Cycle 1
Health 2024-10-02 · Fire 2024-10-02
31 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Lynchburg, VA
Guggenheimer Health And Rehab Center
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
1902 Grace Street, Lynchburg, VA
(434) 947-5103
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hill Valley Healthcare
Operator or chain grouping
Approved since
1978-03-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
0.88
Licensed practical nurse staffing
Aide hours / resident day
1.83
Nurse aide staffing
Weekend hours
2.89
Weekend nurse staffing
RN turnover
79%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
91.2%
2.4 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.6%
3.1 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
15.7%
11.3 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.7%
0.7 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
20.2%
2.9 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
15.0%
0.1 pts worse
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.9% |
17.5%
10.6 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
15.7%
8.7 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.6%
0.5 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
22.2%
0.2 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.2%
0.7 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.4% |
74.6%
22.2 pts worse
|
81.7%
29.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.9% |
11.7%
7.8 pts better
|
12.0%
8.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.7% |
73.6%
11.9 pts worse
|
79.7%
18 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.0%
1.3 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-13 · Fire 2021-10-13
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-01-16 · Fire 2019-01-16
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-02
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-02
K400 · Miscellaneous Deficiencies
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-10-02
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-10-02
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-12-05
F · Potential for more than minimal harm
2021-10-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-12-10
F · Potential for more than minimal harm
2021-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-10
F · Potential for more than minimal harm
2021-10-13
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-03-22
F · Potential for more than minimal harm
2021-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-03-22
F · Potential for more than minimal harm
2021-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-22
F · Potential for more than minimal harm
2021-10-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-22
F · Potential for more than minimal harm
2021-10-13
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 2021-12-10
E · Potential for more than minimal harm
2021-10-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-22
E · Potential for more than minimal harm
2021-10-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-10-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-10-13
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-10-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-10-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-12-10
F · Potential for more than minimal harm
2019-01-16
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-03-13
F · Potential for more than minimal harm
2019-01-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-03-13
F · Potential for more than minimal harm
2019-01-16
K321 · Smoke Deficiencies
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 2019-03-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-07
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-07
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 2026-02-06
E · Potential for more than minimal harm
2024-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-12-10
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 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
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 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
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 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F778 · Administration Deficiencies
Health
Help the resident make transportation arrangements to and from radiology services.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-12-10
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 2025-01-02
D · Potential for more than minimal harm
2024-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
G · Actual harm
2024-10-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-16
E · Potential for more than minimal harm
2024-10-02
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 2025-01-02
E · Potential for more than minimal harm
2024-10-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-10-02
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 2025-01-02
E · Potential for more than minimal harm
2024-10-02
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 2025-01-02
E · Potential for more than minimal harm
2024-10-02
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 2024-11-16
E · Potential for more than minimal harm
2024-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-10-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-16
E · Potential for more than minimal harm
2024-10-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-16
E · Potential for more than minimal harm
2024-10-02
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 2024-11-16
E · Potential for more than minimal harm
2024-10-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-10-02
E · Potential for more than minimal harm
2024-10-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-10-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-02
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 2024-11-16
D · Potential for more than minimal harm
2024-10-02
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 2024-11-16
D · Potential for more than minimal harm
2024-10-02
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 2024-11-16
D · Potential for more than minimal harm
2024-10-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-10-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-10-02
F778 · Administration Deficiencies
Health
Help the resident make transportation arrangements to and from radiology services.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-10-02
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-11-16
D · Potential for more than minimal harm
2024-10-02
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-10-02
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 2025-01-02
D · Potential for more than minimal harm
2024-10-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-11-16
E · Potential for more than minimal harm
2023-10-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-11
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 2023-11-06
D · Potential for more than minimal harm
2023-10-11
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 2023-11-06
E · Potential for more than minimal harm
2021-10-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-21
D · Potential for more than minimal harm
2021-10-13
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 2021-11-21
D · Potential for more than minimal harm
2021-10-13
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 2021-11-21
E · Potential for more than minimal harm
2019-01-16
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 2019-02-10
D · Potential for more than minimal harm
2019-01-16
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 2019-02-10
D · Potential for more than minimal harm
2019-01-16
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 2019-02-10
C · Minimal harm
2019-01-16
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 2019-02-10
Penalties and ownership
What sits behind the stars
$76,681
2024-10-02
Fine
Fine · fine $76,681
Fine
Ownership
Diamond Hill SNF Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Delilah 2626 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hvh Timberlake Management LLC
Operational/Managerial Control · Organization
Idels, Shimon
Corporate Officer · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Martin, Kristi
W-2 Managing Employee · Individual
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Timberlake Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Forest Health & Rehab Center
Lynchburg, VA
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Tate Springs Health & Rehab
Lynchburg, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Seven Hills Rehabilitation And Nursing
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
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