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Waverly Rehabilitation And Healthcare Center

456 E Main St, Waverly, VA 23890 · For profit - Partnership · 120 certified beds · (804) 834-3975 Medicare & Medicaid certified

Call the home — (804) 834-3975 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2026
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (72%) runs well above the national median (45%)
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
109 Railroad Ave · (757) 899-3521 · Call to confirm hours
Pharmacy
328 W Main St · (804) 429-8602 · Call to confirm hours
Grocery
210 N County Dr · (804) 943-9697 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased8.3%14.9%15.4%better
Long-stay residents who lose too much weight12.1%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms32.2%18.7%6.5%worse 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 injury3.9%3.6%3.3%worse
Long-stay residents whose ability to walk worsened11.1%15.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.4%20.6%18.9%worse
Long-stay residents given the seasonal flu vaccine98.2%94.0%95.3%typical
Long-stay residents with pressure ulcers5.2%4.7%4.7%typical
Long-stay residents with worsening bladder/bowel control24.7%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.6%14.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.4%1.3%1.4%worse
Short-stay residents given the seasonal flu vaccine51.4%73.6%79.4%worse
Short-stay residents rehospitalized after admission22.8%22.3%22.6%typical
Short-stay residents with an outpatient ER visit12.9%11.5%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.011.521.67worse
Long-stay outpatient ER visits per 1,000 resident days2.131.481.80worse

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.

42.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.7%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
66.0%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 66.0% 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 47 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% 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 SNF42.7%CMS range 32.8–55.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.5–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.0%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 discharge63.8%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 discharge59.6%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 identified100.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%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 worsened7.6%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 hospitalization7.9%CMS range 4.8–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 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

0.32
RN hours/ resident / day
0.93
LPN hours/ resident / day
1.79
Aide hours/ resident / day
3.03
Total nurse hours/ resident / day
0.16
RN hoursweekends
71.6%
Total nursing turnover
73.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 107.8 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.03 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.61 hrs/resident/day on weekends vs 3.20 on weekdays — 18% thinner on weekends. RN hours go from 0.38 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

1
deficiencies at the latest standard inspection (2023-05-11)
4
at the previous standard inspection (2021-03-11)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2026-05-13 · 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 staff interview and facility documentation review, the facility staff failed to ensure correct completion and acknowledgment of receipt of an insurance Advance Beneficiary Notice [ABN] of Non-Coverage, for one Resident (#1) in a survey sample of 6 Residents.The findings included.For Resident #1 the facility failed to ensure Resident #1 signed and acknowledged receipt of the notice of loss of insurance coverage and her right to appeal the decision.On 5-12-26 at approximately 2:00 PM the business office manager was given the name of the client record required for ABN notices review. She returned with Resident #1's ABN notice which was not dated, nor signed.Page 1 documented Resident #1's name and Effective Date Coverage of Your Current Skilled Nursing Facility Services Will End: 7-14-25. The document informed that a request for immediate appeal should be made as soon as possible but no later than noon on the day before the effective date. The document provided a telephone number to contact QIO Livanta LLC…

    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 before2026-05-13 · 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 staff interview, facility documentation review, and clinical record review, the facility staff failed to protect the resident's right to be free from abuse and neglect for two residents (Residents #3 & #4) in a survey sample of six residents. The findings included. For Resident #3, the facility staff failed to prevent verbal abuse, failed to fully investigate that abuse, failed to report it to the state agency, and failed to train staff timely on abuse after abuse occurred. Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease. The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to investigate, report to the State Agency, and implement the facility abuse policies for two Residents (Residents #3 & #4) in a survey sample of six Residents. The findings included. 1. For Resident #3, the facility staff failed to investigate, report, and implement the facility abuse policies after a staff member witnessed and made an allegation of verbal abuse. Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease. The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or…

