Carrington Place Of Tappahannock
1150 Marsh Street, Tappahannock, VA 22560 · For profit - Corporation · 60 certified beds · (804) 443-4308 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (56%) runs well above the national median (45%)
- 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 | 12.7% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.1% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.8% | 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 | 1.0% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 19.4% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.2% | 20.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 90.7% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.0% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.3% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 31.1% | 73.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 16.0% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 22.5% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.66 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.62 | 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.
57.7% 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 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.4% 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 27 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% 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 | 57.7%CMS range 45.7–69.4 | 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 | 10.4%CMS range 7.1–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.4% | 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 | 59.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.3% | 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 | 91.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 8.3% | 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 | 5.6% | 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 | 7.1%CMS range 3.3–14.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 53.2 residents a day — about 89% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.86 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.63 hrs/resident/day on weekends vs 2.96 on weekdays — 11% thinner on weekends. RN hours go from 0.63 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is well above 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · F2024-07-15 · tag F0680 — widespreadEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in substandard quality of care. The findings included: During the recertification survey conducted 7/9/2024 through 7/11/2024 and an extended survey conducted through 7/15/2024, residents were identified who could benefit from meaningful and individualized activity programs. For the Activities Director, the facility has hired an activities director who does not meet the qualifications set forth in the regulations. On 7/9/24 at approximately 2:00 PM an interview was conducted with Employee E the Activities Director who stated that she had been in that role since September 2023. When asked about her credentials she stated that she did not have any certification or attend a program or training course. She indicated that she would be willing to attend any training necessary to ensure her job security and further her career as…
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 · F2024-07-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and facility documentation review, the facility staff failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with the potential to affect all residents in the facility. The Findings included: The facility staff failed to develop and implement a Legionnaire's water policy or program or Quality Assurance and Process Improvement (QAPI) program . During the entrance conference, the facility's Administrator stated the previous Maintenance Director had quit on 6/28/2024 and had not been replaced at the time of the survey on 7/9/2024. Surveyor C informed the Administrator that she would review the Legionnaires program with the person in charge of the program. The Administrator stated the Maintenance Director was in charge of the testing for Legionnaires. Review of the facility's documentation revealed no records of testing the water for Legionella. There was no documentation 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 · E2024-07-15 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, clinical record review and facility documentation the facility staff failed to act promptly upon the grievances arising from Resident Council. The findings included: Resident council continues to have complaints of the same nature with no improvement month after month, the facility has not effectively addressed the concerns of the Residents regarding menus, timeliness of CNA rounding, cleanliness of the building and issues with patio and temperatures in the building. A review of the Resident Council minutes revealed the following: December 2023- Residents complained there was not enough housekeeping staff on weekends. January 2024 - Housekeeping - Dining room is dirty / filthy. February 2024 - meeting was rescheduled for March due to Covid outbreak. March 7, 2024 - Fixing up the patio putting the umbrellas back so they can enjoy the weather. March 20, 2024 (rescheduled from February) - Collective agreement about the dining room being unclean - as well as resident bathrooms. Fixing up the patio umbrellas for shade. April 2024 - Residents stated they…
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 · E2024-07-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure a Residents right to a safe clean, comfortable homelike environment for Residents in a survey sample of 33 Residents. The findings included: The facility staff has failed to ensure the facility was in good repair, temperatures were comfortable, and failed to ensure the cleanliness of the dining room, and resident bathrooms. On 7/9/24 at approximately 12:30 PM the following observations were made in the dining room: The large table near the windows had puzzles, books, a plastic tub of markers and pens in the center while Residents were eating their meal. The dining room has shelves for activity supplies however they were not put on the shelves in preparation for noon meal. The dining room was warm there was one fan blowing in the front of the dining room and a portable a/c unit vented to the outside at the rear of the dining room however the temperature was still too warm for comfort. There 