Woodhaven Hall at Williamsburg Landing
5500 Williamsburg Landing Dr, Williamsburg, VA 23185 · Non profit - Corporation · 73 certified beds · (757) 258-2196 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $36,374 in federal fines (most recent 2026-02-27)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 3 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 18.7% | 14.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.2% | 5.4% | 5.4% | better |
| 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 | 2.0% | 1.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.0% | 18.7% | 6.5% | check this* — see note marked star 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 | 5.5% | 3.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.2% | 15.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.7% | 20.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 72.7% | 94.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 0.7% | 4.7% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.8% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.6% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.1% | 73.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 19.1% | 22.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 17.6% | 11.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.40 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.11 | 1.48 | 1.80 | better |
* 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.
61.6% 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 182 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 24.1% 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 116 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 61.6%CMS range 54.8–68.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.5–12.8 | 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 | 24.1% | 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 | 43.1% | 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 | 20.7% | 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 | 99.3% | 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 | 75.0% | 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 | 98.9% | 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 | 2.0% | 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 | 2.0% | 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 | 6.7%CMS range 3.4–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 73 beds and averages 40.8 residents a day — about 56% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 5.40 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.90 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 4.73 hrs/resident/day on weekends vs 5.68 on weekdays — 17% thinner on weekends. RN hours go from 1.39 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% 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
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.
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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-02-27 · 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 observation, interview, record review, and policy review, the facility failed to provide supervision and ensure resident safety for two of six Residents (Resident (R)14 and R59) reviewed for elopement. As a result, R14 and R59, who had been assessed as an elopement and fall risk with moderate cognitive impairment, exited the facility without staff knowledge. R14 was found sitting in the parking of the facility next to his wheelchair with a bruised laceration under his right eye and eloped a second time. R59 also eloped from the facility two times, with one of the times being found a mile from the entrance of the facility. This had the potential to result in serious injury, harm, impairment, or death. This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care. On 02/26/26 at 7:14 PM, the Administrator was notified that Immediate Jeopardy (IJ), which also constituted Substandard Quality of Care (SQC), was identified at F689 at a Scope and Severity (S/S) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-02-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure the dish machine wash and rinse temperature was at the proper temperature to sanitize the dishes. This had the potential to affect 44 of 44 skilled nursing residents who consumed food from the kitchen. Findings include:During an observation on 02/26/26 at 12:25 PM, revealed the dishwasher wash and rinse cycle's temperature was registering 158 degrees Fahrenheit (F) for the wash cycle and 150 degrees F for the rinse cycle from the gauge on the dish machine. A second temperature monitor mounted on the wall and connected to the dish machine registered the wash cycle at 155 degrees F and 188.8 degrees F for the rinse cycle. The monitor is designed to alert staff for any temperatures that are out of range. There had been no alerts on the monitor. Due to the discrepancy, the Executive Chef (EC) used an internal thermometer inside the machine to check water temperature. The internal thermometer registered 151.4 degrees F. 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 · D2026-02-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy review, the facility failed to ensure residents were protected from potential abuse for one of one resident (Resident (R) 56) reviewed for an injury of unknown origin. R56 was discovered on the floor with signs and symptoms of pain and was emergently transferred to the hospital for further evaluation. There were no witnesses to the incident, and the resident did not explain the reason he was on the floor and in pain. The facility's failure to identify the incident as an injury of unknown origin caused the resident to be a possible victim of abuse.Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility's on 12/21/23 with diagnoses including dementia and weakness.Review of R56's printed admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Review of a printed Incident/Accident Report, dated 01/03/24, provided…
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 before2026-02-27 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 record review, staff interview, and facility policy review, the facility failed to implement its policies and procedures related to abuse, neglect, and injuries of unknown origin. The facility failed to report an injury of unknown injury and failed to complete an investigation related to an injury for one Resident (Resident (R) 56) of one resident reviewed for potential abuse and neglect out of a total sample of 14 residents. R56 was found on the floor with no witnesses and sustained a right hip fracture requiring surgical repair. This had the potential for abuse as the injury was not reported or investigated. (Cross Reference F609 and F610)Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility's skilled nursing unit on 12/21/23 with diagnoses including dementia and weakness.Review of R56's printed admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment.…