    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 · Dcited before2026-05-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 documentation review, and clinical record review, the facility staff failed to report neglect and abuse for two Residents (Residents #3 & #4) in a survey sample of six residents. For Resident #3, the facility staff failed to report an allegation of verbal abuse.The findings included.Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease.The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or wheelchair.On 5-12-26 at 10:30 a.m. Resident #3's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · 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 staff interview, facility documentation review, and clinical record review, the facility staff failed to investigate neglect and abuse for two Residents (Residents #3 & #4) in a survey sample of six residents. For Resident #3, the facility staff failed to conduct a thorough investigation of an allegation of abuse.The findings included.Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease.The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or wheelchair.On 5-12-26 at 10:30 a.m. Resident #3's electronic clinical record was reviewed. Nursing, Social work, and physician Progress…

    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 · D2024-04-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 Observation, Resident interview, staff interview, and facility document review, the facility staff failed to provide the appropriate size adult brief for one Resident (Resident #1) in a survey sample of 3 Residents. The findings include: For Resident #1, the facility staff applied an adult incontinence brief that was too small for the Resident causing discomfort and spilling of waste onto the Resident's bed Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded…

    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 before2024-04-10 · 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 staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication administration in nursing practice for two Residents(Residents #1 and # 3) in a survey sample of 3 Residents. The findings included: 1. For Resident #1, the facility staff failed to check finger stick blood sugar (FSBS), and failed to administer insulin for an insulin dependent Resident with Diabetes. Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such…

    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 · D2024-04-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to prevent significant medication errors for one Resident (Residents #1) in a survey sample of 3 Residents. The findings included: For Resident #1, the facility staff failed to check finger stick blood sugar (FSBS), and failed to administer insulin for an insulin dependent Resident with Diabetes Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, facility document review, clinical record review, staff interview, and Resident interview the facility staff failed to follow the menu and preferences of two Residents (Resident #1, and #2) in the survey sample of 3 residents. The findings included: 1. For Resident #1, the tray ticket, and menu, were not followed for the lunch meal on 4-9-24. Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-13 · 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 observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for medication administration for 1 resident, Resident #1, in a survey sample of 3 residents. The findings included: For Resident #1, facility staff failed to administer, and/or document medications as administered, as ordered by the physician on 7/16/23 and 7/26/23. On 11/13/23, Resident #1's clinical record was reviewed and revealed physician orders and medication administration documentation as follows: -Depakote Extended Release, 250mg, ordered to be given once a day at 12:00 PM--missed dose on 7/16/23 and 7/26/23. -Diltiazem HCl Extended Release, 300mg, ordered to be given once a day at 9:00 AM--missed dose on 7/16/23 and 7/26/23. -Lisinopril, 5mg, ordered to be given once a day at 8:00 AM--missed dose on 7/16/23. -Plavix, 75mg, ordered to be given once a day at 8:00 AM--missed dose on 7/16/23. -Hydralazine HCl,…

    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
Show the remaining 15 citations
  • Potential for harm · E2023-05-11 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on document review and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for eight continuous hours per day. This failure had the potential to affect residents who needed the skills of an RN on those days. Findings include: Review of the facility provided Daily Staffing sheets for the weekends in the Centers for Medicare and Medicaid (CMS), quarter one (Q1) (October, November, and December 2022), triggered on the Payroll Based Journal [PBJ] facility reporting for no RN coverage for eight continuous hours on weekends in Q1 showed the following dates without RN coverage: 10/08/22 Saturday -- no RN coverage. 10/15/22 Saturday -- no RN coverage. 10/22/22 Saturday -- no RN coverage. 10/23/22 Sunday -- no RN coverage. During an interview on 05/10/23 at 9:45 AM the Administrator confirmed there were no RN's working on the listed dates. At end of day debriefing on 05/11/23, the Administrator and Director of Nursing were made aware of deficient practice and stated there was no further information to provide.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy, the facility failed to ensure a resident's environment promoted their dignity for two of 18 sampled residents (Resident (R) 8 and R71). Observations revealed urinary catheter bags for two residents were fully visible to other residents and staff during the survey, resulting in the potential for residents to have an undignified living situation. Findings include: 1. Review of R8's undated admission Record, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE], with a subsequent readmission on [DATE]and diagnoses which included Alzheimer's dementia, urinary retention and stage 4 coccyx pressure ulcer. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/20, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility's policy and procedures Advance Directives, the facility failed to ensure the medical record had documentation of discussion with three of three residents reviewed for Advance Directives. Resident (R) 25, R28, R67. Findings include: On 03/09/21 at approximately 2:00 PM during an interview with the Unit Manager (UM) 2 she reported if a resident is a Full Code status, there is no Advance Directive Form completed and placed in the resident's charts. 1. Review of the Electronic Medical Record (EMR), face sheet and physician orders for R25 documented the resident was admitted to the facility 07/19/2018. Further review of the updated face sheet and physician order, dated 11/04/19, documented Full Code status under resident status. Review of the EMR did not reveal a documentation of an Advance Directive discussed with R25. Review of the Significant Change Minimum Data Set (MDS), Assessment Reference Date (ARD) of 07/15/20 for R25. The resident's Brief…

