Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Petersburg Healthcare Center during CMS and state inspections, most recent first.
Failure to protect residents from abuse and neglect involved multiple incidents: one resident was transferred alone with a mechanical lift despite a 2-person requirement and later found to have a tibia/fibula fracture; another resident was struck by a peer and sustained a bloody nose and pain; a resident was verbally abused by a CNA and later showed increased anxiety and isolation; and another resident with a language barrier was left unattended and then assaulted, resulting in scratches.
Failure to provide needed ADL hygiene assistance: A resident with severe cognitive impairment and dependence on staff for bathing, grooming, and personal hygiene was observed with oily, unkempt hair, food debris in the beard, stained clothing, and strong urine/body odor. The record showed missed showers and bed baths without refusals, and a CNA stated the resident did not usually refuse care and could not complete hygiene tasks independently.
Failure to Maintain Resident Dignity During Dressing and Personal Care: A resident with behavioral health diagnoses and moderate cognitive impairment was observed leaving her room and traveling down the hall in only an incontinence brief, in full view of others, after staff briefly passed her room during report. Another resident with severe cognitive impairment and total dependence for ADLs was found in her room with a stained T-shirt pulled over her head and her breasts exposed, while an RN commented in front of the resident that she was resistant to care and referred to her as geriatric-psych.
A resident with Parkinson’s disease, bipolar disorder, anemia, and depression suffered a severe injury and later expired after being found with extensive bruising and head trauma, but the facility’s initial state report was late and inaccurately described the event as an unwitnessed fall with no injuries. The addendum and 5-day follow-up also contained conflicting or misleading information about the abuse allegation and injury details. Separately, a record review found an employee without a sworn statement or VSP background check on file, and background check personnel confirmed no check had been performed.
Failure to Timely Report Allegations of Abuse: The facility did not have credible evidence that allegations of abuse involving three residents were reported to APS and the state survey agency within required timeframes. One resident struck another with a rock, another resident was assaulted during a courtyard altercation and required pain medication, and a third resident was involved in a physical altercation with a staff member and another resident, with minor scratches noted. Facility interviews stated abuse reports should be made within 2 hours, with final reports later submitted, but the records did not show timely regulatory reporting for these incidents.
An incomplete abuse investigation involved a resident who had increased isolation, delusions, hallucinations, and anxiety noted in the record. The file contained only a brief synopsis and two CNA statements, with no interviews of other staff, the resident, or the roommate. One CNA reported hearing another CNA make an inappropriate verbal remark to the resident, yet the facility still labeled the allegation unsubstantiated. The Administrator confirmed the investigation was incomplete and could not explain the conclusion.
Outdated Care Plan Intervention for Discontinued 1:1 Supervision: A resident’s care plan still listed 1:1 supervision for a prior resident-to-resident altercation even though the supervision had already been discontinued. RN confirmed the resident was no longer on 1:1 and stated the care plan should have been updated, while the facility policy required nurses to review and revise the care plan as the resident’s condition warranted.
A resident with schizophrenia, bipolar disorder, depression, CKD, HF, and a history of falls did not receive Invega Sustenna as ordered. The MAR showed the monthly antipsychotic was missed in one month, given at the wrong dose after return from the hospital, entered incorrectly on the MAR the following month, and then missed again. The DON stated nurses were expected to follow physician orders and the rights of medication administration.
Failure to provide proper nail care was identified for a resident with severe cognitive impairment, legal blindness, and multiple psychiatric and medical diagnoses. Staff observed the resident's toenails to be thick, long, and dark, with one great toenail markedly overgrown and curved over the adjacent toe. The record showed no podiatry visits or documentation of staff nail care during the review period, and staff interviews confirmed that nail care was expected but had not been completed.
Nurse staffing information was not kept current for resident, staff, and public view at 2 of 2 units. Surveyors observed staffing sheets posted at the front desk and outside the Staffing Mgr’s office, but the Staffing Mgr stated that call outs and no-shows were only marked on a separate sheet behind the nursing station counter, not on the sheets visible to the public. An updated staffing sheet was not seen in plain sight at the nursing desk on unit wing 1, and the findings were reviewed with the Administrator and DON.
A resident with cerebrovascular disease, HTN, edema related to fluid retention, and severe cognitive impairment had an MRR recommendation for scheduled vitals related to Metoprolol, Amlodipine, and furosemide. The DON presented the recommendation to the physician/provider, but the response section was left blank, the physician did not respond, and no orders were implemented despite the facility policy requiring the medical practitioner to document review of the irregularity and any action taken.
