7300 Forest Ave, Richmond, VA 23226 · Henrico County · (804) 288-3152
225 certified beds, about 214 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1991
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495227 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on November 21, 2024, inspectors cited 40 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 126 health citations since October 2021, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 2 fines totaling $64,127 in the last three years; the largest was $55,021, and the latest is dated October 22, 2025.
Nurses and nurse aides worked 3.19 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.33 of those hours.
54.1% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Lifeworks Rehab, an affiliated group of 64 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 126 health citations on file.
Inspectors wroteBased on observation, resident interview, and facility document review, the facility staff failed to promote resident's dignity for one of 6 residents in the survey sample, Resident #3.
Inspectors wroteBased on observation, resident interview, and facility document review, the facility staff failed to follow the comprehensive care plan for one of 6 residents in the survey sample, Resident #3.
Inspectors wroteBased on observations, staff interview, resident interview, clinical document and facility document review, it was determined that the facility staff failed to provide a safe environment for two of 17 residents in the survey sample, Resident #9 (R9) and Resident #5 (R5). For Resident #9, the facility staff left the resident unattended, in an unsafe position, with the bed in the high position on 3/24/25. R9 rolled off the bed and suffered a hematoma. The resident was sent to the emergency room and found to have an occipital condyle fracture (1) thus causing harm to the resident.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of wellbeing for one of twelve residents, Resident #112 (R112).
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to protect a resident's right to consent to receiving a psychoactive medication for one of 17 residents in the survey sample, Resident #14.
Inspectors wroteBased on observation and staff interview, the facility staff failed to accommodate a resident's need by placing the call bell within reach for one of 12 residents in the survey sample, Resident #103.
Inspectors wroteBased on observations and staff interview, facility staff failed to maintain a clean environment for one of 12 resident rooms observed, resident room [ROOM NUMBER].
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement their abuse policy to report an allegation of abuse in the required timeframe for one of 17 residents in the survey sample, Resident #4.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to report an allegation of abuse in the required timeframe for one of 17 residents in the survey sample, Resident #4.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to complete an accurate MDS assessment for one of 17 residents in the survey sample, Resident # 1.
Inspectors wroteBased on observations, staff interview facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for one of twelve residents in the survey sample, Resident #112 (R112).
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the care plan for two of 17 residents in the survey sample, Residents #5 and #1.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice to promote residents highest level of well-being for two of 17 residents in the survey sample, Resident #10 and Resident #4.
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 one of twelve residents, Resident #104 (R104).
Inspectors wroteBased on staff/resident interview, facility document review and clinical record review, it was determined that the facility staff failed to provide treatment and services for an indwelling catheter for one of twelve residents in the survey sample, Resident #104 (R104).
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature for one of twelve residents, Resident #104 (R104).
Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to maintain an accurate clinical record for one of five residents in the survey sample, Resident #1.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner in one of one facility kitchen.
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 one of 16 residents in the survey sample, R208.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 16 residents, R208.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to prevent an avoidable accident for one of six residents in the survey sample, Resident #1. This accident resulted in a fractured pelvis and intractable pain for Resident #1, constituting harm. The facility presented a plan of correction with an allegation of compliance date prior to survey entrance. The facility presented credible evidence that the plan of correction had been implemented, resulting in a finding of past noncompliance.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to prevent an unevaluated CNA (certified nursing assistant) from operating a mechanical lift for one of three CNA (certified nursing assistant) records reviewed, CNA #1.
Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to serve meals in a dignified manner on one of four units, unit two.
Inspectors wroteBased on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for four of 69 residents in the survey sample, Resident (R) #36, R46, R125 and R179.
Inspectors wroteBased on review of facility's documentation and staff interview, it was determined that the facility failed to evidence resolution of resident council concerns.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain confidentiality of resident information for three of 69 residents in the survey sample, Residents #249, #250 and #182.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain a clean, comfortable, homelike environment for one of 69 residents in the survey sample, Resident #121, and in one of one reception area outside of the kitchen.
