1719 Bellevue Avenue, Richmond, VA 23227 · Henrico County · (804) 262-7364
128 certified beds, about 124 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1993
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495283 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 21, 2023, inspectors cited 30 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 101 health citations since April 2021, 4 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $73,788 in the last three years; the largest was $73,788, and the latest is dated September 21, 2023.
Nurses and nurse aides worked 3.10 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.52 of those hours.
65.9% 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 101 health citations on file.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for the facility.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for three of 17 residents in the survey sample, Residents #1, #4, and #9.
Inspectors wroteBased on resident/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 a dependent resident for one of 17 residents, R8.
Inspectors wrote2.a. For Resident #1 (R1), the facility staff failed to administer a physician ordered intravenous antibiotic in a timely manner. A review of R1's clinical record revealed a urine culture report dated 11/11/24 that documented the resident presented with a urinary tract infection. Further review of R1's clinical record revealed a physician's order dated 11/11/24 for Ertapenem Sodium Solution- one gram intravenously every 24 hours for infection for seven days. Pharmacy alerts dated 11/11/24 documented a possible drug allergy and a possible drug interaction for Ertapenem. Administration notes dated 11/12/24 and 11/13/24 documented the nurses were waiting for the pharmacy to send Ertapenem. An administration note dated 11/14/24 documented, Pharmacy originally would not fill (Ertapenem) because of an allergy alert. [...]
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a Foley urinary catheter (1) for one of 17 residents in the survey sample, Resident #1.
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 17 residents in the survey sample, Residents #4 and #9.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician's response to the pharmacist's recommendations on the Medication Regimen Review (MRR) for one of 17 residents in the survey sample, R9.
Inspectors wrote1. The facility staff failed to provide honor dietary and allergy preferences by serving resident products with gluten. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma, morbid obesity, HTN, heart failure, need for therapeutic diet. INTERVENTIONS: [...]
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks during the day and at bedtime for two of 17 residents in the survey sample, R11 and R15.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide supplies, including urinals, gloves, cup tops for the for two of 17 residents in the survey sample, R11 and R15.
Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to provide dignity and respect for two of 17 residents in the survey sample, Residents #4 and #9.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet room change requirements prior to a room change for one of 17 residents in the survey sample, Resident #3.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to honor a resident's right to refuse a room change for one of 17 residents in the survey sample, Resident #3.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner and/or the responsible party of resident changes for two of 17 residents in the survey sample, Residents #6 and #1.
Inspectors wroteBased on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide a safe/clean and homelike environment for three of 17 residents, R9, R11 and R15.
Inspectors wroteBased on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop the care plan for one of 17 residents in the survey sample, R9.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide pharmacy services for one of 17 residents in the survey sample, Resident #4.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to evidence radiology services as ordered for one of 17 residents, R8.
Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 17 residents in the survey sample, Resident #1.
Inspectors wroteBased on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for three of 5 residents in the survey sample, R1, R2 and R3.
Inspectors wroteBased on resident/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 three of five residents, R1, R2 and R3.
Inspectors wroteBased on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 15 residents in the survey sample, Residents #8, #3, #4, #2 and #6.
Inspectors wroteBased on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to maintain transmission based precautions as ordered for three of 15 residents in the survey sample, Residents #5, #8, and #10.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide incontinence care for three of fifteen residents in the survey sample, Residents #2, #5 and #6.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for a colostomy for one of 15 residents in the survey sample, Resident #4.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that staff failed to provide feeding assistance for one of 15 residents, Resident #2 (R2).
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide complete dialysis care and services for one of 15 residents in the survey sample, Resident #3.
