Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Wybe And Marietje Kroontje Health Care Center during CMS and state inspections, most recent first.
Failure to Assess Bed Rail Entrapment Risk Before Side Rail Use: The facility failed to attempt alternatives and failed to assess entrapment risk before installing side rails for multiple residents. A resident with dementia, falls, weakness, and epilepsy, another resident with respiratory failure and epilepsy, and a cognitively intact resident with multiple serious medical conditions all had side rails in place without evidence of a proper seven-zone entrapment assessment. The Maintenance Director stated he was not familiar with the seven zones and only measured certain gaps when a work order was submitted, while records showed orders, risk forms, and negotiated risk agreements but no documented entrapment assessment at installation.
Failure to Document Quarterly Activity Care Plan Reviews: The facility did not complete quarterly activity progress notes or activity assessments for sampled residents, and the activity care plan notes reviewed only listed the initial care plan date, last review/revision date, and the focus, goal, and interventions. The AD and AA gave conflicting statements about whether quarterly progress notes were completed, and the AD later acknowledged that quarterly activity progress notes were not completed and that no activity assessment was used.
Incomplete Person-Centered Activity Care Plans: The facility failed to develop individualized activity care plans for multiple residents with varied cognitive and psychiatric diagnoses. Records showed generic plans that relied on broad statements and monthly calendars rather than resident-specific preferences such as music, reading, animals, outdoor time, news, religious services, and social interaction. Staff, including the AD, stated they did not use an activity assessment and instead copied MDS Section F interests into the plan.
Missing Monthly Pharmacist Medication Reviews: The facility failed to ensure required monthly pharmacist DRRs/MRRs were completed for several residents. Records showed no review for one resident and multiple other residents for May, and one resident also lacked a review for October. The affected residents had significant medical histories including dementia, COPD, heart failure, psychiatric disorders, CKD, and Alzheimer’s disease, and facility leaders acknowledged the missing reviews after a pharmacy change.
Lack of Documented QAPI Training for Sampled Staff: Facility staff could not provide evidence that QAPI training had been completed for four sampled employees, including a CNA, RN, dining server, and the Maintenance Director. The facility policy stated that all staff, contracted staff, and volunteers are to be educated on the QAPI plan and their role in implementing interventions, but the facility had no signature sheets or other documentation to verify the training.
Facility staff failed to follow the abuse prohibition policy requiring a Virginia State Police criminal background check before employment when a Dining Server was re-hired. The HRD stated the employee had worked at the facility before, but the new background check was missed on re-hire; the only check provided was from the prior employment period.
Failure to Report Resident Allegation of Sexual Abuse: A resident with severe cognitive impairment, dementia, and behavioral symptoms made a statement interpreted as a sexual abuse allegation during CNA-assisted toileting. Nursing documented the incident and notified the social worker, but the Administrator stated it was not reported to the State Survey Agency because it was viewed as the same behavior the resident had shown previously in assisted living.
A resident with severe dementia and other significant diagnoses was transferred to a higher level of care, but the facility did not have evidence that the resident's representative received written notice of the reason for the transfer/discharge. The CD stated a transfer form was given to the resident at the time of hospital transfer, but could not confirm that the legal representative was informed in writing as required by facility policy.
A resident with neuropathy, scoliosis, depression, a hx of chronic UTIs, and severe cognitive impairment did not have a baseline care plan completed within 48 hours of admission. The record review found no baseline care plan in the chart at the time of survey, and the compliance director acknowledged the omission. The facility policy stated that a baseline care plan is developed upon admission.
Facility staff failed to follow provider orders for bowel management for two residents and a no-straws diet order for another resident. One resident with constipation and severe cognitive impairment went several days without a BM before a Dulcolax suppository was given, another resident with constipation had a seven-day gap without documented bowel protocol implementation, and a third resident with severe dementia was observed with straws present despite a no-straws order and care plan instruction.
Failure to provide ordered safety devices for two residents with documented fall risk. One resident with severe dementia, weakness, and a history of falls did not have Dycem in the wheelchair, anti-rollbacks on the wheelchair, or the ordered perimeter mattress in place. Another resident with epilepsy, weakness, and prior falls also did not have Dycem in the wheelchair despite an active order and care plan intervention.
