Report
TheVardellReport
Shalom Gardens Health & Rehabilitation
Skilled nursing facility and nursing facility
1600 John Rolfe Parkway
Richmond, VA 23233
Report
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The Vardell Report.Shalom Gardens Health & Rehabilitation
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Richmond, VA
- Record Period
- 2019–2026
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from March 2019 to May 2026, state surveyors documented 48 findings at Shalom Gardens Health & Rehabilitation; 46 have a recorded correction and 2 await one; CMS lists 2 enforcement actions in the window.
- Inspections
- 5
- 2019–2026, complaint and standard
- Findings
- 48
- Deficiencies cited by state inspectors
- Corrected
- 46
- Of 48 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2019 | 1 | 22 | 0 |
| 2020 | 0 | 0 | 0 |
| 2021 | 1 | 12 | 0 |
| 2022 | 0 | 0 | 0 |
| 2023 | 0 | 0 | 0 |
| 2024 | 2 | 6 | 1 |
| 2025 | 0 | 0 | 0 |
| 2026 | 1 | 8 | 2 |
What the Record Shows
- 46 of 48 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $39,555, their payment not published.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, June 28, 2024, recorded 5 findings (most serious: Level E).
What to Ask About
- Quality of Care, Cited in Three Inspections
- Citation F565, Cited in Two Inspections
- Citation F607, Cited in Two Inspections
- Care Plans, Cited in Two Inspections
- Care Plan Timing and Review, Cited in Two Inspections
- Professional Standards, Cited in Two Inspections
- Help With Daily Living, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Accident Hazards and Supervision, No Recorded Correction
- Significant Medication Errors, No Recorded Correction
Report at a Glance
- Facility
- Shalom Gardens Health & Rehabilitation
- Address
- 1600 John Rolfe Parkway, Richmond, VA 23233
- CMS Certification Number
- 495291
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 101
- Ownership
- For profit - Corporation
- Record Window
- March 14, 2019 to October 1, 2026
Chronology
Inspection History
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.
- 2026
Complaint investigation
8 findings
- F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Jun 3, 2026
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level JImmediate jeopardyCorrected Jun 3, 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 ENo actual harm, potential for moreCorrected Jun 3, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 3, 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 Jun 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 moreDeficient, Provider has plan of correction
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreNo revisit needed
- 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 Jun 3, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Dec 13, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
5 findings
The same visit included a complaint investigation.
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Aug 1, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 1, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 1, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Aug 1, 2024
- 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 Aug 1, 2024
Enforcement Action
Civil money penalty, $12,177 imposed November 5, 2024. 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 28, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $27,378 imposed May 6, 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 28, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2021
Standard health inspection
12 findings
- 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 Sep 3, 2021
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level DNo actual harm, potential for moreCorrected Sep 3, 2021
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level DNo actual harm, potential for moreCorrected Sep 3, 2021
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Sep 3, 2021
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Sep 3, 2021
- 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 3, 2021
- 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 Sep 3, 2021
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 3, 2021
- 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 Sep 3, 2021
- 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 Sep 3, 2021
- 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 Sep 3, 2021
- F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected Sep 3, 2021
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2019
Standard health inspection
22 findings
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level ENo actual harm, potential for moreCorrected Apr 28, 2019
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Apr 28, 2019
- 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 28, 2019
- F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Level ENo actual harm, potential for moreCorrected Apr 28, 2019
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel ENo actual harm, potential for moreCorrected Apr 28, 2019
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 28, 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 28, 2019
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Apr 28, 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 28, 2019
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Apr 28, 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 28, 2019
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- F638Assure that each resident’s assessment is updated at least once every 3 months.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- 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 Apr 28, 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 28, 2019
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- 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 DNo actual harm, potential for moreCorrected Apr 28, 2019
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Apr 28, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Apr 28, 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.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in June 2024, November 2024 and May 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.
1921242426F684 across all 5 inspections, oldest to newest - 2
Citation F565, Cited in Two Inspections
Inspectors cited F565 in March 2019 and July 2021. The agency describes it this way: Honor the resident's right to organize and participate in resident/family groups in the facility. 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.
1921242426F565 across all 5 inspections, oldest to newest - 3
Citation F607, Cited in Two Inspections
Inspectors cited F607 in March 2019 and July 2021. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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.
1921242426F607 across all 5 inspections, oldest to newest - 4
Care Plans, Cited in Two Inspections
Inspectors cited F656 in March 2019 and July 2021. 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 D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1921242426F656 across all 5 inspections, oldest to newest - 5
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in March 2019 and May 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 E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1921242426F657 across all 5 inspections, oldest to newest - 6
Professional Standards, Cited in Two Inspections
Inspectors cited F658 in March 2019 and June 2024. 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.
1921242426F658 across all 5 inspections, oldest to newest - 7
Help With Daily Living, Cited in Two Inspections
Inspectors cited F677 in July 2021 and June 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. 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.
1921242426F677 across all 5 inspections, oldest to newest - 8
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in July 2021 and May 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. 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.
1921242426F761 across all 5 inspections, oldest to newest - 9
Accident Hazards and Supervision, No Recorded Correction
F689 was cited in March 2019, July 2021 and May 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious was level E (no actual harm, potential for more). The May 2026 citation has no recorded correction date; its status reads “Deficient, Provider has plan of correction.” The record does not show whether the problem was fixed.
1921242426F689 across all 5 inspections, oldest to newest - 10
Significant Medication Errors, No Recorded Correction
F760 was cited in May 2026. This citation covers whether residents are free from significant medication errors. The most serious was level D (no actual harm, potential for more). The May 2026 citation has no recorded correction date; its status reads “No revisit needed.” The record does not show whether the problem was fixed.
1921242426F760 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 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 three inspections, most seriously at level G.
- 02
What changed after F565 was cited, and how do you check it now?
Citation F565: cited in two inspections, most seriously at level E.
- 03
What changed after F607 was cited, and how do you check it now?
Citation F607: cited in two inspections, most seriously at level D.
- 04
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 D.
- 05
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 E.
- 06
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level E.
- 07
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 two inspections, most seriously at level D.
- 08
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
- 09
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 three inspections, most seriously at level E. The May 6, 2026 citation has no recorded correction date.
- 10
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in one inspections, most seriously at level D. The May 6, 2026 citation has no recorded correction date.
- 11
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 May 2026.
- 12
What led to the 2026 fine, and has it been paid?
A $27,378 civil money penalty was imposed May 6, 2026. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
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 Mar 14, 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 Jul 22, 2021 · 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 28, 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 Nov 5, 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 May 6, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 495291
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowMarch 14, 2019 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before March 2019 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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