Jamestown Health and Rehabilitation
1811 Jamestown Road, Williamsburg, VA 23185 · For profit - Limited Liability company · 90 certified beds · (757) 229-9991 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.0% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.6% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.8% | 18.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 3.6% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.7% | 15.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.4% | 20.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.9% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.3% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.8% | 73.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 22.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.5% | 11.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.56 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.28 | 1.48 | 1.80 | better |
‡ 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.
59.0% 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 238 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 83.7% 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 86 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 0.34 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.0%CMS range 50.3–64.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.1%CMS range 9.8–16.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 83.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 86.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 80.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 4.0–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 83.9 residents a day — about 93% occupied, or roughly 6 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 3.37 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 1.77 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 3.11 hrs/resident/day on weekends vs 3.47 on weekdays — 10% thinner on weekends. RN hours go from 0.37 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2022-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to mitigate a fall hazard for 1 Resident (Resident #135) and failed to utilize a mechanical lift during a transfer from the wheelchair to the bed for 1 resident (Resident #32) in a sample of 33 Residents, resulting in harm for both Residents. The findings included: 1) Resident #135 fell while left alone in the shower room on 2-4-22 at 5:45 a.m., resulting in a fractured upper femur (hip area). This is harm. Resident #135 was sent out to the emergency room on 2-4-22 after the fall and fracture, and returned on 2-14-22 after a 10 day stay. The fractured hip was deemed inoperable at the hospital, and the Resident was sent back to the facility for convalescence. The Resident was no longer in the facility at the time of survey, and so a closed record review was conducted. The Resident's MDS assessment revealed that the Resident required extensive assistance, or was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation, the facility staff failed to provide routine and emergency drugs and biologicals to 1 Residents, (# 240) in a survey sample of 25 Residents. The findings included: For Resident #240 the facility staff failed to provide the IV Antibiotic ordered on admission, causing the Resident to miss 4 consecutive doses of antibiotic therapy, the facility also failed to provide the Latanoprost eye drops for glaucoma instead having family bring in personal supply to use. On 4/23/24 at 1:25 PM Resident #240 was observed sitting up in wheelchair with his lunch tray in front of him. His IV pole sat near bed with empty iv bag/antibiotic hanging from it. Since Resident #240 was a new admission, he was questioned about his admission process. Resident #240 stated that when he arrived at the facility They didn't have my medicines. When asked to elaborate on that he stated Well I came here, and I missed a few doses of my IV antibiotic because they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed ensure Residents were free from significant medication errors for 2 Residents in a survey sample of 25 Residents. The findings included: For Resident #240 the facility staff failed to administer medications as ordered by physician causing the Resident to miss 4 consecutive doses of antibiotics. On 4/23/24 a review of the clinical record revealed that Resident #240 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Acute Hematogenous Osteomyelitis Left ankle and foot with recent surgery for 5th metatarsal head resection, type 2 diabetes mellitus with CKD (Chronic Kidney Disease) Stage 3A, asthma, glaucoma, systolic and diastolic CHF (Congestive Heart Failure), hypertension, chronic atrial fibrillation, anemia in CKD, obstructive and reflux uropathy, gout, and history of CVA (Cerebrovascular Accident) with deficits. A review of the orders revealed that Resident #240…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 observations, interviews, clinical record reviews, and facility documentation, it was found that the facility staff failed to provide drinks, other than water, consistent with the needs and preferences of one resident in a survey sample of 25 residents. The findings included: For Resident #240, the facility staff failed to provide decaf coffee and tea as the resident has health concerns related to caffeine consumption. On April 23, 2024, at 1:25 PM, Resident #240 was observed in his room, sitting up in his wheelchair with his overbed table in front of him, and his lunch tray was on the overbed table. Resident #240, a new admission, was asked about the admission process. He mentioned