The Vardell Report.Colonial Heights Rehabilitation and Nursing Center

Across 8 inspections from February 2019 to August 2026, state surveyors documented 99 findings at Colonial Heights Rehabilitation and Nursing Center; 99 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

8

2019–2026, complaint and standard

Findings

99

Deficiencies cited by state inspectors

Corrected

99

Of 99 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 62026

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Sep 2, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 172026

   Standard health inspection

   17 findings

   The same visit included a complaint investigation.

   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level GActual harmCorrected Jul 30, 2026
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Jul 30, 2026
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Jul 30, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Jul 30, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Jul 30, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 30, 2026
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Sep 2, 2026
   • F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F700Try 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.Level DNo actual harm, potential for moreCorrected Jul 30, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 2, 2026

   Enforcement Action

   Civil money penalty, $22,225 imposed June 17, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 17, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jan 82026

   Complaint investigation

   5 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Feb 3, 2026
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Feb 3, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 3, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 3, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 3, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Mar 262025

   Complaint investigation

   3 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Apr 17, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 17, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 17, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Jan 32025

   Complaint investigation

   27 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 17, 2025
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Feb 16, 2025
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Feb 16, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected Apr 17, 2025
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Apr 17, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Apr 17, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Apr 17, 2025
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Feb 16, 2025
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Feb 16, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 17, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Feb 16, 2025
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 16, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 16, 2025
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 17, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 17, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 17, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Feb 16, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Aug 62024

   Complaint investigation

   7 findings

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Sep 18, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Sep 18, 2024
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Sep 18, 2024
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level ENo actual harm, potential for moreCorrected Sep 18, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Sep 18, 2024
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Sep 18, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Sep 18, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Oct 282022

   Standard health inspection

   17 findings

   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Dec 8, 2022
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Dec 8, 2022
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Dec 8, 2022
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Dec 8, 2022
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Dec 8, 2022
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Dec 8, 2022

   Enforcement Action

   Civil money penalty, $105,289 imposed January 3, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 28, 2022, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Feb 252019

   Standard health inspection

   22 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Apr 2, 2019
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 2, 2019
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Apr 2, 2019
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Apr 25, 2019
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Apr 2, 2019
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Apr 25, 2019
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 25, 2019
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 25, 2019
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Apr 2, 2019
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 25, 2019
   • F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Apr 2, 2019

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Five Inspections

   Inspectors cited F684 in February 2019, October 2022, January 2025, January 2026 and June 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F684 across all 8 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Five Inspections

   Inspectors cited F689 in February 2019, October 2022, January 2025, March 2025 and January 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F689 across all 8 inspections, oldest to newest
3. 3

   Citation F607, Cited in Four Inspections

   Inspectors cited F607 in February 2019, August 2024, January 2025 and January 2026. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F607 across all 8 inspections, oldest to newest
4. 4

   Reporting Suspected Abuse, Cited in Four Inspections

   Inspectors cited F609 in February 2019, January 2025, March 2025 and January 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F609 across all 8 inspections, oldest to newest
5. 5

   Professional Standards, Cited in Four Inspections

   Inspectors cited F658 in February 2019, October 2022, August 2024 and January 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F658 across all 8 inspections, oldest to newest
6. 6

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in February 2019, October 2022, January 2025 and March 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F686 across all 8 inspections, oldest to newest
7. 7

   Pharmacy Services, Cited in Four Inspections

   Inspectors cited F755 in February 2019, October 2022, January 2025 and January 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F755 across all 8 inspections, oldest to newest
8. 8

   Telling Families About Changes, Cited in Three Inspections

   Inspectors cited F580 in August 2024, January 2025 and June 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F580 across all 8 inspections, oldest to newest
9. 9

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in January 2025, June 2026 and August 2026. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   1922242525262626F600 across all 8 inspections, oldest to newest
10. 10

    Pre-Admission Screening, Cited in Three Inspections

    Inspectors cited F645 in February 2019, October 2022 and June 2026. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F645 across all 8 inspections, oldest to newest
11. 11

    Help With Daily Living, Cited in Three Inspections

    Inspectors cited F677 in October 2022, August 2024 and January 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F677 across all 8 inspections, oldest to newest
12. 12

    Significant Medication Errors, Cited in Three Inspections

    Inspectors cited F760 in February 2019, October 2022 and August 2024. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F760 across all 8 inspections, oldest to newest
13. 13

