Cycle 1
Health 2023-07-27 · Fire 2023-07-27
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Gretna, VA
Gretna Health And Rehabilitation Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
595 Vaden Drive, Gretna, VA
(434) 656-1206
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1989-10-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.96
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
3.52
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,906
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.43
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
How the VBP score is built
Readmission
6.08
Baseline 24.44% · Performance 19.57% · Measure score 6.08 · Achievement 4.03 · Improvement 6.08
Healthcare-associated infections
0
Baseline 8.13% · Performance 8.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.29
Performance 42.05% · Measure score 5.29 · Achievement 5.29 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.36 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.42% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 228 · Observed rate 12.72% · Lower 95% interval 9.04% |
| Discharge to community | 58.22% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 238 · Observed rate 57.14% · Lower 95% interval 52.81% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.12% |
95.27%
3.9 pts better
|
Numerator 112 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 29.76% |
53.69%
23.9 pts worse
|
Numerator 25 · Denominator 84 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 24 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 0.88% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 113 · Adjusted rate 1.03% |
| Healthcare-associated infections requiring hospitalization | 8.93% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 9.59% · Lower 95% interval 5.58% |
| Staff COVID-19 vaccination coverage | 3.7% |
8.2%
4.5 pts worse
|
Numerator 5 · Denominator 135 |
| Staff flu vaccination coverage | 34.01% |
42%
8 pts worse
|
Numerator 50 · Denominator 147 |
| Discharge function score | 26.19% |
56.45%
30.3 pts worse
|
Numerator 22 · Denominator 84 |
| Transfer of health information to provider | 93.55% |
95.95%
2.4 pts worse
|
Numerator 29 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 63 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 5% |
25.2%
20.2 pts worse
|
Numerator 2 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.3 |
1.4
2.9 pts worse
|
1.8
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 3.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
91.2%
5.3 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 95.5% · Q3 98.5% · Q4 95.5% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
94.0%
1.7 pts better
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.6%
1.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.5% · Q3 4.5% · Q4 6.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 51.3% |
15.7%
35.6 pts worse
|
11.4%
39.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.3% · Q2 48.3% · Q3 48.4% · Q4 47.6% · 4Q avg 51.3% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
5.7%
5.3 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
20.2%
7.3 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 29.9% · Q3 22.4% · Q4 31.3% · 4Q avg 27.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
15.0%
4.7 pts worse
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 21.7% · Q3 17.7% · Q4 20.0% · 4Q avg 19.7% · 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 | 19.2% |
17.5%
1.7 pts worse
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.7%
2 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 21.7% · Q3 6.7% · Q4 24.1% · 4Q avg 17.7% · 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 2.0% · 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 | 0.8% |
1.6%
0.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
22.2%
2.1 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 32.3% · Q3 17.1% · Q4 14.1% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.2%
1.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.5% · Q3 1.2% · Q4 2.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
74.6%
11.4 pts better
|
81.7%
4.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 82.2% · Q3 82.2% · Q4 89.1% · 4Q avg 86.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.9% |
11.7%
6.2 pts worse
|
12.0%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 15.7% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.2%
1.6 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 4.9% · Q4 2.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.9% |
73.6%
6.7 pts worse
|
79.7%
12.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
22.0%
0.5 pts worse
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 21.7% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-21 · Fire 2021-10-21
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-07-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-18
F · Potential for more than minimal harm
2021-10-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-10
F · Potential for more than minimal harm
2021-10-21
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2021-12-10
F · Potential for more than minimal harm
2021-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-10
F · Potential for more than minimal harm
2021-10-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-10
F · Potential for more than minimal harm
2021-10-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-10
F · Potential for more than minimal harm
2019-08-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-09-19
F · Potential for more than minimal harm
2019-08-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-09-19
F · Potential for more than minimal harm
2019-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-19
F · Potential for more than minimal harm
2019-08-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-09-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-07-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
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 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-05
E · Potential for more than minimal harm
2021-10-21
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 2021-12-03
E · Potential for more than minimal harm
2021-10-21
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-03
Penalties and ownership
What sits behind the stars
Ownership
Gretna Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
America West LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 LLC
5% Or Greater Indirect Ownership Interest · Organization
Kss 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ml 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mrv West LLC
5% Or Greater Indirect Ownership Interest · Organization
Powers, Amanda
W-2 Managing Employee · Individual
Rczbm West Manager LLC
Operational/Managerial Control · Organization
Redrock West LLC
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Chatham Health & Rehabilitation Center
Chatham, VA
5-star overall rating with 4-star inspections with $8,018 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Autumn Care Of Altavista
Altavista, VA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Roman Eagle Rehabilitation And Health Care Center
Danville, VA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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