1776 Cambridge Drive, Richmond, VA 23238 · Henrico County · (804) 740-6174
183 certified beds, about 180 residents a day · For profit - Corporation · Medicare and Medicaid since 1993
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495272 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 25, 2024, inspectors cited 15 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 135 health citations since January 2022, 6 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 3 fines totaling $436,524 in the last three years; the largest was $343,544, and the latest is dated April 9, 2026.
Nurses and nurse aides worked 3.34 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.
58.1% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Marquis Health Services, an affiliated group of 90 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 135 health citations on file.
Inspectors wroteBased on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to prevent abuse for 1 of 8 residents (Resident #2), in the survey sample which resulted in the identification of Immediate Jeopardy.
Inspectors wroteBased on record reviews and staff interview the facility failed to report the results of a facility reported incident investigation within 5 working days of the incident.
Inspectors wroteBased on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 8 residents (Resident #2), in the survey sample.
Inspectors wroteBased on observation, staff interviews, clinical record review and facility document review, the facility staff failed to protect residents' right to be free from abuse by other residents for 4 of 18 residents in the survey sample, Residents #17, #16, #15, and #2, resulting in the identification of immediate jeopardy and substandard quality of care for Resident #2.
Inspectors wroteBased on observation, staff interviews, clinical record review and facility document review, the facility staff failed to provide adequate supervision in an accident and hazard free environment to protect residents' safety and failed to provide adequate supervision of a resident with known aggressive behaviors (Resident #14) which resulted in altercations with four other residents in a survey sample of 18 residents. Residents #17, #16, #15, and #2, resulting in the identification of immediate jeopardy, substandard quality of care and harm for Resident #2.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the necessary care and services, consistent with professional standards of practice, to prevent a pressure injury for one of 18 residents in the survey sample, Resident #8. A tourniquet was left in place on Resident #8's left upper arm for an extended period causing an unstageable pressure injury, resulting in harm cited at past non-compliance.
Inspectors wroteBased on staff interview and employee record review, it was determined that the facility staff failed to ensure that three of five certified nursing assistant (CNA) records reviewed received the required twelve hours of annual trainings.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to accommodate residents' physical limitations for one of 18 residents in the survey sample, Resident #8.
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policies to prevent abuse by one resident, Resident #14, for four of eighteen residents in the survey sample. (Resident #17, # 16, #15, #2)
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy for timely reporting of the final five-day investigative summary to appropriate agencies for one of eighteen residents in the survey sample, Resident #2.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to maintain an accurate minimum data set (MDS) assessment for one of 18 residents in the survey sample, Resident #13.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 18 residents in the survey sample, Resident #8 and Resident #14.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents to one of 18 residents in the resident sample, Resident #8.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for two of 18 residents in the resident sample, Resident #8 and Resident #2.
Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure communication training was completed for one of seven employee reviews.
Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure QAPI (quality assurance and performance improvement) training was completed for three of seven employee reviews.
Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure compliance and ethics training was completed for two of eight employee reviews.
Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure behavioral health training was completed for two of eight employee reviews.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for one of six residents in the survey sample, Resident #5.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify physician orders for one of six residents in the survey sample, Resident #5.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to administer medications per the physician orders for one of six residents in the survey sample, Resident #5.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of wellbeing for three of six residents, Resident #1, #2 and #6.
Inspectors wroteBased on observations, staff interviews facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan for one of six residents in the survey sample, Resident #1 (R1).
Inspectors wrote3. For Resident #22 (R22), the facility staff failed to provide treatment as recommended by the wound nurse practitioner for A) the right heel and B) the right anterior lower leg pressure injury (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/20/25, the resident was assessed as severely impaired for making daily decisions. R22 was assessed as being non-verbal, totally dependent for personal hygiene, bed mobility, toileting and bathing. It further documented R22 always incontinent of bowel and bladder and at risk for pressure injuries but not having any unhealed pressure injuries at the time of the assessment. A) Review of the skin and wound progress note for R22 dated 3/24/2025 by the wound nurse practitioner documented a comprehensive skin assessment completed. It documented in part, . [...]
