Above 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 Westminster-canterbury Of Richmond during CMS and state inspections, most recent first.
A nurse failed to document critical assessments and interventions for a resident in the facility's electronic medical record, despite recording them in a personal notebook. This included fluctuating oxygen levels and declining blood pressure readings. The omission was acknowledged by the nurse and confirmed by the director of nursing, highlighting a breach in the facility's documentation policy.
A resident's clinical record was incomplete due to a nurse's failure to document vital signs and interventions in the electronic medical record. The nurse recorded details in a personal notebook but did not transcribe them, leading to a deficiency in maintaining accurate medical records as per facility policy.
A resident was allowed to self-administer Tylenol without a required assessment to determine if it was clinically appropriate. The resident, who was not cognitively impaired, had unsecured medication in their room, contrary to facility policy. Interviews with the DON and an LPN confirmed the oversight in conducting the necessary evaluation.
A resident's comprehensive care plan for diabetic medication was not followed, as insulin was administered despite a blood sugar level below the threshold set by the physician's order. An LPN confirmed the oversight, and the facility's policy on person-centered care plans was not adhered to, prompting notification to the administrator and DON.
The facility failed to monitor the neurological status of two residents after unwitnessed falls, risking undetected deterioration. One resident with a history of falls and severe cognitive impairment had omitted neurological checks after a fall. Another resident with Alzheimer's experienced two falls, with multiple neurological assessments omitted. The facility's policy requires comprehensive checks, which were not fully completed.
A resident received unnecessary insulin despite a physician's order to hold it if blood sugar was below 100. The resident's blood sugar was 94, yet the insulin was administered. An LPN confirmed the insulin should have been held, as per the facility's medication administration policy.
Failure to Document Resident Care in Medical Record
Penalty
Summary
The facility staff failed to adhere to professional standards of practice for documentation concerning a resident, identified as Resident #1. On 10/19/24, the resident was noted to be lethargic with low blood pressure, and the attending physician was updated. However, the nurse on duty, RN #1, did not document several critical assessments and interventions in the resident's clinical record. These included the resident's fluctuating oxygen saturation levels, the application of supplemental oxygen, and multiple blood pressure readings that indicated a decline. The nurse had recorded these observations in her personal notebook but failed to transcribe them into the facility's electronic medical record. The deficiency was identified during an interview with RN #1, who acknowledged the omission and recognized the importance of documenting all care provided in the clinical record for continuity of care. The facility's director of nursing confirmed that RN #1 did not follow accepted nursing standards of practice for documentation. The facility's policy on Charting and Documentation mandates that all services provided and changes in a resident's condition must be documented in the resident's medical record, which was not adhered to in this instance.
Incomplete Documentation of Resident's Clinical Record
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for a resident, identified as Resident #1, during a specific period. On 10/19/24, the resident was noted to be lethargic with low blood pressure, and the attending physician was updated. However, subsequent vital signs and interventions, including the administration of oxygen and the decision to hold certain medications, were not documented in the resident's electronic medical record. This omission was discovered during an interview with RN #1, who had recorded these details in a personal notebook but failed to transcribe them into the official medical record. The deficiency was acknowledged by the facility's administrative staff, who confirmed that RN #1 did not adhere to accepted nursing standards of practice for documentation. The facility's policy requires that all services provided and changes in a resident's condition be documented in the medical record. The lack of documentation in the clinical record was identified as a failure to ensure continuity of care and proper communication among healthcare providers.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility staff failed to complete an assessment for medication self-administration for one resident, who was admitted with diagnoses including osteoarthritis, spondylosis, and bipolar disorder. The resident was not cognitively impaired, as indicated by a perfect score on the BIMS assessment. Despite this, the facility did not conduct a self-administration evaluation upon the resident's readmission, which was necessary to determine if the resident could safely manage their medication. The resident had a physician's order allowing self-medication of Tylenol, but the required assessment to support this practice was not completed. Observations revealed that the resident's Tylenol was left unsecured on a bedside cabinet, contrary to the facility's policy that requires medication to be locked up. Interviews with the director of nursing and an LPN confirmed that the evaluation was overlooked and that the medication was not properly secured. The facility's policy mandates that each resident desiring to self-administer medication must be assessed to ensure it is clinically appropriate, and this assessment must be documented in the physician's orders. The oversight in conducting the necessary evaluation led to the deficiency identified by the surveyors.
Failure to Implement Diabetic Care Plan
Penalty
Summary
The facility staff failed to implement the comprehensive care plan for a resident, identified as Resident #76, regarding diabetic medication administration. The resident had a physician's order for Basaglar KwikPen U-100 insulin, with instructions to administer 10 units once daily unless the resident's blood sugar was less than 100. On June 1, 2024, the insulin was administered despite the resident's blood sugar being 94, which was contrary to the physician's order. During an interview, an LPN confirmed that the care plan serves as an action plan and that staff must individualize care for each resident. The LPN acknowledged that if a resident's blood sugar is below 100, insulin should be withheld as per the physician's order. The facility's policy on person-centered care plans emphasizes developing a comprehensive plan to maintain the resident's well-being, but this was not adhered to in this instance. The administrator and director of nursing were informed of the issue.
Failure to Monitor Neurological Status Post-Fall
Penalty
Summary
The facility failed to adequately monitor the neurological status of residents following unwitnessed falls, which could lead to undetected neurological deterioration. This deficiency was identified in two residents. The first resident, who had a history of repeated falls and severe cognitive impairment, experienced an unwitnessed fall in their room. Although neurological assessments were initiated, several required checks were omitted, including those scheduled shortly after the fall and the following day. The second resident, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced two falls. In the first incident, the resident fell after losing balance and hitting their head, resulting in a noticeable bump. Despite the initiation of neurological assessments, multiple checks were omitted over the following hours and days. In the second incident, the resident was found on the floor after a loud noise was heard, and while assessments were started, specific motor function checks were omitted. The facility's policy mandates comprehensive neurological assessments following such incidents, but these were not fully completed as required.
Failure to Hold Insulin as Ordered
Penalty
Summary
The facility staff failed to ensure that a resident was free from unnecessary medication, specifically insulin, for one of the residents in the survey sample. Resident #76 had a physician's order dated January 31, 2024, for Basaglar KwikPen U-100 insulin, with instructions to hold the insulin if the resident's blood sugar was less than 100. On June 1, 2024, the resident's blood sugar was recorded at 94, yet the insulin was administered contrary to the physician's order. This incident was confirmed during an interview with LPN #1, who acknowledged that the insulin should have been held according to the physician's directive. The facility's policy on medication administration emphasizes adherence to physician's orders for accuracy and effectiveness, which was not followed in this instance.
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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) |
|---|---|---|---|---|
| Rosedale Health & Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Lakeside Health & Rehabilitation | 1.5 mi | ★★★★★ | 0 | 0 |
| Vcu Health Children's Services At Brook Road | 1.9 mi | ★★★★★ | 0 | 0 |
| Glenburnie Rehab & Nursing Center | 2.7 mi | ★★★★★ | 14 | 0 |
| Parham Health Care & Rehab Center | 3.4 mi | ★★★★★ | 57 | 3 |
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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.