Failure to Obtain Ordered Stool Testing: A resident with chronic respiratory failure with hypoxia, chronic constipation, epilepsy, and months of diarrhea had GI-ordered stool studies for ova and parasite, lactoferrin, giardia antigen, stool culture, and c-difficle PCR/RFLX, but staff did not obtain the specimen. Nursing notes showed repeated attempts and reminders, but the resident used the bathroom independently and shared a bathroom with a roommate, and the chart contained no test results or documentation that the provider was notified.
QAPI Failed to Identify Side Rail Safety System Failure: The facility’s QAPI program did not identify a system failure related to side rail use and safety. The DON/Compliance staff stated they were unaware of the issue, and surveyors found no system to ensure residents were assessed for entrapment risk or that alternatives were tried before side rails were installed. Surveyors also found no system to reassess entrapment risk when side rails were added or bed components were replaced; 34 of 53 residents had at least one side rail attached to the bed.
A resident with an indwelling foley catheter, neurogenic bladder, CKD, and a history of UTIs was observed in a wheelchair with the catheter drainage bag dragging on the floor. The resident’s record included an order for monthly catheter changes and a care plan noting UTI risk and the need for foley care; the IP later agreed the catheter should not have been touching the floor.
Missing Behavioral Health Training for Non-Direct Care Staff: Facility records showed no evidence of behavioral health training for two sampled staff members, including the Maintenance Director and a Dining Server. The Compliance Director stated that non-direct care staff do not receive this training, and the concern was reviewed with the Administrator, Director of Compliance, and DON before the exit conference.
Failure to Assess Bed Rail Entrapment Risk and Use Alternatives Before Installation
Penalty
Summary
The facility failed to assess residents for bed rail entrapment risk and failed to attempt appropriate alternatives before installing side rails for multiple sampled residents, including Resident #41, Resident #5, Resident #1, Resident #3, Resident #25, and Resident #57. The report states that 34 of 53 residents had at least one side rail in use, and that the facility staff member responsible for installation and maintenance of side rails did not have the knowledge to ensure safety measurements of the seven zones of entrapment. Surveyors identified this as an Immediate Jeopardy situation for Resident #41 and substandard quality of care for residents with side rails in place. For Resident #41, the resident had diagnoses including dementia with anxiety, repeated falls, muscle weakness, gait and mobility abnormalities, and epilepsy. The record showed a physician order allowing bed rails for mobility and transfers, a negotiated risk agreement signed by the resident’s POA, and a side rail use form, but the documents did not show that an entrapment risk assessment was completed or that alternatives were attempted before bilateral side rails were installed. A work order later documented that rails were placed on the bed, but there was no evidence of a bed safety inspection or entrapment assessment at the time of installation. During observation, the resident’s bed had bilateral side rails in the up position, and the Maintenance Director stated he was not familiar with the seven zones of entrapment and only measured certain gaps when a work order was submitted. For Resident #5, the resident had diagnoses including chronic respiratory failure with hypoxia, epilepsy, generalized muscle weakness, and a history of traumatic brain injury. The resident had bilateral half side rails in place and stated she liked using them to get in and out of bed. The record included a provider order for bed rails, a side rail use and risk observation, and a negotiated risk agreement, but there was no evidence that alternatives were attempted before installation or that the resident’s entrapment risk was assessed based on height, weight, and medical history. The Maintenance Director stated he only measured when a work order was submitted and was not familiar with the seven zones of entrapment. For Resident #1, the resident was cognitively intact and had diagnoses including sepsis, infective endocarditis, pacemaker aftercare, diabetes, respiratory failure with hypoxia, and atrial fibrillation. Bilateral half side rails were observed on the bed, and the resident stated the rails did not move but the bed did. The record showed a provider order for bed rails and a care plan intervention allowing bed rails as ordered, but there was no evidence that alternatives were attempted or that entrapment risks in the seven zones were assessed. The Maintenance Director demonstrated the rails and stated they were full-size side rails that only moved up and down, while the DON stated the rails enhanced mobility and independence and that the benefits and risks were discussed with the resident and family.
