Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 August Healthcare At Richmond during CMS and state inspections, most recent first.
A resident with Parkinson's disease, dementia, GERD, dysphagia, and other diagnoses had repeated significant weight loss while needing staff help with meals. Staff observed the resident eating very little, and the resident and family reported that feeding assistance was often unavailable. Monthly weights showed major losses, but there were no supplements or weight-maintenance orders, no indication the MD was notified, and RD notes did not reflect interventions for the ongoing decline.
Binding Arbitration Agreement Was Not Neutral: The facility embedded an arbitration clause in the admission contract that allowed the facility to preselect the arbitrator group and venue, and it also assigned fees for both parties. Interviews with cognitively intact residents and family members showed they were not aware the agreement waived their right to have disputes decided in court by a judge and jury. The President of Operations was told the arbitrator could not be prechosen by the facility and that fees could not be delegated, and he had no further information to present.
Unnecessary antipsychotic medication continued without documented indication. A resident with dementia, mood disorder, anxiety, and severe cognitive impairment was admitted on quetiapine for anxiety, and an NP later ordered it discontinued, but the MAR and physician orders still showed quetiapine 25 mg at bedtime. Staff interviews and behavior records showed no agitation, aggression, anxiety, or other behaviors, and the DON confirmed antipsychotics should be tied to a psychiatric diagnosis or justified symptoms with behavior monitoring and GDRs as appropriate.
A resident with diabetes, dementia, impaired mobility, contractures, pressure wounds, and hospice status did not have an accessible call bell available at the bedside. Surveyors found no call device in the room on two observations, and staff said the resident’s contracted hands prevented use of it. When a small call bell was later placed around the resident’s neck, the resident appeared unable to see or use it, and the DON stated the resident could use the device despite the observed limitations.
A resident with multiple comorbidities and a history of pressure ulcers was re-admitted with intact skin but did not receive consistent weekly skin assessments or have a care plan addressing pressure ulcer prevention. Facility staff failed to document or implement preventive interventions such as regular repositioning and use of pressure-relieving surfaces until after two advanced-stage pressure injuries were discovered during a facility-wide skin sweep. Documentation for turning and repositioning was inconsistent, and required assessments and care planning were not completed as per facility policy.
Facility staff did not create a comprehensive care plan for a resident at risk for pressure ulcers, despite a history of sacral wounds and a Braden Scale assessment indicating risk. The care plan lacked specific preventive interventions and did not address the resident's refusal of care, contrary to facility policy. Staff interviews and documentation review confirmed these omissions.
Failure to Address Significant Weight Loss and Feeding Assistance Needs
Penalty
Summary
Facility staff failed to address and implement interventions for significant weight loss for one dependent resident with Parkinson's disease, dementia, anemia, stroke, GERD, dysphagia, and esophageal obstruction. The resident was admitted with a diet order for regular diet, mechanical soft texture, and thin liquids, and the most recent MDS indicated mild cognitive impairment, need for supervision and touch assistance with eating, and no swallowing problems. During observation, the resident was seen not eating at lunch, required staff encouragement and only a few spoonfuls of feeding, and on another occasion ate only a few spoonfuls before giving up. Resident and family interviews stated that the resident needed help to eat and that staff were sometimes unavailable to assist, especially on weekends and holidays. The resident's monthly weights showed a pattern of loss over the year, including a drop from 160.0 pounds to 150.8 pounds in one month and later from 149.0 pounds to 139.4 pounds in one month, a 10-pound loss equaling greater than 7.5% weight loss in one month. The physician orders included no supplements or weight-maintenance orders after the significant loss, and there was no indication the physician was notified. The care plan identified nutritional goals and included monitoring for significant weight loss and RD review, but the RD notes repeatedly documented no significant change or continued overweight status and did not reflect interventions to prevent further weight loss. The facility's administration was informed of the failure to provide adequate nutrition for this dependent resident during debriefings and stated they had nothing further to provide.