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence neurological assessment and monitoring after an unwitnessed fall with head injury for one of six residents in the survey sample, Resident #1.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the plan of care for transporting a resident which resulted in an injury for one of 40 residents in the survey sample, Resident #33. The resident sustained a fracture of the right femur (1) which constituted harm, cited at past non-compliance.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure injuries for three of 40 residents in the survey sample, Residents #106, #108 and #96. For Resident #106, the facility staff failed to assess the resident for risk for pressure injuries, failed to document pressure injuries, failed to obtain physician's orders for the treatment of the pressure injuries, and failed to implement interventions to prevent further pressure injuries, which constituted harm.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to ensure there was an RN (registered nurse) on duty for eight consecutive hours on 9/16/20223.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in condition and/or a need to alter treatment in a timely manner for two of 40 residents in the survey sample, Residents #106 and #96.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for eight of 40 residents in the survey sample, Residents #48, #108, #52, #219, #62, #76, #11, and #16.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor weights for two of 40 residents in the survey sample, Residents #53 and #16.
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 for two of 40 residents in the survey sample, Residents #270 and #48.
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 40 residents in the survey sample, Resident #119 and Resident #83.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 40 residents in the survey sample, Resident #96.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 40 residents in the survey sample, Resident #83.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free of a significant medication error for one of 40 residents in the survey sample, Resident #96.
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 one of 40 residents in the survey sample, Resident #108.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure residents dignity for one of 40 residents in the survey sample, Resident #120.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that written RP (responsible party) and ombudsman notification was provided when three of 40 residents in the survey sample were transferred to the hospital, Residents #49, Resident #33, and Resident #11.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided to the resident and/or responsible party (RP), when three out of 40 residents in the survey sample were transferred to the hospital; Residents #49, Resident #33, and Resident #11.
Inspectors wroteBased on observations, resident interview, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for three of 40 residents in the survey sample, Residents #62, #33 and #49.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to develop and/or implement a baseline care plan for three of 40 residents in the survey sample, Residents #119, #120 and #96. 1. For Resident #119, the facility failed to implement the baseline care plan for pre and post dialysis weights. Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and dialysis. A review of the baseline care plan dated 9/9/23 revealed, FOCUS: The resident has ESRD and receives Hemodialysis on Tuesday/Thursday/Saturday (T-TH-SA). INTERVENTIONS: Pre-Post dialysis weights. Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. [...]
Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to review and revise the care plans for three of 40 residents in the survey sample, Residents #13, 108 and #83.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for two of 40 residents in the survey sample, Residents #106 and #219.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement a safe smoking environment for three out of 40 residents in the survey sample, Residents #13, #62 and #101.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one of 40 residents in the survey sample; Resident #219. During the Medication Administration task, out of 29 opportunities, the facility failed to administer four medications, resulting in an error rate of 13.79%.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to store medications safely in one of three medication carts.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to obtain ordered laboratory testing for one of 40 residents in the survey sample, Resident #53.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for two of 40 residents in the survey sample, Resident #119 and #83.
Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to follow infection control practices for two of 40 residents in the survey sample, Resident #49 and #120.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to maintain a complete antibiotic stewardship program. The facility failed to evidence documentation of antibiotic use monitoring for December 2022.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide education and offer the pneumococcal vaccination for one of five residents reviewed for immunizations; Resident #108.
Inspectors wroteBased on observations, resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence bed inspections for one of 40 resident beds in the survey sample, Resident #52.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure an accessible call bell in the bathroom for one of 40 residents in the survey sample, Resident #76.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to post the nurse staffing information on 9/20/2023.
Inspectors wroteBased on observation, staff interview, facility document review and in the course of a complaint investigation it was determined the facility staff failed to ensure skills competencies for six of six TNA's (temporary nursing assistants) reviewed, TNA #10, TNA #13, TNA #16, TNA #17, TNA #18, and TNA #19. For TNA #10, #13, #16, #17, #18, and #19, the facility failed to ensure each TNA possessed the skills and competencies to provide basic ADL (activities of daily living) care for residents.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for five of five CNA's (certified nursing assistants) reviewed, CNAs #1, #6, #7, #8 and #9.
Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain kitchen equipment in a sanitary manner for one of one microwave, one of one cook's refrigerators, and in one of one traditional ovens in the kitchen. On observation on 3/27/22, the microwave contained numerous pieces of food and debris, the two ovens contained grease and multiple food chunks and debris, and the cook's refrigerators contained evidence of multiple sticky liquid spills on the bottom shelf.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, it was determined the facility staff failed to accommodate the needs of seven of 50 residents in the survey sample, Residents #86, #50, #60, #6, #43, #29, and #58.
