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Rosemont Health & Rehab Center, LLC

3750 Sentara Way, Virginia Beach, VA 23452 · For profit - Corporation · 116 certified beds · (757) 306-2700 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseResident-funds citations (F0567, F0569)Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations
Insights

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

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Sep 2022
  • it has citations for mishandling residents’ money or property (F0567, F0569)
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (32) — 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 (2/5)
  • its last standard health inspection was over 4 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3750 Virginia Beach Blvd Ste I · (757) 486-1712 · Call to confirm hours
Pharmacy
Rite Aid0.4 mi
3653 Virginia Beach Blvd · (757) 463-2011 · Call to confirm hours
Grocery
Food Lion0.4 mi
Birchwood South Park, 3788 Lampl Ave · (757) 340-7920 · Call to confirm hours
Park
Birchwood South Park, 3788 Lampl Ave · (757) 463-3138 · Typically dawn to dusk
Place of worship
166 S Rosemont Rd · (757) 741-8361

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 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.0%14.9%15.4%better
Long-stay residents who lose too much weight6.8%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%1.6%2.0%better
Long-stay residents with depressive symptoms14.3%18.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.6%3.6%3.3%better
Long-stay residents whose ability to walk worsened3.1%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.3%20.6%18.9%better
Long-stay residents given the seasonal flu vaccine97.9%94.0%95.3%typical
Long-stay residents with pressure ulcers2.2%4.7%4.7%better
Long-stay residents with worsening bladder/bowel control18.4%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.1%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine71.0%73.6%79.4%worse
Short-stay residents rehospitalized after admission33.5%22.3%22.6%worse
Short-stay residents with an outpatient ER visit20.1%11.5%12.0%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.

65.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 267 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.8%U.S. median 51.5%
Got home and stayed home
13.9%U.S. median 10.7%
Went back to hospital
41.2%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 41.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 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 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.8%CMS range 59.1–72.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.9%CMS range 12.1–16.810.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge41.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified64.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting62.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge74.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.0%CMS range 5.9–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.36
RN hours/ resident / day
1.07
LPN hours/ resident / day
2.04
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.15
RN hoursweekends
34.9%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 116 beds and averages 111.5 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.475 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 2.95 hrs/resident/day on weekends vs 3.69 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.45 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% 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

17
deficiencies at the latest standard inspection (2022-09-22)
7
at the previous standard inspection (2019-10-18)

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 4 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2022-09-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 closed record review, complaint investigation, and family and staff interviews, the facility staff failed to ensure one resident (Resident #297), in the survey sample of 46 residents, was free from sexual assault which resulted in harm. The findings included: Resident #297 was admitted to the facility on [DATE] with a diagnosis of dementia, anemia, diabetes, cardiovascular disease, aphasia, and cerebrovascular disease. In the most recent Minimum Data Set (MDS) dated [DATE], it was coded that this resident had a BIMS score of 3 out of a possible score of 15 which indicated severe impairment in the cognitive skills necessary for daily decision-making. Resident #297 required extensive assistance for bed mobility and was dependent on staff for transfers, dressing, grooming, eating, toileting and bathing. A Care Plan dated 06/07/21 indicated: Focus- Altered or at risk for altered behaviors and/or mood due to acute confusion. Goal- resident will display a positive affect. Interventions- Ensure the resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-09-22 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 a closed record review, complaint investigation, family and staff interviews, the facility staff failed to preserve evidence following an incident of sexual abuse for one resident (Resident #297) in the survey sample of 46 residents. The findings included: Resident #297 was admitted to the facility on [DATE] with a diagnosis of dementia, anemia, diabetes, cardiovascular disease, aphasia, and cerebrovascular disease. In the most recent Minimum Data Set (MDS) dated [DATE], it was noted this resident had a BIMS score of 3 which indicated the resident was severely impaired in the skills needed for daily decision-making. Resident #297 required extensive assistance for bed mobility and was dependent on staff for transfers, dressing, grooming, eating, toileting and bathing. A Care Plan dated 06/07/21 indicated: Focus- Altered or at risk for altered behaviors and/or mood due to acute confusion. Goal- resident will display a positive affect. Interventions- Ensure the resident feels safe in her environment. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, clinical record review, review of facility documents, the facility staff failed to administer physician ordered medications for 1 of 7 residents (Resident #1), in the survey sample. The findings included: Resident #1 was admitted to the facility 2/16/22 and readmitted on [DATE]. The resident's diagnoses include Diabetes Mellitus without complications and Depression Unspecified. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. In section GG (Functional Abilities Goal) the resident was coded as requiring supervision with eating, requiring partial or moderate assistance with oral hygiene, requiring substantial/maximal assistance with toileting/hygiene, dependent with showering/bathing. According to the Medication Administration…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-09-22 · tag F0569 — pattern
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed to convey within 30 days after the resident's discharge from the facility the resident's funds, and a final accounting of those funds, to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded as rarely to never…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-09-22 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 resident interview, staff interviews and clinical record review, the facility staff failed to follow professional standards of nursing practices for 1 out of 40 residents (Resident #51) in the survey sample. The findings included: The facility staff failed to obtained daily weights per physician orders for Resident #51. Resident #51 was admitted to the facility on [DATE]. Diagnosis for Resident #51 included but are not limited to Congestive Heart Failure (CHF). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/12/22 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #51 total dependence of one with toilet use, personal hygiene and bathing, extensive assistance of one with bed mobility, transfer and dressing and supervision with eating with Activities of Daily Living (ADL) care. Resident #51's person-centered care plan…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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, clinical record review, and review of facility documents, the facility's staff failed to afford two residents (R#62 and R#38) in the survey sample the opportunity to participate in the care planning process. The findings included: Resident #62 was originally admitted to the facility 04/25/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; End Stage Renal Disease and Anxiety Disorder. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 08/18/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #62 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) of the MDS the resident was coded as requiring total dependence of two persons with bed mobility, toileting and bathing. Requires total dependence of one person with dressing and personal hygiene.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on information gleamed during a complaint investigation, family interview, staff interview, and review of facility documents, the facility staff failed the facility staff failed to ensure the resident's personal funds which exceeded $100.00 were kept in an interest bearing account until it was distributed to the Resident and/or Representative for 1 of 21 residents (Resident #121), in the survey sample. The findings included: Resident #121 was originally admitted to the facility 10/18/2021 and was discharged from the facility 6/30/22, return anticipated. The Resident's diagnoses included; dysphagia, malnutrition, quadriplegia, a seizure disorder and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/6/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems, an inability to recall and severely impaired daily decision making abilities. In section B (Hearing Speech, Vision) the resident was coded 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure 2 of 40 residents in the survey sample, (Resident #32 and 81) were given the opportunity to formulate an advance directive. The findings included: 1. The facility staff failed to ensure Resident #32 was given the opportunity to formulate an Advance Directive. Resident #32 was originally admitted to the nursing facility on 09/25/21. Diagnosis for Resident #32 included but are not limited to Parkinson's disease, dementia and heart disease. The current Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) of 07/13/22 coded Resident #32 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. Resident #32's person-centered care plan created on 09/27/21 with a revision date of 07/11/2022 identified the resident has an advance directive as a full code. The goal set for the resident by the staff is to follow the residents' wishes. Some of the interventions to manager goal include…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-22 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 4 residents (Resident #39 and #64) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #39 