No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Summit Square

501 Oak Avenue, Waynesboro, VA 22980 · Non profit - Corporation · 18 certified beds · (540) 941-3100 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Nov 2023Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$50,021 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $50,021 in federal fines (most recent 2025-02-07)
  • its payroll-based staffing score sits well above its independent inspection score

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.

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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
428 S Magnolia Ave · (540) 949-8241 · Call to confirm hours
Pharmacy
436 S Linden Ave · (540) 949-8211 · Call to confirm hours
Grocery
1211 W Broad St · (540) 943-4087 · Call to confirm hours
Park
700 S Magnolia Ave · (540) 942-6735 · Typically dawn to dusk
Place of worship
322 S Poplar Ave

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 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 rating4★
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 increased25.8%14.9%15.4%worse
Long-stay residents who lose too much weight3.1%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.4%1.6%2.0%worse
Long-stay residents with depressive symptoms0.0%18.7%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.6%3.3%better
Long-stay residents on antianxiety or hypnotic medication30.6%20.6%18.9%worse
Long-stay residents with pressure ulcers6.7%4.7%4.7%worse
Long-stay residents with worsening bladder/bowel control26.4%21.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.3%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.3%1.4%better
Short-stay residents given the seasonal flu vaccine46.3%73.6%79.4%worse
Short-stay residents rehospitalized after admission22.3%22.3%22.6%typical
Short-stay residents with an outpatient ER visit14.1%11.5%12.0%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

63.6% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.6%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
63.6%U.S. median 56.6%
Met the expected recovery
2.04U.S. median 0.31
Therapy hours / resident / day
1.10hours / resident / day
Physical therapy
0.69hours / resident / day
Occupational therapy
0.25hours / resident / day
Speech therapy

Met the expected recovery: 63.6% 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 55 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 2.04 therapist hours per resident per day in 2026Q1 — more than 100% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.6%CMS range 55.4–70.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 5.3–13.210.7%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 discharge63.6%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 discharge67.3%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 discharge63.6%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 discharge100.0%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 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 worsened1.5%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 hospitalization6.5%CMS range 3.0–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 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

1.63
RN hours/ resident / day
1.64
LPN hours/ resident / day
4.17
Aide hours/ resident / day
7.44
Total nurse hours/ resident / day
0.63
RN hoursweekends
47.1%
Total nursing turnover
75.0%
RN turnover

How full it usually is: this home is certified for 18 beds and averages 14.6 residents a day — about 81% occupied, or roughly 3 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 7.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.17 is at or above 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 6.02 hrs/resident/day on weekends vs 8.02 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 2.04 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-12-03)
5
at the previous standard inspection (2023-11-15)

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

Inspection deficiencies

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

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.

27 citations, most serious first. The 13 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2025-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment free of avoidable accident hazards and failed to monitor coffee temperatures to prevent burns, resulting in harm for two residents (Resident #4- R4 and Resident #2-R2) in a survey sample of five residents. These findings led to the identification of Immediate Jeopardy (IJ) and the identification of Substandard Quality of Care. The findings included: On 2/5/25, during a review of facility documentation, it was noted that on 6/13/24, Resident #4 (R4) was served coffee which resulted in a burn to her lip and roof of her mouth, requiring hospitalization. On 2/5/25, a closed record review was conducted of R4's chart. This review revealed that a Hot Liquid Risk Assessment had been completed on five occasions in 2023 and four times in 2024. The most recent assessment prior to the burn incident on 6/13/24, was completed on 5/23/24, and noted that R4 had tremors in upper extremities that create risk for spillage and weakness in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-02-07 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide beverages at a safe temperature to prevent injury, which resulted in harm for two residents (Resident #4 - R4 and Resident #2 - R2) in a survey sample of five residents. The findings included: 1. For Resident #4 (R4), the facility staff served coffee at a temperature that resulted in significant burns and scalding, which developed into a life-threatening injury that required hospitalization and the surgical placement of a feeding tube. On 2/5/25, during a review of facility documentation, it was noted that on 6/13/24, Resident #4 (R4) was served coffee which resulted in a burn to her lip and roof of her mouth, causing hospitalization. On 2/5/25 a closed record review was conducted of R4's chart. This review revealed a Hot Liquid Risk Assessment completed on 5/23/24, which noted R4 had tremors in upper extremities that create risk for spillage and weakness in upper extremities that create a risk for spillage. The recommendations…

