Virginia ›Richmond

Parham Health Care & Rehab Center

2400 E Parham Road, Richmond, VA 23228 · Henrico County · 180 certified beds · avg 157 residents/day · certified since Feb 1, 1979

Abuse citation flag (CMS)SFF Candidate

Part of chain: LIFEWORKS REHAB (64 facilities, chain avg rating 2.1★)

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.

1/5
Health inspection rating (on-site)
10
Serious findings on record
$266,181
Fines, last 3 years
2.53
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

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, one-off · Mar 19, 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 (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Mar 30, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Dec 17, 2025 · 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: Jan 27, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Dec 17, 2025 · 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: Mar 30, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Apr 28, 2025 · 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: Jun 12, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Apr 28, 2025 · F-0880 · triggered by a complaint

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.

Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jun 12, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Feb 13, 2026 · F-0805 · triggered by a complaint

The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.

Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.

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: Mar 30, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 17, 2025 · F-0805 · triggered by a complaint

The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.

Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.

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: Mar 30, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 28, 2025 · F-0686 · triggered by a complaint

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: Jun 12, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 27, 2022 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

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: Jun 7, 2022 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 6, 2018 · 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 10, 2019 (Deficient, Provider has date of correction)

All citations in the current public record (126)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Mar 19, 2026▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 19, 2026E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 13, 2026▲ G · Actual harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Feb 13, 2026E · Potential for harm, repeatedThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
Feb 13, 2026E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 13, 2026E · Potential for harm, repeatedThe 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. · from a complaint
Feb 13, 2026E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe 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 13, 2026D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Feb 13, 2026D · Potential for harm, one-offThe 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. · from a complaint
Dec 17, 2025▲ K · Immediate jeopardy, repeatedThe 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
Dec 17, 2025▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 17, 2025▲ G · Actual harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Dec 17, 2025F · Potential for harm, facility-wideThe facility has more than 120 beds but did not hire a qualified full-time social worker as required. · from a complaint
Dec 17, 2025F · Potential for harm, facility-wideThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe 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
Dec 17, 2025E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe 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. · from a complaint
Dec 17, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe 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
Dec 17, 2025D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe 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. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe 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
Dec 17, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe 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
Dec 17, 2025D · Potential for harm, one-offThe 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. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not have firmly secured handrails on both sides of its hallways. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not have policies on smoking. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe 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. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · from a complaint
Dec 17, 2025D · Potential for harm, one-offThe 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. · from a complaint
Sep 3, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Sep 3, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Sep 3, 2025E · Potential for harm, repeatedThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Sep 3, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Sep 3, 2025D · Potential for harm, one-offThe 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
Apr 28, 2025▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 28, 2025▲ K · Immediate jeopardy, repeatedThe 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. · from a complaint
Apr 28, 2025▲ G · Actual harm, one-offThe 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. · from a complaint
Apr 28, 2025F · Potential for harm, facility-wideThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Apr 28, 2025F · Potential for harm, facility-wideThe facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times.
Apr 28, 2025F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 28, 2025F · Potential for harm, facility-wideThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Apr 28, 2025E · Potential for harm, repeatedThe 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.
Apr 28, 2025E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not provide safe and appropriate pain management for a resident who needed it.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Apr 28, 2025E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Apr 28, 2025E · Potential for harm, repeatedThe 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.
Apr 28, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Apr 28, 2025E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Apr 28, 2025D · Potential for harm, one-offThe 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. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 28, 2025D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Apr 28, 2025D · Potential for harm, one-offThe 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
Apr 28, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Apr 28, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe 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.
Apr 28, 2025D · Potential for harm, one-offThe 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.
Apr 28, 2025D · Potential for harm, one-offThe 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.
Apr 28, 2025D · Potential for harm, one-offThe 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.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Apr 28, 2025D · Potential for harm, one-offThe 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.
Apr 28, 2025D · Potential for harm, one-offThe 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.
Apr 28, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 28, 2025D · Potential for harm, one-offThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe 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. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe 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
Sep 14, 2023E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Sep 14, 2023E · Potential for harm, repeatedThe 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
Sep 14, 2023E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Sep 14, 2023E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Sep 14, 2023E · Potential for harm, repeatedThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Sep 14, 2023D · Potential for harm, one-offThe 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
Sep 14, 2023D · Potential for harm, one-offThe 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
Sep 14, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Sep 14, 2023D · Potential for harm, one-offThe 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
Sep 14, 2023D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Apr 27, 2022▲ G · Actual harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Apr 27, 2022E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Apr 27, 2022E · Potential for harm, repeatedThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Apr 27, 2022E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Apr 27, 2022E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Apr 27, 2022D · Potential for harm, one-offThe 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.
Apr 27, 2022D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Apr 27, 2022D · Potential for harm, one-offThe 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.
Apr 27, 2022D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 27, 2022D · Potential for harm, one-offThe 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.
Apr 27, 2022D · Potential for harm, one-offThe 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.
Apr 27, 2022D · Potential for harm, one-offThe 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.
Apr 27, 2022D · Potential for harm, one-offThe facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated.
Apr 27, 2022D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 27, 2022D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 27, 2022D · Potential for harm, one-offThe facility did not perform required COVID-19 testing on residents and staff.
Apr 27, 2022D · Potential for harm, one-offThe facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time.
Dec 6, 2018▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 6, 2018D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Dec 6, 2018D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Dec 6, 2018D · Potential for harm, one-offThe 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.
Dec 6, 2018D · Potential for harm, one-offWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care.
Dec 6, 2018D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 6, 2018D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Dec 6, 2018D · Potential for harm, one-offThe 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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (17 → 36).