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 · D2026-02-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure that an injury of unknown origin was reported to the State Survey Agency (SSA) immediately but not later than two hours for one of one resident (Resident (R) 56) reviewed for injuries of unknown origin out of 14 sampled residents. This failure placed the resident and other residents who are discovered to have an injury of unknown origin at risk of sustaining injuries that could have been caused by abuse. (Cross Reference: (F600, F607, and F610)Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility on [DATE] with diagnoses including dementia and weakness.Record review of a printed Incident/Accident Report, dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor and complained of right leg pain. The report indicated the incident was unwitnessed and R56 was not interviewed about the incident. On 02/25/26, 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 · D2026-02-27 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure an injury of unknown origin that required an emergent hospital transfer was investigated to determine if the incident was a result of abuse for one of one resident (Resident (R) 56) reviewed for injuries of unknown origin out of 14 sampled residents. The facility's failure to investigate R56's injury of unknown origin to determine if the injury was sustained because of abuse placed the resident at risk of being a victim of potential abuse. (Cross Reference: F600, F607 and F609). Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility on [DATE] with diagnoses including dementia and weakness.Review of a printed Incident/Accident Report dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor and complained of right leg pain. The report indicated the incident was unwitnessed. During an interview on 02/24/26 at 6:33 PM,…
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 · F2022-08-19 · tag F0886 — failed to test for COVID-19 as required — widespreadPerform 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 observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements for 4 out of 6 staff members, staff members #4, #5, #6, and #8, the facility staff failed to maintain documentation of COVID-19 testing occurrences and results for all facility staff, and the facility staff failed to conduct COVID-19 testing for 4 out of 4 newly admitted residents, residents #46, #57, #110, and #209. The findings included: 1. The facility staff failed to conduct expanded screening COVID-19 testing for staff members #4, #5, #6, and #8. On 8/16/22 at approximately 1:00 PM, a group interview was conducted with the Facility Administrator, Director of Nursing (DON), and the Infection Preventionist (IP). The IP stated the facility was currently conducting COVID-19 testing twice per week, on Tuesdays and Fridays, due to the high…
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 · E2022-08-19 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and facility documentation review, the facility staff failed to implement their policy and procedure to ensure that all facility staff were fully vaccinated for COVID-19. The facility staff failed to document the COVID-19 vaccination status for 56 contracted nursing agency staff members who provided direct resident care during the months of June, July, and August 2022. The findings included: On 8/18/22, an interview was conducted with the Facility Administrator and the Infection Preventionist (IP). The IP stated that the Human Resources (HR) department was responsible for all staff COVID vaccinations. A copy of the facility policy was requested and received. An interview was conducted with the HR Director who stated, I do not handle anything with Agency staff, the Clinical Staff Coordinator is responsible for all of that, I do not know any of them [agency staff], I am not involved with following their [COVID-19] vaccination status . An interview with the Clinical Staff Coordinator was conducted and she stated, We use 3 different agencies for nurses and nurse…
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 · D2022-08-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation the facility staff failed to promote and facilitate resident self-determination through support of Resident choices, for 1 Resident (# 110) in a survey sample of 47 Residents. The findings included: For Resident # 110, the facility staff failed to assist the Resident out of bed at approximately 2:00 AM as he requested. On 8/16/22 at approximately 1:30 PM an interview was conducted with Resident #110 and his family member. Resident #110 was admitted to the facility on [DATE] and stated that he had no problems with the facility until Last night. When asked what happened, he stated that had recent hip surgery and often woke up uncomfortable and not able to sleep well. He stated that he wanted to get out of bed and get in his recliner and watch TV hoping the change of position would help his discomfort. Resident #110 stated that he rang his call bell and it was answered by the nurse who told him that he could not get out of bed. When he asked why…
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 · D2022-08-19 · 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
Based on clinical record review and staff interview, the facility staff failed to provide an ABN (Advanced Beneficiary Notice) for one Resident (Resident #54) in a sample size of 3 Residents. The findings included: On 08/17/2022 at approximately 11:45 A.M., the facility staff provided a list of Residents who were discharged from a Medicare covered Part A stay with benefit days remaining. Three Residents on the list were identified and placed in the sample. One Resident that remained at the facility following a discharge from Medicare Part A services with benefit days remaining was Resident #54. On 08/18/2022, Resident #54's closed clinical record was reviewed. A Social Services discharge note dated 03/30/2022 at 11:40 A.M. documented, Writer met with resident and presented NOMNC [Notice of Medicare Non-Coverage] with last cover day by Medicare being April 1, 2022 with a discharge from Medicare A stay on April 2, 2022. Right to appeal was reviewed, and all questions addressed. Resident reported she is going to utilize respite days, and remain at [facility]. There was no evidence an…
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 before2022-08-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for 2 Residents (Resident #43, Resident #113) in a sample size of 47 Residents. 1) For Resident #43, the facility staff failed to revise the care plan for 10 out of 10 falls that have occurred in March and April 2022. 2) For Resident #113, the facility staff failed to review and revise care plan upon discovery of arterial and pressure wounds. The findings included: 1) For Resident #43, the facility staff failed to revise the care plan for 10 out of 10 falls that have occurred in March and April 2022. On 08/17/2022, Resident #43's clinical record was reviewed. According to the progress notes, Resident #43 had 6 unwitnessed falls in March 2022 and 4 unwitnessed falls in April 2022. An excerpt of a nurse's note dated 03/12/2022 at 6:33 A.M. documented, Bed in lowest position, fall mat in place, call bell within reach. Will continue to monitor resident 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.