    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
  • Actual harm · G2025-02-07 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record reviews, and facility documentation review, the facility staff failed to implement and maintain an effective quality assurance and performance improvement (QAPI) program, and failed to provide evidence necessary to demonstrate compliance with these requirements, which resulted in harm for two residents (Resident #2 and Resident #4) in a survey sample of five residents. The findings included: On 2/5/25 at 11:40 a.m., an observation was conducted of the on-unit kitchenette where the coffee is prepared. The cook (other employee #1- OE #1) was observed taking the temperature of food items, which included the soup at 174 degrees farenheight and hotdog chili that was 175 degrees farenheight. The cook did not obtain any temperatures of the beverages being served. The coffee maker was noted to have a digital display that read, Ready to Brew. Water temp: 200 degrees. The dietary staff were observed to pour and serve coffee directly from the coffee pot in which it was brewed. 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-03 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in a sanitary manner in the main kitchen and on the on-unit kitchen on the one nursing unit having the potential to affect many residents on the one healthcare unit. The findings included:12/1/25 at 6:02 pm, an observation was conducted of the galley kitchen, located on the healthcare unit. Upon entering the galley kitchen, it was observed that on the beverage table there were 3 partial loaves of bread, open without any date as to when it was opened or to be used by. In the reach-in freezer there was a large container of ice cream that was open to air and had no indication of when it had been opened or was to be used by. There was a smaller metal container with multiple cream-colored cubes in it, wrapped in saran wrap and had no label to indicate the contents, date prepared, or date to be used. The server/cook (Other employee #1- OE #1) stated that it was butter. OE #1 said everything needs to be labeled to make sure everything is safe and in date 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of fourteen residents in the survey sample (Resident #2).The findings include:Resident #2 was admitted to the facility with diagnoses that included diabetes, congestive heart failure, insomnia, neuropathy, osteoarthritis, asthma, anemia and chronic kidney disease. The minimum data set (MDS) dated [DATE] assessed Resident #2 as cognitively intact.On 12/2/25 at 4:38 p.m., Resident #2 was interviewed about any sleeping problems. Resident #2 stated sound sleep at times was an issue. Resident #2 stated interventions provided to assist with sleep included leg elevation in the evening, cool wraps to legs and the medication Trazadone. Resident #2 stated these interventions had been helpful with improving sleep problems.Resident #2's clinical record included a physician's order dated 11/21/25 for the medication Trazadone 125 milligrams (mg) with instructions to administer at each…

    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 before2025-12-03 · 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

    Based on observation, staff interview, facility document review and clinical record review, the facility failed to label a medication according to the physician's order for one of five residents in the medication pass observation (Resident #19).The findings include:A medication pass observation was conducted on 12/1/25 at 7:15 p.m. with licensed practical nurse (LPN #1) administering medications to Resident #19. Included in medications administered was escitalopram 15 milligrams (mg). The 15 mg escitalopram dose included two tablets. One tablet was from a pharmacy supply card labeled escitalopram 10 mg with instructions to give one tablet at bedtime for anxiety. The second tablet was from a pharmacy card labeled escitalopram 5 mg with instructions to give one tablet at bedtime for anxiety. Review of Resident #19's clinical record revealed a physician's order dated 11/24/25 for escitalopram 10 mg with instructions to give 1.5 tablets at each bedtime for anxiety.On 12/2/25 at 10:43 a.m., LPN #2 caring for Resident #19, was interviewed about the discrepancy between the escitalopram…

    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 · D2025-12-03 · 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, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #1-R1) in a survey sample of fourteen residents. The findings included:For R1, the facility staff failed to maintain a complete clinical record to include hospital discharge records and visits with an outside provider, the urologist. On 12/2/25, review of the facility submitted Resident Matrix R1 was noted to be on an antibiotic. R1 was then selected for review of the facility's antibiotic stewardship program. On 12/2/25 at 9:40 am, during an interview with the facility's infection preventionist, who was registered nurse #1 (RN#1) and the director of nursing (DON), R1 and his antibiotic use was discussed. Both RN #1 and the DON reported that R1 had been hospitalized and diagnosed with an urinary tract infection and was admitted to the facility's healthcare unit following discharge from the hospital. They went on to report…

    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 before2025-12-03 · 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