A resident with schizophrenia and other psychiatric and medical diagnoses did not receive a monthly antipsychotic as ordered, received the wrong dose after readmission, and then missed the medication again the following month. The MAR reflected the missed and incorrect administrations, and an LPN and the DON stated that skipped or incorrect monthly Invega Sustena doses can affect behaviors and exacerbate symptoms.
An opened vial of Lispro insulin was found in a medication cart with a discard date that had already passed. The vial was stored in a plastic bag in the top drawer of the cart, and the facility med cart sheet listed a 4-week discard date after opening. An LPN stated the insulin should be good for 30 days after opening and said it would be discarded.
The facility failed to keep complete and accurate clinical records for two residents. One resident was involved in an altercation with an LPN that led to police being called, but the progress notes did not document the incident. Another resident reported debit card misappropriation and financial exploitation involving a roommate and another resident, but the clinical record had no documentation of the incident, the investigation, or related actions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect in multiple incidents involving physical harm, verbal abuse, and inadequate supervision. Four residents were identified in the deficiency findings: one resident sustained a tibia/fibula fracture after being transferred with a mechanical lift by a CNA without the required second staff member; another resident was struck in the face by a different resident during an altercation and sustained a bloody nose and pain; a third resident was verbally abused by a CNA and experienced psychosocial effects documented by a mental health provider; and a fourth resident was left unattended in the presence of another resident and was assaulted, resulting in scratches that required treatment. One resident had severe cognitive impairment, required assistance with all ADLs, and had a care plan directing use of a mechanical lift with two-person support. The resident was later found with bruising and pain to the right leg, and x-rays confirmed a right tibia/fibula fracture. The investigation found that a CNA had been observed transferring the resident alone with the mechanical lift, despite the resident’s care plan requiring two staff members for the transfer. Another resident was involved in a resident-to-resident altercation while outside in the courtyard playing cards. The resident was struck in the nose and cheek, had bleeding from the nose, and was given acetaminophen for pain. The documentation stated that no staff were present when the incident occurred. A third resident was the subject of a verbal abuse allegation involving a CNA, and a counselor note documented increased isolation, delusions, hallucinations, higher anxiety, and possible acute stress after the incident. A fourth resident, who had a communication barrier and used an interpreter because English was not the resident’s dominant language, was left in the presence of another resident after a staff member exited the room, and the resident was then assaulted and sustained minor scratches.
Failure to Provide Needed ADL Hygiene Assistance
Penalty
Summary
Facility staff failed to ensure that a resident who was dependent on staff for activities of daily living received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. The resident had diagnoses including atrial fibrillation, a history of right hemispheric CVA with left upper extremity weakness, low back pain, alcohol abuse, and alcohol-induced dementia. The most recent MDS coded the resident with severe cognitive impairment and as requiring moderate assistance from staff for all aspects of ADL care, including bathing, dressing, and personal hygiene. The resident was observed on multiple occasions with extremely oily and unkempt hair, food in the beard, stains on the shirt, and a strong odor of urine and body odor. The clinical record showed the resident was scheduled for two showers per week, but did not receive 4 of 12 showers in February and had only received 2 bed baths in March, with none of the missed care entries coded as refusals. A CNA stated the resident did not usually refuse showers and was unable to complete personal hygiene, bathing, or shampooing independently. The resident was unable to participate in an interview due to inability to follow the conversation.
Failure to Maintain Resident Dignity During Dressing and Personal Care
Penalty
Summary
The facility failed to ensure dignity for a resident with bipolar disorder, major depressive disorder, schizophrenia, chronic kidney disease, heart failure, and a history of falls when staff allowed the resident to exit her room and propel herself approximately 40 feet down the hall to the nurses’ station wearing only an incontinence brief. The resident’s most recent MDS coded her as having a BIMS score of 13 out of 15, needing moderate to full assistance with ADLs and personal care except eating, and being able to self-propel her wheelchair. Surveyors observed two LPNs briefly stop at the resident’s room during report, and within about one minute the resident was seen leaving her room in full view of other residents, staff, and visitors without being fully dressed. At the nurses’ station, the unit manager redirected the resident back to her room. The clinical record showed a care plan addressing behaviors including taking off her brief, urinating on the floor and in the hallway, yelling, smoking cigarettes in her room, disrobing in her room and wheeling into the hallway, refusing to wear briefs, and refusing incontinence care. The care plan also included interventions such as administering medications as ordered, approaching and speaking in a calm manner, and behavioral health consultation with 1:1 supervision until evaluation was complete. The facility also failed to ensure another resident was dressed appropriately to maintain dignity. This resident had diagnoses including hypertension, hyperlipidemia, seizure disorder, malnutrition, anxiety, depression, bipolar disorder, and schizophrenia, and was coded on the MDS as having a BIMS score of 0 and being dependent on staff for toileting, hygiene, bathing, dressing, footwear, and personal hygiene. Surveyors found the resident in her room with the curtain closed around the bed, linens on the floor, and a dirty stained T-shirt pulled up over her head covering her face and head while her breasts were exposed. When asked if this was acceptable, an RN stated it was not but said the resident was geriatric-psych and resistant to care and pulled the sheets off her bed, making the statement in the resident’s room in front of the resident.