Inspectors wrote2. The facility staff failed to maintain a homelike environment for Resident #86 (R86). The wallpaper behind the bed was torn and ripped. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 3/16/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. Observation was made on 3/28/2022 at 2:02 p.m. of R86's room. The wall behind the bed had torn and ripped wallpaper. A second observation was made on 3/29/2022 at 8:47 a.m. The wall behind the bed had torn and ripped wallpaper. On 3/29/2022 at 9:50 a.m. an interview was conducted with OSM (other staff member) #4, the maintenance director at a sister facility. [...]
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 50 residents in the survey sample were transferred to the hospital, Residents #452, #66, #67, #6, and #93. 1.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident and/or RP (responsible party) and ombudsman upon a facility initiated transfer for five out of 50 residents in the survey sample, Residents #452, #66, #67, #6, and #93. 1.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold was provided at the time of discharge to four out of 50 residents in the survey sample, Residents #452, #66, #67 and #93.
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 care and services in a manner to promote resident safety for four of 50 residents in the survey sample, Residents # 3, # 51, # 21 and # 47.
Inspectors wroteBased on resident interview, 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 50 residents in the survey sample, Residents # 3 (R3). For Resident #3, the facility staff failed to conduct complete pain assessments and attempt non-pharmacological interventions prior to the administration of a prn [as needed] pain medication oxycodone-acetaminophen (1).
Inspectors wroteBased on 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 50 residents in the survey sample, Residents # 73 and # 66.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that two of 50 residents in the survey sample were not invited to their care plan meetings/conference, Resident #50 and Resident #93.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to promote dignity for one of 50 residents in the survey sample, Resident #43 (R43). Resident #43 was observed with visible dandruff flakes and crusty patches on the scalp, a noticeable body odor, dry and cracked areas on the lips with visible film in the corners of the mouth and white filmy substance on the fold area under their neck during an incontinence care observation on 3/29/2022.
Inspectors wroteBased on resident interview and clinical record review, it was determined that the facility staff failed to facilitate a resident's right for self-determination and choice for 1 of 50 residents in the survey sample, Resident #47. The facility staff failed to honor Resident #47's (R47) preference for night time snacks in bed.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the notice of the right to appeal discharge from Medicare Part A services for 1 of 50 residents in the survey sample; Resident #200.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to prevent neglect for one of 50 residents in the survey sample, Resident #43 (R43). Resident #43 was observed with visible dandruff flakes and crusty patches on the scalp, a noticeable body odor, dry and cracked areas on the lips with visible film in the corners of the mouth and white filmy substance on the fold area under their neck during an incontinence care observation on 3/29/2022.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 50 residents in the survey sample, Resident #51. The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #51's (R51) quarterly MDS assessment with an ARD (assessment reference date) of 2/16/2022.
Inspectors wroteBased on observations, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory therapy in a sanitary manner for one of 50 residents in the survey sample, Resident #59. The facility failed to store Resident #59's oxygen equipment in a sanitary manner.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined one of 50 residents in the survey sample received unnecessary psychotropic medications, Resident #6 (R6). For Resident #6, the facility staff failed to ensure a proper diagnosis for the use of Seroquel (Quetiapine Fumarate) (used to treat schizophrenia, Bipolar disorder and in addition to other medications to treat depression) (1); and failed to identify target behaviors for the Seroquel.
Inspectors wrote2. The facility staff failed to maintain a functioning toilet in Resident #47's (R47) room. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/11/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. On 3/28/22 at 3:17 p.m., an interview was conducted with R47. R47 stated the toilet in the room has been broken for the past month and won't flush. R47 stated this was verbalized to someone in the maintenance department but the toilet has not been fixed. R47 stated they did not use the toilet but the staff used the toilet to empty urine from the resident's urinary catheter bag. At this time, an observation of the toilet was conducted. [...]
