Daleville, VA

Daleville Health and Rehabilitation

3-star overall rating with 3-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

290 Commons Parkway, Daleville, VA

(540) 966-0056

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2005-12-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.33

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.22

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

2.12

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

3.67

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.55

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

3.24

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.37

CMS adjusted RN staffing hours

Adjusted total hours

4.02

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,498

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.48

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.45

Baseline 21.08% · Performance 20.30% · Measure score 2.45 · Achievement 2.45 · Improvement 1.44

Healthcare-associated infections

Baseline 6.30% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

5.28

Baseline 83.18% · Performance 49.47% · Measure score 5.28 · Achievement 3.48 · Improvement 5.28

Adjusted total nurse staffing

1.66

Baseline 3.28 hours · Performance 3.55 hours · Measure score 1.66 · Achievement 1.66 · Improvement 0.59

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.7%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 109 · Observed rate 7.34% · Lower 95% interval 6.63%
Discharge to community	55.8%	50.57% 5.2 pts better	No Different than the National Rate · Eligible stays 108 · Observed rate 51.85% · Lower 95% interval 44.84%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	89.55%	95.27% 5.7 pts worse	Numerator 60 · Denominator 67
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 67
Discharge self-care score	53.19%	53.69% 0.5 pts worse	Numerator 25 · Denominator 47
Discharge mobility score	44.68%	50.94% 6.3 pts worse	Numerator 21 · Denominator 47
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 67 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.76%	7.12% 0.6 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 9.52% · Lower 95% interval 3.91%
Staff COVID-19 vaccination coverage	3.39%	8.2% 4.8 pts worse	Numerator 4 · Denominator 118
Staff flu vaccination coverage	19.23%	42% 22.8 pts worse	Numerator 35 · Denominator 182
Discharge function score	55.32%	56.45% 1.1 pts worse	Numerator 26 · Denominator 47
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 21 · Denominator 21
Transfer of health information to patient	93.94%	96.28% 2.3 pts worse	Numerator 31 · Denominator 33
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 43

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.5 0.3 pts worse	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.4 0.1 pts worse	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	89.9%	91.2% 1.3 pts worse	93.4% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 79.5% · Q4 84.0% · 4Q avg 89.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	89.9%	94.0% 4.1 pts worse	95.5% 5.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 89.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.1%	3.6% 1.5 pts better	3.3% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 1.4% · Q4 1.3% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	15.7% 15.7 pts better	11.4% 11.4 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 who lose too much weight	6.1%	5.7% 0.4 pts worse	5.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 11.5% · Q4 10.5% · 4Q avg 6.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.3%	20.2% 2.9 pts better	19.6% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 23.9% · Q3 11.1% · Q4 21.1% · 4Q avg 17.3%
Percentage of long-stay residents who received an antipsychotic medication	10.0%	15.0% 5 pts better	16.7% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.8% · Q3 7.0% · Q4 9.5% · 4Q avg 10.0% · 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	31.2%	17.5% 13.7 pts worse	16.3% 14.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 31.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.9%	15.7% 8.2 pts worse	14.9% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 32.8% · Q3 18.3% · Q4 20.0% · 4Q avg 23.9% · 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 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.8%	1.6% 1.2 pts worse	1.7% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 4.2% · Q4 2.7% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.5%	22.2% 2.3 pts worse	19.8% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 27.4% · Q3 20.2% · Q4 32.4% · 4Q avg 24.5%
Percentage of long-stay residents with pressure ulcers	7.0%	5.2% 1.8 pts worse	5.1% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.2% · Q3 3.9% · Q4 7.7% · 4Q avg 7.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.1%	74.6% 14.5 pts better	81.7% 7.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 95.8% · Q3 83.2% · Q4 77.4% · 4Q avg 89.1%
Percentage of short-stay residents who had an outpatient emergency department visit	10.2%	11.7% 1.5 pts better	12.0% 1.8 pts better	Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.8% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.2% 0.8 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	84.9%	73.6% 11.3 pts better	79.7% 5.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 84.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.0%	22.0% 4 pts worse	23.9% 2.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 25.0% · Expected 22.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-04-10 · Fire 2024-04-10

13 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2023-02-16 · Fire 2023-02-16

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2021-05-27 · Fire 2021-05-27

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

14 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-04-10

K112 · Construction Deficiencies

Fire Safety

Add automatic sprinklers after major renovation.

Corrected 2024-05-20

D · Potential for more than minimal harm 2024-04-10

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-20

D · Potential for more than minimal harm 2024-04-10

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-05-20

F · Potential for more than minimal harm 2023-02-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-04-21

F · Potential for more than minimal harm 2023-02-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-08

F · Potential for more than minimal harm 2023-02-16

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-10-03

E · Potential for more than minimal harm 2023-02-16

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-04-21

E · Potential for more than minimal harm 2023-02-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-02-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-02-16

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-04-21

D · Potential for more than minimal harm 2023-02-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-08

D · Potential for more than minimal harm 2023-02-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-04-21

F · Potential for more than minimal harm 2021-05-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-07-16

F · Potential for more than minimal harm 2021-05-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-07-16

F · Potential for more than minimal harm 2021-05-27

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-07-16

E · Potential for more than minimal harm 2021-05-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-07-16

E · Potential for more than minimal harm 2021-05-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-07-16

E · Potential for more than minimal harm 2021-05-27

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2021-07-16

E · Potential for more than minimal harm 2021-05-27

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2021-07-16

E · Potential for more than minimal harm 2021-05-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-07-16

D · Potential for more than minimal harm 2021-05-27

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2021-07-16

C · Minimal harm 2021-05-27

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2021-07-11

C · Minimal harm 2021-05-27

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2021-07-11

C · Minimal harm 2021-05-27

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2021-07-11

C · Minimal harm 2021-05-27

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2021-07-11

C · Minimal harm 2021-05-27

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2021-07-11

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-04-10

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

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 2024-06-13

D · Potential for more than minimal harm 2024-04-10

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2024-06-13

E · Potential for more than minimal harm 2023-02-16

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 2023-04-05

E · Potential for more than minimal harm 2023-02-16

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 2023-04-05

D · Potential for more than minimal harm 2023-02-16

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 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

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 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

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 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-04-05

D · Potential for more than minimal harm 2023-02-16

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2023-04-05

E · Potential for more than minimal harm 2021-05-27

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 2021-07-11

D · Potential for more than minimal harm 2021-05-27

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-07-11

D · Potential for more than minimal harm 2021-05-27

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-07-11

D · Potential for more than minimal harm 2021-05-27

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 2021-07-11

Penalties and ownership