKLER, EDWARD | Individual | CORPORATE OFFICER | — | since 01/01/2019 |
| HOUSER, JASON | Individual | CORPORATE OFFICER | — | since 01/01/2019 |
| NELSON, LINWOOD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 91% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495430. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, 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.