Gainesville, VA

Gainesville Health And Rehab Center

3-star overall rating with 2-star inspections with 14 recent health deficiencies

7501 Heritage Village Plaza, Gainesville, VA

(571) 248-6100

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

114

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Commonwealth Care Of Roanoke

Operator or chain grouping

Approved since

2006-07-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

12 facilities

Chain averages 4 overall / 3 health / 2 staffing / 4 quality stars

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

0.63

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

2.00

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

3.45

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.45

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

2.95

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.39

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

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.22

CMS adjusted total nurse staffing hours

Case-mix index

1.47

Higher values indicate more complex resident acuity

RN turnover

52%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,696

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

Performance score

22.82

Composite VBP score used to determine payment impact.

Payment multiplier

0.9830

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 16.00% · Performance 23.48% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.77

Baseline 4.46% · Performance 7.31% · Measure score 1.77 · Achievement 1.77 · Improvement 0

Total nurse turnover

6.54

Baseline 35.44% · Performance 36.96% · Measure score 6.54 · Achievement 6.54 · Improvement 0

Adjusted total nurse staffing

0.82

Baseline 2.96 hours · Performance 3.31 hours · Measure score 0.82 · Achievement 0.82 · Improvement 0.74

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.27%	10.72% 2.5 pts worse	No Different than the National Rate · Eligible stays 142 · Observed rate 16.2% · Lower 95% interval 9.59%
Discharge to community	54.24%	50.57% 3.7 pts better	No Different than the National Rate · Eligible stays 145 · Observed rate 46.9% · Lower 95% interval 46.14%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 81 · Denominator 81
Falls with major injury	1.23%	0.77% 0.5 pts worse	Numerator 1 · Denominator 81
Discharge self-care score	43.1%	53.69% 10.6 pts worse	Numerator 25 · Denominator 58
Discharge mobility score	43.1%	50.94% 7.8 pts worse	Numerator 25 · Denominator 58
Pressure ulcers or injuries, new or worsened	2.47%	2.29% 0.2 pts worse	Numerator 2 · Denominator 81 · Adjusted rate 2.2%
Healthcare-associated infections requiring hospitalization	7.31%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 79 · Observed rate 7.59% · Lower 95% interval 4.48%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 124
Staff flu vaccination coverage	40.67%	42% 1.3 pts worse	Numerator 61 · Denominator 150
Discharge function score	43.1%	56.45% 13.4 pts worse	Numerator 25 · Denominator 58
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 55 · Denominator 55
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	28.57%	25.2% 3.4 pts better	Numerator 16 · Denominator 56

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.8	1.5 0.7 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.4 0.1 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · 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	99.0%	94.0% 5 pts better	95.5% 3.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.6% About the same	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 5.8% · Q4 5.8% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.3%	15.7% 13.4 pts better	11.4% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.8% · Q3 1.4% · Q4 2.7% · 4Q avg 2.3%
Percentage of long-stay residents who lose too much weight	7.9%	5.7% 2.2 pts worse	5.4% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 11.1% · Q3 9.2% · Q4 6.9% · 4Q avg 7.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.8%	20.2% 9.4 pts better	19.6% 8.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.4% · Q3 9.2% · Q4 5.3% · 4Q avg 10.8%
Percentage of long-stay residents who received an antipsychotic medication	9.3%	15.0% 5.7 pts better	16.7% 7.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.7% · Q3 5.4% · Q4 6.9% · 4Q avg 9.3% · 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	19.8%	17.5% 2.3 pts worse	16.3% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 32.6% · Q3 19.9% · Q4 7.0% · 4Q avg 19.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.3%	15.7% 1.4 pts better	14.9% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 18.5% · Q3 14.9% · Q4 13.4% · 4Q avg 14.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.5% About the same	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	1.6% 1 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.8%	22.2% 4.4 pts better	19.8% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 23.6% · Q3 19.4% · Q4 13.4% · 4Q avg 17.8%
Percentage of long-stay residents with pressure ulcers	2.7%	5.2% 2.5 pts better	5.1% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.0% · Q3 3.1% · Q4 2.1% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.1%	74.6% 19.5 pts better	81.7% 12.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 90.9% · Q3 95.2% · Q4 97.6% · 4Q avg 94.1%
Percentage of short-stay residents who had an outpatient emergency department visit	9.6%	11.7% 2.1 pts better	12.0% 2.4 pts better	Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.5% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.2% 0.9 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.5%	73.6% 19.9 pts better	79.7% 13.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.0%	22.0% 1 pts better	23.9% 2.9 pts better	Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 20.3% · Expected 23.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-03-01 · Fire 2023-03-01

14 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2021-09-16 · Fire 2021-09-16

18 health deficiencies

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

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2020-01-24 · Fire 2020-01-24

16 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

D · Potential for more than minimal harm 2023-06-07

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-06-06

E · Potential for more than minimal harm 2023-03-01

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 2023-04-11

E · Potential for more than minimal harm 2023-03-01

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-03-01

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-03-01

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2023-04-11

E · Potential for more than minimal harm 2023-03-01

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 2023-04-11

D · Potential for more than minimal harm 2023-03-01

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 2023-04-11

D · Potential for more than minimal harm 2023-03-01

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 2023-04-11

D · Potential for more than minimal harm 2023-03-01

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-03-01

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 2023-04-11

D · Potential for more than minimal harm 2023-03-01

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-03-01

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 2023-04-11

D · Potential for more than minimal harm 2023-03-01

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-03-01

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-04-11

D · Potential for more than minimal harm 2023-03-01

F700 · Quality of Life and Care Deficiencies

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 2023-04-11

D · Potential for more than minimal harm 2023-03-01

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 2023-04-11

E · Potential for more than minimal harm 2021-09-16

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 2021-10-26

E · Potential for more than minimal harm 2021-09-16

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 2021-10-26

E · Potential for more than minimal harm 2021-09-16

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 2021-10-26

E · Potential for more than minimal harm 2021-09-16

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2021-10-26

E · Potential for more than minimal harm 2021-09-16

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

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 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F761 · Pharmacy Service Deficiencies

Health

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2021-10-26

D · Potential for more than minimal harm 2021-09-16

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 2021-10-26

D · Potential for more than minimal harm 2021-09-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-10-26

C · Minimal harm 2021-09-16

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2021-10-26

B · Minimal harm 2021-09-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-10-26

E · Potential for more than minimal harm 2020-01-24

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2020-02-24

E · Potential for more than minimal harm 2020-01-24

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 2020-02-24