2125 Hilliard Road, Richmond, VA 23228 · Henrico County · (804) 266-9666
194 certified beds, about 189 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495045 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 28, 2024, inspectors cited 15 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 72 health citations since May 2019, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.01 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.39 of those hours.
48.3% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Hill Valley Healthcare, an affiliated group of 43 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 72 health citations on file.
Inspectors wroteBased on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a safe/functional, comfortable environment for three of nine residents, Resident #2, #6 and #9.
Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to allow the resident to make decisions regarding his treatment for one of nine residents, Resident #1.
Inspectors wroteBased on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a clean and homelike environment for three of nine residents, Resident #2, #6 and #9.
Inspectors wroteBased on observation, resident/staff interview, facility document review, and clinical record review, it was determined the facility staff failed to report an allegation of residents receiving illegal drugs in a timely manner for two of nine residents, Resident #7 and #8.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of nine residents, Resident #1.
Inspectors wroteBased on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide incontinence care for dependent residents for three of nine residents, Resident #3, #4 and #9.
Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to maintain resident's rooms in good repair for four of 15 resident rooms observed on the Arcadia (secured) unit.
Inspectors wroteBased on observations, staff interviews, resident interviews, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the care plan for six of 49 residents in the survey sample, Residents #169, #66, #188, #166, #180 and #60.
Inspectors wrote2. For Resident #188 (R188), the facility staff failed to provide consistent incontinence care in November 2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/28/2022, the resident was assessed as requiring extensive assistance from one person for toileting and being frequently incontinent of bowel and bladder. Review of the ADL (activities of daily living)-Toileting documentation for 11/1/2022- 11/30/2022 failed to evidence incontinence care provided to R188 on the following dates: -day shift on 11/3/2022, 11/8/2022, 11/13/2022 and 11/15/2022, and on evening shift on 11/8/2022. The comprehensive care plan for R188 documented in part, Urinary Bowel incontinence as evidenced by muscle weakness related to disease process and physical limitations. Date Initiated: 10/21/2022 . Under Interventions it documented in part, . [...]
Inspectors wroteBased on staff and resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence a complete pain management program for one of 49 residents in the survey sample, Residents #169.
Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate needs for one of 49 residents, Resident #145.
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 MDS (minimum data set) assessment for two of 49 residents in the survey sample, Residents #120 and #42.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to revise the comprehensive care plan for two of 49 residents in the survey sample, Residents #23 and #107. 1. For Resident #23 (R23), facility staff failed to revise the comprehensive care plan to identify the specific behaviors being monitored for the use of Zyprexa (1). R23 was admitted to the facility with diagnoses that included but were not limited to psychotic disturbances. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/01/2024, R23 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R23 was severely impaired of cognition for making daily decisions. Section N Medications coded R23 as receiving antipsychotic medication. [...]
Inspectors wroteBased on resident interview, 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 49 residents in the survey sample, Resident #166.
Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, it was determined facility staff failed to provide treatment and services to maintain or improve mobility for one of 49 residents, Resident #66.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care consistent with professional standards, for two of 49 residents in the survey, Residents #180 and #60.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for two of 49 residents in the sample Resident #169 and Resident #159.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for two of 49 residents in the sample Resident #169 and Resident #159.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure two of 49 residents in the survey sample were free from unnecessary antipsychotic medications, Residents #23 and Resident #107. 1. For Resident #23 (R23), facility staff failed to identify and monitor the specific behaviors for the use of Zyprexa (1). R23 was admitted to the facility with diagnoses that included but were not limited to psychotic disturbances. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/01/2024, R23 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R23 was severely impaired of cognition for making daily decisions. Section N Medications coded R23 as receiving antipsychotic medication. [...]
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide dental services for one of 49 residents in the survey sample, Resident #102.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to meet staff vaccination requirements, 15 residents tested positive for COVID-19, and the facility staff failed implement their policy for COVID-19 vaccination for 11 of 166 employee records reviewed. The facility records documented that 15 residents had tested positive for COVID-19 during the previous four weeks but did not require hospitalization; and the facility staff failed to provide evidence of approval of the employee's vaccination exemption as a condition of employment according to the facility's policy.
Inspectors wroteBased on observation, resident interview, staff interview, facility documentation review, clinical record reviews, and in the course of a complaint investigation, the facility staff failed to ensure the facility met the requirements/definitions of a Skilled Nursing Facility (SNF) or a Nursing Facility (NF). This determination has the potential to affect the entire certification of 194 facility beds. There were 83 of the 169 residents in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: [...]
Inspectors wroteBased on observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to serve meals in a palatable manner from 1 of 1 facility kitchens.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare, and serve food in a safe manner in 1 of 1 facility kitchens.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to hold quarterly meetings of the QAPI (quality assurance performance improvement) committee as required. The facility QAPI committee failed to meet in all four quarters of 2020 and 2021, and in the first quarter of 2022.
Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence by restricting the ability to move freely about the facility for 4 of 20 residents in the survey sample, Residents #109, #118, #119 and #105. There were 83 of the 169 resident in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24/50 had no behavioral/elopement assessment and only 1/50 being assessed as exit seeking. [...]
Inspectors wroteBased on review of staff interview and facility documentation review, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by restricting resident's choice in freely moving about the facility for 4 of 20 residents in the survey sample, Resident #109, #118, #119 and #105. There were 83 of the 169 resident in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24/50 had no behavioral/elopement assessment and only 1/50 being assessed as exit seeking. [...]
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for four of 52 residents in the survey sample, Residents #124, #106, #33, and #75.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notice to the RR (resident representative) and/or Office of the State Long-Term Care Ombudsman for resident discharges for five of 52 residents in the survey sample, Residents #124, #106, #33, #75, and #68.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notice of the facility's bed hold policies at the time of discharge for five of 52 residents in the survey sample, Residents #124, #106, #33, #75, and #68.
Inspectors wroteBased on observations, resident interviews, staff interviews and facility document review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for three of 52 residents in the survey sample, Residents #33, #16 and #63.
Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's quality of life by allowing residents to maintain the highest degree of practicability of well-being for 4 of 20 residents in the survey sample, Resident #109, #118, #119 and #105. There were 83 of the 169 resident in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24/50 had no behavioral/elopement assessment and only 1/50 being assessed as exit seeking. [...]
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for two of 52 residents in the survey sample, Residents #16 (R16) and #149 (R149).
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 20 residents in the survey sample were free of a significant medication error, Resident #102 (R102).
Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain sufficient dietary staff to meet the needs of the residents at the lunch meal on 7/5/22 in one of one facility kitchens. There was insufficient staff from the dietary department working at lunch on 7/5/22, resulting in residents' receiving food which had not been prepared according to the therapeutic menu and recipe.
Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined the facility staff failed to provide annual performance evaluations for five of five CNAs (certified nursing assistants) reviewed, CNA # 4, CNA #5, CNA #6, CNA #7, and CNA #8.
Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide accommodations of resident needs by failing to ensure the call bell [a device with a button that can be pushed to alert staff when assistance is needed] was within reach for one of 52 current residents in the survey sample, Resident #317 (R317).
Inspectors wroteBased on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to notify the provider of changes in status for two of 52 residents in the survey sample, Residents #802 and #63.
Inspectors wroteBased on staff interview and facility document review, it was determined during the beneficiary notification facility task, the facility staff failed to provide beneficiary notification for one of three residents, Resident #466.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for two of 52 residents in the survey sample, Resident #135 and Resident #85; and in one of five pantries in the facility.
Inspectors wroteBased on observation, clinical record review, staff interview and facility document review it was determined facility staff failed to revise the care plan for one of 52 residents in the survey sample, Resident #61.
Inspectors wroteBased on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide foot care services for one of 52 residents in the survey sample, Resident #30. The facility staff failed to provide care and services for Resident #30's (R30) toenails.
Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to evaluate smoking hazard and risk for one of 52 residents, Resident #33. The facility staff failed to evidence that they performed a safe smoking assessment for Resident #33.
Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined the facility staff failed to provide mandatory training on an annual basis for two of five CNAs (certified nursing assistants), CNA #5 and CNA #8.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow the menu for one of 20 residents in the survey sample, Resident #116 (R116). The facility staff failed to serve R116 the recommended amount of turkey/rice stir fry on 7/5/22, and failed to prepare the turkey/rice stir fry according to the approved recipe.
Inspectors wroteBased on observation, resident interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to honor the resident's food preferences for two of 20 residents in the survey sample, Residents #115 and #102.
Inspectors wroteBased on staff interview and clinical record review, it was determined that during the immunization record review, that the facility staff failed to offer, obtain consent for, and/or provide education regarding the influenza and pneumococcal vaccines for two of five residents reviewed, Residents #83 (R83) and #132 (R132).
Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician and/or responsible party of a change in condition for four of 56 residents in the survey sample, Residents #93, #12, #26 and #17. 1. The facility staff failed to notify the physician and/or responsible party when Resident #93's insulin was not administered as ordered. 2. The facility staff failed to notify the physician when Resident # 12's insulin (1) was administered with blood sugars (1) below 100 (mg/dl [milligram/deciliter]). 3. The facility staff failed to notify the physician when Resident # 12's insulin was administered with blood sugars below 150. 4. [...]