Inspectors wrote2. For Resident #130 (R130), the facility staff failed to evidence the comprehensive care plan was sent to the hospital upon transfer on 8/3/24. The nurse's note dated. 8/3/24 at 11:16 a.m. documented, Resident observed with an oxygen level of 94%. Resident c/o (complained of) sob (shortness of breath). Resident observed with using accessory muscles to breathe. Resident c/o chest pain and upper right and left abdominal pain. Resident rate pain 10/10. Resident was placed on non-breather oxygen improved to 99%. NP (nurse practitioner) notified of change of condition. New order to transfer to hospital. Resident is own rp (responsible party). Resident was made aware of the transfer. Resident was sent to (name of hospital) ED (emergency department) via ems (emergency medical services) with face sheet, med (medication) list and transfer form. [...]
Inspectors wrote2. For Resident #130 (R130) the facility staff failed to evidence the resident and/or responsible party was provided a written notice for the reason of the need for transfer to the hospital on 8/3/24 and failed to notify the ombudsman of the transfer in a timely manner. The nurse's note dated. 8/3/24 at 11:16 a.m. documented, Resident observed with an oxygen level of 94%. Resident c/o (complained of) sob (shortness of breath). Resident observed with using accessory muscles to breathe. Resident c/o chest pain and upper right and left abdominal pain. Resident rate pain 10/10. Resident was placed on non-breather oxygen improved to 99%. NP (nurse practitioner) notified of change of condition. New order to transfer to hospital. Resident is own rp (responsible party). Resident was made aware of the transfer. [...]
Inspectors wrote2. For Resident #130 (R130), the facility staff failed to provide evidence that a bed hold notice was provided upon transfer to the hospital on 8/3/24. The nurse's note dated. 8/3/24 at 11:16 a.m. documented, Resident observed with an oxygen level of 94%. Resident c/o (complained of) sob (shortness of breath). Resident observed with using accessory muscles to breathe. Resident c/o chest pain and upper right and left abdominal pain. Resident rate pain 10/10. Resident was placed on non-breather oxygen improved to 99%. NP (nurse practitioner) notified of change of condition. New order to transfer to hospital. Resident is own rp (responsible party). Resident was made aware of the transfer. Resident was sent to (name of hospital) ED (emergency department) via ems (emergency medical services) with face sheet, med (medication) list and transfer form. [...]
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for six of 69 residents in the survey sample, Residents #5, #248, #74, #179, #48 and #138.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for two of 69 residents in the survey sample, Residents #179 and #449.
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 69 residents, R138, R448 and R55.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to administer medications per physician's orders for five of 69 residents in the survey sample, Residents #55, #106, #130, #248, and #500.
Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to provide Foley catheter care and services for one of 69 residents in the survey sample, Resident #300.
Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to provide colostomy care and services for one of 69 residents in the survey sample, Resident #300.
Inspectors wroteBased on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 69 residents in the survey sample, R155.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to implement bed rail requirements for four of 69 residents in the survey sample, Residents #147, #55, #182, and #106.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow the menus and provide alternate menu selection for one of one kitchen and for one of 69 residents in the survey sample, Resident #46.
Inspectors wroteBased on observation, resident interview, staff interview and facility document review, it was determined the facility staff failed to served food at a palatable taste and temperature for one of one meals tasted.
Inspectors wroteBased on observation, staff interview and facility document review it was determined the facility staff failed to store, prepare and serve food in a sanitary manner in one of one kitchens.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to protect a resident's rights to confidentiality of his medical record for one of 69 residents in the survey sample, Resident #303; and failed to maintain a complete and accurate clinical record for four of 69 residents in the survey sample, Residents #247, #250, #55, and #167.
Inspectors wroteThe facility staff failed to evidence medical director participation in four of four 2023 QAPI (quality assurance process improvement) meetings.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to provide beneficiary notification for one of three residents in the beneficiary notification facility task, Resident #25.
