30 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Culpeper, VA
2-star overall rating with 1-star inspections with $16,298 in total fines with 30 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
602 Madison Road, Culpeper, VA
(540) 825-2884
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1993-05-01
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
RN hours / resident day
0.25
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
3,136
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9991
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 18.56% · Performance 16.95% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
4.47
Baseline 6.85% · Performance 6.50% · Measure score 4.47 · Achievement 4.47 · Improvement 1.41
Total nurse turnover
3.85
Performance 47.95% · Measure score 3.85 · Achievement 3.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.30 hours · Performance 2.73 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 250 · Observed rate 11.2% · Lower 95% interval 8.09% |
| Discharge to community | 48.98% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 272 · Observed rate 43.75% · Lower 95% interval 42.91% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 148 · Denominator 148 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 148 |
| Discharge self-care score | 75.45% |
53.69%
21.8 pts better
|
Numerator 83 · Denominator 110 |
| Discharge mobility score | 67.27% |
50.94%
16.3 pts better
|
Numerator 74 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 2.03% |
2.29%
0.3 pts better
|
Numerator 3 · Denominator 148 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 5.66% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 175 |
| Staff flu vaccination coverage | 6.41% |
42%
35.6 pts worse
|
Numerator 10 · Denominator 156 |
| Discharge function score | 79.09% |
56.45%
22.6 pts better
|
Numerator 87 · Denominator 110 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 93 · Denominator 93 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 10.96% |
25.2%
14.2 pts worse
|
Numerator 8 · Denominator 73 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.2%
7.9 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 98.7% · Q3 98.6% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.0%
4.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| 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 3.6% · Q2 4.0% · Q3 5.1% · Q4 4.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 65.3% |
15.7%
49.6 pts worse
|
11.4%
53.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.4% · Q2 67.4% · Q3 55.1% · Q4 73.0% · 4Q avg 65.3% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.7%
4.4 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.7% · Q3 1.6% · Q4 0.8% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.3% |
20.2%
11.1 pts worse
|
19.6%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 28.9% · Q3 28.9% · Q4 34.6% · 4Q avg 31.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.6% |
15.0%
7.4 pts better
|
16.7%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 6.8% · Q3 6.5% · Q4 5.4% · 4Q avg 7.6% · 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 | 3.6% |
17.5%
13.9 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.6% · Q3 6.3% · Q4 1.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.9% |
15.7%
12.8 pts better
|
14.9%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.1% · Q3 2.5% · Q4 2.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.6%
0.2 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.4% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
22.2%
15.9 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.5% · Q3 7.9% · Q4 5.1% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.2%
2.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.1% · Q3 2.5% · Q4 2.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
74.6%
21.7 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 94.8% · Q3 96.1% · Q4 98.5% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
11.7%
4.5 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 15.3% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
73.6%
14.6 pts better
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
22.0%
1 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 19.8% · Expected 22.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-09-04
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-04
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-02
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-05
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-06-05
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-23
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 2025-09-23
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-09-23
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-23
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 2025-04-15
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-04-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-20
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-20
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 2024-08-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-20
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-20
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 2024-08-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-20
Health
Provide appropriate foot care.
Corrected 2024-08-20
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 2024-08-20
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 2024-08-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-20
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 2024-08-20
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 2024-08-20
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 2024-08-20
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-08-20
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-08-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-04
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-19
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 2022-10-19
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-10-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-19
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-10-19
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-19
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-10-19
Health
Post nurse staffing information every day.
Corrected 2022-10-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-08
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 2021-06-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-08
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-06-08
Health
Dispose of garbage and refuse properly.
Corrected 2021-06-08
Penalties and ownership
Fine · fine $16,298
Fine
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Culpeper, VA
4-star overall rating with 3-star inspections with 10 recent health deficiencies
Aroda, VA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
Orange, VA
3-star overall rating with 3-star inspections with 9 recent health deficiencies
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