Show the remaining 21 citations
- Potential for harm · D2022-08-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, facility documentation and during the course of a complaint investigation the facility staff failed to provide care that meets professional standards of care for 2 Residents (# 113 and # 43) in a survey sample of 47 Residents. The Findings included 1. For Resident #113 the facility staff failed to accurately perform an admission assessment to include skin assessment. Resident #113 was admitted to the facility on [DATE]. The admission assessment was performed on 6/15/21 the admission Assessment has many areas that have been left blank excerpts are as follows: Pg. 2 - Height - [area left blank] Weight - [area left blank] Pg. 3- Neurological Hand grasp - [area left blank] Pg. 3 Sleep Sleep Pattern- [area left blank] Pg. 6 - Pulmonary Presence of Sleep Apnea No History of Sleep Apnea [Please note Resident #114 uses a CPAP at night] Pg. 8 - Skin Integrity Skin intact- [area left blank] Skin color - Normal appearance for race Skin temperature - cool Skin…
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 before2022-08-19 · 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 interview, clinical record review and facility documentation the facility staff failed to ensure freedom from accident hazards by providing adequate supervision to prevent accidents, for 1 Resident (# 14) in a survey sample of 47 Residents. The findings included: For Resident # 14 the facility staff failed to ensure the Resident #14 was supervised to prevent falls. Resident #14 has diagnoses that include anxiety disorder, age related osteoporosis, cerebral infarction, dementia with behavioral disturbance, repeated falls, restlessness and agitation, and visual impairment from glaucoma with detached lens. On 8/17/22 a review of the clinical record revealed the following progress note: 8/13/22 11:02 PM - At 5:20 PM Assigned sitter reported to this writer resident fell out of chair and was on the floor Sitter stated she went to get food try [sic] off the cart on the unit and went back to room and found that her wheelchair was flipped over and the resident was laying on right side of her body on the floor…
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 · D2022-08-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interview, facility documentation and clinical record review the facility staff failed to appropriately label and store insulin in one of the two medication carts. The findings included: For one medication cart (located on Annex Hall), Surveyor C found 2 insulin pens opened and undated. On 8/19/22 at approximately 8:00 AM while completing the medication storage task it was noted that 2 insulin pens were not dated when opened. Pen #1 was a Lantus insulin pen opened but not dated, and pen #2 was a Humalog Lispro pen opened but not dated. When Licensed Practical Nurse F (LPN F) was asked about the pens, LPN F stated she thought the meds were brought from home. When asked how you would know when they were opened she stated she would not be able to tell. On 8/19/22 at approximately 10:00 AM an interview was conducted with the Director of Nursing (DON) who stated that insulin is to be dated when opened so that you will know when it expires. We keep insulin only for 28 or 30 days depending on which type of insulin that is why it's important to date the insulin when…
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 · D2022-08-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, clinical record review, facility documentation and in the course of an investigation, the facility staff failed to provide and accurate clinical record for 1 Resident (# 114) in a survey sample of 47 Residents. The findings included: For Resident #114 the facility staff failed to ensure the accuracy of the physician progress notes with regards to wound care. On 8/17/22 at approximately 1:00 PM a review of the clinical record was conducted and the following are excerpts from the physician's progress notes. 6/21/21 Exam Findings - Derm. [Dermatological] - NO Rash - Ulcer. 6/22/21 Right leg edema to the knee - +/- from walking boot too tight but will treat. 6/25/21 Exam Findings - Derm [Dermatological] - NO Rash - Ulcer. 6/28/21 Exam Findings - Derm [Dermatological] - NO Rash - Ulcer. 6/30/21 Boot on RLE [right lower extremity] 2+ pitting edema in LLE, multiple wounds in distal LLE with wound between 4th and 5th phalanges, slough build up noted, extremity is erythematous, but no warmth. A&P Cellulitis vs Osteomyelitis -Start Bactrim DS BID X 7 days. -Evaluate 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.