Inspectors wroteBased on clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to resolve a grievance in a timely manner for 1 of 69 residents in the survey sample, Resident #397.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect one of 69 residents from abuse and/or neglect, R447.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to prevent misappropriation of resident's property for one of 69 residents, R451.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement a policy for reporting abuse for two of 69 residents, R447 and R397.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to report allegations of abuse to the state agency in a timely manner for three of 69 residents in the survey sample, Residents #182, #447, and #397.
Inspectors wroteBased on clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to investigate an allegation of misappropriation of property for 1 of 69 residents in the survey sample, Resident #397.
Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for one of 69 residents in the survey sample, R34.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence an accurate PASARR (preadmission screening and resident review) screening for one of 69 residents in the survey sample, R88.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop a complete baseline care plan for two of 22 residents in the survey sample, Resident #112 and #113.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for three of 69 residents in the survey sample, Residents #130, #147 and #182.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide services for a contracture for one of 69 residents in the survey sample, Resident #140.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a PICC line for one of 69 residents in the survey sample, Resident #130.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain respiratory equipment in a sanitary manner for one of 69 residents in the survey sample, Resident #130.
Inspectors wroteBased on resident interview, staff interview and facility document review, it was determined the facility staff failed to follow up on a psychiatric consult for one of 69 residents in the survey sample, Resident #500.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of five residents observed during the medication administration observation, Resident #48. During the medication administration observation, two errors out of 25 opportunities occurred, resulting in an eight percent medication error rate.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a meal tray for one of 69 residents in the survey sample, Resident #500.
Inspectors wroteBased on resident interview, staff interview and facility document review, it was determined the facility staff failed to provide a diet according to the resident's preferences for one of 69 residents in the survey sample, Resident #173.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide meals at times comparable to normal mealtimes for two of 69 residents in the survey sample, Residents #301 and #247.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to notify the provider (physician and/or nurse practitioner) of missed doses of medication for one of 24 residents in the survey sample, Resident #24.
Inspectors wroteBased on 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 two of 24 residents in the survey sample, Residents #24 and #20.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice for the administration of medications for one of 24 residents in the survey sample, Resident #24.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility pharmacy failed to provide medication for administration to one of 24 residents in the survey sample, Resident #24.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to administer medications as ordered, resulting in significant medication errors, to one of 24 residents in the survey sample, Resident #24.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to evidence the provision of medical records to a discharged resident for one of 24 residents in the survey sample, Resident #6.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide a resident with a written summary of the baseline care plan for one of 24 residents in the survey sample, Resident #1.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve food according to the menu for three of 24 residents in the survey sample, Residents #21, #22, and #23.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve palatable food for three of 24 residents in the survey sample, Residents #21, #22, and #23.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to serve food according to the residents' preferences for three of 24 residents in the survey sample, Residents #21, #22, and #23.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of seven residents in the survey sample, Resident #5.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent accidents for one of seven residents in the survey sample, Resident #5.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for one of seven residents in the survey sample, Resident #4.
Inspectors wroteBased on observation, staff interviews, facility document review, and clinical record review, it was determined the facility staff failed to implement the care plan for one of eight 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 provide evidence of ADL (activities of daily living) care for one of eight 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 honor a resident's right to make choices about their ADL (activities of daily living) care for two of 78 residents in the survey sample, Resident #195 and Resident #140.
Inspectors wroteBased on resident interview, 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 physician of a change in a resident's clinical condition for two of 78 residents in the survey sample, Residents #61 and #124.
Inspectors wrote4. For Resident #304 (R304), the facility staff failed to implement the resident's comprehensive care plan for pressure injury treatments per the physician's orders. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/1/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R304's comprehensive care plan dated 3/28/22 documented, (R304) has actual skin breakdown present on admission: SACRUM- PRESSURE INJURY, LLE (left lower extremity) POSTERIOR .Administer treatment per physician order . A wound care nurse practitioner note dated 3/31/22 documented an unstageable pressure injury (1) on R304's left posterior lower leg (present on admission). [...]