Failure to Document Quarterly Activity Care Plan Reviews
Penalty
Summary
The facility failed to revise and/or reassess the effectiveness of interventions in the comprehensive person-centered activity care plan for sampled residents. A review of the clinical records did not show activity progress notes for quarterly care plan reviews. The activity care plan notes that were present included the start date of the initial care plan, the last reviewed/revised date, and the care plan focus, goal, and interventions, but they did not include information about revisions to the activity care plan or the effectiveness of the activity interventions. During interview, the AD stated that a quarterly activity progress note or activity assessment is completed for each resident, while the AA agreed that a quarterly activity progress note is completed with review of the resident care plans. Later, the AD stated that adjustments to residents' activity care plans are made as needed and acknowledged that quarterly activity progress notes are not completed for residents and there is no activity assessment to utilize. The facility also did not provide a policy for activity assessments and/or activity progress notes, and the administrator stated the facility utilizes the regulations for guidance.
Incomplete Person-Centered Activity Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered activity care plans that addressed residents’ activity preferences, interests, and psychosocial needs for five sampled residents. For Resident #1, the record showed diagnoses including sepsis, acute and subacute infective endocarditis, pacemaker aftercare, type 2 diabetes mellitus, acute respiratory failure with hypoxia, and atrial fibrillation. The resident was cognitively intact with a BIMS score of 15, yet the activity care plan only noted concern about participating in activity programs that meet leisure needs and included a goal to choose activities by the next review, with an intervention to place a large monthly calendar in the room. For Resident #2, the record showed diagnoses including dementia, anxiety disorder, obsessive-compulsive disorder, and severe depression with psychotic disturbance. The resident’s MDS indicated inability to complete the BIMS interview, memory problems, and moderate impairment in daily decision making. The activity care plan listed interests such as bird watching, watching TV, visiting with friends and family, and quietly socializing, but the plan also relied on generic interventions such as accepting the resident’s right to decline, praising involvement, providing 1:1 sessions in the room, and placing a large monthly calendar in the room. The MDS Section F also identified preferences such as reading books/newspapers/magazines, being around animals, going outside in nice weather, and participating in religious services or practices, which were not reflected in the care plan. For Resident #19, the record showed severe vascular dementia, cerebrovascular disease, chronic kidney disease stage 3, Alzheimer’s disease, and cerebral infarction. The resident was rarely or never understood, had short- and long-term memory problems, and severe impairment in decision making. The MDS Section F interview for activity preferences could not be completed, and the primary respondent section also could not be completed by resident or family/significant other. The activity care plan only noted listening to music and liking snacks between meals, with a goal to choose activity programs by the next review and an intervention to place a large monthly calendar in the room. For Resident #25, the record showed vascular dementia with behavioral disturbance, neurocognitive disorder with Lewy body dementia, dementia, anxiety disorder, depression, and cognitive communication deficit. The resident was rarely or never understood, had memory problems, and severe impairment in decision making. The activity care plan again used a general focus about being concerned about participating in activity programs that meet leisure needs and wants, with a goal to choose activities by the next review and an intervention to place a large monthly calendar in the room. For Resident #7, the resident was admitted with diagnoses including Alzheimer’s disease, Parkinson’s disease, generalized anxiety, major depressive disorder, and PTSD. The admission MDS showed moderate cognitive impairment and identified music, animals or pets, group activities, going outside for fresh air, books, and keeping up with the news as important or somewhat important, but the report did not show a person-centered comprehensive activity care plan addressing those preferences.
Missing Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure monthly drug regimen reviews were completed by a licensed pharmacist for multiple residents, including Resident #9, #39, #41, #8, and #2. The report states that the facility policy required a consultant pharmacist to conduct a drug regimen review for each resident monthly, including review of the medical chart and irregularity reporting. During record review, no drug regimen review was found for May 2025 for Residents #9, #39, #41, and #8, and no reviews were found for May 2025 and October 2025 for Resident #2. Resident #9 was admitted on 4/19/25 and had diagnoses including major depressive disorder, generalized anxiety disorder, hypertension, and chronic kidney disease. Resident #39 was admitted on 6/2/22 and had diagnoses including chronic systolic heart failure, COPD, hypertension, bipolar disorder, psychotic disturbance, mood disturbance, and anxiety. Resident #41 was admitted on 7/6/24 and had diagnoses including dementia, anxiety, schizophrenia, schizoaffective disorder, major depressive disorder, and generalized idiopathic epilepsy. Resident #8 was admitted on 11/22/20 and had diagnoses including Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, and psychophysiologic insomnia. The MDS assessments cited in the report showed cognitive impairment ranging from intact cognition to moderate impairment for these residents. For Resident #2, the diagnosis list included COPD, atherosclerosis of the coronary artery, dementia, anxiety disorder, obsessive-compulsive disorder, and severe depression with psychotic disturbance. The most recent MDS indicated the resident was unable to complete the BIMS interview and had memory problems and moderate impairment in daily decision making. During interviews with the DON, Administrator, Director of Compliance, and Compliance Director, staff acknowledged that the facility switched pharmacies and that the new pharmacy did not begin reviews until June 2025; they also agreed there was no evidence that the required reviews were completed for the missing months. No further information was provided to the survey team before exit.