encountering a couple of issues, stating, When I was admitted , I was supposed to have a diabetic or heart-healthy diet. I was given a regular diet until Monday (4/22/24), and I am not supposed to have caffeine due to my health conditions. I would like to have coffee and tea, but I need decaf. When questioned if someone from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation, it was determined that the facility staff failed to provide a therapeutic diet as ordered by the physician for 1 Resident (#240) in a survey sample of 25 residents. The findings included: For Resident #240, the facility did not implement the heart-healthy or diabetic diet as ordered by the physician upon admission. On April 23, 2024, at 1:25 PM, Resident #240 was observed in his room sitting up in his wheelchair with his overbed table in front of him, and his lunch tray was on the overbed table. Resident #240, a new admission, mentioned encountering issues with the admission process. He stated, When I was admitted , I was supposed to have a diabetic or heart-healthy diet. I was given a regular diet until Monday (4/22/24), and I am not supposed to have caffeine due to my health conditions. I would like to have coffee and tea, but I need decaf. When asked if someone from the dietary department met with him during admission to discuss…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, clinical record reviews, and facility documentation, it was found that the facility staff failed to ensure residents were provided with necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one resident in a survey sample of 25 residents. The findings included: For Resident #190, the facility failed to provide timely incontinent care for a resident with dementia and incontinence. On April 22, 2024, at approximately 2:00 PM, an interview was conducted with Resident #190's representative, who stated that on July 1, 2023, Resident #190 was found sitting in her wheelchair and was obviously wet and smelled of feces. The representative stated it was evident she had not been changed for a long time. When she complained to staff, she was told, Lunch trays have to be picked up first before we can make rounds to change people. Although interviews with current residents revealed that things are getting better, a review of the grievance log and the Resident Council minutes reflected that during that time frame (June-July 2023), 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.
- Potential for harm · D2024-04-25 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and facility documentation, it was determined that the facility staff failed to ensure that pain management services were provided to residents who required such services, specifically for Resident #190, within a survey sample of 25 residents. The findings included: For Resident #190, the facility staff failed to implement physician orders regarding pain medication / pain management. Resident #190 was admitted on [DATE], with various diagnoses including CKD (Chronic Kidney Disease), DJD (degenerative joint disease) status post right total knee replacement, dementia, depression, anxiety, COPD (Chronic Obstructive Pulmonary Disease), restless leg syndrome, hearing loss, history of breast cancer, history of uterine cancer, and history of scoliosis with spinal fusion. On April 23, 2024, a review of the clinical record revealed that the resident was admitted to the facility on [DATE], with orders that included, among others: - Tramadol HCl Oral Tablet 50 MG: Give 0.5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-12 · tag F0577 — patternAllow 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, Resident interview, and staff interview, the facility failed to post survey results in a place readily accessible to Residents. The findings included: On 05/11/2022 at approximately 10:30 A.M., a resident Council meeting was conducted. There were six residents in attendance. When the group was asked if they knew where the survey results were located, all of the residents in the meeting indicated they did not know where the survey results were located. On 05/11/2022 11:04 A.M., the binder containing the survey results was observed in a glasstop display table in the front lobby. The glass top display was situated in the corner with a chair and a side table on each side. There was approximately 18 clearance to approach the glass top display table which is not wheelchair accessible. Also, the glass top display table had a heavy, glass frame positioned on the top making it difficult to open. The Health survey and Emergency Preparedness survey result binders were both in the case making it difficult to lift either binder out of the display box. On 05/11/2022 at 11:09…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-12 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 documentation review, and clinical record review, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Residents (Resident #9, #81, and #287), in a sample of 5 Residents reviewed for immunizations. The findings included: On 5/10/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following: 1. In Resident #9 electronic health record (EHR) there was no documentation with regards to the pneumonia vaccine status of Resident #9. There was evidence that Resident #9 had refused the flu vaccine for the 2020-2021 flu season. There was no evidence of her being offered the flu shot for the 2021-2022 flu season. Review of the misc. (miscellaneous) tab revealed no evidence of vaccine administration or offering of the vaccine for flu and pneumonia. Review of the Medication Administration Records (MAR) revealed no evidence of the pneumonia or flu immunization being provided to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-12 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and facility documentation review, the facility staff failed to conduct routine COVID-19 testing in accordance with the CDC recommendations for 5 facility staff (RN D, CNA B, CNA D, LPN D and LPN E), who were not up-to-date with COVID vaccinations, in a survey sample of 5 staff reviewed for COVID testing. The findings included: The facility staff failed to conduct routine testing of facility staff who were not fully vaccinated for COVID-19 as per the guidance from CDC and the facility policy. On 5/10/22, during the entrance conference, the facility Administrator was provided a copy of the entrance conference worksheet and asked to submit documentation related to COVID-19 testing, to include the facility's testing plan, log of the level of community transmission, and if there were any testing issues and contact with the local and state health departments with regards to testing issues. On 5/10/22, the facility submitted an employee vaccination matrix and employee testing records for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure a Resident's right to a dignified existence for 1 Resident (#24) in a survey sample of 33 Residents. For Resident #24, the facility staff failed to dress the Resident in her own clothing, and instead dressed her in a hospital gown. The Resident expressed embarrassment and requested her own clothing for appointments and anytime she was out of her room or out of the facility. The findings included; Resident #24's most recent MDS (minimum data set) assessment was dated 3-17-22. The document coded the Resident continent of bowel and bladder, No Cognitive impairment, and required extensive assistance from one staff member for bathing, however, with set up help could dress herself. On 5-11-22 at approximately 11:30 a.m., during Resident Council meeting, the Resident stated her clothing had been removed to the laundry 2 weeks prior and she had not received them back. After the meeting, the surveyor went to the Resident's room and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2022-05-12 · tag F0582 — isolatedGive 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, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #286) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #286, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #286 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill. The findings included: Resident #286, was admitted to the facility on [DATE], for skilled care following a hospitalization for a fall resulting in a right hip fracture. Resident #286 was discharged from a Medicare covered Part A stay on 4/6/22, she remained in the facility. Review of the clinical record revealed the facility staff issued a NOMNC (notice of Medicare non-coverage) which contained 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.
- Potential for harm · Dcited before2022-05-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident interview, staff interview, and clinical record review the facility staff failed to provide one Resident (Resident #28) with a homelike environment, in a survey sample of 33 Residents. For Resident # 28, the facility staff failed to hang a framed picture (a portrait of the resident as a young child drawn by her brother). The findings included: Resident # 28's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/22/2022 was coded as a quarterly assessment. Resident # 28 was coded as having a BIMS (brief interview for mental status) score of 15 indicating no cognitive impairment. Resident # 28 was coded as being totally dependent on one to two staff persons for activities of daily living. On 5/10/2022 at 12: 15 p.m.during the initial tour, there was an observation of a large framed personal picture sitting on the floor behind the wardrobe. It was not hanging up on the wall. A Resident interview was conducted with Resident # 28 who stated her brother drew it (the picture for her as a Christmas gift and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, clinical record review, and facility documentation review facility staff failed to revise the resident's care plan for one resident (Resident 7) in a sample size of 33 residents. Resident #7's care plan was not re-evaluated or additional interventions added related to the ongoing complaints of tooth pain. The findings included: On 05/12/22, at approximately 1:43 p.m. Surveyor E asked Resident 7 how was lunch. Resident 7 stated that he could not eat that. The basis for not being able to eat the lunch as served according to Resident 7 was explained as having been served a piece of beef that was too tough and caused the resident's tooth to hurt. Resident 7 went on to state I could not eat that beef, my tooth is still hurting from trying to eat it. The resident was observed to be eating chocolate candy to supplement the meal that resident felt unable to eat to being too tough. Resident 7 stated he keeps snacks at the bedside because the food is too tough to eat. Resident 7 went on to explain that the food is often too tough and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide care and services based on the professional standards of nursing practice for Two Residents (Resident # 168 & Resident #7) in a survey sample of 33 residents. Findings included: For Resident # 168, the facility staff failed to obtain neurological checks per policy after a fall with a head injury. Resident # 168's diagnoses included but were not limited to: Unsteadiness on