- Potential for harm · Dcited before2022-08-19 · 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
2. For Resident #158 (on Transmission-Based Precautions), the facility staff failed to post signage to indicate what personal protective equipment (PPE) should be worn prior to entering the room. On 08/16/2022 at approximately 1:05 P.M., this surveyor observed Transmission-Based Precautions (TBP) supplies outside Resident #158's room but there was no signage to indicate what PPE should be worn prior to entering the room. At approximately 1:10 P.M., Certified Nursing Assistant E (CNA E) was observed at nurse's station. When asked about what PPE should be worn prior to entering Resident #158's room, CNA E indicated that all PPE, except eye protection, should be worn upon entering Resident #158's room. On 08/16/2022 at 2:30 P.M., CNA D was interviewed. When asked what PPE should be worn prior to entering Resident #158's room, CNA D explained that all the staff know what to wear because it's all right here and pointed to the TBP supplies on Resident #158's room door. CNA D then noticed one of the pouches on the supply caddy was empty and stated that the masks needed to be replenished.…
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 · D2022-08-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunizations for 3 residents in a survey sample of 5 residents reviewed for pneumococcal vaccination. The facility staff failed to provide pneumococcal immunizations for Residents #8, #14, and #53. The findings included: On 8/18/22, clinical record review was performed for Residents #8, #14, and #53 and revealed no documentation with regard to pneumococcal immunization including the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. The admission dates for these residents include, Resident #8 admitted [DATE], Resident #14 admitted [DATE], and Resident #53 admitted [DATE]. These findings were verified with the Infection Preventionist and stated, we are supposed to assess whether or not a resident has received a [pneumonia] vaccine or not when they are…
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 · D2022-08-19 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and facility documentation review, the facility staff failed to provide COVID-19 immunization for 2 staff members, staff #7 and #8, in a survey sample of 5 staff members reviewed for COVID-19 vaccination. The facility staff failed to provide COVID-19 booster vaccines for staff members #7 and #8. The findings included: On 8/16/22 at approximately 1:00 PM, a group interview was conducted with the Facility Administrator, Director of Nursing (DON), and Infection Preventionist (IP). The IP stated that the Human Resources (HR) department handles all matters involving staff members with regard to COVID vaccination and testing. A staff COVID vaccination matrix and COVID vaccination policies were requested and received. On 8/18/22, staff vaccination records for staff member #7 and #8 were reviewed and revealed the following: Staff member #7, hire date 10/27/20, had completed a primary COVID-19 vaccine series on 3/2/21 but had not received a booster dose. Staff member #8, hire date 6/15/21, had completed a primary COVID-19 vaccine series on 9/17/21 but had not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-05-31 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
12. On 5/29/19 at 12:40 PM while observing lunch in second floor dining room, EMPLOYEE M was observed plating and serving meals. At 12:41 PM while wearing gloves Employee M scratched her face then platted food for cart. After plating the food she took off her gloves and did not wash hands. She then was approached by a staff member who wanted ice cream for a Resident's tray. Employee M scooped the ice cream without washing hands or donning gloves. At 12:42 PM she then put on gloves still without washing her hands, touched the top and sides of food cart while moving it out of her way. She then plated more food and then placed it on the cart then walked away from food prep area came back a minute later and with same gloves on began chopping carrots and chicken for a patient with a chopped diet. At 12:45 PM she removed the gloves and again did not wash her hands. On 5/29/19 in an interview Employee E stated that hand washing is expected before and after using gloves. He also stated that hand washing and