Lack of Documented QAPI Training for Sampled Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not documented for four of four sampled staff members: CNA #3, RN #1, Dining Server #1, and the Maintenance Director. Facility review found a policy titled Quality Assurance and Performance Improvement (QAPI), reviewed 1/29/26, stating that all facility staff, contracted staff, and volunteers will be educated about the QAPI plan and their role in developing and implementing interventions. During staff interview and document review, the facility staff were unable to provide evidence of QAPI training for the sampled staff members. On 4/13/26 at 2:53 PM, the Compliance Director stated that the facility provides QAPI training but does not have staff signature sheets as evidence of the trainings. The concern was discussed with the Administrator, Director of Compliance, and DON on 4/13/26 at 4:38 PM, and no further information was presented to the survey team before the exit conference.
Missing Background Check for Re-Hired Dining Server
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after facility staff failed to follow the written abuse prohibition policy requiring criminal background checks on every candidate through the Virginia State Police prior to employment. The policy, implemented 4/25/24, stated that applicants found guilty of barrier crimes or abuse, neglect, exploitation, misappropriation of resident property, or mistreatment would be disqualified for employment. Dining Server #2 was documented as re-hired on 2/02/26, but the only Virginia State Police background check provided was dated 7/06/23 and reflected no identifiable records found. During interview, the Human Resource Director stated the employee had previously worked at the facility from 7/10/23 through 3/09/25 and that a new criminal background check should have been completed when the employee was re-hired, but it was missed. The concern was discussed with the Administrator, Director of Compliance, and DON on 4/13/26, and no further information was provided to the survey team before exit.
Failure to Report Resident Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report a resident allegation of sexual abuse to the State Survey Agency for one resident. The facility policy titled Abuse Prohibition Policy stated that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property must be reported immediately, but no later than 2 hours after the allegation is made, or no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. Resident #48 was admitted with a history of parkinsonism, vascular dementia with agitation, generalized anxiety disorder, and major depressive disorder. The admission MDS assigned a BIMS score of 6 out of 15, indicating severe cognitive impairment, and the care plan noted dementia with behaviors such as wandering, grabbing others, restlessness, delusions, and agitation. A nursing progress note documented that a CNA assisted the resident to the bathroom, after which the resident stated, "This is rape." The CNA reported the statement to nursing, and the nurse instructed CNAs not to enter the room without another staff member as a witness. The nurse notified the social worker and obtained written statements from the CNAs, but the Administrator later stated the incident was not reported to the State Survey Agency because it was considered the same behavior the resident had displayed while in assisted living.