    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 · D2021-03-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Assessment (MDS) for one of 18 sampled Residents (R), R42 was incorrectly assessed as needing assistance with eating meals. Findings include: On 03/10/21 at 12:00 PM, R42 was observed independently eating lunch. R42 was observed sitting in a wheelchair in his/her room with a bedside table placed in front of the wheelchair. Certified Nursing Assistant (CNA)1 was observed serving R42 a lunch tray. CNA1 placed the tray on the bedside table in front of the resident and informed R42 what foods were on the tray During the continued observation, R42 was observed eating the food without any assistance. On 03/10/21 at 12:25 PM, an interview was conducted with CNA1. CNA1 stated R42 was a picky eater and only ate approximately 50% of the food on the lunch tray. CNA1 further stated R42 always eats meals independently and does not need any assistance with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-11 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to post the nurse staffing timely and daily, resulting in the potential for inaccurate information to be presented to residents and visitors. Findings include: During an observation on 03/08/21 at 9:30 AM, the daily nursing staff report posted in the main lobby was dated 03/05/21. During an interview on 03/11/21 at 9:55 AM with the staffing scheduler, she stated she was the responsible person for posting the nurse staffing hours Monday through Friday. She also stated she did not work on the weekends and the staffing hours were not posted on the weekends. The staffing scheduler stated, .I was not aware the hours were to be posted on the weekends. and did not have any completed nursing staff hour postings for the weekend of 03/05/21 - 03/06/21. During an interview on 03/11/21 at 10:05 AM with the Administrator, he stated the facility expectation was that nurse staffing hours are to be posted 7 days a week. He was unable to state why the scheduler had not been informed, or trained, to post them on the weekends.…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2018-06-07 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, and Clinical record review the facility failed to develop and implement a comprehensive person centered care plan for 5 Residents ( Residents #19, #44, #72, #86, and #187) in a survey sample of 25 Residents. 1. For Resident #19 the facility failed to incorporate the focus area of discharge planning in the care plan. 2. For Resident #44 the facility failed to incorporate the focus area of discharge planning in the care plan. 3. For Resident #72 the facility failed to incorporate the focus area of discharge planning in the care plan. 4. For Resident #86 the facility failed to incorporate the focus area of discharge planning in the care plan. 5. For Resident #187 the facility failed to incorporate the focus area of discharge planning in the care plan. The findings included: 1. For Resident #19 the facility failed to incorporate the focus area of discharge planning in the care plan Resident #19, a [AGE] year female, was admitted to the facility on [DATE] with diagnoses that include but are not…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-06-07 · 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 staff interview, resident interview and clinical record review, the facility staff failed to ensure that one resident (Resident # 41) in a survey sample of 25 residents was free from neglect. For Resident # 41, the facility staff failed to ensure enough oxygen was available for her trip to the Pulmonologist on 5/7/2018. The findings include: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only for Activities of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-06-07 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and facility documentation review the facility failed to include correct reporting times in all the facility's abuse policies. The abuse policy provided by the facility from their Nursing Policies and Procedures did not include the correct abuse reporting time frames. The findings included: The abuse policy was requested during the entrance conference on 6/5/18 as part of the survey process. The policy was reviewed on 6/7/18. The policy referenced abuse reporting requirements for a different state. At this time, the policy specific to Virginia was requested. The correct policy was provided by Licensed Practical Nurse B (LPN B). The policy titled Abuse/ Investigative Reporting was dated 11/4/16. The section titled Policy read A licensed nurse will immediately respond to and all allegations and/ or reasonable suspicions of staff to patient, patient to patient, and/or visitor to patient, abuse, neglect, mistreatment, exploitation or any misappropriations of patient property or crime against a patient. The Procedure section read 8. The Administrator and/or…

