Health inspections
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.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
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 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
11E
5F
Potential for minimal harm
0A
0B
0C
March 4, 2026Standard inspection · 14 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on interview and record review, the facility failed to employ kitchen staff with the appropriate credentials. This deficient practice had the potential to affect all of the residents receiving meals in the facility. Facility Census: 56.
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe food temperatures to prevent foodborne illness and an appetizing temperature of the food. The facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice had the potential to affect all of the residents. Facility census:
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect all of the residents. Facility census: 56.
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and staff interview, the facility failed to store and dispose of garbage and refuse properly. The dumpster had two sliding doors that were both open. The lid on the trash can located in the kitchen was not on securely, during two different observations of the kitchen during the survey process. This was a random opportunity for discovery that has the potential to affect every resident at the facility. Facility census: 56.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on resident interview, observation, and staff interview, the faciltiy failed to ensure resident dignity during dining. The facility failed to ensure roommates and tablemates in the dining room received their meal trays at the same time. These were random opportunities for discovery. Resident Identifiers: #27, #55, #15, #54, #40, #31, #50, #13, and #43. Facility Census: 56.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on resident interviews, record review, and staff interviews, the facility failed to develop/implement a care plan for resident #2 regarding their role as Resident Council President. The facility also failed to follow interventions for Resident #10's falls. This finding was true for one (1) of 14 resident care plans reviewed during the long term care survey process. Resident identifiers: #2, #10. Facility census: 56a)Resident #2During an interview with Resident #2 on 02/03/26 at 1:20 PM she revealed she was the Resident Council President. During the interview, Resident #2 expressed concern about not having enough evening activities. She stated she holds a weekly reading group at 6:00 PM, but some residents would enjoy crafting and games such as Bingo in the evenings. [...]
- E
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, record review, resident interviews, and staff interviews, the facility failed to ensure the ongoing activity program met the interests and psychosocial needs of residents by a) failing to provide sufficient evening activities desired by residents, b) listing hydration cart services on the activity calendar as an activity, and c) failing to provide sensory stimulation programming for lower-functioning residents. These failures demonstrate the facility did not ensure residents were provided person-centered activities designed to meet individual interests, preferences, and functional abilities. This deficient practice had the potential to affect all residents residing in the facility. Resident identifiers: #7, #10, #13, #14, #18, #24, #32, and #48 Facility census: 56. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, observation and staff interview the facility failed to provide an environment free from accident hazzards. this failed practice was found true for one (1) of one (1) residents reviewed for falls during the Long term Care Survey pricess. Resident identifier: #2 Facility census:
- E
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the posted daily nurse staffing information was accurate by not havinf total hours worked on the staff posting. This was found true for all staff postings reviewed for the past year. Facility census: 56Findings include:An observation on 03/02/26 at 12:04 PM showed the staff posting did not have the total hours worked posted.]Record review on 03/02/26 for staff postings for the past year revealed none of the staff posting contained total hours worked. During an interview on 03/02/26 at 1:04 PM with the Director of Nursing (DON) who questioned what's missing? When informed of the requirement for staff posting the DON stated Ok, i will get working on fixing this now. confirming the staff postings did not contain the required information.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure a medication error rate of less than five (5) percent (%). Three (3) medication errors were made during 25 medication opportunities to make an error rate of 12%. Resident Identifier: #9. Facility Census: 56.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and staff interview, the facility failed to ensure proper infection control practices were completed during medication administration and hand hygiene for staff between passing trays and offering residents hand hygiene on the resident halls. These were random opportunities for discovery. Facility Census: 56. Findings Include: a) Medication Administration On 03/04/26 at 9:39 AM, an observation of Registered Nurse (RN) #26 preparing medication for Resident #3 was made. During the observation, RN #26 dropped a pill (Zoloft) directly on the medication cart, which had no barrier, and picked the pill up with a bare hand. RN #26 did not complete hand hygiene before or after administering the medication. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure documentation the physician was notified when the resident experienced a change in condition. Resident Identifier: #2. Facility Census: 56.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store medications within acceptable standards of care. A bottle of Aplisol (tuberculin purified protein derivative) located in refrigerator in med room had been opened more than 30 days ago. This was a random opportunity for discovery during the facility task of medication storage and labeling. Facility Census: 56.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to meet the nutritional needs of the residents in accordance with established national guidelines due to not following the menu. The facility failed to follow the approved menus, making random substitutions of food items. This had the potential to affect more than a limited number of residents. This is true for Resident #51, Resident #35 and Resident Council. Facility census: 56.