YearCitationsSerious (G–L)Worst severity that year
201881G ▲
2022171G ▲
2023100E
202420D
2025786K ▲
2026112J ▲

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)

2 fines totaling $266,181, plus 1 Medicare payment denial period.

DateTypeAmount / length
Dec 17, 2025Fine$205,445
Dec 17, 2025Payment Denial43 days from Mar 17, 2026
Apr 28, 2025Fine$60,736

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityVirginia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.533.673.95bottom 4% in Virginia; bottom 4% in the U.S.
Registered Nurse hours0.290.660.69bottom 5% in Virginia; bottom 9% in the U.S.
Weekend total nurse staffing2.173.213.50bottom 3% in Virginia; bottom 3% in the U.S.
Weekend RN hours (not acuity-adjusted)0.160.460.48bottom 11% in Virginia; bottom 7% in the U.S.
Total nursing staff turnover (%)62.248.145.8bottom 18% in Virginia; bottom 13% in the U.S.
RN turnover (%)50.048.242.9top 50% in Virginia; bottom 39% 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 2.93, RN 0.34, weekend 2.51. Staffing rating: 1/5.

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: 3/5 · long-stay residents: 4/5 · short-stay residents: 1/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Ak 2003 Family TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Al 2003 Family TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Central Bay LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Charles 1994 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Edward 1998 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Golden 2017 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Golden 2017 LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Matt 2002 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Matt 2002 LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
MRCZ Central LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Nathan 5604 & Family LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Nathan 5604 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Nathan 5604 LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Parharm Holdings I LLCOrganization5% or Greater Direct Ownership Interest100%05/28/2021
Pivotal Central LLCOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Sas 1998 Family TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Saul 2012 Family Grantor TrustOrganization5% or Greater Indirect Ownership Interest—05/28/2021
Hales-Richards, KourtneyIndividualCorporate DirectorNOT APPLICABLE09/13/2023
Hales-Richards, KourtneyIndividualOperational/Managerial ControlNOT APPLICABLE09/13/2023
Rybst Central Manager LLCOrganizationOperational/Managerial ControlNOT APPLICABLE05/28/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 495097.