Feet, Difficulty Walking, Hypertension, and Syncope. The most recent MDS (Minimum Data Set) was an initial assessment, dated 4/10/2022 was reviewed. Resident # 168 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident # 168 was coded as requiring limited physical assistance of 1 staff person for Activities of Daily Living except required total assistance of one staff person for bathing. Review of the closed clinical record was conducted on 5/10/2022 -5/12/2022. Review of the Progress Notes revealed documentation of: 4/13/2022 a 07:06…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to treat a pressure sore for one Resident (Resident #84) of the 33 residents in the survey sample. For Resident #84, the staff failed to assess, and treat, an unstageable coccyx pressure sore. The findings included; For Resident #84, the staff failed to provide a baseline assessment and treatment for an unstageable coccyx pressure sore from 4-27-22 through 5-3-22 (7 days). Resident #84 was originally admitted on [DATE]. Diagnoses for Resident #84 included but were not limited to; an unstageable coccyx pressure sore. Resident #84's admission Minimum Data Set (an assessment protocol) was not submitted at the time of survey as the Resident was a new admission. Staff stated Resident #84 was completely dependent, on 1-2 staff members for all Activities of Daily Living care. The Resident was incontinent with an indwelling foley urinary catheter for the pressure sore, and able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide consistent oxygen therapy for one Resident (Resident #29) in a survey sample of 33 Residents. The findings included: On 05/10/2022 at 3:30 P.M., Resident #29 was observed in his wheelchair in his room. Resident #29 was receiving oxygen via nasal cannula from the oxygen tank situated on the back of the wheelchair. The oxygen tank gauge indicated the oxygen level in the tank was in the red zone (meaning it was nearly or actually empty). When asked if the oxygen was flowing, Resident #29 removed the nasal cannula and determined there was no airflow coming out of the ports. At approximately 3:40 P.M., Licensed Practical Nurse G (LPN G) and this surveyor entered the room for an observation. LPN G observed Resident #29's oxygen tank and verified the oxygen tank was empty. LPN G checked Resident #29's oxygen saturation level and it was 97%. LPN G then went to get a new oxygen tank. On 05/10/2022, Resident #29's clinical record was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide consistent social services for one Resident (Resident #14) in a sample size of 33 Residents. The findings included: On 05/10/2022 at 12:25 P.M., Resident #14 was observed in bed in her room. During the course of a brief interview, Resident #14 indicated that she was feeling depressed and stated, I got personal problems. Resident #14 also indicated she was on medication for depression. On 05/11/2022, Resident #14's clinical record was reviewed. One medical diagnosis listed for Resident #14 included but was not limited to major depressive disorder. A review of Resident #14's physician's orders revealed an order dated 03/22/2022 for the medication Wellbutrin for depression. The social services notes were reviewed. The most recent social services note was dated 12/28/2020 [over 16 months ago]. A document entitled, Trauma Informed Care Evaluation ([NAME]) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 documentation review, the facility staff failed to adhere to infection control practices to minimize the spread of COVID-19 within the facility based on CDC (Centers for Disease Prevention and Control) recommendations and facility policy, on one of three nursing units, having the potential to affect multiple Residents residing on that unit. The findings included: 1. CNA B, who was not vaccinated for COVID-19 failed to wear an N-95 mask and eye protection while passing meal trays and interacting with multiple Residents. On 5/10/22 and 5/11/22, a review of the staff vaccination record revealed that CNA B had an approved non-medical exemption for COVID-19 and therefore was not vaccinated for COVID-19. On 5/11/22 at 2PM, CNA B, who is not vaccinated for COVID-19, was observed passing meal trays to Residents, wearing a procedure mask and no eye protection. CNA B was interviewed, she stated that the mask she was wearing she had purchased herself because she can't breathe while wearing an N-95 (medical respirator). When asked, what is the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, Resident interviews, staff interviews, and clinical record reviews, the facility staff failed to maintain a functioning call bell system for two Residents (Resident #30, Resident #34) in the sample size of 33 Residents. 1) For Resident #30, the facility staff failed to ensure the call light was functioning on 05/10/2022. 2) For Resident #34 (roommate of Resident #30), the facility staff failed to ensure the call light was functioning on 05/10/2022. Also, the outer covering at the distal end of the call light cord was torn exposing the inner wire insulation. The findings included: 1) On 05/10/2022 at approximately 12:30 PM, Resident #30 was interviewed. When asked about any concerns about the care received at the facility, Resident #30 stated her call light was not working. This surveyor observed Resident #30 press the call button to activate the call light. No overhead sound was made and the central light near Resident #30's room did not light up. Resident #30's most recent Minimum Data Set with an Assessment Reference Date of 03/25/2022 was coded as 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.
