5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Richmond, VA
4-star overall rating with 4-star inspections with 5 recent health deficiencies
13700 North Gayton Road, Richmond, VA
(804) 360-1960
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
75
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.68
Registered nurse staffing
LPN hours / resident day
1.27
Licensed practical nurse staffing
Aide hours / resident day
2.40
Nurse aide staffing
Weekend hours
3.69
Weekend nurse staffing
RN turnover
72%
Annual RN turnover
Total nurse turnover
74%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.4
0.3 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
91.2%
1.1 pts better
|
93.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.3% |
94.0%
10.7 pts worse
|
95.5%
12.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.6%
2 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 14.4% |
5.7%
8.7 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
20.2%
8.5 pts better
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
15.0%
1.9 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.1% |
17.5%
20.6 pts worse
|
16.3%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
15.7%
1.4 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.5%
2.5 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 11.9% |
1.6%
10.3 pts worse
|
1.7%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
22.2%
6.2 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
5.2%
6.2 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
74.6%
17.1 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.7%
3.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
73.6%
11.4 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.0%
0.6 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-18
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-02-18
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-27
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-18
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-02-18
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-02-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-01-20
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-01-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-01-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-01-20
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-01-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-01-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-01-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-01-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-01-20
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-07
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-17
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 2023-10-17
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-10-17
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-17
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-17
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-17
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 2023-05-17
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 2021-12-29
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-29
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-12-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-12-29
Health
Dispose of garbage and refuse properly.
Corrected 2020-04-03
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-04-03
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 2020-04-03
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 2020-04-03
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-04-03
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 2020-04-03
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-04-03
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 2020-04-03
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-04-03
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2020-04-03
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-04-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-04-03
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-04-03
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 2020-04-03
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
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
Richmond, VA
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
Richmond, VA
3-star overall rating with 3-star inspections with 3 recent health deficiencies
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