Binding Arbitration Agreement Was Not Neutral
Penalty
Summary
The facility failed to allow for a neutral binding arbitration process. During an interview on 2-18-26, the Administrator stated that the admissions Director had all admissions documented and signed, and that the company had arbitration in the admission contract. A copy of the Binding Arbitration Agreement was reviewed and showed that the facility had chosen the arbitrator group and the location, which would coincide with that chosen entity. The agreement was embedded in the admission contract and was binding to the resident and representative, and it also included fees with a percentage payment outlined for both parties in the event of arbitration. The Administrator stated that all residents admitted to the facility would be affected because the arbitration agreement was located in the admission contract. Interviews conducted on 2-18-26 with cognitively intact residents and family members found that none were aware of Binding Arbitration Agreements removing their rights to a court decision in legal disputes with the facility. When asked if they understood and agreed that by entering into the arbitration agreement they were giving up and waiving their constitutional right to have claims decided in a court of law before a judge and jury, they all answered no. On 2-19-26, the President of Operations was informed that the arbitrator could not be prechosen by the facility and that fees could not be delegated, as the Virginia Bar Association would provide arbitrators free of charge. He stated that he had no further information to present.
Unnecessary antipsychotic medication continued without documented indication
Penalty
Summary
Failure to ensure Resident #5 was free from unnecessary drugs occurred when the facility continued an antipsychotic medication without documented ongoing need. Resident #5 was admitted with multiple diagnoses including dementia with behavioral disturbance, psychotic disturbance, mood disturbance, Parkinson's disease with dyskinesia, major depressive disorder, anxiety disorder, and severe cognitive impairment as reflected by a BIMS score of 7. The resident was admitted from the hospital with an order for quetiapine/Seroquel for anxiety, and on 12/31/25 the NP ordered the medication weaned with a plan to decrease it and obtain a psych NP evaluation. A nurse progress note dated 1/6/26 documented that the NP ordered Seroquel discontinued and that the responsible party was updated, but the physician orders and MAR from 12/31/25 through 2/19/26 still showed quetiapine fumarate 25 mg at bedtime for anxiety. The medication was not discontinued as documented in the progress note. A multidisciplinary care conference on 1/7/26 included the resident and a family member who expressed a desire for psych services, but there was no review of the quetiapine order by the interdisciplinary team. On 1/24/26, the psych NP increased sertraline from 50 mg to 75 mg daily. On 2/3/26, the attending physician documented that the resident was pleasantly confused at baseline, sleeping well, and receiving sertraline 75 mg daily with quetiapine 25 mg at bedtime for MDD with mood disorder, while also noting no tearful moments, suicidal ideations, or visual or auditory hallucinations. Progress notes from the NP and physician described the resident as pleasant without confusion, agitation, depression, or anxiety. ADL behavior monitoring for January and February 2026 showed no behaviors observed, and staff interviews on 2/19/26 confirmed the resident had not exhibited agitation, aggression, nervousness, tearfulness, or anxiety. The DON stated antipsychotics should be used to treat a psychiatric diagnosis or when justified for other symptoms and that behavior monitoring, side effect monitoring, and GDRs were expected as appropriate. The consultant pharmacist had recommended behavior monitoring, adverse effect tracking, and AIMS monitoring, but the report states the consultant pharmacist recommendations were not located in the electronic record and behavior monitoring/adverse effect tracking was not found on the MAR for the antipsychotic. The facility later presented a consultant pharmacist recommendation and NP note stating the resident had no behavioral disturbances, no agitation, no mood instability, and no symptoms consistent with active generalized anxiety disorder, and that discontinuation of Seroquel was clinically appropriate.
