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 26 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
4E
0F
Potential for minimal harm
0A
0B
3C
June 12, 2025Complaint inspection · 1 citation
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, staff interviews, clinical record review, and facility document review, the facility staff failed to provide a resident with food prepared in a form designed to meet the individual needs for 1 of 6 sampled residents. (Resident #3)
December 11, 2024Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to report an incident of visitor-to-resident abuse within two (2) hours of the observed abuse for one (1) of four (4) residents sampled. (Resident #1)
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one (1) of four (4) residents sampled. (Resident #1)
October 16, 2024Standard inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview and clinical record review, facility staff failed to administer an an antibiotic medication per provider orders for 1 of 14 sampled current residents (Resident 30).
- D
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 staff interview, clinical record review, and facility document review, the facility staff failed to ensure the medical provider documented the action and/or rationale for the action on a pharmacy recommendation, as part of a medication regimen review for (1) one of (5) five residents sampled for medication regimen reviews, Resident #9.
- D
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on staff interviews and facility document review the facility staff failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one agency staff member working in the facility.
September 26, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, family interview, and clinical record review, the facility staff failed to ensure the highest practicable physical well-being for 1 of 4 Residents (Resident #2). The facility staff failed to identify an injury of unknown origin.
March 17, 2022Standard inspection · 2 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on staff interview, Resident interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 4 out of 12 residents, Resident #8, Resident #14, Resident #28 and Resident #37. For Resident #8 the facility staff failed to document blood sugar levels and the administration of insulin on one occasion and failed to document a weekly ordered weight on one occasion. For Resident #14 the facility staff failed to document the administration of the medications Prevacid and Neurontin for one occasion and failed to document tube feeding water flushes for one occasion. For Resident #28 the facility staff failed to document the administration of the medications Levothyroxine and Prilosec on one occasion, and failed to document blood sugar levels and insulin administered on two occasions. [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 12 residents in the survey sample, Resident #22. For Resident #22, the facility staff failed to secure the resident's cigarettes and lighter.
May 31, 2019Standard inspection · 17 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure the highest practicable well-being for 7 of 22 Residents, Resident #43, #31, #19, #34, #4, #40, and #22.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 6 of 22 residents were free of an unnecessary psychotropic medication (Resident #6, Resident #40, Resident #154, Resident #19, Resident #53, and Resident # 7).
- E
Ensure that residents are free from significant medication errors.
Inspectors wrote[NAME] F tag 760 E Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 2 of 22 residents were free of a significant drug error (Resident #40 and Resident #22).
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the Virginia Department of Health Durable Do Not Resuscitate (DDNR) form was complete for 1 of 22 residents (Resident #154).
- D
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, resident interview, staff interview, and clinical record review, the facility staff failed to ensure a clean and comfortable homelike environment for 1 of 22 residents (Resident #41).
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the PASSARs (Pre-admission Screening and Resident Review) were complete for 2 of 22 residents (Resident #45 and Resident #7).
- 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 staff interview and clinical record review, the facility staff failed to develop care plans for psychotropic medication (Zyprexa and Restoril) and insomnia for 1 of 22 residents (Resident #40).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to review and revise the comprehensive plan of care for 2 of 22 Residents in the survey sample, Resident # 31 and Resident # 7.
- 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 observation, clinical record review, staff interview, Resident interview, and facility document review, the facility staff failed to provide services to prevent urinary tract infections for 1 of 22 Residents in the survey sample, Resident 34.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to utilize non-pharmacological interventions prior to the use of pain medication for 1 of 22 residents (Resident #154).
- 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 and staff interview, the facility staff failed to dispose of expired medications on two of two halls.
- D
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on staff interview and clinical record, the facility staff failed to obtain a physician ordered laboratory test for 1 of 22 residents (Resident #40).
- D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on staff interview and clinical record, the facility staff failed to obtain a physician order prior to obtaining laboratory tests for 1 of 22 residents (Resident #40).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to clean scissors before use or after use for 1 of 22 residents (Resident #45).
- C
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to ensure that comprehensive care plan goals were sent with facility residents upon transfer for 7of 22 residents.
- C
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 staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of transfer/discharge to include the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman and documentation in the medical record that the notice was sent to the Ombudsman for 3 of 22 residents (Resident #45, Resident #40, and Resident #6).
- C
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on clinical record review, staff interview, and facility document review, the facility staff failed to provide written notice of bed hold upon transfer or discharge for 8 of 22 residents
Fire safety inspections
25 fire safety citations on file: 6 on October 16, 2024, 13 on March 17, 2022, 6 on May 31, 2019.
Every fire safety citation25 citations
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · October 16, 2024 · Waiver
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 16, 2024 · Waiver
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 16, 2024 · Waiver
- D
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 16, 2024 · Waiver
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 16, 2024 · Waiver
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · October 16, 2024 · Waiver
- F
Have properly located and lighted "Exit" signs.
K 293 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · March 17, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 17, 2022 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · March 17, 2022 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 17, 2022 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 17, 2022 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 17, 2022 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 17, 2022 · Corrected (the home has a date of correction)
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 31, 2019 · 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 · May 31, 2019 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 31, 2019 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · May 31, 2019 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 31, 2019 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 31, 2019 · Corrected (the home has a date of correction)