Failure to Notify Resident Representative of Transfer/Discharge Reason
Penalty
Summary
The facility failed to provide written notification of the reason for transfer/discharge to the resident representative for one sampled resident, Resident #19, after the resident was transferred to a higher level of care. Resident #19 had diagnoses including vascular dementia-severe, cerebrovascular disease, chronic kidney disease stage 3, Alzheimer's disease, and cerebral infarction. The most recent significant change MDS, with an ARD of 4/1/26, coded the resident as rarely/never understood, with short- and long-term memory problems and severe impairment in decision making, indicating severe cognitive impairment. A review of the clinical record showed that Resident #19 was transferred to a higher level of care on 2/24/26, but no evidence was found that written notification of the reason(s) for the transfer/discharge was provided to the resident's representative. The compliance director stated that a written transfer form was provided to the resident at the time of transfer to the hospital, but was unsure whether the resident representative received written notice. Later, the compliance director agreed there was no evidence that written notification for the reason(s) for transfer/discharge had been provided to the resident's representative. The facility policy titled, Discharge of Residents, stated that under emergency conditions the resident's legal representative shall be informed as rapidly as possible, but by the close of the business day following discharge, of the reasons for the move.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident #59. The resident had diagnoses including neuropathy, scoliosis, depression, and a history of chronic urinary tract infections, and the most recent admission MDS had not been completed at the time of survey. A BIMS assessment dated [DATE] showed a score of 6 out of 15, indicating severe cognitive impairment. The resident was admitted on [DATE], but a baseline care plan could not be located in the clinical record. A baseline care plan dated 4/7/26 was later requested and received, and on 4/13/26 at approximately 9:00 AM the compliance director acknowledged that the baseline care plan had not been completed within 48 hours of admission. The facility policy titled Comprehensive Care Plans stated that a baseline care plan is developed upon the resident's admission.
Failure to Follow Provider Orders for Bowel Protocol and No-Straws Diet Instruction
Penalty
Summary
Facility staff failed to follow medical provider orders for bowel management for three sampled residents and failed to follow a no-straws order for one resident. The report documents that Resident #50 had diagnoses including constipation and severe cognitive impairment, and the facility’s bowel regimen required a laxative after three days without a bowel movement. The resident went from 03/30/2026 until 04/06/2026 without a documented bowel movement, and a Dulcolax suppository was administered on 04/06/2026 after the prolonged period without bowel activity. For Resident #2, the record showed diagnoses including constipation and a bowel protocol order that included Senna-S, Dulcolax suppository, and Fleet enema as needed for no bowel movement in three days. The resident had one small bowel movement on 03/28/2026 and then no documented bowel movement until 04/05/2026, a seven-day period. The MAR did not show administration of a bisacodyl suppository during that interval, and the DON agreed there was no evidence the bowel protocol was followed from 03/29/2026 through 04/04/2026. A nursing note on 04/05/2026 stated the resident had not had a bowel movement for several days, had been given PRN senna with no results, was placed on the commode, and then had two extra-large bowel movements. For Resident #19, the provider ordered a regular pureed diet with special instructions of no straws. The resident had diagnoses including severe vascular dementia, cerebrovascular disease, chronic kidney disease stage 3, Alzheimer’s disease, and cerebral infarction, and was described as severely impaired in cognition. During observation, surveyors saw a straw present in the resident’s water pitcher and later in an empty glass on the over-the-bed table, despite the no-straws order and care plan instruction to avoid coughing/choking. The facility policy stated that physician orders would be implemented by qualified professional staff according to state and federal regulations and clinical standards of practice.
Failure to Provide Ordered Wheelchair and Bed Safety Devices
Penalty
Summary
The facility failed to ensure assistive safety devices were in place for two sampled residents who had documented fall risk and fall history. Resident #6 was admitted with severe vascular dementia with anxiety, generalized muscle weakness, a history of falling, and gait and mobility abnormalities. The resident’s MDS showed severe cognitive impairment and multiple falls with and without injury since the prior assessment. The care plan and provider orders included Dycem in the wheelchair, a perimeter mattress, and anti-rollbacks on the wheelchair, but during an observation the resident was assisted from the wheelchair and no Dycem was present above or below the cushion, the wheelchair did not have anti-rollbacks, and the mattress in the room was a regular mattress rather than a perimeter mattress. Resident #5 was admitted with chronic respiratory failure with hypoxia, epilepsy, generalized muscle weakness, and a history of traumatic brain injury. The resident’s MDS showed intact cognition, but the resident was coded with multiple falls with injury and one fall without injury since the prior assessment. The care plan and active provider order required Dycem in the wheelchair, and during an interview the resident stated she wanted something in the wheelchair to keep the cushion from sliding. An observation of the wheelchair showed no Dycem present below or on top of the cushion. The concern for both residents was discussed with the Administrator, DON, and Compliance Director, and no further information was provided before the exit conference.