- Potential for harm · Dcited before2020-03-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, facility documentation and clinical record review the facility staff failed to maintain the Resident dignity for 1 Resident (#7) in a survey sample of 26 Residents. The findings include: For Resident #7 the facility staff left Resident #7 dressed only in a hospital gown, no incontinence brief, no blanket or sheet and the door open and curtains open. Resident #7 a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to diabetes, chronic kidney disease stage 2, major depressive disorder, dementia and contractures of multiple sites. Resident #7's most recent MDS (Minimum Data Set) labeled as a quarterly assessment, with an ARD (assessment reference date) of 12/9/19, coded Resident #7 as having a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. In the MDS section G - Functional Status the Resident is coded as requiring (4) Total dependence on staff with (2) one person physical assistance 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.
- Potential for harm · D2020-03-05 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, staff interview and clinical record review and facility documentation review, the facility staff failed to accommodate the needs of one Resident (Resident # 46) in a survey sample of 26 Residents. The Findings Include: 1. For Resident # 46, the facility staff failed to ensure the opportunity to vote on 3/3/2020. Resident #46 was admitted to the facility in 2018 with diagnoses that included, but were not limited to: Chronic Obstructive Pulmonary Disease, Diabetes, Gastroesophageal Reflux Disease, Chronic Congestive Heart Failure, and Hypertension. Resident #46's most recent Minimum Data Set (MDS) Assessment was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/21/2020. The Brief Interview for Mental Status (BIMS) coded Resident #46 at 15 out of 15, indicating no cognitive impairment. Resident #46 was coded as requiring limited assistance of 1 person for transfers, bed mobility, ambulation, dressing, and hygiene, and requiring setup and assistance of one staff person for eating. Review of the clinical record was conducted on 3/3/2020 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and clinical record review, the facility staff failed to provide respiratory care according to the professional standards of care for two Residents (Residents # 44 and # 46) in a survey sample of 26 residents. The findings include: 1. For Resident # 44, the facility staff failed to administer oxygen at the rate as ordered by the physician. During the initial tour of the facility on 3/3/2020 at 12:26 PM, Resident # 44 was observed sitting up in bed with oxygen infusing at 1.5 liters per minute via nasal cannula. ON 3/3/2020 at 12:51 PM, after concluding the initial tour, the surveyor went to the nurses station to ask for assistance in Resident # 44's room. An interview was conducted with LPN (Licensed Practical Nurse) A who stated she was not assigned to work with Resident # 44 but could help. LPN A went to Resident # 44's room with the surveyor, looked at the oxygen concentrator and stated the oxygen was infusing at 1.5 liters per minute. When asked how much oxygen was ordered by the physician, LPN A stated she would check the physicians orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-03-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility documentation and clinical record reviews the facility staff failed to ensure Residents were free from unnecessary psychotropic medications for 1 Resident (#5) in a survey sample of 26 Residents. There findings include: For Resident #5 the facility staff failed to address the Pharmacy recommended Gradual Dose Reduction (GDR). Resident #5 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to chronic kidney disease stage III, generalized anxiety disorder, bipolar disorder, major depressive disorder, diabetes and dementia. Resident #5's last MDS (minimum data set) with an ARD (assessment reference date) of 12/9/19, a quarterly assessment coded the Resident as having a BIMS (brief interview of mental status) score of 13 indicating mild cognitive impairment. On 3/5/19 the Aspen program selected this Resident as an unnecessary medication review. Upon review of the clinical record it was discovered that on 11/11/19 the pharmacy recommendation read:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-03-05 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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, facility documentation and clinical record review and in the course of an investigation the facility staff failed to provide laboratory services that were timely for one (resident #133) of 26 sampled residents. The findings included: For Resident #133 the facility staff failed to obtain STAT bloodwork as ordered. Resident # 133 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to acute and chronic respiratory failure, chronic renal failure Stage 3, pain in legs, unsteady on feet, hypertension, Alzheimer's dementia, COPD (Chronic Obstructive Pulmonary Disease) and a history of falls with hip fracture. The Resident's code status was DNR. Resident #133's most recent MDS with an ARD (Assessment Reference Date) of 11/21/19 coded Resident #133 as having a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. On 3/4/20 at approximately 3:00 PM a review of the clinical record was conducted and it was discovered that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-03-05 