Inspectors wrote5. The facility staff failed to maintain a homelike environment for A) two of three nursing units and B) one of three common hallways. A) On 4/29/25 at 10:48 a.m., an observation of the Westham nursing station area and the three hallways of the Westham unit revealed a strong urine odor present. Housekeeping staff were observed on the unit cleaning resident rooms. On 4/29/25 at 11:12 a.m., an observation of the Grove unit revealed a strong urine odor immediately upon exiting the elevator in the common resident area, nurses station area and three hallways on the unit. Housekeeping staff were observed mopping the floors at that time. Additional observations of the Westham unit and Grove unit were made on 4/29/25 at approximately 3:39 p.m., 4/30/25 at approximately 8:19 a.m., 4/30/25 at approximately 2:12 p.m. and 5/1/25 at approximately 8:22 a.m. [...]
Inspectors wrote3. For Resident #12 (R12), the facility staff failed to implement the abuse policy for reporting an injury of unknown origin (IUO) in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/22/25, the resident was assessed as being severely impaired for making daily decisions. The progress notes for R12 documented in part, - 04/18/2025 14:46 (2:46 p.m.) Note Text: Resident has been in the dining room all morning outside of therapy. She was found with a large bruise on her left hand in the dining room by activities. Resident does not have any pain or discomfort. MD (medical doctor) notified. RP (responsible party) was called and a message was left. - 04/18/2025 08:51 (8:51 a.m.) Nurse Practitioner Note: LATE ENTRY Note Text : X-ray ordered to rule out acute pathology. [...]
Inspectors wrote2. For Resident #22 (R22), the facility staff failed to implement the comprehensive care plan to provide treatment as recommended by the wound nurse practitioner for A) the right heel and B) the right anterior lower leg pressure injury (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/20/25, the resident was assessed as severely impaired for making daily decisions. R22 was assessed as being non-verbal, totally dependent for personal hygiene, bed mobility, toileting and bathing. It further documented R22 always incontinent of bowel and bladder and at risk for pressure injuries but not having any unhealed pressure injuries at the time of the assessment. The comprehensive care plan for R22 documented in part, The resident has a pressure ulcer or has the potential for pressure ulcer development r/t immobility, diabetes. [...]
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for two of 25 residents in the survey sample, Residents #1 and #9.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide complete dialysis services for one of 25 residents, Resident #5.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to prevent significant medication errors for one of 25 residents, Resident #5.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide dignity for two of 25 residents in the survey sample, Residents #18 and #20.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the resident of a change in treatment for one of 25 residents in the survey sample, Resident #2 (R2). For R2, the facility staff failed to inform them in advance of the physician's order for the use of Percocet (1) and Xanax (2) and the risks, benefits and alternatives.
Inspectors wroteBased on observation, resident interview, staff interview and facility document review, it was determined that facility staff failed to respect a resident's personal possessions for one of 25 residents in the survey sample, Resident #17. For R17, the facility staff failed to assure all clothing was within their possession and accessible.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to provide privacy for two of 25 residents in the survey sample, Residents #19 and #20.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to assure a resident was free of a chemical restraint for one of 25 residents in the survey sample, Resident #2 (R2). For R2, the facility staff failed to evidence attempts of alternate interventions prior to the administration of Xanax (1).
Inspectors wrote2. For Resident #12 (R12), the facility staff failed to report an injury of unknown origin (IUO) in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/22/25, the resident was assessed as being severely impaired for making daily decisions. The progress notes for R12 documented in part, - 04/18/2025 14:46 (2:46 p.m.) Note Text: Resident has been in the dining room all morning outside of therapy. She was found with a large bruise on her left hand in the dining room by activities. Resident does not have any pain or discomfort. MD (medical doctor) notified. RP (responsible party) was called and a message was left. - 04/18/2025 08:51 (8:51 a.m.) Nurse Practitioner Note: LATE ENTRY Note Text : X-ray ordered to rule out acute pathology. - 04/18/2025 08:48 (8:48 a.m.) Nurse Practitioner Note: [...]
