Cycle 1
Health 2022-11-16 · Fire 2022-11-16
19 health deficiencies
Top issue: Resident Rights (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Emporia, VA
Emporia Rehabilitation And Healthcare Center
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
200 Weaver Avenue, Emporia, VA
(434) 634-6581
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
2004-03-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.28
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.13
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.81
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
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,162
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.72
Baseline 21.34% · Performance 19.71% · Measure score 3.72 · Achievement 3.72 · Improvement 3.29
Healthcare-associated infections
5.16
Baseline 8.03% · Performance 6.31% · Measure score 5.16 · Achievement 5.10 · Improvement 5.16
Total nurse turnover
0.69
Performance 60.87% · Measure score 0.69 · Achievement 0.69 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.48
Baseline 2.74 hours · Performance 3.34 hours · Measure score 1.48 · Achievement 0.93 · Improvement 1.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 7.14% · Lower 95% interval 6.64% |
| Discharge to community | 35.63% |
50.57%
14.9 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 18.52% · Lower 95% interval 22.4% |
| Medicare spending per beneficiary | 1.46 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 4.64% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 3.23% |
| Staff COVID-19 vaccination coverage | 2.29% |
8.2%
5.9 pts worse
|
Numerator 3 · Denominator 131 |
| Staff flu vaccination coverage | 4.24% |
42%
37.8 pts worse
|
Numerator 5 · Denominator 118 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.4
1.5 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.0%
4.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
15.7%
14.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.3% · Q4 1.3% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
5.7%
4.5 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.0% · Q3 7.4% · Q4 6.4% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
20.2%
2.3 pts worse
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 21.8% · Q3 22.7% · Q4 24.2% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.2% |
15.0%
16.2 pts worse
|
16.7%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 31.6% · Q3 25.4% · Q4 31.1% · 4Q avg 31.2% · 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 | 9.5% |
17.5%
8 pts better
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 8.3% · Q3 10.4% · Q4 3.7% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
15.7%
4.5 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 4.7% · Q3 10.3% · Q4 10.7% · 4Q avg 11.2% · 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 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.6%
0.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
22.2%
7.3 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 35.9% · Q3 30.8% · Q4 28.7% · 4Q avg 29.5% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.2%
0.9 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.1% · Q3 4.7% · Q4 5.2% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
74.6%
24.4 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.9% |
11.7%
11.2 pts worse
|
12.0%
10.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 23.1% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
73.6%
22.1 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
22.0%
6.4 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 26.9% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-18 · Fire 2019-04-18
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
30 fire-safety deficiencies
Top issue: Emergency Preparedness (25 deficiencies)
Cycle 3
Health 2018-01-29 · Fire 2018-01-29
32 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-11-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-16
K400 · Miscellaneous Deficiencies
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-03
F · Potential for more than minimal harm
2019-04-18
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2019-05-29
F · Potential for more than minimal harm
2019-04-18
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-05-29
F · Potential for more than minimal harm
2019-04-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-05-29
F · Potential for more than minimal harm
2019-04-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-05-29
F · Potential for more than minimal harm
2019-04-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-05-29
E · Potential for more than minimal harm
2019-04-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-04-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-04-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-04-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-04-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-06-25
C · Minimal harm
2019-04-18
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-05-29
C · Minimal harm
2019-04-18
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-05-29
F · Potential for more than minimal harm
2018-01-29
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 2018-04-10
F · Potential for more than minimal harm
2018-01-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-07-09
F · Potential for more than minimal harm
2018-01-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-07-09
F · Potential for more than minimal harm
2018-01-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-07-09
F · Potential for more than minimal harm
2018-01-29
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2018-07-09
F · Potential for more than minimal harm
2018-01-29
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 2018-04-10
D · Potential for more than minimal harm
2018-01-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-04-10
D · Potential for more than minimal harm
2018-01-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-04-10
D · Potential for more than minimal harm
2018-01-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-04-10
D · Potential for more than minimal harm
2018-01-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-07-09
D · Potential for more than minimal harm
2018-01-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-04-10
D · Potential for more than minimal harm
2018-01-29
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-04-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-23
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 2025-12-03
E · Potential for more than minimal harm
2025-10-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-03
D · Potential for more than minimal harm
2024-07-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-29
D · Potential for more than minimal harm
2023-10-16
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 2023-12-19
D · Potential for more than minimal harm
2023-10-16
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 2023-12-19
D · Potential for more than minimal harm
2023-10-16
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 2023-12-19
D · Potential for more than minimal harm
2023-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-10-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-10-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-10-16
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-10-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-10-16
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 2023-12-19
D · Potential for more than minimal harm
2023-10-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-10-16
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 2023-12-19
E · Potential for more than minimal harm
2023-03-31
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-31
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 2023-04-25
E · Potential for more than minimal harm
2022-11-16
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-16
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 2022-12-30
E · Potential for more than minimal harm
2022-11-16
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 2022-12-30
E · Potential for more than minimal harm
2022-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-16
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
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 2022-12-30
D · Potential for more than minimal harm
2022-11-16
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 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-16
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 2022-12-30
E · Potential for more than minimal harm
2019-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-29
E · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
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 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-04-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-05-29
G · Actual harm
2018-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-03-05
E · Potential for more than minimal harm
2018-01-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-04-10
E · Potential for more than minimal harm
2018-01-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2018-03-05
E · Potential for more than minimal harm
2018-01-29
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 2018-03-05
E · Potential for more than minimal harm
2018-01-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-03-05
D · Potential for more than minimal harm
2018-01-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-03-05
D · Potential for more than minimal harm
2018-01-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-03-05
D · Potential for more than minimal harm
2018-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-03-05
D · Potential for more than minimal harm
2018-01-29
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 2018-04-10
D · Potential for more than minimal harm
2018-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-03-05
Penalties and ownership
What sits behind the stars
Ownership
Emporia Operating Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Scott, Sherry
W-2 Managing Employee · Individual
Sukenik, Charne
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Greensville Health And Rehabilitation Center
Emporia, VA
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Lawrenceville Health & Rehabilitation
Lawrenceville, VA
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare of Roanoke Rapids
Roanoke Rapids, NC
2-star overall rating with 2-star inspections with $9,110 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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