    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 · Dcited before2018-06-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 documentation review and clinical record review, the facility staff failed to report an allegation of neglect for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to report an allegation of neglect to the State Agency. The facility failed to provide enough oxygen to last to and from a Pulmonologist appointment on 5/7/2018 Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging…

    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 · Dcited before2018-06-07 · 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 staff interview, facility documentation review and clinical record review, the facility staff failed to report an allegation of neglect for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to investigate an allegation of neglect to the State Agency. The facility failed to provide enough oxygen to last to and from a Pulmonologist appointment on 5/7/2018. Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-06-07 · 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 interview, facility documentation review and clinical record review, the facility staff failed to ensure the highest practicable well being for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to ensure transportation to and from doctor's appointments were timely. Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up assistance only 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-06-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to ensure pressure ulcer prevention interventions were in place for 1 resident (Resident #16) of 25 residents in the survey sample. Resident #16 was observed with the heels up cushion (used to prevent pressure ulcers on the heels) was placed under the calves with both heels flat on the mattress. The findings included: Resident #16, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included hyperlipidemia, hypothyroidism, hypertension, congestive heart failure and dementia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/12/18. Resident #16 was coded with a Brief Interview of Mental Status score of 9 indicating severe cognitive impairment and required extensive assistance with activities of daily living. On 6/5/18 at 11:40 a.m., Resident #16 was observed lying in bed. She was verbal but confused. A heels up cushion was placed under the calves…

    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 · D2018-06-07 · 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 resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one resident (Resident # 41) received oxygen as ordered by the physician. For Resident # 41, the facility staff failed to ensure enough oxygen was available to last to and from a doctor's appointment 5/7/2018 (Pulmonologist). Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent to requiring supervision and set up…

    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 · D2018-06-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate record for one resident (Resident # 41) in a survey sample of 25 residents. For Resident # 41, the facility staff failed to document in the clinical record about the resident returning late to the facility and running out of oxygen during an office visit to the Pulmonologist on 5/7/2018. Findings included: Resident # 41, a [AGE] year old female, was admitted to the facility 1/17/2018. Her diagnoses included but were not limited to Sarcoidosis of Lung, Pulmonary Fibrosis, Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease, Stage 3, Edema, Long term use of Steroids, Hypertension and repeated falls. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 5/1/2018. The MDS coded Resident # 41 as having a Brief Interview of Mental Status score of 14, indicating no cognitive impairment. Resident # 41 was coded as ranging from independent 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-06-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to ensure an effective infection control program was in place for 1 resident (Resident #138) of 25 residents in the survey sample. Resident #138 was on contact precautions. Staff was observed to enter the room with a gown but no gloves. The findings included: Resident #138, an [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, hyponatremia, ileostomy, depression, sepsis and abdominal wound. As Resident #138 was new to the facility, a Minimum Data Set assessment had not been completed. She was able to hold a conversation and did not appear to have a cognitive impairment during an interview. On 6/5/18 at 11:25 a.m., the door to Resident #138's room was closed. Outside of the door was a plastic set of drawers that contained masks, gowns and gloves. On 6/5/18 at 11:45 a.m., Licensed Practical Nurse E (LPN E) was asked if Resident #138 was on contact precautions. LPN E stated…

    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

“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 YAD HEALTHCARE — 13 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 3 of 51.7+1.3 vs chain
Health inspection 4 of 52.2+1.8 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 12 homes this chain runs (chain average 1.7★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
WAVERLY OPERATING HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/2022
ALTER, TZVIIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER99%since 03/01/2022
SEELEY, AUDREYIndividualW-2 MANAGING EMPLOYEEsince 03/01/2022
SUKENIK, CHARNEIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 03/01/2022

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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
+16.0%
Operating marginrevenue minus expenses
$670K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 8%Other / private 7%

About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $670K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$268per resident / day
operating cost
$8,138per month
≈ monthly operating cost
$319per 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 495185. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-05-11, 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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