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 six of 56 residents in the survey sample, Residents #93, #26, #12, #17, #127, #72. 1. The facility staff failed to implement Resident #93's comprehensive care plan related to the the resident's diabetes. 2. The facility staff failed to implement the comprehensive care plan for the administration of insulin (1) for Resident # 26. 3. The facility staff failed to implement the comprehensive care plan for the administration of insulin (1) for Resident # 12. 4. The facility staff failed to implement Resident #17's comprehensive care plan for the administration of diabetic medications. 5. The facility staff failed to develop a comprehensive care plan to address Resident #127's oxygen use. 6. [...]
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one of 56 sampled residents, (Resident #89), received care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to ensure continuity of care and collaboration with hospice care services for Resident # 89.
Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to ensure the medication regimen for two of 56 sampled residents, (Resident #26 and Resident #17) were free from unnecessary drugs. 1. The facility staff failed administered insulin to Resident # 26's when the resident's blood sugar was below the physician ordered parameter of 150 on multiple dates in February, March and April 2019. 2. The facility staff administered insulin to Resident #17 when the resident's blood sugar was below the physician prescribed parameter of 100, on three occasions in February 2019.
Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to ensure three of 56 residents were free from significant medication errors, Residents # 93, #26 and #17. 1. The facility staff held Resident #93's prescribed insulin without a physician order on multiple occasions in April 2019. 2. The facility staff failed to hold the administration of insulin and administered insulin to Resident # 26's when the resident's blood sugar was below the physician ordered parameter of 150 on multiple dates in February, March and April 2019. 3. [...]
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store and prepare food in accordance with professional standards of food service safety. 1. The facility staff failed to ensure food was discarded on before the expiration date. 2. The facility staff failed to ensure hair was covered in the food preparation area.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide comprehensive hospice services for one of 65 residents in the survey sample, Resident # 89. The facility staff failed to evidence consistent communication and collaboration for resident # 89's hospice care.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow infection control practices for two of 56 residents in the survey sample, Residents # 65 and # 127 and during dining observations in two of two dining facility dining rooms, (main dining room and Arcadia dining room). 1. The facility staff failed to implement infection control practices during Resident # 65's wound care. 2. The facility staff failed to keep their thumbs off the food surface of dinner plates and refrain from touching resident's dinner rolls with bare hands while serving the resident's lunch in the main dining room. 3a. [...]
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to serve food in a manner to promote resident dignity for two of 56 residents in the survey sample, Residents # 118 and # 30. 1. On 04/30/19 at 12:00 p.m., during lunch service in the facility's main dining room the facility staff failed serve Resident # 118 her meal until after the two other residents seated at the table were served and were eating their meals. Resident # 118 waited fifteen minutes to be served her meal. 2. On 4/30/19 during the lunch service in the Arcadia dining room the facility staff failed to serve Resident #30 her meal until after the residents seated at her table had been served and were eating their meals, Resident #30 waited 12 minutes for her meal to be served.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for two of 56 residents in the survey sample, Residents #354 and #355. 1. Resident #354's last covered day of Medicare Part A services was 11/7/18. The facility staff failed to notify Resident #354 (and/or the resident's representative) of the last covered day and the right to appeal. 2. Resident #355's last covered day of Medicare Part A services was 1/21/19. The facility staff failed to notify Resident #355 (and/or the resident's representative) of the last covered day and the right to appeal.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a homelike environment for one of 56 residents in the survey sample, Resident #58. Resident #58's room failed to provide a homelike environment as she only had a bed and over bed table. There was no other furniture on her side of the room.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the required documentation was provided to the receiving facility at the time of a transfer for one of 56 residents in the survey sample, Resident # 48. The facility staff failed to evidence that all required documentation and information was provided to the receiving provider for Resident # 48's facility-initiated transfer to the hospital on [DATE].
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the required notifications of a transfer for one of 56 residents in the survey sample, Resident # 48. The facility staff failed to provide Resident # 48 and the Resident # 48's representative written notification and failed to notify the ombudsman of a facility-initiated transfer on 04/18/19 for Resident # 48.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate MDS (minimum data set) assessment for two of 56 residents in the survey sample, Resident #66 and Resident #65. 1. The facility staff failed to accurately code a BIMS (brief interview for mental status) assessment for Resident #66 on the quarterly MDS (minimum data set), assessment, with an ARD (assessment reference date) of 3/12/19. 2. The facility staff failed to ensure Resident # 65's MDS, a quarterly review assessment with an ARD (assessment reference date) of 03/12/19 was complete and accurate. Section C and section D of the assessment had columns marked with dashes [-] instead of numbers.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 56 residents in the survey sample, (Resident #93) had a completed Level I PASARR (preadmission screening and resident review). The facility staff failed to have a Level I PASARR completed for Resident #93, to ensure the resident was evaluated and receiving care and services in the most integrated setting appropriate for the resident's needs.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for two of 56 residents in the survey sample, Resident # 18 and # 39. 1. The facility staff failed to update Resident # 89's comprehensive care with current diversionary interventions to alleviate Resident # 89's pain. 2. The facility staff failed to review and revise the comprehensive care plan to address Resident #18's AICD (automatic internal cardiac device).