glove use is very important in the healthcare setting it should be everyone's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-05-31 · tag F0880 — failed to prevent and control infections — patternProvide 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, facility documentation review, the facility staff failed to maintain infection prevention practices to prevent the potential for transmission of infections involving two residents (Resident #279, 278) in a sample size of 29 residents. The findings included: 1. For Resident #279, the facility staff failed to follow contact precaution protocols on 12/14/2017. Resident #279 was admitted to the facility on [DATE]. Diagnoses for Resident #279 included but are not limited to post-polio syndrome, generalized muscle weakness, and polyneuropathy. Resident #279's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/12/2017 was coded as a discharge assessment. Resident #279's Brief Interview for Mental Status was not coded but Cognitive Skills for Daily Decision-Making were coded as moderately impaired with cues and supervision required from staff. Functional status for bed mobility and transfers were coded as requiring limited…
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 · D2019-05-31 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 assess that the Resident was safe to self-administer medications for two Residents, (Resident #326, Resident #325) in a survey sample of 29 Residents. The findings included: 1. For Resident #326, the facility staff failed to determine that the Resident was safe to self administer medications. On 5/29/19 during initial tour at approximately 11:40am, a 16 oz. bottle of dermal wound cleanser and a 250 ml bottle of normal saline were observed in the bathroom of Resident #326. On 05/30/19 at 05:05 PM observation of the bathroom for Resident #326 revealed the 16 oz. bottle of dermal wound cleanser and a 250 ml bottle of normal saline were still present. On 5/31/19 at approximately 10:05 am CNA C was taken to Resident #326's bathroom and shown the dermal wound cleanser and normal saline. When asked if Resident #326 has a wound, CNA C stated, no she doesn't, maybe she did previously or they have it in there just in case. On 5/31/19 at 10:12am LPN C was taken to the room and show…
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 before2019-05-31 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy. The Findings included: 1. The facility staff failed to verify licensure prior to hire for 4 employees, including the Administrator, one Licensed Practical Nurse, and two Certified Nursing Assistants. The Facility failed to implement abuse training for three Certified Nursing Assistants. On 5/30/19, a review was conducted of employee records. The facility Director of Human Resources (Employee J) was interviewed in her office. The employee records were computer-based. The Director of Human Resources utilized her computer to facilitate the review. The records did not contain documentation of status and disciplinary actions from licensing boards. The facility failed to verify the licenses prior to hire of the following employees with their respective hire dates: Administrator (Employee A) 10/20/17 Licensed Practical Nurse (LPN I) 2/2/18 Certified Nursing Assistant (CNA G)…
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 · D2019-05-31 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to notify the ombudsman of transfer to hospital for one resident (Resident #275) in a sample size of 29 residents. The findings included: 1. For Resident #275, the facility staff failed to notify the ombudsman for transfer to hospital on [DATE]. Resident #275, an [AGE] year old male, was admitted to the facility on [DATE]. An excerpt of a physician's note dated 05/10/2019 documented, I am seeing [Resident #275] today in follow-up for an ER [emergency room] visit yesterday . On 05/30/19 at 02:35 PM, documentation and ombudsman notification for transfer to hospital was requested. The facility provided a list of documentation that was sent with Resident #275 but there was no evidence the ombudsman was notified. On 05/31/2019 at 9:30 PM, an interview with Employee L, a social worker, was conducted. When asked if she notified the ombudsman when Resident #275 was transferred to hospital, she stated, No, 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.