    Based on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene between residents during a medication pass observation on one of one unit.The findings include:On 12/1/25 starting at 7:00 p.m., a medication pass observation was conducted with licensed practical nurse (LPN #1) administering medications to three residents. On 12/1/25 at 7:00 p.m., without prior hand hygiene, LPN #1 prepared and administered oral medications to Resident #9. LPN #1 touched and disposed of Resident #9's medication cup prior to exiting the room. Without performing hand hygiene, LPN #1 then prepared and administered oral medications to Resident #4. While administering medications to Resident #4, LPN #1 handled the resident's personal thermal mug in addition to the used medication cup. Without performing hand hygiene, LPN #1 then prepared and administered oral medications to Resident #19. On 12/1/25 at 7:21 p.m., LPN #1 was interviewed about the lack of hand hygiene between contact with multiple residents during the medication pass. LPN #1 stated, I…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-07 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and employee record reviews, the facility staff failed to provide QAPI (Quality Assurance and Performance Improvement) training to 9 of 9 sampled employees reviewed for educational requirements. The findings included: On 2/6/25, a sample of nine employees was selected from a listing of current staff. The sample included management staff, CNAs (certified nursing assistants), LPNs (Licensed practical nurses) and RNs (registered nurses). The facility administrator was given the names of the nine sampled staff and was asked to provide all education and in-service training for those employees to include evidence of QAPI training. On 2/7/25, the facility provided a transcript for an electronic training system for the sampled employees. These documents were reviewed and revealed that none of the 9 sampled employees had received any training with regards to the elements and goals of the facility's QAPI program. During a meeting held at approximately 10:35 a.m., on 2/7/25, the facility Administrator, Director of Nursing, and corporate staff were made aware that there…

    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
  • Potential for harm · E2025-02-07 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility staff failed to post the results of the most recent survey results in a place readily accessible to residents and families having the potential to affect multiple residents on one of one unit. The findings included: On 3/31/25 at 4:45 p.m., observations were conducted on the one healthcare unit. Upon entry to the unit there was a wall pocket that held a three-ring binder. The cover of the binder read, [facility name redacted] 2022-2023 Virginia State Survey Results. Within the binder were survey results, the most recent survey report was dated 11/15/2023. On 4/1/25 at 8:56 a.m., observations were conducted of the survey results binder. There were no results from the survey conducted February 7, 2025, in the binder. On 4/1/25 at 10:36 a.m., an interview was conducted with the facility administrator. When asked about the survey results, the administrator said, [executive director's name redacted] spoke about survey results at his last meeting with all the residents and those minutes were sent to all the resident's family member.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-07 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 reviews, the facility staff failed to effectively administer in the facility in a manner to prevent accident hazards, which resulted in the identification of immediate jeopardy and substandard quality of care during the survey, that had been identified during a prior survey and not corrected, having the potential to result in more than minimal harm for many residents residing on one of one units. The findings included: The facility administrator, who was responsible for monitoring and ensuring ongoing compliance to provide an environment free of accident hazards, failed to effectively administer the facility in a manner to ensure residents were not at risk for injury from hot liquids. During the survey conducted 2/5/25-2/7/25, the facility was determined to be in immediate jeopardy due to the lack of monitoring of the temperature of hot liquids, which resulted in harm when two residents suffered injury from spilled coffee.…

    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
  • Potential for harm · D2025-02-07 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident interviews, and staff interviews, the facility staff failed to serve meals in the dining room in a manner to promote dignity affecting three residents (Resident #106, Resident #107 and Resident #108) out of a survey sample of eight residents. The findings included: The facility staff failed to serve the residents sitting at the same table at the same time. On 3/31/25 at 12:00 p.m., an observation was made in the main dining room at lunchtime of the residents being served their meals. Resident #105 was observed at 12:03 p.m., at the table with two other residents, and she received her lunch meal, ate and was leaving the table before Resident #106, and Resident #107 was served their meals. Resident #108 was observed at the table waiting for the other residents to be served before she began eating her meal. On 3/31/25 at 12:10 p.m., Resident #106 was interviewed. Resident#106 said, [Resident#107's name redacted], maybe we will get some more help. Resident #106 said, I am hungry, but patience is a virtue. Registered nurse RN#2 came by the table and said,…