Failure to Obtain Ordered Stool Laboratory Testing
Penalty
Summary
The facility failed to obtain provider-ordered stool laboratory testing for one resident who had a history of chronic respiratory failure with hypoxia, chronic constipation, epilepsy, and several months of diarrhea with one to two loose stools per day. A gastroenterology consult documented orders for stool studies to evaluate for infections, inflammation, and exocrine pancreatic insufficiency, including ova and parasite, lactoferrin fecal quantitative, giardia specific antigen, stool culture, and c-difficle PCR/RFLX. The resident was cognitively intact with a BIMS score of 15 out of 15. Nursing notes documented that staff had difficulty collecting the stool specimen because the resident used the bathroom independently, had a roommate using the same bathroom, and staff gave reminders a couple of times per shift. One note stated the resident said the bowel movement came on suddenly and she forgot, and another noted no stool sample had been obtained during the shift. The clinical record did not include results of the ordered stool testing, and the DON verified the testing was not completed and that there was no documentation the medical provider was notified. The DON also stated the resident's diarrhea had resolved.
QAPI Failed to Identify Side Rail Safety System Failure
Penalty
Summary
The facility failed to identify a system failure regarding side rail use and safety as part of its QAPI and QAA activities. The facility QAPI Plan, reviewed on 2/25/2026, stated that the QAPI program would aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life by ensuring data collection tools and monitoring systems were in place and consistent for proactive analysis, system failure analysis, and corrective action. A facility policy titled Quality Assurance and Performance Improvement (QAPI), reviewed on 1/29/26, stated that the facility would develop, implement, and maintain a QAPI program that is effective, data driven, comprehensive, and focused on indicators of outcomes of care and quality of life, including identifying and prioritizing quality deficiencies. During an interview on 4/13/26 at 4:00 PM, the Director of Compliance stated they were unaware of an issue regarding side rails. During the survey, it was identified that the facility lacked a system to ensure residents were assessed for the risk of entrapment and that appropriate alternatives were attempted prior to the installation of side rails. The facility also failed to maintain a system to ensure side rails were assessed for entrapment risk when installed on a bed or when bed components were replaced. At the time of the survey, the census was 53 residents, and 34 residents had at least one side rail attached to the bed. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/13/26.
Foley Drainage Bag Dragging on Floor
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to maintain effective infection control for a resident with an indwelling foley catheter. The resident was admitted with diagnoses including chronic kidney disease, flaccid neuropathic bladder, neuromuscular dysfunction of the bladder, and a personal history of urinary tract infections. The resident’s record showed an order to change the catheter monthly and as needed for obstruction if flushing was not successful, and the care plan identified the resident as having an indwelling foley catheter and being at risk for UTIs due to the catheter and history of UTIs. During observation, the resident was seen in a wheelchair with a scraping sound as the chair moved, and it was noted that the right corner of the catheter drainage bag was dragging on the floor. The resident was cognitively intact with a BIMS score of 14 out of 15. When the concern was discussed with the Administrator, DON, Director of Compliance/Infection Preventionist, ADON, and MDS Coordinator, the Infection Preventionist agreed that the catheter should not have been touching the floor.
Missing Behavioral Health Training for Non-Direct Care Staff
Penalty
Summary
Behavioral health training was not provided for two of five sampled staff members, the Maintenance Director and Dining Server #1, based on staff interview and facility document review. On 4/13/26, the Compliance Director provided their training records, and each record lacked evidence of prior behavioral health training. The Maintenance Director had worked at the facility since 11/10/21, and Dining Server #1 had worked there since 1/27/25. During an interview on 4/13/26 at 3:08 PM, the Compliance Director stated that non-direct care staff do not receive behavioral health training. The concern was discussed with the Administrator, Director of Compliance, and DON on 4/13/26 at 4:38 PM, and no further information was provided to the survey team before the exit conference.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Blacksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Hall Blacksburg | 1.2 mi | ★★★★★ | 1 | 0 |
| Radford Health And Rehab Center | 9.5 mi | ★★★★★ | 0 | 0 |
| Highland Ridge Rehab Center | 15.6 mi | ★★★★★ | 14 | 0 |
| Richfield Health Center - Salem | 17.1 mi | ★★★★★ | 0 | 0 |
| Skyline Nursing & Rehabilitation | 20.6 mi | ★★★★★ | 11 | 0 |
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