who was discharged from skilled services with Medicare days remaining. Resident #39 was admitted to the nursing facility on 07/14/22. Diagnosis for Resident #39 included but are not limited to Congestive Heart Failure (CHF) and COVID-19. The Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) date of 09/18/22 coded Resident #39 a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated moderate cognitive impairment. Review of the SNF Beneficiary Notification provided by the facility was noted that Resident #39 was not issued a SNF ABN letter. Resident #39 started Medicare Part A stay on 07/14/22 and the last covered day was 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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, clinical record review, and review of facility documents, the facility's staff failed to send a care plan to include their goals when discharged and admitted to the hospital for 1 of 46 residents (Resident #50), in the survey sample. The findings included; The facility staff failed to send a copy of Resident #50's care plan to include their goals when discharged and admitted to the hospital on [DATE]. Resident #50 was originally admitted to the nursing facility on 10/22/21. Diagnosis for Resident #50 included but are not limited to Cerebrovascular accident (stroke) with left hemiparesis (weakness or inability to move one side of the body). Resident #50's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 08/03/22 coded a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. A review of Resident #50'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to send a notice to a representative of the Ombudsman office for 1 of 46 residents (Resident #77), in the survey sample. The findings included: The facility staff failed to send a notice to a representative of the Ombudsman office for Resident #77's discharge to the hospital. Resident #77 was admitted to the facility on [DATE]. Diagnoses for this resident included COPD, sepsis, CVA, dysphagia and hypotension. A review of the clinical records indicated this resident was admitted to the hospital on [DATE]. Resident #77 was observed in bed with his eyes closed during the survey at 9:33 a.m. on 09/19/22. Resident #77 was also observed observed in bed watching television at 2:15 p.m. on 09/19/22. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having a BIMS score of 1. This resident was assessed as total care in the areas of Activities of Daily…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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, clinical record review, and review of facility documents, the facility's staff failed to send a copy of the facility's bed hold policy for 1 of 46 residents (Resident #50), in the survey sample. The findings included: The facility staff failed to provide Resident #50 or resident's representative a copy of the bed hold policy when discharged and admitted to the hospital on [DATE]. Resident #50 was originally admitted to the nursing facility on 10/22/21. Diagnosis for Resident #50 included but are not limited to Cerebrovascular accident (stroke) with left hemiparesis (weakness or inability to move one side of the body). Resident #50's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 08/03/22 coded a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. A review of Resident #50's quarterly MDS…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2022-09-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and clinical record review, the facility staff failed to include anticoagulation in the comprehensive care plan, for 1 of 40 resident (Resident #32), in the survey sample. The findings included: The facility staff failed to develop a care plan for Resident #32 who was receiving an anticoagulant medication (Coumadin). Resident #32 was originally admitted to the nursing facility on 09/25/21. Diagnosis for included but are not limited to Atrial Fibrillation (A-Fib). The current Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) of 07/13/22 coded Resident #32 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The residents MDS was coded for the usage of anticoagulant. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an anticoagulant for 6 days. The review of Resident 32's comprehensive care plan did not include a care plan for the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and clinical record review, the facility staff failed to ensure a resident received the application of his right hand splint as ordered by the physician to prevent further decrease in range of motion for 1 of 40 residents, (Resident #35), in the survey sample. The findings included: Resident #35 was originally admitted to the facility 07/14/22. Diagnosis for Resident #35 included but are not limited to Cerebral Infarction (stroke) with right hemiparesis (weakness or inability to move one side of the body). Resident #35's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 07/14/22 coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. In section G (Physical limitation in Range of Motion) the resident was coded for limitation one side to both upper and lower extremity. Resident #35's person-centered care plan initiated on 11/13/20 identified the resident requires the use of a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure one resident did not receive PRN Psychoactive medications for more than 14 days for 1 of 46 residents (Resident #91), in the survey sample. The findings included; Resident #91 received a PRN anti-psychotic drug for more than 14 days without a new order and first evaluating the resident. Resident #91 was admitted to the facility on [DATE] with diagnoses which included adjustment disorder with mixed anxiety, depressed mood, and insomnia. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having a BIMS score of 15 out of a possible score of 15 which indicated the resident was cognitively intact. In the area of Activities of Daily Living this resident was assessed as requiring extensive assistance of two persons to transfer. In the area of dressing this resident required extensive assistance of one person to dress. In the area of eating 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interviews, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 46 residents (Resident #38) in the survey sample received the services needed to meet their dental needs. The findings included: The facility staff failed to follow-up with a dental visit recommended by the dentist on 07/31/22 for Resident #38. Diagnosis for Resident #38 included but not limited to depression and anemia. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 07/20/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. The MDS coded Resident #38 supervision with eating. Under section L0200 (Dental) was coded for having his own teeth. The MDS was also coded for Resident #38 being without mouth or facial pain, discomfort or difficulty with chewing. The current physician order dated 05/20/21 read Dental services as needed. An interview was conducted with Resident #38 on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on a revisit survey conducted 11/15/22 through 11/17/22 to the standard survey that was conducted on 09/18/22 through 09/22/22, the facility staff failed to correct identified quality deficiencies. The findings included: During a revisit survey conducted 11/15/22 through 11/17/22 uncorrected deficiencies were cited as follows: F- tag 791 Routine/emergency Dental services. A review of the QA (Quality Assurance) indicated that weekly meeting were held in October 2022. During an interview on 11/17/22 at 2:22 PM the administrator stated (QA) meetings were held weekly during the month of October. All staff were educated on the cited deficiency. The administrator stated all residents were screened for dental services.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0882 — isolated
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility documentation, the facility staff failed to designate at least one qualified staff member as the facility's Infection Preventionist (IP). The finding included: An interview was conducted with the Director of Nursing (DON) and Infection Preventionist (IP) Registered Nurse (RN) #2 on 09/21/22 at approximately 10:22 a.m. When asked who is responsible for the Infection Prevention and Control Program (IPCP), the DON stated RN #2 but she has not completed the specialized training in infection prevention and control. RN #2 stated she took over being the IP after the previous DON. The RN stated she haven't had time to complete the specialized training in infection prevention and control. A debriefing was held with the Interim Administrator, Director of Nursing and Regional Director of Clinical Services on 09/22/22 at approximately 3:00 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility provided a document titled Infection Preventionist. -The Infection Preventionist is to oversee…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-18 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a record review, facility document review and staff interviews the facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day for 2 of 39 residents in the survey sample, Resident # 238 and Resident #239. The findings included: 1. Resident #238 was a [AGE] year old that was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus. Resident #238's Notice of Medicare Non-Coverage was reviewed and is documented in part, as follows: The Effective Date Coverage of Your Skilled Therapy or Nursing Services Will End: 9/16/19 Resident #238's signed and dated the notice on 9/16/19. On 10/17/19 at approximately 3:19 P.M. an interview was conducted with the facility Social Worker regarding the Resident #238's Medicare Notices of Non-Coverage and if it was given timely in order for the resident to appeal if so desired. The Social Worker stated, The Notice of Non-Coverage should be given 48 hours prior to the last covered day. I am new 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-18 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to develop a baseline care plan for one of 39 residents in the survey sample, Resident #288. The findings include: Resident #88 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Parkinson's Disease, and Alzheimer's Disease. Resident #288's most recent MDS (Minimum Data Set) assessment was an entry assessment with an ARD (assessment reference date) of 10/14/19. Resident #288 did not have a completed comprehensive assessment. Resident #288 was documented in a nursing note dated 10/14/19 as being pleasantly confused. Review of Resident #288 nursing notes revealed that Resident #288 was admitted to the facility for Respite Care. The following note was documented on 10/14/19: Received Resident via stretcher .Resident is here for Respite stay until 10/19/19. Resident is alert to self. Pleasantly confused at this time . Further review of Resident #288'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 interview and review of