Cycle 1
Health 2024-03-13 · Fire 2024-03-13
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mechanicsville, VA
Covenant Woods Nursing Home
4-star overall rating with 4-star inspections with 5 recent health deficiencies
7090 Covenant Woods Drive, Mechanicsville, VA
(804) 569-8003
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-12-15
CMS approved date
Coverage
Medicare
Participation flags
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
0.49
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.35
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
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.77
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
97%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,485
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0035
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 19.15% · Performance 20.23% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Healthcare-associated infections
5.21
Baseline 6.48% · Performance 6.28% · Measure score 5.21 · Achievement 5.21 · Improvement 0.89
Total nurse turnover
5.72
Baseline 42.10% · Performance 40.30% · Measure score 5.72 · Achievement 5.72 · Improvement 0.55
Adjusted total nurse staffing
6.27
Baseline 5.54 hours · Performance 4.86 hours · Measure score 6.27 · Achievement 6.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 145 · Observed rate 8.97% · Lower 95% interval 8.13% |
| Discharge to community | 48.86% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 45.39% · Lower 95% interval 41.13% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 77 |
| Discharge self-care score | 86.21% |
53.69%
32.5 pts better
|
Numerator 50 · Denominator 58 |
| Discharge mobility score | 46.55% |
50.94%
4.4 pts worse
|
Numerator 27 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.6% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 77 · Adjusted rate 3.38% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 3.45% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 4.8% |
8.2%
3.4 pts worse
|
Numerator 6 · Denominator 125 |
| Staff flu vaccination coverage | 98.84% |
42%
56.8 pts better
|
Numerator 170 · Denominator 172 |
| Discharge function score | 60.34% |
56.45%
3.9 pts better
|
Numerator 35 · Denominator 58 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 19.05% |
25.2%
6.1 pts worse
|
Numerator 8 · 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 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
91.2%
4.6 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 98.0% · Q3 95.7% · Q4 91.3% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.7% |
94.0%
1.3 pts worse
|
95.5%
2.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.1% · Q3 4.3% · Q4 4.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
15.7%
14.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.7%
2.5 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.4% · Q3 2.6% · Q4 2.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
20.2%
7.9 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 11.9% · Q3 12.5% · Q4 9.8% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
15.0%
1.5 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 18.8% · Q3 17.2% · Q4 17.9% · 4Q avg 16.5% · 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 | 37.0% |
17.5%
19.5 pts worse
|
16.3%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.3% |
15.7%
12.6 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 25.6% · Q3 34.2% · Q4 25.0% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.6%
0.6 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 4.3% · Q4 2.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.3% |
22.2%
10.9 pts better
|
19.8%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 20.6% · Q3 10.8% · Q4 4.3% · 4Q avg 11.3% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.2%
0.1 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.0% · Q3 8.0% · Q4 4.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.4% |
74.6%
1.8 pts better
|
81.7%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 80.5% · Q3 79.5% · Q4 59.5% · 4Q avg 76.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.7%
0.6 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 9.9% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.2%
3.5 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 0.0% · Q4 7.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
73.6%
12.4 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
22.0%
2.5 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 21.0% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-21 · Fire 2022-04-21
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-25 · Fire 2021-02-25
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-02-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-05-06
F · Potential for more than minimal harm
2021-02-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-06
E · Potential for more than minimal harm
2021-02-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-05-06
E · Potential for more than minimal harm
2021-02-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-05-06
E · Potential for more than minimal harm
2021-02-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-05-06
E · Potential for more than minimal harm
2021-02-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-02-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-02-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-02-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-05-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-03-13
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 2024-04-25
D · Potential for more than minimal harm
2024-03-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-03-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-04-25
D · Potential for more than minimal harm
2022-04-21
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-06-03
C · Minimal harm
2022-04-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-06-03
D · Potential for more than minimal harm
2021-02-25
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 2021-04-08
D · Potential for more than minimal harm
2021-02-25
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 2021-04-08
D · Potential for more than minimal harm
2021-02-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-04-08
D · Potential for more than minimal harm
2021-02-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-04-08
D · Potential for more than minimal harm
2021-02-25
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 2021-04-08
D · Potential for more than minimal harm
2021-02-25
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 2021-04-08
Penalties and ownership
What sits behind the stars
Ownership
Adams, Richard
Operational/Managerial Control · Individual
Adams, Richard
Corporate Director · Individual
Armor, Brandon
Corporate Director · Individual
Ball, Melissa
Corporate Director · Individual
Beaulieu, Kelsey
Operational/Managerial Control · Individual
Beaulieu, Kelsey
Corporate Director · Individual
Bowers, Roger
Corporate Director · Individual
Clingman, Ed
Operational/Managerial Control · Individual
Clingman, Ed
Corporate Director · Individual
Cooke, Karen
Corporate Director · Individual
Cooke, Marjorie
Operational/Managerial Control · Individual
Covenant Woods
Operational/Managerial Control · Organization
Davis, Carrie
Operational/Managerial Control · Individual
Dhaliwal, Anju
Operational/Managerial Control · Individual
Floyd, Abigail
Operational/Managerial Control · Individual
Fuller, David
Corporate Director · Individual
Gibbons, Richard
Operational/Managerial Control · Individual
Graves, Charles
Corporate Director · Individual
Hamann, Katie
Operational/Managerial Control · Individual
Jackson, Lafon
Operational/Managerial Control · Individual
Jackson, Lafon
Corporate Officer · Individual
Kent, Janet
Corporate Director · Individual
Kottkamp, Nathan
Operational/Managerial Control · Individual
Mauritsen, Erik
Corporate Officer · Individual
O'conner, Joe
Operational/Managerial Control · Individual
O'conner, Joe
Corporate Director · Individual
Parks, Juanita
Operational/Managerial Control · Individual
Parks, Juanita
Corporate Officer · Individual
Pearson, Linda
Corporate Director · Individual
Pisecki, Marie
Operational/Managerial Control · Individual
Russell, Kyle
Operational/Managerial Control · Individual
Russell, Kyle
Corporate Director · Individual
Satterlund, Michele
Operational/Managerial Control · Individual
Satterlund, Michele
Corporate Director · Individual
Scholer, John
Corporate Director · Individual
Stokes, Patrice
Operational/Managerial Control · Individual
Tomes, Meghan
Operational/Managerial Control · Individual
Tulli, Julia
Operational/Managerial Control · Individual
Wright, Thomas
Operational/Managerial Control · Individual
Wright, Thomas
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Hanover Health And Rehabilitation Center
Mechanicsville, VA
1-star overall rating with 1-star inspections with $22,925 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Autumn Care Of Mechanicsville
Mechanicsville, VA
3-star overall rating with 2-star inspections with $10,358 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Henrico Health & Rehabilitation Center
Highland Springs, VA
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $259,077 in total fines with 38 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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