Inspectors wrote2. For Resident #304 (R304) the facility staff failed to apply physician ordered Nystatin (1) powder to the resident's groin on 4/9/22 and complete physician ordered treatment to the resident's left medial lower leg arterial wound on 5/6/22 and 5/7/22. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/1/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R304's comprehensive care plan dated 3/28/22 documented, (R304) has actual skin breakdown present on admission. GROIN-IRRITATION/REDNESS .Administer treatment per physician order . [...]
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide a safe environment for four of 78 residents in the survey sample, Residents #108, #60, #86, and #120.
Inspectors wrote2. For Resident #64 (R64), the facility staff failed to store oxygen in a safe manner and failed to store respiratory equipment in a sanitary manner. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/12/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatment, Procedures and Programs, R64 was not coded as receiving oxygen. Observation was made of R64's room on 10/11/2022 at approximately 12:30 p.m. An unsecured oxygen tank was observed next to the resident's dresser, not in a stand. A second oxygen tank was observed under the window but was stored in a stand. [...]
Inspectors wroteBased on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility failed to maintain a complete dialysis program for two of 78 residents in the survey sample, Residents #11 and #61.
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 administer medications in a manner free of significant errors for one of 78 residents in the survey sample, Resident #61.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain dignity for two of 78 residents in the survey sample, Residents #130 and #54.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a homelike environment for two of 78 residents in the survey sample, Residents #58 and #197.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon a reported grievance for missing personal items for one of 78 residents in the survey sample, Resident #62.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence required documents were sent to the receiving facility at the time of transfer for one of 78 residents in the survey sample, Resident #96.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to comprehensively complete an MDS (minimum data set) assessment for one of 78 residents in the survey sample, Resident #29.
Inspectors wroteBased on resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigations, the facility staff failed to provide residents with a summary of the baseline care plan for three of 78 residents in the survey sample, Residents #304, #195 and #140.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 78 residents in the survey sample, Resident #304.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow professional standards of nursing for medication administration documentation for one of 78 residents in the survey sample, Resident #124.
Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for strict intake and output (I & O) for one of 78 residents, Resident #171.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure required physician visits were conducted for one of 78 residents in the survey sample, Resident #94.
Inspectors wroteBased on resident interview, facility staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide a medication as ordered by the physician for one of 78 residents, Resident #124.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to monitor a resident on psychoactive medication, in order to prevent unnecessary medication administration for one of 78 residents in the survey sample, Resident #96
Inspectors wroteBased on observation, staff interview, facility document review, it was determined the facility staff failed to maintain a medication error rate of less than five percent for one of four residents in the medication administration observation, Resident #87 (R87). There were two errors within 25 opportunities.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to provide routine dental services for one of 78 residents in the survey sample, Resident #54 (R54).
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for one of 78 residents in the survey sample, Resident #124.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow transmission based precautions for one of 78 residents in the survey sample, Resident #96.
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 provide written notice to the resident and or resident representative, including the reason for the change, before the resident's room or roommate in the facility is changed for eighteen of 84 residents in the survey sample, (Residents #510, #111, #29, #153, #30, #75, #26, #512, #66, #513, #139, #515, #13, #516, #517, #511, #514 and #383). The facility staff failed to evidence written notification for multiple room changes were provided to the resident represenative and or Residents #510, #111, #29, #153, #30, #75, #26, #512, #66, #513, #139, #515, #13, #516, #517, #511, #514 and #383.
Inspectors wrote5. The facility staff failed to implement Resident #145's comprehensive care plan for the administration of oxygen at the physician ordered rate. Resident #145 was admitted on [DATE] with the diagnoses of but not limited to COVID-19, respiratory failure, atrial fibrillation, and hypothyroidism. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 9/9/21. The resident was code as being cognitively impaired in ability to make daily life decisions. Resident #145 was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, and bed mobility; and limited assistance for transfers and eating. On 9/28/21 at 12:53 PM, an observation of Resident #145 and the resident's oxygen was conducted. The resident was observed receiving oxygen via a nasal cannula that was connected to an oxygen concentrator that was running. [...]