Inspectors wroteBased on staff interview, clinical record review, facility document review, it was determined that the facility staff failed to submit the follow-up report of an investigation for two of 25 residents in the survey sample, Resident #2 (R2) and R11.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to follow professional standards of practice for one of 25 residents in the survey sample, Resident #2.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to position an indwelling urinary catheter collection bag in a sanitary manner for one of 25 residents in the survey sample, Resident #13.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 25 residents in the survey sample, Resident #2 (R2).
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for one of 25 residents in the survey sample, Resident #7.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence monitoring of anticoagulant medication use for one of 25 residents in the survey sample, Resident #2.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow infection control practices for three of 25 residents in the survey sample, Residents #10, #7 and #13.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for four of six residents, R2, R3, R4 and R5.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for three of 11 residents in the survey sample, Residents #7, #4, and #3.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications and/or treatments per the physician order for two of 11 residents in the survey sample, Residents #3 and #4.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services for the treatment of pressure injuries (1) for three of 11 residents in the survey sample, Residents #7, #9, and #3.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the physician and/or responsible party when medications were not administered for one of 11 residents in the survey sample, Resident #4.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to protect one of 11 residents from sexual abuse, Resident #1.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 11 residents in the survey sample, Resident #4.
Inspectors wroteThe facility staff failed to provide a safe environment by monitoring trach residents for two of eight residents, Residents #3 and #1.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to comply with the accepted professional standards and principles that apply to professionals providing services for two of 8 residents, Resident #1 and Resident #3.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report an allegation of neglect and death in a timely manner for Resident #3.
Inspectors wroteThe facility staff failed to take actions aimed at performance improvement (including adverse resident events) and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for Resident #1.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for four of 56 residents in the survey sample, R429, F128, F479, F84
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain the resident's highest level of well-being for two of 56 residents in the survey sample, Resident #229 and #479.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide care and services for a catheter for three of 56 residents in the survey sample, Residents #129, #429 and #479.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for 3 of 56 residents, Resident #128, #165 and #84.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain food preparation utensils in good repair and/or in a sanitary manner in one of one kitchen in the facility.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for three of 56 residents in the survey sample, Residents #229, #95 and #92.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide dignity for one of 56 residents in the survey sample, Resident #282.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain confidentiality for three of 56 residents in the survey sample, Residents #21, #162, and #44.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a clean and homelike environment for two of 56 residents in the survey sample, Resident #86 and Resident #4.
Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to evidence ombudsman notification of a facility initiated transfer for one of 56 residents in the survey sample, Resident #30.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for dependent residents for two of 56 residents in the survey sample, Resident #10 and #433.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide colostomy care and services for one of 56 residents in the survey sample, Resident #479.
Inspectors wroteBased on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for two of 56 residents in the survey sample, Resident #46 and #128.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store medications in a locked compartment for one of seven medications carts, a cart on the Tuckahoe unit.
Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain a heating/air conditioning unit in a resident room in a safe condition, Resident #4.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for three of 17 residents in the survey sample, Residents #4, #6 and #3.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for two of 17 residents in the survey sample, Residents #3 and #4.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to utilize outside resources to obtain COVID vaccines.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide the COVID-19 (coronavirus disease) vaccine for five of 17 residents in the survey sample, Residents #6, #8, #13, #16 and #17.
Inspectors wroteBased on clinical record review, staff interview and facility document reviews it was determined that the facility staff failed to revise the comprehensive care plan with person-centered interventions for one of 17 residents in the survey sample, Residents #4.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide treatment to a pressure injury to promote healing, for one of 17 residents in the survey sample, Resident #6.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide a resident's representative with written notification of a room change for one of 11 residents in the survey sample, Resident #1.
Inspectors wroteBased on observations, resident interview, staff interview, and facility document review, the facility staff failed to provide a clean and homelike environment for one of 11 residents in the survey sample, Resident #9.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to maintain a comfortable environment for one of 11 residents in the survey sample, Resident #11.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain resident dignity for four of 57 residents in the survey sample, Residents #74, #48, #5, and #86.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to physician notification for seven of 57 residents in the survey sample, Residents #90, #63, #86, #115, #360, #95 and #358.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide, to the receiving facility, the required documents for four of 57 residents in the survey sample, Resident #155, #508, #3 and #106.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for 19 of 57 residents in the survey sample, Resident #90, #144, #106, #358, #86, #74, #48, #37, #43, #409, 118, #5, #54, #149, #142, #133, #34, #63, and #127.
