Cycle 1
Health 2022-10-28 · Fire 2022-10-28
25 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Chesterfield, VA
Colonial Heights Rehabilitation And Nursing Center
1-star overall rating with 1-star inspections with $105,289 in total fines with 25 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
831 Ellerslie Ave, Chesterfield, VA
(804) 526-6851
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
196
Certified beds
Average residents
133
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1979-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
87%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,584
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.22
Baseline 19.83% · Performance 19.01% · Measure score 5.22 · Achievement 5.22 · Improvement 2.42
Healthcare-associated infections
7.82
Baseline 8.40% · Performance 5.57% · Measure score 7.82 · Achievement 7.59 · Improvement 7.82
Total nurse turnover
1.22
Baseline 67.73% · Performance 60.36% · Measure score 1.22 · Achievement 0.81 · Improvement 1.22
Adjusted total nurse staffing
0
Baseline 2.55 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 206 · Observed rate 10.19% · Lower 95% interval 7.53% |
| Discharge to community | 47.1% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 226 · Observed rate 39.82% · Lower 95% interval 37.98% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.88% |
95.27%
1.4 pts worse
|
Numerator 92 · Denominator 98 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 98 |
| Discharge self-care score | 64.71% |
53.69%
11 pts better
|
Numerator 44 · Denominator 68 |
| Discharge mobility score | 64.71% |
50.94%
13.8 pts better
|
Numerator 44 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 4.08% |
2.29%
1.8 pts worse
|
Numerator 4 · Denominator 98 · Adjusted rate 3.19% |
| Healthcare-associated infections requiring hospitalization | 5.57% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 3.33% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 216 |
| Staff flu vaccination coverage | 10.93% |
42%
31.1 pts worse
|
Numerator 27 · Denominator 247 |
| Discharge function score | 60.29% |
56.45%
3.8 pts better
|
Numerator 41 · Denominator 68 |
| Transfer of health information to provider | 93.1% |
95.95%
2.9 pts worse
|
Numerator 27 · Denominator 29 |
| Transfer of health information to patient | 75.61% |
96.28%
20.7 pts worse
|
Numerator 31 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 4.76% |
25.2%
20.4 pts worse
|
Numerator 2 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.4
0.9 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
91.2%
19.6 pts worse
|
93.4%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 66.4% · Q3 66.7% · Q4 65.6% · 4Q avg 71.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 43.5% |
94.0%
50.5 pts worse
|
95.5%
52 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 43.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.6%
0.9 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 3.6% · Q4 1.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 61.6% |
15.7%
45.9 pts worse
|
11.4%
50.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.5% · Q2 48.9% · Q3 73.6% · Q4 83.5% · 4Q avg 61.6% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.7%
3.1 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.9% · Q3 1.5% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
20.2%
6.1 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 14.6% · Q3 14.2% · Q4 15.6% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
15.0%
1.5 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 13.8% · Q3 12.6% · Q4 13.9% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.7% |
17.5%
14.8 pts better
|
16.3%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 0.0% · Q3 1.7% · Q4 1.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
15.7%
8.8 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 3.0% · Q3 3.1% · Q4 7.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.6%
1.4 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.2% |
22.2%
6 pts worse
|
19.8%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 26.0% · Q3 25.6% · Q4 26.2% · 4Q avg 28.2% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.2%
0.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 3.2% · Q3 2.9% · Q4 4.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.3% |
74.6%
11.3 pts worse
|
81.7%
18.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 65.0% · Q3 66.7% · Q4 52.3% · 4Q avg 63.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.9% |
11.7%
6.2 pts worse
|
12.0%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 19.4% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 55.7% |
73.6%
17.9 pts worse
|
79.7%
24 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 55.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.0%
1.9 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 22.4% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-02-25 · Fire 2019-02-25
56 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2017-11-09 · Fire 2017-11-09
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-10-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-28
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-11-18
F · Potential for more than minimal harm
2019-02-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-05-23
D · Potential for more than minimal harm
2019-02-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-05-23
D · Potential for more than minimal harm
2019-02-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-23
D · Potential for more than minimal harm
2019-02-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-05-23
D · Potential for more than minimal harm
2019-02-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-05-23
E · Potential for more than minimal harm
2017-11-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-02-21
E · Potential for more than minimal harm
2017-11-09
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2018-02-21
E · Potential for more than minimal harm
2017-11-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-02-21
D · Potential for more than minimal harm
2017-11-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-02-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-03
E · Potential for more than minimal harm
2025-03-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-17
G · Actual harm
2025-01-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-17
F · Potential for more than minimal harm
2025-01-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-02-16
F · Potential for more than minimal harm
2025-01-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-01-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-01-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-01-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-17
E · Potential for more than minimal harm
2025-01-03
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-16
E · Potential for more than minimal harm
2025-01-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-16
D · Potential for more than minimal harm
2025-01-03
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-02-16
D · Potential for more than minimal harm
2025-01-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-01-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-16
D · Potential for more than minimal harm
2025-01-03
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-02-16
D · Potential for more than minimal harm
2025-01-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-16
D · Potential for more than minimal harm
2025-01-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-01-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-01-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-01-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-16
E · Potential for more than minimal harm
2024-08-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-06
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-18
E · Potential for more than minimal harm
2023-05-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-05-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-05-12
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-06
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-05-10
D · Potential for more than minimal harm
2023-04-06
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-05-10
C · Minimal harm
2023-04-06
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-05-10
E · Potential for more than minimal harm
2022-10-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-28
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-08
G · Actual harm
2019-02-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-02
G · Actual harm
2019-02-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-04-02
E · Potential for more than minimal harm
2019-02-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-04-02
E · Potential for more than minimal harm
2019-02-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-25
E · Potential for more than minimal harm
2019-02-25
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-04-25
D · Potential for more than minimal harm
2019-02-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-04-25
D · Potential for more than minimal harm
2019-02-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-04-25
D · Potential for more than minimal harm
2019-02-25
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-25
D · Potential for more than minimal harm
2019-02-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-04-02
G · Actual harm
2017-11-09
F314 · Quality of Life and Care Deficiencies
Health
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Corrected 2017-08-03
E · Potential for more than minimal harm
2017-11-09
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-12-15
D · Potential for more than minimal harm
2017-11-09
F221 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Keep each resident free from physical restraints, unless needed for medical treatment.
Corrected 2017-12-15
D · Potential for more than minimal harm
2017-11-09
F281 · Quality of Life and Care Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2017-12-15
D · Potential for more than minimal harm
2017-11-09
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-12-15
D · Potential for more than minimal harm
2017-11-09
F315 · Quality of Life and Care Deficiencies
Health
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Corrected 2017-12-15
D · Potential for more than minimal harm
2017-11-09
F362 · Nutrition and Dietary Deficiencies
Health
Hire sufficient dietary support personnel.
Corrected 2017-12-15
D · Potential for more than minimal harm
2017-11-09
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-12-15
Penalties and ownership
What sits behind the stars
$105,289
2025-01-03
Fine
Fine · fine $105,289
Fine
Ownership
Virginia Care Holco LLC
5% Or Greater Direct Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Innovative Healthcare Management LLC
Operational/Managerial Control · Organization
Isva Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Jkva Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Mlva Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Rajchenbach, Moshe
W-2 Managing Employee · Individual
Rajchenbach, Moshe
5% Or Greater Mortgage Interest · Individual
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
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