Failure to Report Serious Injury and Complete Required Employee Screening
Penalty
Summary
The facility failed to implement its abuse policy for a resident who later expired after a severe injury event, and failed to complete required screening for an employee. The resident had diagnoses including Parkinson’s disease, bipolar disorder, anemia, and depression, and prior to the event was coded with a BIMS score of 13, indicating mild cognitive impairment. Nursing documentation described the resident being found with bruising and bleeding to the head and face, with the throat appearing discolored-purple, darkened eyes, a purple lower lip, a bloodied mouth, grogginess, and delayed verbal responses, after which the resident was transferred to the ER for evaluation. Facility records showed the resident was found lying face down on the floor with legs straight and arms at the side, with a floor mat present. The facility initially reported the event to the state agency as an unwitnessed fall with no injuries and later submitted an addendum stating injuries were none and that the event was an injury of unknown origin, while also noting the hospital had communicated allegations of sexual and physical abuse. The resident was sent to the hospital about an hour after the incident, then transferred to a second hospital where documentation described extensive bruising and injuries over much of the body, swelling and bleeding of the brain, and vaginal tearing and bleeding. The resident was later transferred to ICU and expired. The facility’s initial report to the state agency was submitted about 9 hours after the event, despite the facility being aware of the serious injury within about 2 hours, and the addendum was also late. The 5-day follow-up report described the event as an unwitnessed fall and included statements that were not substantiated by the known facts, while also stating the facility could not substantiate or unsubstantiated the allegations until police concluded their investigation; no later update was made. In addition, a review of employee records found that one employee did not have a sworn statement on file and did not have a Virginia State Police background check on file, and the background check personnel confirmed no background check had been performed for that employee.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the appropriate regulatory authorities in a timely manner for three residents. For Resident #52, the record showed the resident struck another resident with a small rock, causing a cut to the other resident’s forehead after the other resident attempted to place a flower in Resident #52’s hair. Facility documentation stated police were notified, but there was no credible evidence that the incident was reported to adult protective services or the state survey agency within 24 hours. The only credible evidence available showed the investigation findings were reported to adult protective services on 9/6/24. For Resident #74, the clinical record documented a resident-to-resident altercation in which Resident #74 was struck in the nose and cheek by another resident, with bleeding from the nose, swelling to the cheek, and pain treated with acetaminophen and ice. The facility’s incident synopsis described the event as escalating from a verbal altercation while the residents were playing cards in the courtyard, ending with one resident striking Resident #74 in the face and causing a bloody nose. During interview, Resident #74 recalled the incident and stated no staff were present when it occurred. There was no evidence that the incident was reported to adult protective services or the state survey agency until the investigation summary was faxed on 9/13/24. For Resident #76, the record showed a physical altercation involving the resident, a staff member, and another resident. The progress note stated Resident #76 assaulted the wound nurse and spit on another resident, staff separated the residents, the resident was relocated to his room, and a head-to-toe assessment found minor scratches to the back, abdomen, and both arms and legs with no complaints of pain or discomfort voiced through an interpreter line. The facility investigation documents stated Resident #76 hit and pushed the wound care nurse, then spit on another resident, after which the other resident physically assaulted him. The facility had no credible evidence that this incident or the investigation summary was reported to the state survey agency or other regulatory agencies.
Incomplete Investigation of Alleged Verbal Abuse
Penalty
Summary
Facility staff failed to have credible evidence of a thorough investigation of an allegation of abuse involving Resident #77. The record showed that on 03/12/26 an attempt was made to interview Resident #77, but the resident was not available. A clinical record review noted a Licensed Professional Counselor entry dated 10/30/24 stating that the staff accused was heard by another staff member and removed, and that Resident #77 had more isolation, stayed in her room longer, had increased delusions and hallucinations, higher anxiety, and was possibly experiencing acute stress. The note also stated staff were supporting and monitoring her mood. The investigation file contained a typed investigation summary, an incident synopsis with minimal details, and only two staff witness statements. There was no evidence that any additional staff who were working had been interviewed, and no resident interviews were included for Resident #77 or her roommate. One statement from CNA #6 indicated that CNA #6 heard CNA #5 say, "What the f*** is your problem? We need to get ready," to Resident #77. Although the facility investigation summary concluded the allegation of abuse was unsubstantiated, the Administrator reviewed the file and confirmed the investigation was incomplete and could not determine why that conclusion had been made based on the information present.