Inspectors wrote4. For Resident #510, the facility failed to revise the comprehensive care plan to include the use of a wound vac (1). Resident #510 was observed in with wound vac in place on 8/7/23 at 12:00 PM. A review of the comprehensive care plan dated 12/30/22 and revised 8/1/23, revealed, FOCUS: Resident has a pressure ulcer or has the potential for pressure ulcer development related to immobility. INTERVENTIONS: Administer treatments as ordered and monitor for effectiveness. Offload my heels when in bed as tolerated using: (pillows). Monitor wound dressing during care to ensure it is intact and adhering. Report loose dressing to nurse. Resident need reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Keep resident's skin clean and moisturized as needed. Do not massage over bony prominences and use mild cleansers for peri-care and bathing. [...]
Inspectors wroteBased on observation, resident interview, family interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for seven of 57 residents in the survey sample, Residents #74, #48, #5, #118, #361, #358, and #127.
Inspectors wrote4. For Resident #360 (R360), the resident was admitted to the facility on [DATE] with pressure injuries. The facility staff failed to initiate treatment for the pressure injuries until 8/2/23 and 8/3/23. R360 was admitted to the facility on [DATE]. A review of R360's clinical record revealed a wound progress report dated 8/2/23 that documented the resident presented with a stage two pressure injury (1) on the right heel on 7/31/23. Further review of R360's clinical record revealed treatment was not initiated until 8/2/23. A physician's order dated 8/2/23 documented to cleanse the right heel with normal saline and apply a hydrocolloid dressing once a day. A wound progress report dated 8/2/23 documented R360 presented with a stage four pressure injury (1) on the sacrum on 7/31/23. Further review of R360's clinical record revealed treatment was not initiated until 8/3/23. [...]
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide foot care for five of 57 residents in the survey sample, Residents #48, #34, #144, #63, and #121.
Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to keep residents free of accidents and hazards for one of 57 residents, Resident #144, and one of three wings on Grove Unit, the west wing.
Inspectors wroteBased on observation, resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide care and services for urinary catheter care for two of 15 residents with urinary catheters; Resident #144 and #86.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services consistent with professional standards for four of 57 residents in the survey sample, Residents #360, #358, #106 and #54.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for two of 57 residents in the survey sample, Residents #63 and #133.
Inspectors wroteBased on staff interview and clinical record review, it was determined that facility staff failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, for one of seven residents receiving dialysis services; Resident #149.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for five of 57 residents in the survey sample, Residents #86, #115, #360, #95 and #358.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure five of 57 residents in the survey sample were free of unnecessary medications, Resident #90, #11, #160, #149 and #133.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain an accurate clinical record for four of 57 residents in the survey sample, Residents #86, #361, #144 and #63.
Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide a safe and homelike environment for one of 57 residents, Resident #129 and in one of six bathrooms on the Westham Unit.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 57 residents in the survey sample, Resident #86.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop and/or implement the baseline care plan for one of 57 residents in the survey sample, Resident #160.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for medication administration for two of 57 residents in the survey sample, Residents # 90 and #11.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to meet the assessed activities needs of one of 57 residents in the survey sample, Resident #5.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to maintain the highest level of well-being for one of 57 residents in the survey sample, Residents #360.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide treatment for contractures (1) for two of 57 residents in the survey sample, Residents #5 and #48.
Inspectors wroteBased on observations, staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide tube feeding per physician orders, for one of 16 residents; Resident #144.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement bed rail requirements for three of 57 residents in the survey sample, Residents #359, #95 and #358.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide services related to trauma-informed care for one of 57 residents in the survey sample, Resident #37.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 57 residents in the survey sample, Resident #37.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to take action on a recommendation from the pharmacist for one of 57 residents in the survey sample, Resident #90.