- Potential for harm · D2019-05-31 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility staff failed to ensure the Resident had a Level I PASARR screening for 2 Residents (#278 and #5) of 29 residents prior to admission to the facility The findings include: 1. For Resident #278 the facility staff failed to obtain a Level I PASARR screening prior to admission. Resident #278 an 81 yr. old man admitted to the facility on [DATE]. On 5/28/18 during clinical record review it was noted that Resident # 278 did not have a PASARR Level I screening in his electronic medical record. On 5/28/19 at 11:30 AM the DON presented a copy of the PASARR screening completed on 5/14/19. 2. For Resident #5 the facility staff failed to obtain a Level I PASARR screening prior to admission. Resident #5, an [AGE] year old woman was admitted to the facility on [DATE]. On 5/31/18, during clinical record review, it was noted that Resident # 5 did not have a PASARR Level I screening in her electronic medical record. On 5/31/19 the facility…
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 · D2019-05-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observation, Resident interview, clinical record review, staff interview, and facility document review, the facility staff failed to provide a base line, or comprehensive care plan for urinary suprapubic catheter for one Resident (Resident #22) in a survey sample of 29 residents. The findings included: 1. For Resident #22 the facility staff failed to care plan, and provide, physician ordered supra-pubic urinary catheter care. Resident #22 was admitted to the facility on [DATE]. Diagnoses included; benign prostatic hyperplasia with supra-pubic indwelling urinary catheter. Resident #22's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-14-19 was coded as a 14 day assessment. Resident #22 was coded with a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. Resident #22 was coded as incontinent of bowel, and as having a urinary catheter for bladder function. Initial surveyor observations for this Resident began on 5-29-19 at 12:00 p.m.,…
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 before2019-05-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to review and revise the careplan after a change in treatment, for one Resident (Resident # 327) in a survey sample of 29 residents. The findings included: 1. For Resident #327 the facility staff failed to update the careplan after a change in treatment plan occurred to treat a UTI (urinary tract infection). Resident #327 was initially admitted to the facility on [DATE], most recent readmission was on 5/25/19. Review of Resident #327's physician orders and nursing notes reveal that on 5/25/19 Resident #327 was started on an antibiotic for a UTI (urinary tract infection). Review of Resident #327's careplan, revealed no dates for interventions, no initiation date for interventions and no review or revision dates for new diagnosis of UTI and the initiation of the antibiotic use. On 5/30/19 at 4:17pm an interview was conducted with RN A, MDS Coordinator and she was asked to show this writer the careplan revision. The MDS Coordinator…
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 · D2019-05-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, clinical record review, staff interview, and facility document review, the facility staff failed to provide urinary suprapubic catheter care and serives to one Resident (Resident #22) in a survey sample of 29 residents. The findings included: 1. For Resident #22 the facility staff failed to plan, and provide, physician ordered supra-pubic urinary catheter care. Resident #22 was admitted to the facility on [DATE]. Diagnoses included; benign prostatic hyperplasia with supra-pubic indwelling urinary catheter. Resident #22's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-14-19 was coded as a 14 day assessment. Resident #22 was coded with a Brief Interview for Mental Status (BIMS) score off 14 indicating no cognitive impairment. The Resident was also coded as needing extensive assistance of one to two staff members to perform activities of daily living, such as toileting transferring and dressing. Resident #22 was coded as incontinent of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-05-31 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, and facility documentation review, the facility failed to provide annual nursing staff training based on their annual reviews. The Findings included: On 5/30/19, a review was conducted of employee records. The facility Director of Human Resources (Employee J) was interviewed in her office. The employee records were computer-based. The Director of Human Resources utilized her computer to facilitate the review. The records did not contain documentation identifying the required training for the identified employees based on their annual review. In addition, according to the Relias System Course Completion History, the facility failed to implement required annual training for the following employees with their respective hire dates:: Certified Nursing Assistant (CNA I) 10/8/18 Certified Nursing Assistant (CNA J) 7/29/18 Certified Nursing Assistant (CNA K) 12/31/18 The Director of Human Resources stated that she had worked in her position for several years. She further stated that it was the nursing departments' responsibility to ensure that the required…
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 · D2019-05-31 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 documentation and clinical record review the facility staff failed to provide Dementia Services to attain highest practicable well-being for 1 Resident (#5) in a survey sample of 29 Residents. The findings include: 1. For Resident #5 the facility staff failed to provide specific dementia care to include non-pharmacological interventions and behavior monitoring. Resident #5, an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Altered mental status unspecified, Anxiety disorder due to a known physiological condition, unspecified dementia without behavioral disturbances, unspecified dementia with behavioral disturbances, major depressive disorder and unspecified psychosis not due to a substance or known physiological condition. According to the most recent (Minimum Data Set) MDS screening with an (Assessment Reference Date) ARD of 4/10/19 the Resident was coded as having a (Brief Interview of Mental Status) BIMS score of 6…