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to post daily staffing for three of four days reviewed. The facility failed to post daily nursing staffing on 3/27/22, 3/28/22, and 3/29/22.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards for medication administration for one of 25 residents in the survey sample, (Resident #47). The facility staff failed to provide the care and services in accordance with professional standards of practice for documenting the administration of medications on 7/2/2020 for Resident #47. On the evening of 7/2/2020, Resident #47 was inadvertently assigned to both LPN [licensed practical nurse] #4 and RN [registered nurse] #2. [...]
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure one of 25 residents in the survey sample, (Resident #47), was free of a significant medication error. On the evening of 7/2/2020, Resident #47 was administered all of her multiple physician prescribed evening medications twice, by two nurses, LPN [licensed practical nurse] #4 and RN [registered nurse] #4, resulting in a significant medication error. Resident #47 was subsequently was transferred to a local hospital for evaluation/treatment. The hospital record documented Resident #47 was sleepy, weak and confused in the emergency room, displayed a drop in blood sugar, blood pressure and slow hear rate (bradycardia) readings; [...]
Inspectors wrote2. The facility staff failed to evidence Resident #11's comprehensive care plan goals were provided to the receiving facility, for the residents transfer to the hospital on 1/17/21, and failed to ensure that the physician wrote a note regarding the need for the 1/17/21 hospitalization for Resident #11. Resident #11 was admitted to the facility on [DATE] with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21. Resident #11 was coded as cognitively impaired in ability to make daily life decisions. [...]
Inspectors wrote2. The facility staff failed to evidence that a written notification was provided to the resident and or resident representative upon Resident #11's transfer to the hospital on 1/17/21. Resident #11 was admitted to the facility on [DATE] with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21. The resident was coded as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance. [...]
Inspectors wrote2. The facility staff failed to evidence that a written bed hold policy was provided to the Resident or Resident Representative for Resident #11's hospital transfer on 1/17/21. Resident #11 was admitted to the facility on [DATE], with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21, coded the resident as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance. A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM, documented in part: [...]
Inspectors wrote4. The facility failed to develop a comprehensive care plan to include trach [tracheostomy] care and ROM (range of motion) for Resident #24. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3). Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: [...]
Inspectors wrote4. The facility staff failed to review and/or revise Resident #44's comprehensive care plan to address a worsened pressure ulcer (1). Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (2) and tracheostomy (3). Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/12/21 coded Resident #44 as non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependent on one staff member for eating and personal hygiene. Section M coded Resident #44 having one unstageable pressure ulcer. [...]
Inspectors wroteBased on resident interview, staff interview, facility document review 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 prevent and promote healing of a pressure injury for two of 25 residents in the survey sample, Residents #25 and #44. 1. The facility staff failed to ensure ongoing assessments to include measurements, descriptions and the completion of a PUSH tool for the Resident #25's right lateral fifth toe pressure injury. Resident #25's clinical record revealed a PUSH tool (8) was completed for each of the resident's pressure injuries except for the right lateral foot, fifth toe pressure injury. [...]
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide services related to a urinary catheter for one of 25 current residents in the survey sample, Resident #25. The facility failed to monitor and record urinary output amounts on multiple dates since the resident's admission on [DATE]. The facility failed to evidence Foley catheter care on multiple dates since the resident's admission on [DATE].
Inspectors wrote6. The facility failed to provide oxygen at the physician prescribed flow rate for Resident #24 and failed to ensure tracheostomy care was provided as ordered by the physician on 4/12/21, 4/13/21 and 4/16/21 day shift and failed to ensure an ambu bag was present at Resident #24's bedside per the facility policy. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3). [...]
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide dialysis services for two of 25 residents in the survey sample, (Residents #19 and #67). 1. The facility staff failed to ensure communication regarding Resident #19's care with the dialysis center, failed to assess the resident's dialysis access site per physician's order, failed to follow up on a fluid restriction recommendation from Resident #19's dialysis RD (registered dietician). 2. For Resident #67, the facility staff failed to obtain a physician's order for dialysis (1), failed to follow a physician's order for fluid restriction, failed to evidence documentation of assessment of her dialysis access site, and failed to maintain communication with the dialysis center.