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide food prepared to conserve appearance for one resident (Resident #69) in a sample size of 26 residents. The findings included: For Resident #69, the facility staff failed to provide grits at his preferred consistency on 3/05/2020. Resident #69, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to paraplegia, chronic kidney disease, major depressive disorder, and generalized anxiety disorder. Resident #69's most recent Minimum Data Set with an Assessment Reference date of 02/17/2020 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Functional status for eating was coded as requiring supervision - oversight, encouragement, or cueing from staff. On 03/05/2020 at approximately 8:45 AM, Resident #69 was observed awake in bed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-03-05 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, clinical record review, and facility documentation review, the facility staff failed to implement an effective infection control & isolation program concerning handwashing during medication pour and pass, and for 3 specific Residents (Residents #284, 70, and #72) in a survey sample of 26 residents. The findings included: 1. For Resident #284, contact isolation precautions were not maintained for a Resident with a communicable infection. On 3-4-2020 at 10:00 a.m., surveyors observed the following incident; An isolation cart was in the hallway by the door of Resident #284. The cart held personal protective equipment (PPE) to be worn by staff entering the room because of a communicable infection in the room. The cart included gloves, gowns, and biohazardous waste red trash bags in a clear rolling cart with 3 drawers. There was a sign which read see nurse before entering. The Registered charge nurse (RN-A) was in the hallway, as was the Activities Director (Employee F), and 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.
- No harm found · B2020-03-05 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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, clinical record review, and in the course of a complaint investigation, the facility staff failed to accommodate for individualized need and preference for two residents (Resident #78 and #2) in a sample size of 26 residents. This happened over multiple days. The findings included: 1. For Resident #78, the facility staff failed to provide a device so he could independently move himself up in bed. Resident #78, a [AGE] year old male, was admitted to the facility most recently on 01/28/2020. Diagnoses included but not limited to displaced fracture of base of neck right femur, epilepsy, muscle weakness, heart failure, and end stage renal failure. Resident #78's most recent Minimum Data Set with an Assessment Reference Date of 02/21/2020 was coded as a quarterly review. The Brief Interview for Mental Status (BIMS) was coded as 14 out of possible 15 indicative of intact cognition. Functional status for bed mobility was coded as requiring limited assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2020-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, staff interview, the facility staff failed to ensure a clean comfortable home environment for two residents (Residents # 65 and # 46) in a survey sample of 26 residents. This happened over multiple days. The Findings Include: 1. For Resident # 65, the facility staff failed to fix a hole in the wall behind the door across from the bed. During the initial tour on 3/3/2020, a large hole was observed behind the door to the room where Resident # 65 resided. The hole measured approximately 8 inches wide and 3 inches tall. On 3/4/2020 at 10:30 AM, an interview was conducted with Resident # 65 who stated she didn't like seeing the hole behind the door. Resident # 65 stated she complained about it a few weeks before but the Maintenance Director works on his own schedule. Resident # 65 stated there had been a hole in the wall behind her bed that was not fixed for several weeks. Resident # 65 stated the hole behind the bed was even more upsetting than the hole behind the door. Resident # 65 stated the hole behind the door was obvious when the door 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AVARDIS HEALTH — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.0 | +2.0 vs chain |
| Health inspection | 3 of 5 | 1.9 | +1.1 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 3.2 | +1.8 vs chain |
The other 37 homes this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WILLIAMSBURG PARENTCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2025 |
| JAMES CITY HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2025 |
| VAOP HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/01/2025 |
| HOBACK, TIFFANY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| MORGAN, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| SNF MGR LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/18/2025 |
| ADAMS, SEBASTIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| JONES, TEQUILLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| REID, LORI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| WALTERS, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% 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 $516K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in VA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 495190. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-25, 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.