17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Emporia, VA
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
214 Weaver Ave, Emporia, VA
(434) 348-2150
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
Beds
65
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-08-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.51
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
2.89
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.56
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
7,931
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.52
Baseline 23.79% · Performance 21.75% · Measure score 2.52 · Achievement 0 · Improvement 2.52
Healthcare-associated infections
4.27
Baseline 12.86% · Performance 9.11% · Measure score 4.27 · Achievement 0 · Improvement 4.27
Total nurse turnover
4.55
Baseline 33.33% · Performance 45.10% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.41 hours · Performance 2.84 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.05% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 9.09% · Lower 95% interval 7.54% |
| Discharge to community | 54.71% |
50.57%
4.1 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 47.69% · Lower 95% interval 47.29% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.15% |
95.27%
3.9 pts better
|
Numerator 116 · Denominator 117 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 117 |
| Discharge self-care score | 39.44% |
53.69%
14.2 pts worse
|
Numerator 28 · Denominator 71 |
| Discharge mobility score | 29.58% |
50.94%
21.4 pts worse
|
Numerator 21 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 117 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.11% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 12.77% · Lower 95% interval 5.78% |
| Staff COVID-19 vaccination coverage | 1.79% |
8.2%
6.4 pts worse
|
Numerator 1 · Denominator 56 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 40.85% |
56.45%
15.6 pts worse
|
Numerator 29 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 60 · Denominator 60 |
| Transfer of health information to patient | 93.55% |
96.28%
2.7 pts worse
|
Numerator 29 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 32.73% |
25.2%
7.5 pts better
|
Numerator 18 · Denominator 55 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.4
0.9 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · 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 | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 2.2% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
15.7%
7.8 pts better
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.0% · Q3 14.3% · Q4 2.0% · 4Q avg 7.9% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
5.7%
3.5 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.0% · Q3 7.7% · Q4 2.3% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
20.2%
11.1 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 8.2% · Q3 4.8% · Q4 10.4% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
15.0%
2.9 pts better
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 14.3% · Q3 9.7% · Q4 5.6% · 4Q avg 12.1% · 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 | 22.6% |
17.5%
5.1 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 9.9% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
15.7%
2.8 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 14.0% · Q3 15.8% · Q4 20.5% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.6%
About the same
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
22.2%
1.1 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 29.4% · Q3 32.7% · Q4 15.3% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.2%
0.2 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.6% · Q3 4.4% · Q4 0.0% · 4Q avg 5.0% · 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 91.4% · Q2 92.2% · Q3 98.6% · Q4 94.0% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.7%
4.4 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 16.7% · 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 2.2% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
73.6%
9.5 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
22.0%
0.3 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 24.0% · Expected 25.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-26
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-15
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-09-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-16
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-16
Fire Safety
Use approved construction type or materials.
Corrected 2021-06-16
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-06-16
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-16
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-01-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-31
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-01-31
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-04-02
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-01-31
Fire Safety
Use approved construction type or materials.
Corrected 2019-01-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-01-31
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-01-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-04-02
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-01-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-01-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-01-31
Inspection history
Health
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Corrected 2023-09-11
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 2023-09-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-11
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-11
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-11
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-11
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 2023-09-11
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-11
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 2023-09-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-11
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-11
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 2023-09-11
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-11
Health
Provide or obtain dental services for each resident.
Corrected 2023-09-11
Health
Provide or obtain dental services for each resident.
Corrected 2021-05-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-05-28
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 2021-05-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-11-19
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 2018-11-19
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2018-11-19
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 2018-11-19
Health
Implement a program that monitors antibiotic use.
Corrected 2018-11-19
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2018-11-19
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2018-11-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-11-19
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 2018-12-13
Health
Provide activities to meet all resident's needs.
Corrected 2018-11-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-11-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-11-19
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 2018-11-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-11-19
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 2018-11-19
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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