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

Staffing

Hours and turnover

RN hours / resident day

0.33

Registered nurse staffing

LPN hours / resident day

1.22

Licensed practical nurse staffing

Aide hours / resident day

2.12

Nurse aide staffing

Weekend hours

3.24

Weekend nurse staffing

RN turnover

60%

Annual RN turnover

Total nurse turnover

54%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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