Inspectors wroteBased on observation, 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 review and revise the comprehensive care plan for eight of 84 residents in the survey sample, Residents #502, #91, #111, #65, #21, #19, #155, and #47. 1. The facility staff failed to review and revise Resident #502's comprehensive care plan to address the resident being found physically restrained on 5/6/21, and the resident care needs post the incident. 2. The facility staff failed to review and revise Resident #91's comprehensive care plan following the resident's angry outburst, during which he fractured his hand by punching a hole in his wall on 6/21/21. 3. The facility staff failed to review and revise Resident #111's comprehensive care plan after the resident fell on 7/6/21 and 7/7/21. 4. [...]
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure the weights were monitored per the comprehensive person-centered plan of care for two of 84 residents in the survey sample, (Resident #153 and Resident #82); and failed to ensure physician ordered wound treatments were provided as ordered for one of 84 residents in the survey sample, (Resident #433). 1. Resident #153 was identified as being at risk nutritionally with interventions to obtain weights, monitor for weight loss and report significant weight loss, and had not been weighed since 3/6/21. 2. Resident #82 was assessed and identified as being at risk nutritionally with interventions to obtain weights, monitor for weight loss and report significant weight loss and had not been weighed since 5/8/21. 3. [...]
Inspectors wroteBased on staff interview, resident interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to provide the necessary treatment and services, to promote healing of a pressure ulcer for five of 84 residents in the survey sample, Resident #433, Resident #142, Resident #22, Resident #153 and Resident #129. 1. The facility staff failed to provide the physician ordered treatments to Resident #433's sacral pressure injury on multiple dates during April and May 2021. 2. The facility staff failed to provide the physician ordered treatments to Resident #142's left lateral foot (stag), right elbow (stage), sacral (stage) and left lateral heel (what stage it is) pressure injuries on multiple dates during September 2021. 3. [...]
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide supervision, and interventions to prevent accidents for four of 84 residents in the survey sample, Residents #111, #65, #19, and #40. The facility staff failed to address and/or implement fall prevention interventions to prevent further falls, for Resident #111 after the resident fell on 7/6/21 and 7/7/21, for after Resident #65 after the resident [NAME] on 6/17/21, 6/24/21 and 6/25/21 and for Resident #19, after the resident fell on 1/5/21, 2/16/21 and 3/15/21; and failed to provide supervision to Resident #40 while he smoked on 9/28/21. Resident #40 was assessed as requiring supervision while smoking for his safety.
Inspectors wroteBased on observation, resident interview, 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 provide respiratory care and services in accordance with professional standards and the resident plan of care for four of 84 residents in the survey sample, Residents #501, #22, #145, and #165. The facility staff administered oxygen to Resident #501 without a physician's order, failed to store Resident #22's oxygen tubing in a clean and sanitary manner; failed to administer oxygen to Resident #145 at the physician ordered rate, and failed to ensure Resident #165's incentive spirometer was maintained in a sanitary manner.
Inspectors wroteBased on observation, 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 84 residents in the survey sample, Resident #153. The facility staff failed to attempt /provide non-pharmacological interventions prior to administering as needed pain medication to Resident #153 on multiple dates in August 2021 and September 2021.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed maintain food in a safe and sanitary manner. A gallon of whole milk unopened with an expiration date of 9/24/21 and one-half of a gallon of whole milk with an expiration date of 9/24/21 were found in the refrigerator.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for the facility. The facility failed to have current written contracts with two dialysis companies being utilized for residents. The facility failed to ensure new contracts were obtained when undergoing a CHOW (change of ownership) in January 2020.
Inspectors wroteBased on clinical record review, staff interview and facility document review and in the course of a complaint investigation it was determined that the facility staff failed to notify the responsible party of an fall and physician orders for diagnostic testing for one of 84 residents in the survey sample, Resident #383. The facility staff failed to evidence Resident #383's responsible party was notified on Resident #383's fall on 6/2/21 and the physician order for an x-ray of the resident's left knee.
Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to issue an advanced beneficiary notification for the ending of skilled services for three of three residents in the survey sample, (Residents #132, #13 and #483). The facility staff failed to issue an advanced beneficiary notice upon discontinuing Medicare services for Resident #132 on 7/14/202, Resident #13 on 7/17/2021, and Resident #483 on 9/16/2021, thus not allowing the residents and/or their responsible party's to appeal the discharge from services decision.
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, comfortable, homelike environment for one of 84 residents in the survey sample, Resident #72. The facility staff failed to clean Resident #72's bed rail. On 9/28/21, 9/29/21 and 9/30/21, a brown substance was observed on the resident's left bed rail.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon and make prompt efforts to resolve a reported grievance for one of 84 residents in the survey sample, Resident #153. The facility staff failed to evidence Resident #153's verbal grievance regarding a missing clothing item was promptly acted upon and efforts made to resolve the resident's grievance.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide documented evidence of facility-initiated transfer requirements for two of 84 residents in the survey sample, Residents #111 and #72. 1.a. Resident #111 was transferred to the hospital on 8/30/21. The physician failed to document the basis for the transfer, the specific resident needs that could not be met, facility attempts to meet the resident needs and the service available at the receiving facility to meet the resident's needs. 1.b. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #111 was transferred to the hospital on 9/6/21. 2. [...]
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 transfer to a RR (resident representative) and/or the ombudsman for three of 84 residents in the survey sample, Residents #111, #72 and #19. 1. Resident #111 was transferred to the hospital on 8/30/21 and on 9/6/21. A. The facility staff failed to provide written notification of the transfer to the resident's representative and the ombudsman for the 8/30/21 transfer, and B. failed to provide written notification of the transfer to the resident's representative for the 9/6/21 transfer. 2. Resident #72 was transferred to the hospital on 7/18/21. The facility staff failed to provide written notification of the transfer to the resident's representative. 3. Resident #19 was transferred to the hospital on 7/31/21. [...]
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to complete a significant change MDS (minimum data set) assessment for one of 84 residents in the survey sample, Resident #47. The facility staff failed to complete a significant change MDS assessment after dialysis services for the resident were discontinued due to improved laboratory values on 9/6/21.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure a preadmission screening and resident review, (PASARR) was completed and or completed accurately for two of 84 residents in the survey sample, Resident #160 and Resident #22. 1. The facility failed to ensure a PASARR was completed upon admission for Resident #160. 2. The facility staff failed to thoroughly complete Resident #22's level I PASRR (Preadmission Screening and Resident Review) and failed to refer the resident for a level II PASRR as recommended.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to follow professional standards of practice for two of 84 residents in the survey sample, Resident #153, and #129. The facility staff failed to clarify a duplicate physician order for Alpralozem for Resident #153, and failed to transcribe a telephone order for treatment of Resident #129's pressure ulcer. (1)
Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to evidence ongoing communication and collaboration with the dialysis facility for one of 84 residents, Resident #110. The facility staff failed to evidence ongoing communication and collaboration with Resident #110's dialysis center. Multiple dialysis progress notes were incomplete and or missing in June 2021, July 2021, August 2021 and September 2021.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to assess the risks and benefits of side rails for two of 84 residents in the survey sample, Resident #127 and Resident #67. The facility staff failed to evidence that the risks / benefits for the use of side rails had been reviewed with Resident #127 and Resident #67 prior to use of side rails.
Inspectors wroteBased on staff interview and employee record review, it was determined the facility staff failed to document the annual training to include in dementia and abuse and neglect, for four of five CNA (certified nursing assistant), (CNA # 13, #14, #6 and #16).
Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed had expired medications and IV (intravenous) fluids that were available for use in one of two medication rooms and one of four medication carts, Wing Two medication room and Wing Two front hall medication cart. In the Wing two medication room, three bags of IV solution, Dextrose 5% with .9%Normal Saline were observed available for resident use. Two of the bags expired Sep (September) 2021 and one bag documented the expiration date of [DATE]. In the front hall medication cart for Wing two on 10/5/2021, a bottle of Aspirin 325 mg (milligrams) was opened on 2/4/2021 and available for resident use. The expiration date on the bottle documented, expired 7/2021. A bottle of One Daily Multivitamin was open, available for resident use and had an expiration date documented on the bottle that read, Best by: 11/20.
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 timely laboratory services for one of 84 residents in the survey sample, Resident #13 and failed to ensure laboratory supplies past their expiration date were not available for use in one of two medication rooms observed, Wing two medication room. 1. The facility staff failed to ensure timely results of an ordered urinalysis for urinary tract infection symptoms for Resident #13. Resident #13 complained of concerns of a urinary tract infection with a urinalysis ordered on [DATE], collected on [DATE] and results still pending from laboratory on [DATE] when discussed with facility staff. 2. [...]
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete clinical record for two of 84 residents in the survey sample, Residents #111 and #158. The facility staff failed to maintain a physician's note in Resident #111's and Resident #158's clinical records.
11 fire safety citations on file: 4 on November 21, 2024, 3 on October 19, 2022, 4 on October 5, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| October 22, 2025 | Fine | $55,021 |
| November 21, 2024 | Fine | $9,106 |
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) | 3.19 | 3.76 | 3.86 |
| Registered nurses | 0.33 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.86 | 3.29 | 3.42 |
| Nurse aides | 1.89 | ||
| Licensed practical nurses | 0.97 | ||
| Nursing staff turnover (share who left in a year) | 54.1% | 48.1% | 45.8% |
| Registered nurse turnover | 55.6% | 48.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.23 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 3.33 on weekdays and 2.86 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.63 in April to June 2025 to 3.19 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 | 3.19 | 0.33 | 3.33 | 2.86 | 0.8% | 0 of 90 | 214 |
| Oct to Dec 2025 | 3.40 | 0.40 | 3.55 | 3.02 | 0.0% | 0 of 92 | 189 |
| Jul to Sep 2025 | 3.50 | 0.42 | 3.66 | 3.10 | 2.2% | 0 of 92 | 182 |
| Apr to Jun 2025 | 3.63 | 0.45 | 3.79 | 3.24 | 5.0% | 0 of 91 | 193 |
| 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 | 15.9 | 14.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.8 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.9 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.5 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.3 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.7 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 11.1 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.9 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.3 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.3 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Westport Rehabilitation and Nursing Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (44.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
44.4% this home
Worse than 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. 396 eligible stays.
12.9% 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. 369 eligible stays.
6.5% 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. 218 eligible stays.
49.2% 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. 65 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. 110 residents counted.
3.7% 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. 110 residents counted.
70.0% 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. 20 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: WESTPORT OPERATOR LLC. CMS links this home to Lifeworks Rehab, a group of 64 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Virginia Care Holco LLC | 5% or greater direct ownership interest | Organization | 100% | 01/01/2020 |
| Charles 1994 Family Grantor Trust | 5% or greater indirect ownership interest | Organization | 01/01/2020 | |
| Edward 1998 Family Grantor Trust | 5% or greater indirect ownership interest | Organization | 01/01/2020 | |
| Isva Holdings LLC | 5% or greater indirect ownership interest | Organization | 01/01/2020 | |
| Jkva Holdings LLC | 5% or greater indirect ownership interest | Organization | 01/01/2020 | |
| Mlva Holdings LLC | 5% or greater indirect ownership interest | Organization | 01/01/2020 | |
| Saul 2012 Family Grantor Trust | 5% or greater indirect ownership interest | Organization | 01/01/2020 | |
| Rajchenbach, Moshe | 5% or greater indirect ownership interest | Individual | 01/17/2020 | |
| Rajchenbach, Moshe | W-2 managing employee | Individual | 01/17/2020 | |
| Innovative Healthcare Management LLC | Operational/managerial control | Organization | 01/01/2020 |
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.
These are the official offices in Virginia. NursingHomeClear cannot take or act on complaints.