Inspectors wroteBased on clinical record review, staff interview and facility document review it was determined that the facility staff failed to evidence monitoring of antipsychotic medication for one of 57 residents in the survey sample, Resident #160.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure medications were stored properly on one of four medication carts on the Tuckahoe unit.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to provide laboratory services in a timely manner for one of 57 residents in the survey sample, Resident #360.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide food at a palatable temperature.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen, in one of three nourishment rooms in the facility and during meal service.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to maintain effective infection control practices in one of two dining rooms.
Inspectors wroteBased on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe and functional environment for one of 12 resident rooms (for Resident #129).
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to perform regular bed inspections per the manufacturers'' instructions for 10 of 62 residents in the survey sample, Residents #105, #138, #326, #148, #146, #131, #22, #13, #15, and #168. The facility staff failed to perform regular bed inspections per the manufacturer's instructions for 2021 for Residents #105, #138, #326, #148, #146, #131, #22, #13, #15, and #168 beds. The failure to conduct regular inspections to identify possible entrapment hazards as part of the routine maintenance program had the potential to affect all 177 residents using beds in the facility.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review it was determined that the facility staff failed to honor the preference for showers twice a week for one of 62 residents in the survey sample, Resident # 162. The facility staff failed to honor Resident #162 preference for a shower on multiple dates in September 2021, October 2021 and November 2021.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence a written notification was provided to the Resident Representative and/or Ombudsman for a hospital transfer for five of 62 residents in the survey sample; Residents #97, #149, #15, #13, and #177.
Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for six of 62 residents in the survey sample, Residents #103, #32, #94, #146, #22 and #56.
Inspectors wroteBased on observation, staff interview and facility document review it was determined that the facility staff failed to provide respiratory services consistent with the comprehensive person-centered plan of care for four of 62 residents in the survey sample, Resident #15, Resident #73, Resident #117 and Resident #328. The facility staff failed to administer oxygen to Resident #15 at the flow rate ordered by the physician, failed store Resident # 73's nebulizer mask in a sanitary manner when it was not in use, failed to administer oxygen to Resident #117 per physician's orders, and failed to obtain a physician's order for the administration of oxygen to Resident #328.
Inspectors wroteBased on resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet the needs for one of 62 residents in the survey sample, Resident # 162. The facility staff failed to provide Resident # 162 who is coded as dependant on one staff member for bathing, with a shower two times a week, Wednesdays and Saturdays, due to insufficient CNA (certified nursing assistant) staffing.
Inspectors wroteBased on observation, resident interview and staff interview, it was determined that the facility staff failed to provide food at a palatable temperature during the lunch meal service on the Tuckahoe unit. The facility staff failed to provide food at a palatable temperature during lunch service on 1/12/2022. A test tray sampled on the Tuckahoe unit found the food was not warm or palatable.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide dignity for two of 62 residents in the survey sample, Residents #327 and #171. 1. The facility staff failed to maintain Resident #327's urinary catheter in a dignified manner. Urine in the catheter bag was observed from the hall while Resident #327 was lying in bed. 2. CNA (certified nursing assistant) #2 failed to close the door to Resident #171's room and bathroom while toileting and providing Resident #171 personal care. Resident #171 was observed exposed to the open doorways unclothed from the wait up.
Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a clean and homelike environment for one of 62 residents in the survey sample, Resident #426. The facility staff failed to clean a spill off of the floor in Resident #426's room in a timely manner.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold notice was provided upon transfer for three of 62 residents in the survey sample, Resident #13, Resident #15 and Resident #177. The facility staff failed to provide a bed hold notice to Resident #13 upon transfer and admission to the hospital on [DATE], and failed to provide a bed hold notice to the resident or resident responsible party (RP), at the time of Resident #15's transfer to the hospital on [DATE], and at the time of Resident #177's transfer to the hospital on [DATE].
Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to correctly code MDS (minimum data set) resident assessments for two of 62 residents in the survey sample, Resident #94 and #89. 1. The facility staff failed to code the quarterly MDS (minimum data set) for Resident #94 with the ARD (assessment reference date) of 12/3/2021 for falls sustained since the previous quarterly assessment on 9/14/2021. 2. The facility staff failed to code the quarterly MDS (minimum data set) for Resident #89 with the ARD (assessment reference date) of 11/27/2021 for restraint usage.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 62 residents in the survey sample, Residents #326 and #328. The facility staff failed to develop a complete baseline care plan to address colostomy care for Resident #326 and failed to develop a baseline care plan to address and include Resident #328's oxygen use.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop/implement the comprehensive care plan for three of 62 residents in the survey sample, Resident #131, Resident #426 and Resident #117. The facility staff failed to implement Resident #131's comprehensive care plan for a left hand splint, failed to implement Resident #426's comprehensive care plan for preferred activities and failed to implement Resident #117's comprehensive care plan for the administration of oxygen.
Inspectors wroteBased on clinical record review, staff interview, resident family interview and facility document review, it was determined that facility staff failed to review or revise the comprehensive care plan for two of 62 residents in the survey sample, Resident #426 and Resident # 148. The facility staff failed to include the resident representative in reviewing and revising the comprehensive care plan for Resident #426 and failed to review and revise Resident #148's comprehensive care plan for the use of bed rails.
Inspectors wroteBased on observations, clinical record review, family interview, staff interviews and facility document review it was determined that the facility staff failed to provide preferred activities to meet the needs of one of 62 residents in the survey sample, Resident #426.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer medication per physician's order and comprehensive plan of care for one of 6 residents in the Medication Administration task, Resident #14. The facility staff administered a Lidocaine patch 5% to Resident #14 instead of Lidocaine cream 4% to neck, shoulder topically four times a day for pain as ordered by the physician, the incorrect type (patch vs cream) and dose 5% vs 4% and location knee vs neck/shoulder of this medication.
Inspectors wroteBased on observation, staff interview and facility document review it was determined that the facility staff failed to provide treatment and services to maintain or improve mobility for one of 62 residents in the survey sample, Resident #131. Resident #131 was observed on separate occasions on 1/11/21 and 1/12/21 without the physician ordered neutral resting splint for the resident's left hand and wrist in place.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for two of 62 residents in the survey sample, Residents #326 and #148. The facility staff implemented bed rails for Resident #326 without a documented clinical need and failed to obtain informed consent for the use of bed rails and the facility staff implemented bed rails for Resident #148 without a documented clinical need.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to store medications in a safe and secure manner on one of three nursing units, the Grove unit. The facility staff failed to secure medications and lock the medication cart and left unsecured medications on top of the cart while the cart was out of the line of sight when administering medications to residents on the Grove unit.
Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to maintain kitchen equipment in a sanitary manner and in accordance with professional standards for food service safety.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow infection control practices for the administration of medication for one of 6 residents in the Medication Administration task; Resident #23.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to evidence mandatory CNA (certified nursing assistant) annual education in dementia training and abuse prevention training for three of five CNA records reviewed, CNA #4, CNA #5, and CNA #6.
7 fire safety citations on file: 6 on July 25, 2024, 1 on January 13, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| April 9, 2026 | Fine | $343,544 |
| May 2, 2025 | Fine | $61,448 |
| July 25, 2024 | Fine | $31,532 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Virginia | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.34 | 3.76 | 3.86 |
| Registered nurses | 0.67 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.81 | 3.29 | 3.42 |
| Nurse aides | 1.65 | ||
| Licensed practical nurses | 1.03 | ||
| Nursing staff turnover (share who left in a year) | 58.1% | 48.1% | 45.8% |
| Registered nurse turnover | 78.4% | 48.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.86 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.55 on weekdays and 2.81 on weekends, 21% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.69 in April to June 2025 to 3.34 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.34 | 0.67 | 3.55 | 2.81 | 1.0% | 0 of 90 | 180 |
| Oct to Dec 2025 | 3.33 | 0.64 | 3.50 | 2.90 | 1.5% | 0 of 92 | 179 |
| Jul to Sep 2025 | 3.66 | 0.58 | 3.83 | 3.24 | 0.9% | 0 of 92 | 176 |
| Apr to Jun 2025 | 3.69 | 0.58 | 4.00 | 2.92 | 5.4% | 0 of 91 | 177 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Virginia, Jan to Mar 2026 | 3.58 | 0.56 | 3.76 | 3.12 | 5.7% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Virginia, all employers | |||
| CNAs (nursing assistants) | $20.77 | $17.80 to $22.56 | 40,580 |
| LPNs and LVNs | $31.21 | $28.66 to $35.84 | 15,550 |
| Registered nurses | $45.00 | $38.51 to $49.53 | 77,490 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Virginia | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.6 | 14.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.3 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.0 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.7 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 13.3 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.4 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.4 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Canterbury Rehabilitation and Healthcare Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (48.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
48.7% this home
No different from the national rate
US median of homes 51.5% · Virginia: 101 better, 22 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 189 eligible stays.