    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 · D2025-02-07 · 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, staff interviews and facility documentation, the facility staff failed to post daily staffing information on 1 of 1 unit. The findings included: The facility staff failed to post the daily staffing information for residents and visitors to be able to view. On 2/7/25 at 9:27 a.m. during a walkthrough of the nursing facility the surveyor observed that the daily staffing posting was dated 2/6/25. On 2/7/25 at 9:30 a.m. an interview was conducted with the unit manager, who was a registered nurse (RN #1). When asked about the purpose of the daily staffing posting, RN#1 stated, Because it is regulation and so families know who we have in here. The unit manager identified a staff member as being responsible for it and reported that she posts it daily when she arrives at 7:30 a.m. During the above interview, the facility administrator walked in, was notified of the concern, and was invited to also confirm the finding. On 2/7/25 at approximately 9:35 a.m., the surveyor was accompanied by the unit manager and facility administrator back to the lobby where it 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-02-07 · tag F0941 — isolated
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and facility documentation, the facility staff failed to provide effective communications training for one employee (the social worker), in a survey sample of nine employee records reviewed. The findings included: The facility staff failed to have credible evidence of effective communication training for the social worker. On 2/6/25, a sample of nine employees was selected for review of training requirements, as part of the extended survey. The list of employees was given to the facility administrator, and they were asked to provide evidence of the staff training to include the area of effective communication. On 2/7/25, the employee records were reviewed. It was noted that the facility's social worker had no evidence of having received training for effective communication. On 2/7/25 at approximately 10:35 a.m., the above findings were reviewed with the facility administrator, director of nursing and corporate staff. On 2/7/25, in the afternoon, the facility administrator stated they had nothing further to provide the survey team. No additional information…

    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
  • Potential for harm · D2025-02-07 · tag F0949 — failed to train staff on dementia and abuse — isolated
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, staff record review, and facility documentation review, the facility staff failed to provide behavioral health training to two of nine employees. The findings included: For other employee #1 (OE #1) and other employee #6 (OE #6), the facility staff had no credible evidence of the employees having received behavioral health training. On 2/6/25, a sample of nine employees was selected for review of educational requirements as part of the extended survey review. The facility administrator was given the list of employees selected for review and was asked to provide evidence of their educational training to include behavioral health training. On 2/7/25, the facility provided the surveyor with the employee training records. This review revealed no evidence that either OE #1 or OE #6 received any behavioral health training. According to the facility assessment, which was last reviewed on 2/4/25, the facility provides care for residents with mental health and behavioral needs. Section 2: Services and Care We Offer Based on Residents' Needs read in part, . Mental…

    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
  • Potential for harm · E2023-11-15 · tag F0607 — failed to have anti-abuse policies — pattern
    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, employee record review, and facility document review, the facility failed to follow and implement their abuse employee screening policy. Criminal background checks through the Virginia State Police (VSP) and/or sworn statements for five of 20 employees reviewed were not obtained. The findings include: During an employee record review conducted on 11/15/23, there was no documentation to indicate that five employees had completed a required Virginia state police (VSP) background check and/or Sworn Disclosure Statements prior to hire. On 11/15/23 at 11:45 AM, the human resource manager (other staff, OS#1) identified the employees as agency nursing staff and verbalized she hadn't received much guidance on agency staff requirements, but will find out more information. On 11/15/23 at 2:59 PM, OS#1 verbalized that sworn disclosure statements and VSP background checks are credentials we get from them (employees) prior to coming to work. A policy titled Abuse, Neglect, Exploitation & Misappropriation HC [Health Care] read in part, Screening: persons applying 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-15 · 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 staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for one of eleven residents in the survey sample (Resident #17). The findings include: Resident #17's (R17's) MDS (minimum data set) dated 9/19/23 inaccurately coded R17 as discharged to the hospital, when he was actually discharged to an assisted living facility. R17 was admitted with diagnoses that included coronary artery disease, atrial fibrillation, ulcerative colitis, colonic polyps, hyperlipidemia, hypertension, and dementia. The MDS dated [DATE] assessed R17 with severely impaired cognitive skills. R17's clinical record documented a Discharge MDS dated [DATE]. Section A2100 of this MDS for discharge status documented that R17 was discharged to an acute care hospital. A nursing note dated 9/19/23 documented that R17 was discharged to an assisted living facility, accompanied by family. On 11/15/23 at 10:40 am, the registered nurse MDS coordinator (RN#1) responsible 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 · D2023-11-15 · 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, the facility staff failed to administer oxygen as ordered by the physician for one of eleven residents in the survey sample (Resident #11). The findings include: Resident #11 (R11) had oxygen administered at 3.5 lpm (liters per minute) and 4.0 lpm when the physician's order and plan of care required 2 lpm. R11 was admitted to the facility with diagnoses that included COPD (chronic obstruction pulmonary disease), depression, hypothyroidism, emphysema, polyneuropathy, protein-calorie malnutrition, contractures, and anxiety. The minimum data set (MDS) dated [DATE] assessed R11 with moderately impaired cognitive skills. On 11/14/23 at 4:33 p.m., R11 was observed in bed with oxygen administered at 3.5 lpm from an oxygen concentrator. R11 was observed on 11/15/23 at 8:44 a.m. with oxygen administered at 3.5 lpm. R11's clinical record documented a physician's order dated 10/12/21 for oxygen administration via nasal cannula at 2 lpm continuously. 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 · Dcited before2023-11-15 · 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

