Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amelia Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to protect a cognitively intact resident from financial exploitation occurred when a staff member accessed the resident’s debit card kept in an AD office lock box and withdrew cash from an ATM. The resident had diagnoses including CP, MDD, GAD, insomnia, and contractures, and he was reluctant to discuss the incident. Facility interviews and records showed conflicting statements about whether the resident authorized the withdrawal, while the resident reportedly feared reporting the theft. The chart contained little documentation of the incident beyond a note that SS helped the resident set a new PIN.
An LPN and RN failed to initiate CPR when a resident was found not breathing and without a heartbeat, even though the resident's chart showed Full Code status and a care plan intervention to perform CPR. The RN relied on the LPN's assumption that the resident was DNR, and the LPN did not verify code status or call 911 before the resident was pronounced deceased.
The facility failed to ensure mandatory effective communication training was provided to a sampled RN, LPN, and four CNAs. Training records showed none of the six employees had received this training, and the DON and regional director stated that effective communication was not included in the training program.
The facility failed to provide QAPI training to an LPN, an RN, and four CNAs. Review of training records showed none of the six staff members had received instruction on the facility’s quality assurance program elements and goals, and the DON and regional director confirmed the training program did not include QAPI.
A resident reported that his debit card was taken and $604 was withdrawn from his bank account. During the abuse investigation, the activity assistant who was suspected of involvement returned to the facility after admin staff had left and had the resident sign a statement. The admin confirmed the facility policy required staff involved or suspected of abuse to be removed until the investigation was complete to protect the resident.
Failure to include and follow code status in care plans. One resident had a DNR order and signed DDNR form, but the care plan did not reflect advance directive wishes. Another resident was documented as Full Code with a care plan intervention for CPR, yet staff found the resident not breathing and without a heartbeat and did not initiate CPR. Interviews confirmed the RN and LPN did not verify code status at the time of the event.
Care plan did not reflect a resident’s DNR status. The resident had a physician DNR order and a signed Durable DNR in the chart, but the care plan still listed the resident as Full Code. The CPC stated that advance directives should be on the care plan and that code status changes should be reflected there, with social services responsible for updating it.
The facility failed to ensure RN coverage included 8 consecutive hours on 2 days for 2 units. Staffing records showed one day with no RN coverage and another day with only 7.62 hours of RN coverage. The Administrator, DON, and Regional Director of Clinical Services confirmed the 8-hour RN coverage requirement during interview.
The facility failed to ensure that two of six employees had infection control training as part of its IPC program. During an extended survey, the administrator could not provide evidence of training for two CNAs, and record review showed no documentation that they had received infection control training. The DON and regional director later confirmed that all staff should have infection control training.
Staff failed to document compliance and ethics training for two of six employees reviewed, including two CNAs. During the survey, the administrator could not provide evidence of the required training, and the DON and regional director confirmed that all staff should have compliance and ethics training.
Three residents were moved to different rooms without receiving written notice or reasons for the changes. One resident was moved due to a broken heater, another due to COVID-19 isolation needs, and the third for unspecified nursing reasons. Staff interviews revealed confusion about who was responsible for providing written notices.
