Lynn Care Center
1000 Shenandoah Avenue, Front Royal, VA 22630 · Warren County · 120 certified beds · avg 109 residents/day · certified since Mar 1, 1997
Abuse citation flag (CMS)
Part of chain: HILL VALLEY HEALTHCARE (43 facilities, chain avg rating 1.8★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jan 12, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 10, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jan 12, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 10, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 6, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 3, 2023 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 31, 2021 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 5, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (54)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 12, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 12, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 12, 2026 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jan 12, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. |
| Jan 12, 2026 | D · Potential for harm, one-off | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 16, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 16, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 16, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 6, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 6, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not properly run its feeding assistant program — assessing which residents are appropriate for it, following each resident's care plan, and making sure feeding assistants are trained and supervised. Feeding assistants are trained helpers who assist residents at mealtimes. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Jan 6, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Aug 31, 2021 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 31, 2021 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 31, 2021 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 31, 2021 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 31, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 31, 2021 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 31, 2021 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 31, 2021 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Aug 31, 2021 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (20 → 19).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 9 | 1 | G ▲ |
| 2023 | 20 | 1 | G ▲ |
| 2024 | 3 | 0 | D |
| 2025 | 3 | 0 | E |
| 2026 | 19 | 2 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $38,110.
| Date | Type | Amount / length |
|---|---|---|
| Jan 12, 2026 | Fine | $38,110 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.70 | 3.67 | 3.95 | top 29% in Virginia; bottom 47% in the U.S. |
| Registered Nurse hours | 0.63 | 0.66 | 0.69 | top 32% in Virginia; top 44% in the U.S. |
| Weekend total nurse staffing | 3.11 | 3.21 | 3.50 | top 37% in Virginia; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.46 | 0.48 | top 22% in Virginia; top 35% in the U.S. |
| Total nursing staff turnover (%) | 56.6 | 48.1 | 45.8 | bottom 31% in Virginia; bottom 22% in the U.S. |
| RN turnover (%) | 56.7 | 48.2 | 42.9 | bottom 33% in Virginia; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.11, RN 0.70, weekend 3.45. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Shenandoah SNF Operations Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/01/2022 |
| Idels, Shimon | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2022 |
| Long, Jason | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/20/2024 |
| Long, Jason | Individual | ADP of the SNF | NOT APPLICABLE | 03/20/2025 |
| Shenandoah Operators Manager LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Heritage Hall Front Royal | 1.3 mi | Front Royal, VA | ★★★★★ | 5/5 | |
| Evergreen Health and Rehabilitation Center | 16.7 mi | Winchester, VA | ★★☆☆☆ | 2/5 | |
| Woodstock Valley Health and Rehabilitation | 17.4 mi | Woodstock, VA | ★☆☆☆☆ | 1/5 | abuseSFF |
| Skyline Terrace Conv Home | 17.8 mi | Woodstock, VA | ★★★★★ | 5/5 | |
| The Village at Orchard Ridge | 18.7 mi | Winchester, VA | ★★★★★ | 4/5 | |
| Shenandoah Valley Westminster Canterbury | 18.9 mi | Winchester, VA | ★★★★☆ | 3/5 | |
| Winchester Health & Rehabilitation | 19.1 mi | Winchester, VA | ★☆☆☆☆ | 1/5 | |
| Rose Hill Health and Rehab | 19.1 mi | Berryville, VA | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 495316.