    Based on observation, facility document review and staff interview, the facility staff failed to follow infection control practices for hand hygiene during a medication pass on one of one nursing units. The findings include: A medication pass observation was conducted on 11/14/23 at 7:41 a.m. with licensed practical nurse (LPN) #1. LPN #1 prepared and administered medications to Resident #7. After the oral medications were administered, LPN #1 discarded Resident #7's used water cup, opened the window blinds and then exited the room. Without prior hand hygiene, LPN #1 prepared the medications for the next resident in the pass. On 11/14/23 8:18 a.m., LPN #1 was interviewed about hand hygiene after administering medicines to Resident #7 and touching his used cup. LPN #1 stated hands were supposed to be washed or sanitized after each resident. On 11/15/23 at 10:26 a.m., the director of nursing (DON) was interviewed about hand hygiene between residents during medication administration. The DON stated the infection policies included a requirement to perform hand hygiene after contact 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility document review, and clinical record review, the facility staff failed to offer a pneumococcal vaccine and provide education about the vaccine to one of five residents reviewed for immunizations. The findings include: Resident #8, residing in the facility for over eight months, had not been educated about or offered a pneumococcal vaccination. On 11/15/23, five residents were reviewed for compliance with immunization protocols as part of the infection control task. During this review, Resident #8's clinical record documented no pneumococcal immunization status. The record documented no evidence that Resident #8 had been educated about the vaccine or offered the vaccine since his admission. There was no documentation regarding consent or refusal of the immunization. On 11/15/23 at 10:33 a.m., the registered nurse infection preventionist (RN #1) and director of nursing (DON) were interviewed about Resident #8's pneumococcal immunization status. RN #1 stated they would review and advise regarding Resident #8's pneumococcal vaccination status. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-10 · 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 interview, clinical record review, and facility document review the facility staff failed to follow professional standards of care for 2 of eleven residents in the survey sample, Resident 14 and #10. Resident #14 was not accurately monitored for bowel elimination. During a medication pass observation, a nurse removed a lidocaine patch from the original packaging and left it in Resident #10's room after the resident requested to have the patch at a later time. Approximately 1.5 hours later, the patch was found in the unit's shower room and had not been applied to the resident. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included overactive bladder, mxed irritable bowel syndrome, depression, anemia, muscle weakness, and hypertension. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #14 as moderately impaired for daily decision making with a score of 10 out of 15. Under Section…

    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 · E2022-03-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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, facility document review and clinical record review, the facility staff failed to assess and implement interventions for prevention/care of pressure ulcers for one of eleven residents in the survey sample, Resident #8. For over two months, physician ordered treatments of Resident #8's pressure ulcers were not implemented and facility staff failed to thoroughly assess and provide routine monitoring of the wounds. Resident #8 acquired new pressure ulcers after weeks without routine skin assessments/body audits. The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism, COPD (chronic obstructive pulmonary disease), gastroesophageal reflux disease, severe protein-calorie malnutrition, polyneuropathy, major depressive disorder, sacral pressure ulcer and chronic pain. The minimum data set (MDS) dated [DATE] assessed Resident #8 as cognitively intact and a requiring the extensive assistance of one person for bed mobility…