Outdated Care Plan Intervention for Discontinued 1:1 Supervision
Penalty
Summary
The facility failed to keep Resident #76’s care plan updated after the resident’s one-on-one supervision was discontinued. The clinical record showed an intervention dated 10/22/25 that still directed 1:1 supervision related to a resident-to-resident altercation, even though RN #2 confirmed during interview that the resident was no longer on one-to-one observation. RN #2 also stated that the care plan should be updated when there is a change in condition or order changes, and later acknowledged that the resident’s one-to-one had been for less than 24 hours and should have been resolved before then. On 3/10/26, R76 was observed in his room lying in bed with no one else present, and he did not respond when spoken to. On 3/11/26, the resident told the surveyor through the facility’s interpreter line that he had no concerns. During record review the same day, the outdated care plan intervention remained in place. The facility policy titled Plan of Care Overview Revision 7.0 stated that nurses are expected to participate in reviewing and revising the resident plan of care as the resident’s condition warrants, and that care plan documents are resident-specific and resident-focused. The findings were reviewed with the administrator and DON during an end-of-day meeting, and no additional information was provided.
Medication Administration Error for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that Resident #10 received medication in accordance with physician orders and professional standards of practice. The resident was admitted with diagnoses including bipolar disorder, major depressive disorder, schizophrenia, chronic kidney disease, heart failure, and a history of falls. The most recent MDS coded the resident with a BIMS score of 13, indicating moderate cognitive impairment, and documented that the resident required moderate to full dependence for ADLs and personal care except eating, could self-propel a wheelchair, and had behavioral symptoms including physical and verbal behaviors toward others, other disruptive behaviors, and wandering. Clinical record review showed that the resident had been hospitalized and returned to the facility on 12/29/25. The resident had an order for Invega Sustenna 156 mg/mL IM every 30 days for schizophrenia prior to the hospital stay, with the dose due on 12/19/25 but not given because of the hospital stay. After return, the order was changed to Invega Sustenna 117 mg/0.75 mL IM every 30 days, but the MAR showed the resident did not receive Invega Sustenna during December 2025, received the incorrect 156 mg/mL dose on 1/21/26, had the incorrect dose entered on the MAR for February, and did not receive the medication in February. The DON stated that nurses were expected to follow physician orders and the rights of medication administration.
Failure to Provide Proper Nail Care
Penalty
Summary
Proper foot care was not provided to Resident #94, who was admitted and readmitted to the facility with diagnoses including hypertension, legal blindness, schizoaffective disorder, bipolar disorder, seizures, and generalized anxiety disorder. The most recent MDS showed a BIMS score of 00 out of 15, indicating severe cognitive impairment, and the resident required assistance with ADLs. During the initial tour and subsequent rounds, the resident was observed lying in bed with both feet uncovered, and the toenails on both feet were thick and long. The right great toenail was dark in color, approximately an inch and a half long, pointed, and curved to the right over the second toe, while the left great toenail was also thick and dark and approximately one-half inch to one-half inch long. The clinical record contained no documentation that the resident was seen by podiatry or that staff trimmed the toenails during the months reviewed. Podiatry records showed the resident was not listed to be seen from November 2025 through February 2026. A CNA stated that nursing assistants were expected to cut residents' toenails unless they were diabetics and that nurses should be notified if a resident refused nail care. An LPN stated the resident needed foot care, and the DON stated staff should provide nail care and observed that the right great toenail was very long and needed to be trimmed. The DON also stated the resident often refused care.
Nurse Staffing Information Not Kept Current for Public View
Penalty
Summary
The facility failed to properly post nurse staffing information at 2 of 2 units with an up-to-date and current nursing sheet for resident, staff, and public view. During a facility tour on 2/26/2026, surveyors observed daily nursing staffing sheets posted at the front desk and outside the Staffing Manager’s office near the nursing station on unit wing 1. The Staffing Manager stated that the daily nursing staff sheets were located in two locations, but when staff called out or did not show for a shift, they were marked off on an additional sheet located behind the counter at the nursing station, outside the Staffing Manager’s office. The Staffing Manager also stated that the sheets in public view were not updated with call outs or no shows, and only the sheet behind the desk at the nursing station was updated. On observation, an updated nursing staff sheet was not seen in plain sight at the nursing desk on unit wing 1. The findings were reviewed with the Administrator and DON on 2/27/2026, and no additional information was provided.