the facility's Medication Administration Record (MAR), the facility failed to administer medications as ordered for 1 of 39 residents in the survey sample, Resident #52. The findings included: Resident #52 was admitted to the facility on [DATE], with a readmission occurring on 8/29/2019 with diagnoses including, but not limited to, chronic systolic (congestive) heart failure, diabetes mellitus with hyperglycemia, and chronic kidney disease. Resident #52's most recent MDS (Minimum Data Set) was a Quarterly review scheduled assessment with an ARD (Assessment Reference Date) of 9/10/2019. Resident #52 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (brief interview for mental status) exam. A review of Resident #52's physician's orders dated 9/4/2019 for the administration of NovoLOG U-100 insulin, aspart 100 unit/ml (milliliter) subcutaneous solution sliding scale insulin (SSI) three times daily, for blood sugar readings greater than 150…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to obtain an order for the use of a Foley catheter for one of 39 residents in the survey sample, Resident #55. The findings include: Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, enlarged prostate and urinary obstruction. Resident #55's most recent MDS (Minimum Data Set assessment) was an admission assessment with an ARD (assessment reference date) of 9/2/19. Resident #55 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #55 was coded in Section H (Bowel and Bladder) as having a urinary catheter. On 10/16/19 at 12:29 p.m., an observation was made of Resident #55. He was sitting up in his wheelchair with a Foley catheter in place. The catheter collection bag was covered in a dignity bag. Review of Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 it was determined that facility staff failed to administer oxygen per physician's order for one of 39 residents in the survey sample, Resident #291. The findings include: Resident #291 was admitted to the facility on [DATE] with diagnoses that included but not limited to acute respiratory failure, hypoxia and chronic obstructive pulmonary disease. Resident #291's did not have a completed MD'S (minimum data set) assessment. Review of Resident #291's POS (physician order summary) dated October 2019 documented the following order: 02 (oxygen) at 2 AL (liters) /min (minute) per nasal annular continuously. This order was initiated on 10/8/19. On 10/16/19 at 11:48 a.m., an observation was made of Resident #291. Resident #291 was lying up in bed with his nasal annular in place. His oxygen flow meter was set to 2.5 liters of oxygen. On 10/16/19 at 12:31 p.m., a second observation was made of Resident #291. Resident #291 was lying up in bed with his nasal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-18 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of the facility's Medication Administration Record (MAR), the facility failed to ensure 1 of 39 residents in the survey sample was free from unnecessary medication, Resident #52. The findings included: Resident #52 was admitted to the facility on [DATE], with a readmission occurring on 8/29/2019 with diagnoses including, but not limited to diabetes mellitus with hyperglycemia, and chronic kidney disease. Resident #52's most recent MDS (Minimum Data Set) was a Quarterly assessment with an ARD (Assessment Reference Date) of 9/10/2019. Resident #52 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (brief interview for mental status) exam. A review of Resident #52's physician's orders dated 9/4/2019 for the administration of NovoLOG U-100 insulin, aspart 100 unit/ml (milliliter) subcutaneous solution sliding scale insulin (SSI) three times daily, for blood sugar readings greater than 150 mg/dL (milligrams per deciliter) read: 150-200 = 1 unit…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-05-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, closed record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed for one (Resident #379) of 34 residents in the survey sample to notify the responsible party of a fall. The findings included: Resident #379 was admitted to the facility on [DATE] with diagnoses included but were not limited to cerebral vascular accident (CVA or stroke), COPD (Chronic Obstructive Pulmonary Disease), major depressive disorder, unspecified injury of head, difficulty in walking, and muscle weakness. Resident #379 was discharged from the facility on 2/10/17. An initial care plan dated 2/6/17 included, Problems: At risk for falls, Goals: Resident #379 will demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 days, Interventions: Keep areas free from obstruction to reduce the risk of falls or injury, Place call bell within easy reach, Remind Resident #379 to call for assistance before moving from bed-to-chair 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-05-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 resident (#8) in the survey sample of 34 residents. Facility staff failed to maintain an accurate person centered care plan related to transfer needs for Resident #8. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that include and are not limited to: Acute post hemorrhagic anemia, cirrhosis of the liver, liver failure, alcohol abuse, coagulation deficit (bleeds easily) and sepsis (infection). A care plan for Resident #8 prepared 5/14/18 included: Problems: Bathing - Resident #8 requires extensive assistance, Goals: Resident #8 will be bathed/showered with the assistance of 1-2 people, Interventions: Bathe/shower Resident #8 Use lifts/transfer devices. A quarterly MDS 3.0 (Minimum Data Set) assessment for resident #8 was dated 5/14/18 was coded with a BIMS (Brief Interview 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-05-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical document and facility documentation review the facility staff failed to maintain proper infection control practices for indwelling Foley catheter maintenance for 2 residents (#23) and (#129) in the survey sample of 34 residents. 1. The facility staff failed to ensure Resident #23's indwelling Foley catheter urine collection bag was not in contact with the floor. 2. The facility staff failed to ensure Resident #129's indwelling catheter bedside drainage bag was emptied and prevented from making contact with the floor. The findings included: 1. Resident # 23 was admitted to the facility on [DATE] with diagnoses that include but are not limited to bladder neck obstruction, CVA (cerebral vascular accident or stroke), unspecified dementia, hypertension, and Alzheimer's disease. Resident #23's care plan was prepared, reviewed and updated on 5/22/18 and included: Problem: At risk for infection R/T (related to) indwelling catheter. Goals: Res #23 will remain free from…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-05-25 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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, clinical record review the facility staff failed to ensure non-pharmacological measures were offered prior to the administration of analgesic medications. The facility staff failed to ensure non-pharmacological measures were offered prior to the administration of analgesic medications for one Resident (Resident # 11) of 34 residents in the survey sample. The findings included: Resident observations were made on the following dates in her room: 5/22/18 at approximately 6 PM: Resident well groomed in her room and without complaints of pain 5/23/18 at approximately 6:30 PM: Resident in her room and without complaints 5/24/18 at approximately 6:45 PM: Resident well groomed and without complaints Resident #11 was admitted to the facility on [DATE]. Diagnoses for Resident #11 included but are not limited to Left Shoulder Pain, Alzheimer's Disease, Arthritis, Osteoporosis and Hemiplegia (paralysis) following Cerebral Infarction…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-05-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review facility staff failed to ensure 2 residents (Resident #7 and #52) were free from unnecessary psychotropic medications. 1. The facility staff failed to ensure Resident #7's as needed Trazodone was reassessed and extended for another 14 days. 2. The facility staff failed to ensure Resident #52 received gradual dose reductions in an effort to decrease and/or discontinue psychotropic drugs use. The findings included: 1. Resident #7 was admitted to the facility on [DATE]. Diagnoses for Resident #7 included but were not limited to Non Alzheimer's Dementia and Depression. Resident #7's Re-entry Quarterly Minimum Data Set (MDS) (an assessment protocol) with an Assessment Reference Date of 5/15/18 scored him with a 15 out of a possible 15 on his Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the Quarterly MDS coded Resident #7 as needing supervision with set up only…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-05-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on general observation of the nursing facility, staff interviews, the facility failed to ensure medications were labeled and stored in accordance with currently accepted professional principles in 1 out of 8 facility medication carts. The facility staff failed to ensure one *Humalog (insulin) vial was dated once open and one Humalog vial was removed from medication cart once expired. *Humalog is a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood (https://www.drugs.com/humalog.html). On [DATE] at approximately 12:25 p.m., this surveyor inspected the medication cart on Unit 2 (Front Hall) with LPN #1. During the inspection of the insulin stored inside the medication cart; one Humalog vial was open with no open date and one Humalog vial dated open on [DATE] with an expiration date of [DATE] remained inside the cart. An interview was conducted…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-05-25 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, clinical record review, and review of the Hospice policy; the facility staff failed to ensure the Hospice Agency provided a written agreement describing the provision of services for 1 of 34 residents (Resident #129), in the survey sample. The facility staff failed to ensure the Hospice Agency provided the facility staff with the coordinated plan of care for Resident #129, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency. The findings included; Resident #129 was originally admitted to the nursing facility 5/15/18 from an in-patient Hospice facility has never been discharged from the nursing facility. The current diagnoses included; dementia with major depressive disorder, cerebrovascular disease, contractures and multiple pressure ulcers. No Minimum Data Set (MDS) assessment had been completed by the nursing facility for Resident #129. Review of the May 2018 Physician's order Summary revealed an order 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-10-18 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 the facility's Missing Assessment Report, facility document review and