10.8% this home
No different from the national rate
US median of homes 10.7% · Virginia: 1 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 193 eligible stays.
8.6% this home
No different from the national rate
US median of homes 7.1% · Virginia: 2 better, 8 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 118 eligible stays.
56.4% this home
Median of homes: Virginia60.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 101 residents counted.
0.4% this home
Median of homes: Virginia0.7% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 249 residents counted.
3.0% this home
Median of homes: Virginia2.1% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 249 residents counted.
96.7% this home
Median of homes: Virginia97.8% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 60 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: CANTERBURY OPERATOR LLC. CMS links this home to Marquis Health Services, a group of 90 nursing homes averaging 3.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Quinto Delta LLC | 5% or greater direct ownership interest | Organization | 89% | 12/31/2019 |
| Tryko Delta Holdings LLC | 5% or greater indirect ownership interest | Organization | 67% | 12/30/2019 |
| M&t Bank Corporation | 5% or greater security interest | Organization | 12/30/2019 | |
| Haskins, Veronica | Managing control - governing body | Individual | 04/24/2025 | |
| Law, Joseph | Managing control - governing body | Individual | 02/10/2020 | |
| Posen, Mindee | Corporate officer | Individual | 12/30/2019 | |
| Marquis Limited LLC | Operational/managerial control | Organization | 12/30/2019 | |
| Reliant Pro Rehab LLC | Operational/managerial control | Organization | 12/30/2019 | |
| Abbasi, Gohar | Operational/managerial control | Individual | 12/30/2019 | |
| Haskins, Veronica | Operational/managerial control | Individual | 04/24/2025 | |
| Flagler, Osher | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/05/2025 | |
| Kahanow, Aviva | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/05/2025 | |
| Levovitz, Tzvi | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/05/2025 | |
| Rokeach, Fraide | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/05/2025 | |
| Rokowsky, Yitzchok | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/05/2025 | |
| Canterbury Property 1 LLC | Adp of the SNF | Organization | 12/30/2019 | |
| Kohn Fam Tr Gst Exempt Uad 3-25-13 | Adp of the SNF | Organization | 12/19/2019 | |
| Marquis Limited LLC | Adp of the SNF | Organization | 05/05/2025 | |
| Nfr 2020 Irrv Tr | Adp of the SNF | Organization | 12/30/2019 | |
| Quinto Delta LLC | Adp of the SNF | Organization | 12/30/2019 | |
| Reliant Pro Rehab LLC | Adp of the SNF | Organization | 05/05/2025 | |
| Rsbrmk Holdings LLC | Adp of the SNF | Organization | 12/30/2019 | |
| Sk 2013 Delta Trust | Adp of the SNF | Organization | 12/30/2019 | |
| Tryko Delta Holdings LLC | Adp of the SNF | Organization | 12/30/2019 | |
| Uak 2020 Irrv Tr | Adp of the SNF | Organization | 12/30/2019 | |
| Ukr Consulting LLC | Adp of the SNF | Organization | 12/30/2019 | |
| Yr 2013 Delta Tr Ua 03252013 | Adp of the SNF | Organization | 12/30/2019 | |
| Abbasi, Gohar | Adp of the SNF | Individual | 12/30/2019 | |
| Haskins, Veronica | Adp of the SNF | Individual | 04/24/2025 | |
| Law, Joseph | Adp of the SNF | Individual | 02/10/2020 | |
| Posen, Mindee | Adp of the SNF | Individual | 12/30/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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