    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 · E2022-03-10 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    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 resident interview, staff interview and clinical record review, the facility staff failed to ensure four of eleven residents were free from unnecessary medications, Resident #3, #16, #6 nd #15. Resident #3 had physician orders for an antianxiety medication beyond the 14-day limit and without a specified duration. Residents #16 and #6 had no attempted gradual dose reduction of psychotropic medications and no rationale to decline reduced doses. Facility staff failed to respond to a pharmacy recommendation to discontinue a prn (as needed) order of lorazepam in a timely manner for Resident #15. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia with behaviors, delusional disorder, anxiety, myocardial infarction, heart failure, hypothyroidism, diabetes, chronic pain and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed Resident #3 with severely impaired cognitive skills. Resident #3's clinical record documented a physician's order…

    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 · Ecited before2022-03-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility policy review, the facility staff failed to store food in a sanitary manner on one of one nursing unit and in the main kitchen. Milk and homemade food items were stored in the unit's nourishment refrigerator with no date or resident name. The findings include: On 3/8/22 at 11:20 a.m., accompanied by the certified dietary manager (other staff #2), the food storage areas for the main kitchen were inspected. In the dry food storage area was a plastic container of brown rice, a container of wheat flour and a container of breadcrumbs. The food items were not in their original packaging. The plastic container of brown rice was dated 4/30/19. The containers of flour and breadcrumbs were not labeled with a date opened or use-by date. When the top was removed from the brown rice container, the rice had a rancid-type smell. The dietary manager was interviewed at this time about storage of the rice, crumbs and flour. The dietary manager stated the 4/30/19 date written on the brown rice container was the day the rice was opened/removed from 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-10 · 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 staff interview and facility document review, the facility staff failed to provide advance notice of Medicare non-coverage for one of three residents reviewed regarding beneficiary notification protection. Resident #5 was not provided notice of Medicare non-coverage. The findings include: The facility's notifications of Medicare non-coverage were reviewed on 3/9/22. The facility documented on the review sheet that Resident #5's skilled Medicare part A services began on 8/12/21 and the last day of part A services was 9/13/21. This form indicated that no notification about the non-coverage was provided to the resident or the resident's representative. The explanation documented about the lack of notification was unable to locate. On 3/9/22 at 4:06 p.m., the facility's social services director (other staff #1) was interviewed about the lack of notification of Medicare non-coverage for Resident #5. The social services director stated she started working at the facility in October 2021 and this occurred prior to her hire date. The social services director stated she looked 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-10 · 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 observation, staff interview, facility document review and clinical record review, the facility staff failed to label medications stored in one of one medication cart. Three bottles of eye drops stored in the unit's medication cart had no pharmacy label and no label indicating date opened. The findings include: On [DATE] at 8:25 a.m., accompanied by registered nurse (RN #1), the unit's medication cart was inspected. Stored in the cart were the following: Timolol 0.5% eye drops, Azopt 1% eye drops and Latanoprost 0.005% eye drops. There was no pharmacy label on any of the eye drops indicating a resident name or dosing instructions for administration. The bottles had no legible date opened written on the bottles. RN #1 was interviewed at this time about the eye drops with no label. RN #1 stated the eye drops were found in the Resident #10's belongings after admission. RN #1 stated the drops were expensive and the resident wanted to use them instead of wasting them. When asked about the eye drops stored…

    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 · Dcited before2022-03-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to offer the influenza vaccine, and failed to document education and/or refusal for the vaccine, for one of five resident records reviewed, Resident #15. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD), hypothyroidism, hyperlipidemia, hypertension, gait abnormalities, muscle weakness and depression. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #15 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #15's clinical record was reviewed for the immunization status of influenza (flu), pneumonoccocal, and COVID vaccines on 3/10/22. Documented under the Immunization tab of the electronic health record (EHR) was the following, Influenza - High Dose/Quad Date Given: 11/7/2019. The EHR also included Resident #15's official immunization record uploaded from 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.

    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

$50,021 in federal fines across 1 penalty.

  • $50,021 — penalty dated 2025-02-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
LYONS, JOSHUAIndividualW-2 MANAGING EMPLOYEEsince 03/01/2022
ROWE, JAMESIndividualCORPORATE DIRECTORsince 04/30/2010

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$2.8M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$429K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 2%Medicare 21%Other / private 78%

This home reported $429K 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

$1,556per resident / day
operating cost
$47,316per month
≈ monthly operating cost
$462per 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 495405. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, 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.

What to do next