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 · E2024-07-15 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide an ongoing program to support residents in their choice of activities for 4 Residents (#'s 9, 16, 34, & 36) in a survey sample of 33 Residents. The findings included: For Resident #9 the facility staff failed to conduct an activity assessment to ensure Residents were receiving services from the activities dept that met their interest and personal preferences. Resident #9's most recent Activity Assessment was on 7/14/2023 it read as follows: Reason for Assessment: Initial assessment Orientation: Comments - No change in resident's level of participation since last assessment. Please see 06/26/2023. Progress Summary Note: Quarterly late entry for ARD 07/14/2023: No change in resident's level assessment. Please see assessment dated for ARD 06/26/2023. Proceed with POC. Will monitor. [Former Activities Director name redacted] Resident # 16 did not have an activity assessment. Resident # 34's Activity Assessment read as follows. Reason for Assessment: Initial assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-15 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, clinical record review and facility documentation, the facility staff failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, for 14 out of 14 Residents that attended the group meeting. The findings included: For Residents attending the group meeting, the facility staff failed to assign a shower aid during the time that CNA B (the shower aid) was on vacation, resulting in no showers being given to 14 out of 14 Residents attending the group meeting. On the afternoon of 7/10/24 during the group interview it was stated that there was no shower aid to give showers while Employee B (the shower aid) was on vacation. Fourteen out of 14 Residents representing both units agreed on this statement. The group agreed that CNA (Certified Nursing Assistant) G was the only one who gave showers, and she gave them only to residents on her assignment list. They stated the facility did not…
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 · E2024-07-15 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and facility documentation review, the facility staff failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, having the potential to affect all 58 residents residing in the facility. The findings included: 1. The facility staff failed to maintain an effective QAPI program regarding the residents receiving showers at least twice per week. On 07/09/2024 during the initial tour, the survey team interviewed alert and oriented residents who stated they had did not receive baths or showers when the assigned Shower Aide was not on duty. During the Group Interview/Resident Council Meeting conducted on 07/10/2024, there were fourteen alert and oriented residents in attendance. The residents stated they only received showers when the Shower Aide (Certified Nursing Assistant -B) was on duty. But when she was off, they did not get showers. The residents stated one other Certified Nursing Assistant (Certified Nursing Assistant-G) did give showers to those residents on her assignment during the previous week when the Shower Aide 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 · E2024-07-15 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Observation, staff interview, Resident interview, clinical record review, and facility documentation review, the facility staff failed to measure the success, and track, performance in their Quality Assurance and Process Improvement (QAPI) program for the provision of showers to residents. The findings included; The facility failed to implement their plan to ensure all residents received a shower as scheduled when the Shower Aide was out on leave. As part of the facility's plan to correct the problem regarding showers, the QAPI committee was tasked with monitoring, measuring, tracking data, and sustaining compliance performance. The facility staff failed to implement measures to ensure Residents received showers as evidenced by their failure to assign the task of Showers/bathing when the Shower Aide was off on leave during July 1- July 7, 2024. Surveyor D documented the following observations: On 7/10/24 at 9:45 AM Resident #3 was observed in his bed dressed in a hospital gown and covered with a sheet. Resident #3 expressed being sweaty. Resident appeared unkempt hair 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 · E2024-07-15 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public The findings included: For the residents, staff and the public the facility staff failed to maintain a working elevator, working air conditioning in the common areas (not Resident Rooms), dining area that clean and free of clutter, and Resident bathrooms that were clean. On 7/9/24 observations were made: 11:30 a.m. - Entrance to facility the lobby area was very warm apparent that there was an issue with the air conditioning. 11:45 a.m. - Sign on elevator in lobby Do not use elevator is broken. 11:55 p.m. - The large table near the windows had puzzles, books, a plastic tub of markers and pens in the center while Residents were eating their meal. The dining room has shelves for activity supplies however they were not put on the shelves in preparation for noon meal. The dining room was warm there was one…
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 · D2024-07-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents receive services in the facility with reasonable accommodation of resident needs for 1 Resident (Resident #9) in a survey sample of 33 Residents. The findings included: For Resident # 9 the facility staff failed to ensure the Resident had a bed that was suitable for his size and weight, comfortable and allowed him enough space to turn safely. On 7/9/24 at approximately 1:00 PM Resident was observed in a regular hospital bed. Resident #9 was interviewed and stated that his bed was uncomfortable. When asked to elaborate he stated I can feel the bed frame digging into my hips in this bed and it is hard to turn over there isn't much room. When asked if he had told the staff he was uncomfortable he stated that he had. When asked what their response was, he stated that they don't have any different beds. When asked if he would like a bariatric bed and mattress, he stated that he would. On 7/9/24 a review of the clinical record revealed that Resident #9 weighed 450 lbs. 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.