August 8, 2024Standard inspection · 12 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. This was a random opportunity for discovery. Room identifier: east and west shower rooms. Facility census: 58.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and staff interview, the facility failed to provide care and services in accordance with acceptable standards of practice. The facility failed to ensure the physician was notified when Resident #56's blood sugar levels were above 400. This affected one (1) of five (5) residents reviewed for unnecessary medications during the long-term care survey process. Additionally, the facility failed to have matching treatment orders when comparing the Physician Orders for Scope of Treatment (POST) form and written physician orders on the chart. This was true for one (1) of 19 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #56 and #3. Facility census: 58.
- E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on review of the staff schedules for Registered Nurse (RN) coverage and staff interview, the facility failed to ensure RN coverage eight (8) consecutive hours a day, seven (7) days a week. This had the potential to affect all residents at the facility. Facility census: 58. a) RN Coverage A review of the staffing schedules for RN coverage, completed on 08/08/24 at 12:30 PM, revealed ten (10) occasions when RN coverage did not occur eight (8) consecutive hours a day: [...]
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and staff interview the facility failed to have a clean sanitized mobile utility food cart and debris under the kitchen prep tables, the stove and [NAME]. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census. 58.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on record review and resident interviews, the facility failed to ensure residents had the right to make choices about aspects of their life in the facility that are significant to the resident, including the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility. This was true for two (2) of five (5) residents reviewed for the category of choices, during the long-term care survey. Resident Identifiers: #25 and #40. Facility Census: 58. Findings Included: a) Resident #25 During an interview on 08/06/24 at 11:05 AM, Resident #25 revealed she would like to have three showers a week, but the facility only schedules her for showers on Tuesdays and Saturdays. She stated that she had mentioned her preference to the Nursing Assistants (NAs) on more than one occasion, but her requests had been ignored. [...]
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This was true for one (1) of three (3) grievances reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #55. Facility census: #58. Findings Include: a) Policy Review Record review of the facility's policy titled, Grievance, revision dated 09/14/22, showed: -Upon receipt of an oral, written or anonymous grievance submitted by a Resident, the grievance official will take immediate action to prevent further potential violations of any residents' rights while alleged violation is being investigated, if indicated. -The Grievance Committee / Grievance official shall complete an investigation of the resident's grievance. [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one (1) of 19 residents reviewed during the Long-Term Care Survey process. The MDS for Resident #36 did not accurately reflect the resident had bilateral hearing amplifiers. Resident identifier: Resident #36. Facility Census: 58.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASRR (Pre-admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifier: #58. Facility census: 58.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation and interview, the facility failed to identify and implement measures to reduce hazards and risks, and to ensure that the resident environment remained free of accident hazards. This failed practice had the potential to affect more than a limited number of residents who resided at the facility. This was a random opportunity for discovery. Facility census:58. Findings Included: a) On 08/06/24 at 1:24 PM, it was observed that two bathrooms in close proximity to the physical therapy room, and conference room/lounge, were unlocked and accessible to both staff and residents at any time. Upon further inspection, it was discovered that these bathrooms were not equipped with nurse call devices or emergency pull alarms. During an interview with Administrator #72 on 08/06/24 at 1:39 PM, he stated that Those bathrooms are not for residents. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review the facility failed to provide services to provide appropriate toileting schedule for one (1) of one (1) resident reviewed for the bowel and bladder care area during the long term care survey. Resident identifier #32. Facility census: 58.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and review of documents, facility failed to adequately assess and control resident's pain. This failed practice had the potential to cause harm to one (1) of two (2) residents reviewed for pain. Resident #13. Facility Census: 58.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on review of facility documentation and staff interview, the facility failed to have the required members attend the Quality Assessment and Assurance (QAA) meetings at least quarterly. The facility failed to ensure the Medical Director or designee attended the QAA meetings at least on a quarterly basis. This practice had the potential to affect more than a limited number of residents. Facility census: 58.