Failure to Protect Resident Funds from Staff Theft
Penalty
Summary
The facility failed to protect a cognitively intact resident from financial exploitation when a staff member accessed and withdrew money from the resident’s debit card. The resident had diagnoses including cerebral palsy, major depressive disorder, contracture of the muscle, generalized anxiety disorder, and insomnia. His most recent MDS coded him with a brief interview for mental status score of 15 out of 15, indicating he was cognitively intact. The resident told the surveyor that a staff member had taken money using his debit card, but he was reluctant to discuss the incident in detail. The resident’s debit card had been kept in a lock box in the activities director’s office, and the activities director reported that this arrangement had been in place for years because the resident needed assistance accessing his funds and ordering items. The activities director stated that she checked the card balance at the resident’s request and discovered a $604 ATM withdrawal at a grocery store, which she reported to the administrator. She also reported that an activities assistant later confessed to taking the card and withdrawing the money, and that police became involved. The administrator stated that the resident was interviewed and that the resident trusted the activities director, while the resident also reportedly said he was scared he would get kicked out if he reported the theft. The facility investigation file contained a statement attributed to the resident saying he sent the activities assistant to go out to send money, and a statement from the activities assistant saying the resident asked her to go to the ATM and that she had him sign a paper. The administrator later reported that the activities assistant returned after work and coerced the resident into writing the statement. The clinical record contained no documentation of the incident other than a note that social services helped the resident set up a new PIN and that he had his card and mail. The resident was reimbursed $600, and the administrator and RDCS stated the remaining $4 was the ATM fee.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Basic life support, including CPR, was not initiated for a resident who was found not breathing and without a heartbeat, despite the resident having a Full Code status in the clinical record. The resident had been admitted and re-admitted after hospitalization for sepsis secondary to a urinary tract infection and had diagnoses including hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, pulmonary emphysema, anemia, COPD, and Alzheimer's disease. At the time of the event, an RN documented being called to the resident's room and finding the resident lying in bed with no heart or breath sounds, warm and clammy to the touch. The RN notified an LPN, who then contacted the family and the NP. The LPN documented that the resident had expired, and the NP documented being notified that the patient was pronounced deceased. The record also showed the resident's code status as Full Code, with a care plan intervention to perform CPR and notify the physician of any change. During interviews, the RN stated she relied on the LPN's word that the resident was DNR and pronounced the resident without knowing the resident was Full Code. The LPN stated she checked for a pulse and heartbeat, told aides to get the RN because she could not pronounce death, did not check the code status, and did not start CPR. A CNA stated that when the resident was found not breathing, the nurse was notified, the LPN checked the resident, and no 911 call or CPR attempt was made.
Failure to Provide Mandatory Effective Communication Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on effective communication for six of six employees reviewed, including one RN, one LPN, and four CNAs. During the extended survey review, the facility administrator was asked to provide training records for the sampled employees, and the records showed that none of the six had received training on effective communication. When the findings were reviewed with the administrator, DON, and regional director of operations, the DON and regional director stated that they identify training needs based on policies and sometimes by talking to people or employees, and that effective communication was not included as a topic in their training program.
Lack of Staff Training on QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program included training for staff on the program elements and goals. During review of employee training records for six staff members, including an LPN, an RN, and four CNAs, none had received training on the facility’s quality assurance program elements and goals. During an interview with the DON and regional director, they confirmed that the facility’s training program did not include training on the QAPI program.
Failure to Protect Resident During Financial Abuse Investigation
Penalty
Summary
Facility staff failed to protect a resident from an alleged perpetrator during an investigation of financial abuse. The resident reported that his debit card was taken and $604 was removed from his bank account, and he stated that he later got his money back. The facility’s investigation file included a signed statement from the resident indicating he had asked the activity assistant to get money from his account. During interview, the administrator stated that after the investigation was initiated, the activity assistant was suspended, but later returned to the facility after administrative staff had left and had the resident sign that statement. The administrator confirmed the facility’s abuse policy required staff involved or suspected of abuse to be removed from the facility until the investigation was complete to protect the resident, and the policy stated the facility would protect residents from harm during an investigation.
Failure to Include and Follow Resident Code Status in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive resident-centered care plan for a resident whose record contained a physician order for DNR status and a signed Durable Do Not Resuscitate form executed prior to admission. Although the resident’s chart included advance directive documentation, the care plan did not show any evidence of the resident’s wishes regarding code status or what to do in the event of cardiopulmonary arrest. During interview, the care plan coordinator stated that code status should be included in the care plan. The facility also failed to implement the care plan for another resident with Full Code status. The resident had diagnoses including hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, pulmonary emphysema, anemia, COPD, and Alzheimer’s disease. A progress note documented that the resident was found not breathing and without a heartbeat, yet the nurse did not initiate CPR. Instead, staff notified the NP and the responsible party, and post-mortem care was completed. The resident’s care plan identified Full Code status and included interventions to perform CPR and notify the physician of any change. Interviews with staff confirmed that CPR was not started and that the resident’s code status was not checked at the time of the event. The RN stated she took the LPN’s word that the resident was DNR and later learned the resident was Full Code. The LPN stated she did not check the code status and did not start CPR. The NP stated the resident was pronounced deceased after being notified that morning, and the RN and LPN both acknowledged that the resident’s wishes were not honored because the resident was Full Code and no resuscitation was attempted.