    Kitchen and Food Safety, Cited in Three Inspections

    Inspectors cited F812 in October 2022, January 2025 and June 2026. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F812 across all 8 inspections, oldest to newest
14. 14

    Residents Taking Their Own Medication, Cited in Two Inspections

    Inspectors cited F554 in February 2019 and June 2026. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F554 across all 8 inspections, oldest to newest
15. 15

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in February 2019 and October 2022. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F641 across all 8 inspections, oldest to newest
16. 16

    The First 48 Hours, Cited in Two Inspections

    Inspectors cited F655 in August 2024 and June 2026. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F655 across all 8 inspections, oldest to newest
17. 17

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in January 2025 and June 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F656 across all 8 inspections, oldest to newest
18. 18

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in February 2019 and June 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F657 across all 8 inspections, oldest to newest
19. 19

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in October 2022 and January 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F695 across all 8 inspections, oldest to newest
20. 20

    Citation F697, Cited in Two Inspections

    Inspectors cited F697 in February 2019 and January 2025. The agency describes it this way: Provide safe, appropriate pain management for a resident who requires such services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F697 across all 8 inspections, oldest to newest
21. 21

    Citation F726, Cited in Two Inspections

    Inspectors cited F726 in February 2019 and January 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F726 across all 8 inspections, oldest to newest
22. 22

    Citation F727, Cited in Two Inspections

    Inspectors cited F727 in October 2022 and June 2026. The agency describes it this way: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F727 across all 8 inspections, oldest to newest
23. 23

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in February 2019 and October 2022. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F761 across all 8 inspections, oldest to newest
24. 24

    Garbage and Refuse, Cited in Two Inspections

    Inspectors cited F814 in January 2025 and June 2026. This citation covers whether garbage and refuse are disposed of properly. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F814 across all 8 inspections, oldest to newest
25. 25

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in January 2025 and June 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F842 across all 8 inspections, oldest to newest
26. 26

    Citation F925, Cited in Two Inspections

    Inspectors cited F925 in October 2022 and January 2025. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    1922242525262626F925 across all 8 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in five inspections, most seriously at level G.

2. 02

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in five inspections, most seriously at level G.

3. 03

   What changed after F607 was cited, and how do you check it now?

   Citation F607: cited in four inspections, most seriously at level E.

4. 04

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in four inspections, most seriously at level D.

5. 05

   How do you check that nurses and aides follow professional standards, and what happens when they do not?

   Professional Standards: cited in four inspections, most seriously at level E.

6. 06

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in four inspections, most seriously at level E.

7. 07

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in four inspections, most seriously at level E.

8. 08

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in three inspections, most seriously at level E.

9. 09

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in three inspections, most seriously at level E.

10. 10

    Was the required pre-admission screening done for every resident, and how is it tracked?

    Pre-Admission Screening: cited in three inspections, most seriously at level D.

11. 11

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in three inspections, most seriously at level E.

12. 12

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in three inspections, most seriously at level E.

13. 13

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in three inspections, most seriously at level E.

14. 14

    How do you decide whether a resident may keep and take their own medications?

    Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

15. 15

    Who completes resident assessments, and how are they checked for accuracy?

    Accurate Assessments: cited in two inspections, most seriously at level D.

16. 16

    What happens in the first 48 hours after admission, and who writes the first care plan?

    The First 48 Hours: cited in two inspections, most seriously at level D.

17. 17

    How is a care plan written and reviewed here, and how do families take part in it?

    Care Plans: cited in two inspections, most seriously at level E.

18. 18

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level D.

19. 19

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

20. 20

    What changed after F697 was cited, and how do you check it now?

    Citation F697: cited in two inspections, most seriously at level D.

21. 21

    What changed after F726 was cited, and how do you check it now?

    Citation F726: cited in two inspections, most seriously at level E.

22. 22

    What changed after F727 was cited, and how do you check it now?

    Citation F727: cited in two inspections, most seriously at level F.

23. 23

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

24. 24

    How is waste handled around the kitchen and resident areas?

    Garbage and Refuse: cited in two inspections, most seriously at level F.

25. 25

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level D.

26. 26

    What changed after F925 was cited, and how do you check it now?

    Citation F925: cited in two inspections, most seriously at level E.

27. 27

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in January 2025.

28. 28

    What led to the 2026 fine, and has it been paid?

    A $22,225 civil money penalty was imposed June 17, 2026. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Virginia state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Feb 25, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Oct 28, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Aug 6, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Jan 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Mar 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Jan 8, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Jun 17, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Aug 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 495115

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.