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 · D2019-05-31 · 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, staff interview, facility documentation and clinical record review the facility staff failed to ensure routine medications were available for administration for 2 Residents (#18 and #278) in a survey sample of 29 Residents. The findings include: 1. For Resident #18 the facility staff failed to ensure that Resident's Dorzolamide 2% eye drops were available. Resident #18 a [AGE] year old man was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of shaft of right tibia, atrial fibrillation, Heart failure, Diabetes and Hyponatremia. On 5/30/19 at 9:30 AM during medication administration observation RN B pulled medications for Resident #18 however she could not find the Dorzolamide 2% eye drops (Dorzolamide 2% is used to lower the intraocular pressure caused by glaucoma). RN B stated that she knew the eye drops were not in the drawer because she worked on the evening shift and knew they were waiting for them from the pharmacy. According to the (Medication…
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 · D2019-05-31 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 employ staff with appropriate competencies to carry out the functions of food and nutrition services. The findings included: 1. The facility staff assigned an employee to perform chemical sanitization of the dishwasher in N2 kitchen and she was not trained to do so. On 05/30/2019 at approximately 9:35 AM, Employee E, an Executive Chef, and this surveyor went to N2 kitchen to observe the chemical sanitation process. There was one employee working in N2 kitchen at the time, Employee F. Employee F was observed removing a rack full of glasses and plates from the dishwasher and place them on a cart. This surveyor requested that Employee F demonstrate a chemical sanitization test. Employee F walked over to a drawer, looked inside, and stated, There are none up here. Employee E then left to get chemical sanitization strips. Upon return, Employee E took a strip out of the bottle and this surveyor requested that Employee F perform the test. Employee F placed the strip in the water at the bottom of the dishwasher and then…
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 · B2019-05-31 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review the facility staff failed to transmit resident assessment information for 5 Residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #8) in a survey sample of 29 Residents. The findings included: 1. For Resident #2, that resided in a certified bed within the facility, the facility staff failed to transmit a Quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/5/19. Resident #2 was admitted to the facility on [DATE]. Resident #2's most recently transmitted MDS assessment with an ARD of 1/8/19 was coded as a quarterly assessment. Review of Resident #2's clinical record revealed that the quarterly MDS with an ARD of 4/5/19 was completed on 4/19/19 but was not transmitted. On 5/31/19 at 10:58 an interview was conducted with RN A, the MDS Coordinator. When asked about the transmission of MDS, RN A stated, they are private pay so they get done but not transmitted. When asked why this is, RN 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.
“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
$36,374 in federal fines across 1 penalty.
- $36,374 — penalty dated 2026-02-27
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 / manager | Type | Role | Since |
|---|---|---|---|
| ADAMS, VONNIE | Individual | W-2 MANAGING EMPLOYEE | since 01/01/2022 |
| BATES, LISA | Individual | W-2 MANAGING EMPLOYEE | since 09/01/2014 |
| BECKE, RACHEL | Individual | W-2 MANAGING EMPLOYEE | since 04/01/2024 |
| PARKS, JUANITA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 01/01/2022 |
| WILLIAMS, MIKE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | since 05/17/2021 |
| WILLIAMS, SUZANNE | Individual | W-2 MANAGING EMPLOYEE | since 01/22/2024 |
| WOLFE, SALLY | Individual | W-2 MANAGING EMPLOYEE | since 09/01/2009 |
| BRODY, ALLISON | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| BUCKLESS, DONALD | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| CANFIELD, LOUISE | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| DAVIS, ELIZABETH | Individual | CORPORATE DIRECTOR | since 09/01/2014 |
| GEDDY, VERNON | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| GERHARDT, PAUL | Individual | CORPORATE DIRECTOR | since 09/01/2009 |
| HARSHAW, CONNIE | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| LAMBERT, MATTHEW | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| STORER, GREG | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| ZEIDLER, JEANNE | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| DRISCOLL, EDWARD | Individual | CORPORATE OFFICER | since 01/01/2024 |
| FOX, MICHAEL | Individual | CORPORATE OFFICER | since 01/01/2024 |
| HILL, TERRY | Individual | CORPORATE OFFICER | since 01/01/2024 |
| KNUDSON, JUDY | Individual | CORPORATE OFFICER | since 01/01/2024 |
| MILLS, TIMOTHY | Individual | CORPORATE OFFICER | since 01/01/2024 |
| PITTMAN, CARLANE | Individual | CORPORATE OFFICER | since 01/01/2024 |
| RANDALL, BRANDON | Individual | CORPORATE OFFICER | since 01/01/2024 |
| SMITH, CHRISTOPHER | Individual | CORPORATE OFFICER | since 01/01/2024 |
| STABLER, SCOTT | Individual | CORPORATE OFFICER | since 01/01/2024 |
| UNDERWOOD, ROBERT | Individual | CORPORATE OFFICER | since 01/01/2024 |
CMS files one row per role, so the 29 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 495184. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-27, 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.