Cycle 1
Health 2024-07-25 · Fire 2024-07-25
40 health deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Richmond, VA
Canterbury Rehabilitation And Healthcare Center
1-star overall rating with 1-star inspections with $92,980 in total fines with 40 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1776 Cambridge Drive, Richmond, VA
(804) 740-6174
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
183
Certified beds
Average residents
176
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1993-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
74%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,136
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.81
Baseline 22.84% · Performance 19.75% · Measure score 4.81 · Achievement 3.62 · Improvement 4.81
Healthcare-associated infections
0
Baseline 6.94% · Performance 8.64% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Baseline 61.03% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 2.55
Adjusted total nurse staffing
0.37
Baseline 2.60 hours · Performance 2.88 hours · Measure score 0.37 · Achievement 0 · Improvement 0.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 193 · Observed rate 10.88% · Lower 95% interval 7.96% |
| Discharge to community | 48.7% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 38.62% · Lower 95% interval 39.38% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.57% |
95.27%
4.3 pts better
|
Numerator 233 · Denominator 234 |
| Falls with major injury | 0.43% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 234 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 48 · Denominator 112 |
| Discharge mobility score | 41.07% |
50.94%
9.9 pts worse
|
Numerator 46 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 9 · Denominator 234 · Adjusted rate 2.4% |
| Healthcare-associated infections requiring hospitalization | 8.64% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 12.71% · Lower 95% interval 6.25% |
| Staff COVID-19 vaccination coverage | 8.74% |
8.2%
0.5 pts better
|
Numerator 27 · Denominator 309 |
| Staff flu vaccination coverage | 33.23% |
42%
8.8 pts worse
|
Numerator 106 · Denominator 319 |
| Discharge function score | 47.32% |
56.45%
9.1 pts worse
|
Numerator 53 · Denominator 112 |
| Transfer of health information to provider | 99.11% |
95.95%
3.2 pts better
|
Numerator 111 · Denominator 112 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 66 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 36.22% |
25.2%
11 pts better
|
Numerator 46 · Denominator 127 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
91.2%
5.5 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 97.3% · Q4 91.3% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.0%
5.4 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.6%
2.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 1.4% · Q4 2.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 58.6% |
15.7%
42.9 pts worse
|
11.4%
47.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.6% · Q2 49.2% · Q3 54.3% · Q4 64.8% · 4Q avg 58.6% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.7%
2.2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 10.5% · Q3 7.2% · Q4 6.4% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
20.2%
2.2 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 23.0% · Q3 25.0% · Q4 25.0% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
15.0%
1.2 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 16.0% · Q3 14.4% · Q4 12.8% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.0% |
17.5%
2.5 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.2% · Q3 10.9% · Q4 4.9% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
15.7%
5.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 11.2% · Q3 8.2% · Q4 4.6% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.5% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.6%
1.1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
22.2%
8.5 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 15.7% · Q3 10.2% · Q4 11.0% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
5.2%
2.9 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.3% · Q3 8.5% · Q4 8.9% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.0% |
74.6%
8.6 pts worse
|
81.7%
15.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 82.0% · Q3 58.6% · Q4 37.7% · 4Q avg 66.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
11.7%
0.9 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 16.1% · Expected 14.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.5% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.9% |
73.6%
6.3 pts better
|
79.7%
0.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
22.0%
2 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 33.9% · Expected 33.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-16 · Fire 2023-08-16
52 health deficiencies
Top issue: Quality of Life and Care (21 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-13 · Fire 2022-01-13
30 health deficiencies
Top issue: Resident Rights (9 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-07-25
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-07-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-07-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-11
D · Potential for more than minimal harm
2022-01-13
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-02-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-11
E · Potential for more than minimal harm
2025-12-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-14
D · Potential for more than minimal harm
2025-12-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-01-14
G · Actual harm
2025-05-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-05-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-05-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-05-02
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-02-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-06
E · Potential for more than minimal harm
2025-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-20
D · Potential for more than minimal harm
2025-01-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-06
J · Immediate jeopardy
2024-08-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-08-06
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-08-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-03-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-06
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-03-06
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-01-04
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-02-17
D · Potential for more than minimal harm
2024-01-04
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-17
D · Potential for more than minimal harm
2024-01-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-17
E · Potential for more than minimal harm
2023-08-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-06-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-24
F · Potential for more than minimal harm
2022-01-13
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-02-08
E · Potential for more than minimal harm
2022-01-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-02-08
E · Potential for more than minimal harm
2022-01-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-02-08
E · Potential for more than minimal harm
2022-01-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-02-08
E · Potential for more than minimal harm
2022-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-08
E · Potential for more than minimal harm
2022-01-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-02-08
E · Potential for more than minimal harm
2022-01-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-08
D · Potential for more than minimal harm
2022-01-13
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-02-08
Penalties and ownership
What sits behind the stars
$61,448
2025-05-02
Fine
Fine · fine $61,448
Fine
$31,532
2024-07-25
Fine
Fine · fine $31,532
Fine
Ownership
Quinto Delta LLC
5% Or Greater Direct Ownership Interest · Organization
Ukr Consulting LLC
5% Or Greater Direct Ownership Interest · Organization
Abbasi, Gohar
Operational/Managerial Control · Individual
Jones, Nichelle
Operational/Managerial Control · Individual
Jones, Nichelle
Corporate Director · Individual
Kohn Fam Tr Gst Exempt Uad 3-25-13
5% Or Greater Indirect Ownership Interest · Organization
M&T Bank
5% Or Greater Security Interest · Organization
Marquis Limited LLC
Operational/Managerial Control · Organization
Nfr 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Posen, Mindee
Corporate Officer · Individual
Reliant Pro Rehab LLC
Operational/Managerial Control · Organization
Rsbrmk Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sk 2013 Delta Trust
5% Or Greater Indirect Ownership Interest · Organization
Tryko Delta Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Uak 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Yr 2013 Delta Tr Ua 03252013
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Lakewood Manor
Richmond, VA
3-star overall rating with 3-star inspections with 3 recent health deficiencies
#2
Shalom Gardens Health & Rehabilitation
Richmond, VA
4-star overall rating with 4-star inspections with $12,177 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Our Lady Of Hope Health Center
Richmond, VA
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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