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for documentation in the clinical record anf the admoinistartion of medications for two of 56 residents in the survey sample, Resident #93 and Resident #12. 1. On 5/1/19, the facility staff documented Resident #93's Acute Transfer Document Checklist dated, 3/18/19, without indicating the date the documentation was completed on the form or that the documentation made was a late entry. 2. The facility staff failed to clarify Resident # 12's physician ordered parameters for Novolog insulin to determine when and if the insulin should be held based on the residents blood sugar of 100.
Inspectors wroteBased on observation, staff interview, facility and clinical record review, it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection of a pressure injury for one of 56 residents in the survey sample, Resident 65. The facility staff failed to provide a clean barrier under Resident # 65's right heel and failed to prevent the heel from coming into contact with a contaminated area.
Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that facility staff failed to provide appropriate treatment and services for a suprapubic catheter for one of 56 residents in the survey sample, Residents # 127. The facility staff failed to prevent Resident # 127's catheter collection bag and tubing from resting on the floor.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 56 residents in the survey sample, Resident #72 and Resident #127. 1. The facility staff failed to provide oxygen according to the physicians order for Resident #72. 2. The facility staff failed to ensure Resident # 127's nasal cannula was stored in a sanitary manner when not in use.
Inspectors wroteBased on resident interview, staff interview and clinical record review, it was determined that facility staff failed to provide pain management for one of 56 residents in the survey sample, Residents # 12. The facility staff failed to implement non-pharmacological interventions prior to administering as needed pain medication to Resident #32.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure that expired laboratory supplies were not available for resident use in one of three medication supply rooms inspected. The facility staff failed to ensure that expired laboratory supplies were not available for resident use in the 600 Unit medication supply room.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide functional furniture for one of 56 residents in the survey sample, Resident #58. Resident #58's room failed to provide a nightstand for Resident #58.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to dispose of garbage and refuse properly. The facility staff failed to ensure the ground around the dumpster's were free from garbage.
33 fire safety citations on file: 3 on February 28, 2024, 12 on May 23, 2022, 18 on May 2, 2019.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
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) | 3.01 | 3.76 | 3.86 |
| Registered nurses | 0.39 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.70 | 3.29 | 3.42 |
| Nurse aides | 1.71 | ||
| Licensed practical nurses | 0.90 | ||
| Nursing staff turnover (share who left in a year) | 48.3% | 48.1% | 45.8% |
| Registered nurse turnover | 65.0% | 48.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.80 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 3.14 on weekdays and 2.70 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 10.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.15 in April to June 2025 to 3.01 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 | 3.01 | 0.39 | 3.14 | 2.70 | 10.5% | 0 of 90 | 189 |
| Oct to Dec 2025 | 3.16 | 0.42 | 3.29 | 2.83 | 11.4% | 0 of 92 | 181 |
| Jul to Sep 2025 | 3.11 | 0.47 | 3.24 | 2.78 | 10.4% | 0 of 92 | 176 |
| Apr to Jun 2025 | 3.15 | 0.44 | 3.27 | 2.87 | 13.5% | 0 of 91 | 175 |
| 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. If you work here, your report helps start one.
| 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 | 0.0 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.1 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.4 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.0 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 6.4 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.6 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 24.5 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 17.3 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.5 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Lakeside Health & Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (58.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
58.4% 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. 87 eligible stays.
11.6% 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. 90 eligible stays.
6.0% 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. 59 eligible stays.
57.5% 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. 47 residents counted.
0.0% 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. 69 residents counted.
3.4% 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. 69 residents counted.
91.3% 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. 23 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: LAKESIDE VA SNF OPERATIONS LLC. CMS links this home to Hill Valley Healthcare, a group of 43 nursing homes averaging 1.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| VA Pro 7 SNF Operations Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 02/01/2023 |
| Crg VA Pro 7 SNF Holdings LLC | 5% or greater indirect ownership interest | Organization | 13% | 02/01/2023 |
| Hvh VA Pro 7 SNF Operations Holdings LLC | 5% or greater indirect ownership interest | Organization | 53% | 02/01/2023 |
| Ph VA LLC | 5% or greater indirect ownership interest | Organization | 11% | 02/01/2023 |
| Catrambone, Joseph | W-2 managing employee | Individual | 02/01/2023 | |
| Idels, Shimon | Corporate officer | Individual | 02/01/2023 |
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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