Unavailable Call Bell for Resident With Contractures
Penalty
Summary
The facility failed to maintain an available call bell system for one resident in the sample, Resident #14, as a means to call for assistance from the bedside. Resident #14 was readmitted to the facility with diagnoses including diabetes, chronic inflammatory demyelinating poly neuritis, disc degeneration, malnutrition, dementia, impaired cognitive function, and impaired mobility. The most recent MDS described the resident as having a BIMS score of 15 out of 15, requiring assistance with eating, being dependent on staff for self-care and hygiene, having contractures, a urinary catheter, pressure wounds, and being mostly bed bound. The resident had also been ordered hospice care on 2-3-26. During the initial tour on 2-17-26, surveyors found no call bell device in the resident’s room. On 2-18-26, a second surveyor again found no call bell device, and a staff member stated the resident’s hands were so contracted she could not use it and that staff rounded on her more often. On 2-19-26, the resident was found wearing a small call bell device around her neck on a short lanyard, but when asked to use it, she appeared unable to do so; her son stated she could not use it. The DON stated the resident could use the device, while the resident was observed with washcloths rolled in both contracted hands and appeared unable to see or access the device. The resident care plan addressed contracture of the left hand with a splint order, but nothing was included for the right hand, which was also contracted.
Failure to Prevent and Timely Identify Pressure Ulcers in At-Risk Resident
Penalty
Summary
Facility staff failed to implement necessary interventions, care, and services to prevent the development of pressure ulcers in a resident identified as being at risk. The resident, who had multiple comorbidities including end stage renal disease, diabetes, heart failure, dementia, and a history of sacral pressure ulcers, was re-admitted to the facility with intact skin. Despite being at risk, as indicated by a Braden Scale score of 17 and a history of previous pressure injuries, the resident did not have a care plan addressing pressure ulcer prevention, and no specific interventions were documented to prevent pressure-related injuries. Weekly skin assessments, as required by facility policy, were not consistently performed between the resident's re-admission and the discovery of two advanced-stage pressure injuries. The facility only identified the injuries during a facility-wide skin sweep, which was initiated after it was recognized that weekly skin reviews were not being completed. Documentation also showed inconsistent or missing records for turning and repositioning, which are critical interventions for pressure ulcer prevention, especially for residents with limited mobility and incontinence. Interviews with facility staff, including the Wound Care Nurse and DON, confirmed that preventive measures such as air mattresses and regular repositioning were only implemented after the wounds were discovered, rather than proactively based on the resident's risk profile. The care plan lacked interventions for pressure ulcer prevention and did not address the resident's refusal of care or changes in condition. Facility policies required systematic risk assessment, care planning, and intervention for at-risk residents, but these were not followed, resulting in the resident developing two advanced pressure injuries.
Failure to Develop Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan to address the risk of pressure ulcer development for one resident who had a history of a sacral ulcer and was identified as being at risk for pressure injuries. Upon re-admission, the resident's Braden Scale assessment indicated risk, but the care plan did not include specific interventions for pressure ulcer prevention. Staff interviews revealed that weekly skin reviews were not consistently performed according to facility policy, and preventive measures such as air mattress use, protein supplementation, frequent turning and repositioning, and off-loading of heels were not documented in the care plan prior to the development of new pressure injuries. The care plan also lacked documentation addressing the resident's refusal of care, including baths, skin assessments, and dialysis treatments. Facility policy required the interdisciplinary team to develop a care plan with measurable goals and appropriate interventions for residents at risk of pressure injuries, but this was not followed. The deficiency was confirmed through staff interviews, clinical record review, and facility documentation, with no additional information provided by facility staff during the exit meeting.
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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 Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westport Rehabilitation And Nursing Center | 0.8 mi | ★★★★★ | 16 | 0 |
| The Laurels Of University Park | 2 mi | ★★★★★ | 1 | 0 |
| Cedarfield Pinnacle Living | 2.6 mi | — | 0 | 0 |
| Glenburnie Rehab & Nursing Center | 2.7 mi | ★★★★★ | 14 | 0 |
| Parham Health Care & Rehab Center | 3.8 mi | ★★★★★ | 57 | 3 |
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