Inspectors wroteBased on clinical record reviews, facility document review and staff interviews it was determined that the facility failed to maintain a complete and accurate clinical record for eight of 25 residents in the current resident sample, Residents #44, #67, #25, #11, #80, #19, #24 and #47.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide privacy and dignity for a Foley catheter for one of 25 residents in the survey, Resident #80. On 4/21/21, Resident #80 was observed lying in bed with an uncovered Foley catheter bag visible from the hall. The facility staff failed to provide privacy and dignity for the Foley catheter bag.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a clean environment for one of 25 current residents in the survey sample, (Resident #25). The facility staff failed to clean Resident #25's feeding tube pump.
Inspectors wroteBased on staff interview, and facility document review, it was determined that the facility staff failed to orient a resident prior to transfer for one of 25 current residents reviewed, Resident #55. The facility staff failed to provide evidence that all required information including the resident notification and orientation prior to transfer was provided to Resident #55 upon transfer to the hospital on 4/12/21.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 25 current residents in the survey sample, Resident #24. The facility failed to develop a baseline care plan for Resident #24 to address the care required for the resident's tracheostomy and failed to address ROM (range of motion), which was triggered on the 2/6/21, admission assessment for the baseline care plan.
Inspectors wroteBased on resident interview, 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 one of 25 residents in the survey sample, Resident #19. On three Sundays in March 2021, the facility staff failed to provide assistance with transfers, dressing or personal hygiene, to Resident #19, who was assessed as requiring extensive assistance of one staff with personal hygiene and dressing.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide foot care and treatment, in accordance with professional standards of practice for one of 25 current residents in the survey sample, Resident #67. The facility staff failed to trim Resident #67's toenails to an optimal length to prevent infection or disease.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to provide services to prevent a decrease in range of motion (ROM) for one of 25 current residents in the survey sample, Resident #24. The facility failed to provide ROM services after identification of weakness and impaired mobility on admission for Resident #24.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to address a significant weight gain for one of 25 residents in the survey sample, Resident #19. The facility staff failed to address Resident #19's monthly weight gain of 11.10 percent in March 2021.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for one of five CNA record reviews. The facility staff failed to complete an annual performance review for CNA #5.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer medication in a sanitary manner to prevent the spread of infection for one of 5 residents in the Medication Administration task, (Resident #28). During the medication observation RN #4 used her bare finger to tap at a Cardizem pill that was not easily dislodged from the packaging, her bare finger was in direct contact with the Cardizem pill that was partially protruding from the package. RN #4 dislodged the Cardizem pill from the package into the pill cup.
1 fire safety citation on file: 1 on March 30, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| September 21, 2023 | Fine | $73,788 |
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) | 3.10 | 3.76 | 3.86 |
| Registered nurses | 0.52 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.69 | 3.29 | 3.42 |
| Nurse aides | 1.64 | ||
| Licensed practical nurses | 0.94 | ||
| Nursing staff turnover (share who left in a year) | 65.9% | 48.1% | 45.8% |
| Registered nurse turnover | 75.0% | 48.2% | 42.9% |
| Administrators who left | 2 |
CMS expects 4.54 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 3.26 on weekdays and 2.69 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 23.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.96 in April to June 2025 to 3.10 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 | 3.10 | 0.52 | 3.26 | 2.69 | 23.6% | 0 of 90 | 124 |
| Oct to Dec 2025 | 3.03 | 0.39 | 3.18 | 2.66 | 18.5% | 0 of 92 | 120 |
| Jul to Sep 2025 | 2.92 | 0.33 | 3.01 | 2.68 | 14.3% | 0 of 92 | 117 |
| Apr to Jun 2025 | 2.96 | 0.41 | 3.10 | 2.61 | 30.3% | 0 of 91 | 120 |
| 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 | 17.4 | 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 | 0.7 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.9 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.1 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 24.9 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.5 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.0 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 45.1 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.4 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Rosedale Health & Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (58.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
58.3% 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. 57 eligible stays.
10.7% 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. 61 eligible stays.
6.8% 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. 32 eligible stays.
51.5% 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. 33 residents counted.
1.9% 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. 54 residents counted.
2.8% 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. 54 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 17 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: ROSEDALE 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 |
| Crabbe, Stephanie | 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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