Failure to Document Response to Pharmacy Recommendation
Penalty
Summary
The facility failed to respond to a pharmacy recommendation for one resident regarding scheduled vital signs. The resident had diagnoses of cerebrovascular disease, hypertension, and edema related to fluid retention, and the most current MDS showed the resident had long- and short-term memory problems and was severely cognitively impaired. The Medication Regimen Review showed the pharmacist made a recommendation on 12/26/25, and on 2/26/26 the DON presented the recommendation to the physician/provider. The recommendation addressed three medications: Metoprolol, Amlodipine, and furosemide, and asked that scheduled vitals be considered. The Note to Attending Physician/Provider form had a section for the physician/provider response, but it was left blank. The DON stated the physician did not respond to the recommendation and no orders were implemented. The facility policy stated the resident's medical practitioner must document in the medical record that the identified irregularity has been reviewed and what action, if any, has been taken to address it.
Medication Administration Errors With Monthly Antipsychotic
Penalty
Summary
The facility failed to ensure Resident #10 was free from significant medication errors involving Invega Sustena, an antipsychotic ordered monthly for schizophrenia. Resident #10 had diagnoses including bipolar disorder, major depressive disorder, schizophrenia, chronic kidney disease, heart failure, and a history of falls, and the most recent MDS coded the resident with a BIMS score of 13, moderate to fully dependent ADL needs, and behavioral symptoms including physical, verbal, and other behaviors directed toward others, as well as wandering. The record showed the resident went to the hospital and returned to the facility on 12/29/25, and the monthly injection due on 12/19/25 was not given during December 2025. After the resident returned, the order for Invega Sustena was changed to 117 mg/0.75 mL, but the MAR showed the resident received the incorrect dosage of 156 mg/mL on 1/21/26. The MAR also showed the medication was incorrectly ordered for February and was not administered that month. During interview, an LPN stated that if a resident who receives monthly Invega Sustena skips a month or receives the wrong dose, it can affect behaviors and cause escalation or increase in behavioral symptoms. The DON stated nurses are expected to verify orders on admission or readmission using the discharge summary and notify the provider if medication is not given for any reason, and that missed routine antipsychotic doses could allow behaviors to change and symptoms to exacerbate.
Outdated insulin vial found stored in medication cart
Penalty
Summary
The facility failed to ensure that medications were stored correctly for one of two medication carts inspected. During an inspection of medication carts #1 and #2, an opened vial of Lispro insulin 100 mL was found in the top drawer of medication cart #1 inside a transparent plastic bag with a sticker stating, "Discard by: 2/24/26." The vial itself had an opened date transcribed of 12/25/25. Facility policy stated that outdated medications are to be discarded immediately, and the facility med cart sheet indicated that Lispro has a discard date of 4 weeks after opening. An interview with an LPN confirmed that Lispro should be good for 30 days after opening and that the medication would be discarded.
Incomplete Clinical Documentation for Resident Incidents
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for two residents. For one resident who was involved in an incident that resulted in police being called, the record contained an incident synopsis describing that the resident pushed and hit an LPN while attempting to retrieve linen from a closet, but the resident’s progress notes did not include entries for the day of the incident or the following day. The administrator stated that incidents should be clearly documented in the resident’s clinical record, and the facility policy on clinical documentation standards required timely and accurate resident information in the medical record. For another resident, the facility failed to document details of a reported misappropriation and financial exploitation incident involving the resident’s debit card. The resident reported that a roommate had stolen debit card information months earlier and that another resident had been given the card information; the roommate confirmed providing the information to another resident. The clinical record contained no documentation of the incident, the facility investigation, or actions taken during and after the investigation, despite the resident later confirming the details during interview.
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Illustrative
What surveyors actually found near you
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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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Illustrative
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Nursing homes near Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Battlefield Park Healthcare Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Hiram W Davis Medical Ctr | 3.7 mi | ★★★★★ | 6 | 0 |
| Colonial Heights Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 5 | 0 |
| Wonder City Rehabilitation And Nursing Center | 5 mi | ★★★★★ | 21 | 1 |
| Dinwiddie Health And Rehab Center | 5.9 mi | ★★★★★ | 1 | 0 |
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