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
Chain footprint
40 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
0.57
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.28
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
2.89
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
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,988
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.91
Baseline 20.42% · Performance 19.15% · Measure score 4.91 · Achievement 4.91 · Improvement 3.24
Healthcare-associated infections
1.67
Baseline 5.39% · Performance 7.34% · Measure score 1.67 · Achievement 1.67 · Improvement 0
Total nurse turnover
4.68
Performance 44.56% · Measure score 4.68 · Achievement 4.68 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 4.22 hours · Performance 2.97 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 251 · Observed rate 11.16% · Lower 95% interval 8.76% |
| Discharge to community | 58.79% |
50.57%
8.2 pts better
|
Better than the National Rate · Eligible stays 237 · Observed rate 57.81% · Lower 95% interval 53.52% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.71% |
95.27%
2.4 pts better
|
Numerator 128 · Denominator 131 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 131 |
| Discharge self-care score | 54.29% |
53.69%
0.6 pts better
|
Numerator 38 · Denominator 70 |
| Discharge mobility score | 45.71% |
50.94%
5.2 pts worse
|
Numerator 32 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 6.87% |
2.29%
4.6 pts worse
|
Numerator 9 · Denominator 131 · Adjusted rate 7.26% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 7.32% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 138 |
| Staff flu vaccination coverage | 9.34% |
42%
32.7 pts worse
|
Numerator 24 · Denominator 257 |
| Discharge function score | 45.71% |
56.45%
10.7 pts worse
|
Numerator 32 · Denominator 70 |
| Transfer of health information to provider | 92.11% |
95.95%
3.8 pts worse
|
Numerator 35 · Denominator 38 |
| Transfer of health information to patient | 90.77% |
96.28%
5.5 pts worse
|
Numerator 59 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 38.03% |
25.2%
12.8 pts better
|
Numerator 27 · Denominator 71 |
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 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 97.6% · Q2 98.8% · Q3 93.0% · Q4 85.6% · 4Q avg 93.6% |
| 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 | 6.7% |
3.6%
3.1 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.2% · Q3 5.8% · Q4 5.6% · 4Q avg 6.7% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 0.0% · Q3 1.4% · Q4 13.9% · 4Q avg 4.4% |
| 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 · Q1 3.9% · Q2 2.7% · Q3 6.1% · Q4 7.1% · 4Q avg 5.0% |
| 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 · Q1 24.4% · Q2 20.5% · Q3 21.7% · Q4 25.6% · 4Q avg 23.1% |
| 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 · Q1 10.9% · Q2 13.8% · Q3 17.5% · Q4 17.6% · 4Q avg 15.1% · 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 | 6.9% |
17.5%
10.6 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 0.0% · Q3 3.2% · Q4 6.1% · 4Q avg 6.9% · Used in QM five-star |
| 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 · Q1 13.5% · Q2 7.9% · Q3 5.0% · Q4 2.4% · 4Q avg 7.0% · 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 0.7% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 1.2% · Q3 3.5% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| 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 · Q1 27.1% · Q2 20.0% · Q3 23.0% · Q4 18.1% · 4Q avg 22.0% |
| 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 · Q1 6.7% · Q2 6.0% · Q3 6.7% · Q4 4.4% · 4Q avg 5.9% · Used in QM five-star |
| 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 · Q1 73.2% · Q2 59.8% · Q3 39.3% · Q4 33.1% · 4Q avg 52.4% |
| 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 · Adjusted 3.9% · Observed 3.8% · Expected 11.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 61.7% |
| 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 · Adjusted 20.7% · Observed 19.2% · Expected 22.2% · Used in QM five-star |
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
Jump out