September 14, 2022Standard inspection · 9 citations
- F
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on policy review, record review and staff interview The facility failed to develop and implement policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. In addition, pharmacy recommendations were kept in the Director of Nursing's (DON) office and not forwarded to the physician for a timely response. This is true for one of five reviewed for unnecessary medications, but has the potential to affect all residents. Resident identifier: #51. Facility census: 56.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on Resident Council Interview, observation, resident interview, staff interview, record review and documentation review the facility neglected to have a system in place for Residents to notify staff when outside on the patio. Resident identifier: #7. Facility census: 56.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frames. This was a random opportunity for discovery. Resident identifier: #1. Facility census: 56. Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: -It is the facility's policy to investigate all allegations involving Abuse, Neglect, Exploitation & Misappropriation of Resident Property, including injuries of unknown source, in accordance with this policy. -Facility staff should immediately report all such allegations to the Administrator and to [NAME] Virginia Office of Health Facility Licensing and Certification (OHFLAC) in accordance with the procedures in this policy. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, staff interview, and operation policy the facility failed to take actions to investigate an alleged violation related to, verbal abuse. This was a random opportunity for discovery. Resident identifier #1. Facility Census 56. Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed: -It is the facility's policy to investigate all allegations involving Abuse, Neglect, Exploitation & Misappropriation of Resident Property, including injuries of unknown source, in accordance with this policy. -Facility staff should immediately report all such allegations to the Administrator and to [NAME] Virginia Office of Health Facility Licensing and Certification (OHFLAC) in accordance with the procedures in this policy. -If Abuse or serious Bodily Injury is Alleged. [...]
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and staff interview the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge / transfer or the Resident Representative. This was true for two (2) of three (3) Hospitalizations reviewed. Resident Identifier #40 and #54. Facility Census 56. Findings Included: a) Resident #40 Record review on 09/13/22 at 1:27 PM, revealed resident #40 was discharged to the hospital on [DATE] and 09/02/22. Subsequent review of the resident #40's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman of the discharges on 08/28/22 or 09/02/22. b) Resident #54 Record review on 09/13/22 at 1:27 PM, revealed resident #54 was discharged to the hospital on [DATE]. [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to implement a care plan. Resident #50's foot brace was not applied when up in her wheel chair. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 56.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followed for the application of a foot brace when up in a wheel chair. This was a random opportunity for discovery. Resident identifier: #50. Facility census: 56.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Weekly pressure ulcer assessments were not completed. This is true for one of three reviewed for pressure ulcers. Resident identifier: R #106. Facility census: 56.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and staff interview the facility failed to store oxygen tubing in the appropriate bag when not in use and ensure there was a physician order to administer oxygen to a resident. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of residents. Resident identifier: #10. Facility census: 56.
Fire safety inspections
12 fire safety citations on file: 4 on March 4, 2026, 6 on August 8, 2024, 2 on September 14, 2022.
Every fire safety citation12 citations
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 4, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 4, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 4, 2026 · Corrected (the home has a date of correction)
- C
Have proper medical gas storage and administration areas.
K 923 · March 4, 2026 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 8, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · August 8, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 8, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · August 8, 2024 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · August 8, 2024 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · September 14, 2022 · deficient, provider has
- C
Have simulated fire drills held at unexpected times.
K 712 · September 14, 2022 · deficient, provider has