Show the remaining 14 citations
- Potential for harm · Dcited before2024-07-15 · 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, interview, clinical record review and facility documentation the facility staff failed to ensure Residents received the necessary services to maintain good grooming, and personal hygiene for 4 Resident (#'s 3, 9, 56 & 44) in a survey sample of 33 Residents. The findings included: 1. For Resident #3 the facility staff failed to cut nails and wash Resident's hair. On 7/9/24 at approximately 11:45 Resident #3 was observed in bed dressed in hospital gown sheet covering body. Resident #3 has a dx of a traumatic brain injury and has a BIMS (Brief Interview of Mental Status) score of 7/15 indicating severe cognitive impairment. Resident #3 appeared unkempt hair uncombed and greasy looking, nails were not cut about 1/4 inch over tip of fingers and had debris visible under the nail. Interview with Resident #3 was conducted, and he stated he was hot and sweaty. When asked if he had a shower recently, he stated he does not like showers. When asked how he bathes he stated, They wash me up in bed. When asked about his hair being washed and nails being cut, he stated It'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 · D2024-07-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents who use psychotropics receive gradual dose reduction and are free from unnecessary psychotropic medications for 1 Resident #9 in a survey sample of 33 Residents. The findings included: For Resident #9 the facility staff failed to act on a recommendation from the pharmacy to reduce one or both of the Resident's psychotropic medications. On 7/11/24 a clinical record review was conducted on Resident #9's electronic health record. The record showed that on a pharmacy recommendation dated over a year ago (5/29/23), had not been addressed until 7/18/23 and then was not acted on. The pharmacy recommendation read as follows: The resident receives the following medications that may significantly prolong QT interval and increase risk for arrhythmias and or torsade's (TdP): Citalopram 30 mg QHS and doxepin 50 mg Q PM. Rationale: QT intervals in apparently normal older individuals when combined with expected…
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 · D2024-07-15 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility staff interview, and facility documentation, the facility failed to implement and maintain an effective training program for all new and existing staff. The findings included: The facility failed to maintain an effective training program for 7 employees in the survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff employees in the survey sample had maintained an effective training program. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager who was asked about, an effective training program, she stated that training and education are recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that they have no documentation of trainings completed prior to this date. On 07/15/2024 during the end of day meeting, the Administrator and the Director…
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 · D2024-07-15 · tag F0941 — isolatedDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility staff interview, and facility documentation, the facility failed to ensure that all direct care staff complete mandatory Effective Communication training. The findings included: The facility failed to ensure that all direct care staff complete mandatory Effective Communication training for 7 employees in a survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff has documented completion of mandatory Effective Communication training. On 07/12/2024 at 2:00 p.m., an interview was conducted with the Human Resource (HR) Manager who was asked about, direct care staff having completed mandatory Effective Communication training, she stated that training and education are recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that they have no documentation of trainings completed prior 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 · D2024-07-15 · tag F0946 — isolatedProvide training in compliance and ethics.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility staff interview, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training for 7 employees in a survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff in the survey sample had completed the mandatory Ethics and Compliance Training. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager who was asked about staff training regarding, Ethics and Compliance Training, and she stated that training and education are recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that they have no documentation of trainings completed prior 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 · D2024-07-15 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility staff interview, and facility documentation, the facility failed to ensure that the nurse aides had 12 hours of in-service training including dementia, abuse preventions and facility assessments, and special needs of residents in a year. The findings included: The facility failed to ensure that all Certified Nursing Assistants (CNA's) had performance evaluations, and regular in-service education every 12 months for 2 CNA's #B and #F, in a survey sample of 7 employees. The facility failed to ensure that the ensure Certified Nursing Assistants (CNA's) have a performance evaluation every 12 months and have regular in-service education. Review of the Medline University Training Transcripts and Staff Education files revealed that the CNA's, in the staff survey did not have the mandatory in-services education and training. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager, and the Director of Nursing (DON) who were asked about staff training regarding, the CNA's, mandatory in-services education and training. The DON stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-15 · tag F0949 — failed to train staff on dementia and abuse — isolatedProvide behavior health training consistent with the requirements and as determined by a facility assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility staff interview, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training for 7 employees in a survey sample of 7 employees: 2 Certified Nursing Assistants (CNA's) #B and #F, 3 Licensed Practical Nurses (LPN's) #E, #F, and #G, 1 Registered Nurse, RN #D, and the Administrator. Review of the Medline University Training Transcripts and Staff Education files revealed that none of the direct care staff in the survey sample had completed the mandatory Behavioral Health Training. On 07/12/2024 at 2:00 p.m. an interview was conducted with the Human Resource (HR) Manager who was asked about staff training regarding mandatory Behavioral Health Training, she stated that training and education are maintained and recorded by Medline University and was initiated in January 2024. The HR Manager went on to say that the Behavioral Health Training is scheduled for later this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-01-20 · 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, facility documentation review and clinical record reviews, the facility staff failed to provide assistance with ADL's (activities of daily living) (bathing, dressing, toileting, personal hygiene, incontinence care, etc.) to four Residents (Residents #11, #24, #45, #43) who were dependent upon staff assistance, in a survey sample of 22 Residents. 1. For Residents #11, #24, and #45, all who were dependent upon facility staff for assistance with ADL's, the facility staff 1a) failed to provide personal hygiene assistance and 1b) failed to provide baths and/or showers. The findings included: 1. For Residents #11, #24, and #45, all who were dependent upon facility staff for assistance with ADL's, the facility staff 1a) failed to provide personal hygiene assistance and 1b) failed to provide baths and/or showers. Review of the clinical records for Residents #11, #24, and #45 were conducted. This review revealed the following: Resident #11's care plan read, ADL/Restorative Nursing program Self-care deficit- I require 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 · E2022-01-20 · 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, interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to ensure the environment was free from accidents and hazards for 1 Resident (#32) in a survey sample of 22 Residents and failed to store oxygen cylinders in a safe and secure manner. The findings include: 1. For Resident #32, the facility staff failed to ensure the proper placement of sling hooks on the mechanical lift while transferring from the chair to the bed on 08/19/2021 causing Resident #32 to fall to the floor resulting in a sprained toe and contusion on her back. On 01/19/2022 at 1:15 P.M., an interview Resident #32 was conducted. When asked if she had fallen recently, Resident #32 stated she had fallen recently. When asked about how the fall occurred, Resident #32 explained that in the process of getting transferred from the chair to the bed with a mechanical lift, the sling wasn't hooked right. Resident #32 went on to say that the staff member…