Care Plan Did Not Reflect Resident DNR Status
Penalty
Summary
The facility failed to review and revise the care plan for one resident to reflect the resident’s code status. Resident #8 had a physician order dated 2/19/26 for Do Not Resuscitate (DNR), and the miscellaneous tab of the chart contained a Durable Do Not Resuscitate signed and dated the same day. However, the resident’s care plan focus area, initiated 1/22/26 and revised on 3/23/26, stated that the resident had exercised the right to self-determination and had decided after informed decision making to be Full Code. During an interview on 5/14/26, the care plan coordinator stated that the care plan is developed and used by the interdisciplinary team as a guide for resident care and that advance directives should be included on the care plan. When asked whether a change in code status should be reflected on the care plan, the coordinator said yes and stated that social services was responsible for updating it. The findings were reviewed with the facility administrator, director of nursing, and regional director during an end of day meeting on 5/14/26, and no additional information was provided.
RN Coverage Not Maintained for Required 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure RN coverage included 8 consecutive hours for 2 days within the past 30 days on 2 of 2 units. A review of staffing records for the period from 4/14/26 through 5/14/26 showed that on 4/24/26 there was no RN coverage and on 4/30/26 there were 7.62 hours of RN coverage, which did not meet the 8-hour requirement. During an interview on 5/15/26, the Administrator, DON, and Regional Director of Clinical Services confirmed that 8 consecutive hours of RN coverage was required and stated they strived to comply. The staffing sheets were reviewed with facility management, and no additional information was provided.
Missing Infection Control Training for Two CNAs
Penalty
Summary
The facility failed to ensure that two of six employees had infection control training as part of its infection prevention and control program, which is required to include mandatory training with written standards, policies, and procedures. During the extended survey on 5/14/26, surveyors selected a sample of six employees for review of training requirements and asked the facility administrator to provide evidence of each employee’s training. Review of the training records for CNA #6 and CNA #8 showed no evidence that infection control training had been received. On 5/15/26 at 2:06 PM, the findings were reviewed with the DON and regional director, who confirmed that all staff should have training on infection control, and no additional information was provided.
Missing Compliance and Ethics Training for Two CNAs
Penalty
Summary
Staff failed to ensure that compliance and ethics training was documented for two of six employees reviewed, identified as CNA #7 and CNA #8. During the extended survey on 5/14/26, the facility administrator was asked to provide evidence of training for the sampled employees, and review of the training records for CNA #7 and CNA #8 showed no evidence that compliance and ethics training had been received. On 5/15/26 at 2:06 PM, the DON and regional director were interviewed and confirmed that all staff should have training on compliance and ethics.
Failure to Provide Written Notice for Room Transfers
Penalty
Summary
The facility staff failed to provide written notice, including the reason for room changes, to three residents prior to their room transfers. Resident #1 was moved from the North unit to the South unit on February 15, 2024, without receiving a written notice. The resident, who was cognitively intact and their own responsible party, expressed distrust towards the staff, believing they were misled about the reason for the move, which was initially stated as a broken heater. The facility's documentation did not show any evidence of a written notice being provided before the move. Resident #3 experienced a room change on February 20, 2024, from the South unit to the North unit, also without receiving a written notice. The resident, who was cognitively intact and their own responsible party, was informed verbally that the move was due to other residents needing the room for COVID-19 isolation. The clinical record lacked documentation of a written notice being provided prior to the room change. Resident #4 was transferred from the North unit to the South unit on April 4, 2024, without receiving a written notice. The resident, who was cognitively intact and their own responsible party, confirmed they were not informed of the reason for the move and did not receive any written notice. Interviews with staff members, including the director of social services and the admissions director, revealed a lack of clarity and responsibility regarding the provision of written notices for room changes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Amelia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Hall-blackstone | 18.4 mi | ★★★★★ | 0 | 0 |
| The Haven At Brandermill Woods | 19.7 mi | ★★★★★ | 0 | 0 |
| Farmville Health & Rehab Center | 22.9 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Willow Creek | 24 mi | ★★★★★ | 0 | 0 |
| Holly Manor Rehab And Nursing | 24.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.