10 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lynchburg, VA
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2406 Atherholt Road, Lynchburg, VA
(434) 846-3200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
89
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1995-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 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
0.41
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
926
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0170
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 18.83% · Performance 16.23% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.31
Baseline 8.29% · Performance 6.38% · Measure score 5.31 · Achievement 4.88 · Improvement 5.31
Total nurse turnover
8.24
Performance 30.00% · Measure score 8.24 · Achievement 8.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.28
Baseline 3.22 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.35
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 226 · Observed rate 11.5% · Lower 95% interval 7.64% |
| Discharge to community | 59.25% |
50.57%
8.7 pts better
|
Better than the National Rate · Eligible stays 231 · Observed rate 51.08% · Lower 95% interval 51.82% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.9% |
95.27%
2.6 pts better
|
Numerator 140 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 68% |
53.69%
14.3 pts better
|
Numerator 68 · Denominator 100 |
| Discharge mobility score | 57% |
50.94%
6.1 pts better
|
Numerator 57 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 143 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.38% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 5.6% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 0.9% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 111 |
| Staff flu vaccination coverage | 44% |
42%
2 pts better
|
Numerator 55 · Denominator 125 |
| Discharge function score | 66% |
56.45%
9.5 pts better
|
Numerator 66 · Denominator 100 |
| Transfer of health information to provider | 98.96% |
95.95%
3 pts better
|
Numerator 95 · Denominator 96 |
| Transfer of health information to patient | 80.77% |
96.28%
15.5 pts worse
|
Numerator 21 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 39.51% |
25.2%
14.3 pts better
|
Numerator 32 · Denominator 81 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
91.2%
0.3 pts better
|
93.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 88.7% · Q3 93.7% · Q4 91.0% · 4Q avg 91.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.0%
4.5 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 3.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.1% |
15.7%
6.6 pts better
|
11.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 6.5% · Q3 6.0% · Q4 11.5% · 4Q avg 9.1% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.7%
2.7 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 4.9% · Q4 3.2% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
20.2%
1.6 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 16.9% · Q3 25.8% · Q4 16.9% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
15.0%
8.8 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.1% · Q3 6.9% · Q4 8.0% · 4Q avg 6.2% · 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 | 38.9% |
17.5%
21.4 pts worse
|
16.3%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 56.8% · 4Q avg 38.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
15.7%
7.9 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 17.0% · Q3 35.2% · Q4 28.6% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.6%
0.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 3.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
22.2%
2.4 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 17.3% · Q3 23.3% · Q4 21.8% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.2%
2.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 2.8% · Q4 5.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
74.6%
6.4 pts better
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.3% · Q2 80.4% · Q3 86.4% · Q4 78.7% · 4Q avg 81.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
11.7%
3.6 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 8.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 2.0% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
73.6%
13.1 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
22.0%
1.8 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 21.4% · Expected 25.3% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Resident Assessment and Care Planning (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-08-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-29
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-29
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-29
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-08-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-29
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-04-30
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-04-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-04-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-04-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-05-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-05-31
Fire Safety
Have an externally vented heating system.
Corrected 2019-05-31
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-21
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-04-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-09
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-09
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-09
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-07-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-11
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-07-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-11
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-11
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-04-02
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-04-02
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 2021-04-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-04-02
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-04-02
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-04-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-04-02
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-04-02
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-02
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-13
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-05-13
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 2019-05-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-13
Health
Keep all essential equipment working safely.
Corrected 2019-05-13
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-05-13
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-05-13
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-05-13
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-05-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-05-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-13
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 2019-05-13
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-05-13
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 2019-05-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-05-13
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Lynchburg, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Lynchburg, VA
1-star overall rating with 1-star inspections with abuse icon flag with $235,850 in total fines with 29 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Lynchburg, VA
2-star overall rating with 1-star inspections with $76,681 in total fines with 31 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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