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 · D2022-01-20 · 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 observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care consistent with professional standards of practice to prevent pressure ulcer development for one Resident (Resident #43) in a sample size of 22 Residents. For Resident #43, the facility staff failed to provide soft boots on 01/19/2022 and 01/20/2022 as ordered by a physician. The findings included: On 01/19/2022 at 2:38 P.M., Resident #43 was observed sleeping in his bed. Resident #43 was lying supine with the head of the bed elevated approximately 30 degrees. Resident #43 was wearing a yellow shirt and covered with a blanket from the chest down. There were 3 soft boots on the bedside table. At 3:55 P.M., Resident #43 was observed sleeping in his bed as before and the 3 soft boots were still on the bedside table. On 01/19/2022 at approximately 4:00P.M., this surveyor and Certified Nursing Assistant CNA D entered Resident #43's room to make an observation. When asked if Resident #43 wears soft boots, CNA D stated, Yes. CNA D pulled down 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 · D2022-01-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, facility documentation review and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 3 Residents (Residents #11, #24, and #45) in a survey sample of 22 Residents. For Residents #11, #24, and #45, the facility staff failed to document ADL care provided, therefore rendering an incomplete clinical record. The findings included: On 1/19/22 and 1/20/22, clinical record reviews were conducted for Residents #11, #24, and #45. The surveyor was not able to access ADL (activities of daily living) (bathing, dressing, toileting, personal hygiene, etc.) records and therefore, the facility staff were asked to provide the ADL records to the survey team. On 1/20/22, Surveyor E was provided and reviewed the requested ADL records. This review revealed the following: 1. For Resident #11, no ADL information was recorded for the following dates: 12/26/21, 12/29/21, 1/4/22, 1/5/22, 1/12/22, 1/13/22, 1/16/22, and 1/18/22. 2. For Resident #24, ADL information was not recorded on the following dates: 11/25/21, 12/1/21,…
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 · D2018-11-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, clinical record review, facility record review, and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 3 residents (Residents #13, #3, and #8) in a sample of 20 residents. 1. For Resident #13, the facility staff failed to ensure a complete Preadmission Screening and Resident Review (PASARR) was conducted prior to admission. 2. Resident #3 did not have a PASARR screening done prior to admission. 3. For Resident #8, the facility staff failed to ensure a PASARR I was completed prior to admission. The Findings included: 1. Resident #13 was admitted on [DATE] with diagnoses including: Psychosis, hallucinations, and dementia. Resident #13's most recent Minimum Data Set (MDS) assessment was an admission Assessment with an Assessment Reference Date of 9-13-18. The assessment coded Resident #13 as having a Brief Interview of Metal Status Score of 11, indicating mild to moderate impaired…
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 · D2018-11-29 · 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
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 notify the physician of laboratory results for two resident (Resident # 3 and #4) in a survey sample of 25 Residents. 1. For Resident #3, the facility staff failed to notify physician of failure to obtain a HGA1C (hemoglobin A1C) as ordered. 2. For Resident #4, the facility staff failed to notify the physician of failure to obtain a Valproic acid level. The findings included: 1. For Resident #3, the facility staff failed to notify physician of failure to obtain a HGA1C (hemoglobin A1C) as ordered. Resident #3 was admitted to the facility on [DATE]. Diagnoses included dementia, bipolar disorder, high blood pressure and diabetes. The most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 9/5/18. Resident #3 was coded with a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment and required extensive assistance with activities…
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 · D2018-11-29 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to provide an ordered eating assistance, therapeutic device, for one Resident (Resident #13) in a survey sample of 20 Residents. For Resident #13, the facility staff failed to provide a divided plate to assist the Resident with eating at the noon meal on 11-27-18. The findings included: Resident #13 was admitted on [DATE] with diagnoses including: Stroke with difficulty eating due to (L) side weakness, hypertension, atrial fibrillation, and diabetes. Resident #13's most recent Minimum Data Set (MDS) assessment was an admission Assessment with an Assessment Reference Date of 9-13-18. The assessment coded Resident #13 as having a Brief Interview of Metal Status Score of 11, indicating mild to moderate impaired cognition. The Resident was also coded as requiring extensive assistance to total dependence on one to two staff members for all activities of daily living, with the exception of eating which required a special…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 79% 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 $888K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 495328. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-15, 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.