staff interviews the facility staff failed to ensure that Discharge Assessments were completed and transmitted timely for 3 of 39 residents in the survey sample, Resident #3, Resident #4 and Resident #5. The findings included: 1. Resident #3 was a [AGE] year old that was admitted to the facility on [DATE] with diagnoses to include but not limited to, Hypertension and Anxiety. On 10/17/19 at 1:51 P.M. the facility's Missing Assessment Report showing late assessments for Resident #3 was reviewed with the facility's traveling MDS (Minimum Data Set) Coordinator. After the MDS Coordinator had time to review and investigate the Missing Assessment Report for the resident the following interview was conducted: On 10/17/19 at 3:51 P.M. the MDS Coordinator stated., Name (Resident #3's) discharge assessment for 5/14/19 was not completed or transmitted. We have completed it and it has be submitted today. I am not sure how the assessment was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SABER HEALTHCARE GROUP — 126 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 125 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Autumn Care of MarshvilleMarshville, NC 1 of 5Autumn Care of Myrtle GroveWilmington, NC 1 of 5Autumn Care of WaynesvilleWaynesville, NC 1 of 5Brunswick Health & Rehab CenterAsh, NC 1 of 5Bryn Mawr Extended Care CenterBryn Mawr, PA 1 of 5Caring Heights Community Care & Rehab CtrCoraopolis, PA 1 of 5Colonial Health & Rehab Center, LLCVirginia Beach, VA 1 of 5Currituck Health & Rehab CenterBarco, NC 1 of 5Davidson Health & Rehab CenterLexington, NC 1 of 5Edison Manor Nursing & Rehabilitation CenterNew Castle, PA 1 of 5Gastonia Health & Rehab CenterGastonia, NC 1 of 5Greene Health & Rehab CenterGreensburg, PA 1 of 5Grey Stone Health And Rehabilitation CenterFort Wayne, IN 1 of 5Harmar Village Health & Rehab CenterCheswick, PA 1 of 5Highland Pointe Health & Rehab CenterHighland Heights, OH 1 of 5Hilltop Heights Health & Rehab CenterJohnstown, PA 1 of 5Maple Heights Health & Rehab Center, LLCEbensburg, PA 1 of 5Midtown Oaks Health & Rehab CenterAltoona, PA 1 of 5Mountain City Nursing & Rehabilitation CenterHazleton, PA 1 of 5Providence Health & Rehab CenterBeaver Falls, PA 1 of 5River's Bend Health & Rehab CenterHarrisburg, PA 1 of 5Riverside Health & Rehab CenterMcKeesport, PA 1 of 5South Boston Health & Rehab CenterSouth Boston, VA 1 of 5Tallmadge Health & Rehab CenterTallmadge, OH 1 of 5University Manor Health & RehaCleveland, OH 1 of 5Village Care of KingKing, NC 1 of 5Woodhaven Health & Rehab CenterMonroeville, PA 1 of 5Woodlands Health And Rehab CenterRavenna, OH 2 of 5Aurora Manor Special Care CentAurora, OH 2 of 5Autumn Care Of MadisonMadison, VA 2 of 5Autumn Care Of MechanicsvilleMechanicsville, VA 2 of 5Autumn Care Of SuffolkSuffolk, VA 2 of 5Autumn Care of CorneliusCornelius, NC 2 of 5Autumn Care of RaefordRaeford, NC 2 of 5Autumn Care of SaludaSaluda, NC 2 of 5Autumn Care of ShallotteShallotte, NC 2 of 5Azalea Health & Rehab CenterWilmington, NC 2 of 5Bath Manor Special Care CentreAkron, OH 2 of 5Berea Health & Rehab CenterFredericksburg, VA 2 of 5Broad Mountain Health And Rehabilitation CenterFrackville, PA

Showing 40 of 125; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
BENJAMIN N. VOLPE FAMILY DYNASTY TRUST (DATED DECEMBER 29, 2020)OrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2023
BNV DYNASTY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2023
DECANTED WILLIAM I. WEISBERG FAMILY DYNASTY TRUST (DATED SEPT 30, 2020OrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2023
WIW DYNASTY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2023
OHI ASSET (VA) VIRGINIA BEACH LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 11/01/2020
SABER GOVERNANCE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
SHG MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
HUGHES, CANDICEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/14/2022
JACKSON, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/28/2022
SALYERS, GARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/13/2021
VOLPE, BENJAMINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2020
WEISBERG, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 01/09/2026
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 11/01/2020
SABER HEALTHCARE GROUP LLCOrganizationADP OF THE SNFsince 11/01/2020
SHG BOA LLCOrganizationADP OF THE SNFsince 01/09/2026
SHG MT, LLCOrganizationADP OF THE SNFsince 01/09/2026
THE HUNTINGTON NATIONAL BANKOrganizationADP OF THE SNFsince 12/02/2022
WALKER & ASSOCIATES PCOrganizationADP OF THE SNFsince 11/01/2020
NICOLUZAKIS, GREGORYIndividualADP OF THE SNFsince 11/01/2020

CMS files one row per role, so the 28 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

13 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.

$12.8M
Net patient revenuemost recent cost report
+9.7%
Operating marginrevenue minus expenses
$1.8M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 8%Medicare 7%Other / private 85%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$296per resident / day
operating cost
$8,990per month
≈ monthly operating cost
$327per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.

Typical monthly cost in Virginia
$10,250/mo
Nursing home (semi-private)
$11,680/mo
Nursing home (private)
$6,945/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495270. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-09-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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