Cycle 1
Health 2022-04-28 · Fire 2022-04-28
12 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mechanicsville, VA
Hanover Health And Rehabilitation Center
1-star overall rating with 1-star inspections with $22,925 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8139 Lee Davis Road, Mechanicsville, VA
(804) 559-5030
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1992-07-13
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
0.39
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.33
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,956
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.2
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.34
Baseline 21.42% · Performance 18.03% · Measure score 7.34 · Achievement 7.34 · Improvement 7.22
Healthcare-associated infections
2.25
Baseline 7.76% · Performance 7.16% · Measure score 2.25 · Achievement 2.25 · Improvement 1.67
Total nurse turnover
2.89
Performance 51.89% · Measure score 2.89 · Achievement 2.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.83 hours · Performance 2.58 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 480 · Observed rate 10.63% · Lower 95% interval 8.93% |
| Discharge to community | 64.03% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 481 · Observed rate 58.42% · Lower 95% interval 60.34% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.27% |
95.27%
4 pts better
|
Numerator 272 · Denominator 274 |
| Falls with major injury | 1.46% |
0.77%
0.7 pts worse
|
Numerator 4 · Denominator 274 |
| Discharge self-care score | 64.2% |
53.69%
10.5 pts better
|
Numerator 113 · Denominator 176 |
| Discharge mobility score | 70.45% |
50.94%
19.5 pts better
|
Numerator 124 · Denominator 176 |
| Pressure ulcers or injuries, new or worsened | 3.28% |
2.29%
1 pts worse
|
Numerator 9 · Denominator 274 · Adjusted rate 3.02% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 293 · Observed rate 6.83% · Lower 95% interval 4.94% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 130 |
| Staff flu vaccination coverage | 44.5% |
42%
2.5 pts better
|
Numerator 93 · Denominator 209 |
| Discharge function score | 67.05% |
56.45%
10.6 pts better
|
Numerator 118 · Denominator 176 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 122 · Denominator 124 |
| Transfer of health information to patient | 97.46% |
96.28%
1.2 pts better
|
Numerator 115 · Denominator 118 |
| Resident COVID-19 vaccinations up to date | 34.85% |
25.2%
9.7 pts better
|
Numerator 46 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.5
1.5 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 4.4 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
91.2%
1.4 pts worse
|
93.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 89.7% · Q3 89.4% · Q4 88.9% · 4Q avg 89.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.6% |
94.0%
9.4 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.4% · Q3 4.5% · Q4 6.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 73.4% |
15.7%
57.7 pts worse
|
11.4%
62 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 79.0% · Q3 52.3% · Q4 81.0% · 4Q avg 73.4% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.7%
4.5 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.7% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
20.2%
5.2 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.8% · Q3 12.5% · Q4 16.7% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
15.0%
3.4 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 19.6% · Q3 17.5% · Q4 20.8% · 4Q avg 18.4% · 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 | 6.5% |
17.5%
11 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
15.7%
5.9 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.8% · Q3 12.7% · Q4 8.3% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.6%
1.8 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 7.4% · Q3 3.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
22.2%
4 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 41.7% · Q3 18.4% · Q4 22.8% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.2%
1.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.4% · Q3 9.4% · Q4 2.8% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.6% |
74.6%
3 pts better
|
81.7%
4.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 77.7% · Q3 75.4% · Q4 78.1% · 4Q avg 77.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
11.7%
3.6 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 7.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.9% · Q3 1.3% · Q4 2.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.1% |
73.6%
10.5 pts worse
|
79.7%
16.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
22.0%
4.5 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 25.6% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-07 · Fire 2019-08-07
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2018-03-05 · Fire 2018-03-05
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-04-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-04-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-20
E · Potential for more than minimal harm
2019-08-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-19
E · Potential for more than minimal harm
2019-08-07
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 2019-11-19
E · Potential for more than minimal harm
2019-08-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-11-19
D · Potential for more than minimal harm
2019-08-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-11-19
D · Potential for more than minimal harm
2019-08-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-09-11
C · Minimal harm
2019-08-07
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-09-21
C · Minimal harm
2019-08-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-09-21
C · Minimal harm
2019-08-07
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-09-21
C · Minimal harm
2019-08-07
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-09-21
C · Minimal harm
2019-08-07
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-11-19
C · Minimal harm
2019-08-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-09-11
C · Minimal harm
2019-08-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-09-11
C · Minimal harm
2019-08-07
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 2019-09-11
C · Minimal harm
2019-08-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-11
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-09
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.
Not marked corrected
D · Potential for more than minimal harm
2023-06-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-30
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 2023-07-20
E · Potential for more than minimal harm
2022-04-28
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 2022-06-07
E · Potential for more than minimal harm
2022-04-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-06-07
E · Potential for more than minimal harm
2022-04-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-07
E · Potential for more than minimal harm
2022-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-28
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 2022-06-07
D · Potential for more than minimal harm
2022-04-28
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 2022-06-07
D · Potential for more than minimal harm
2022-04-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-28
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 2022-06-07
D · Potential for more than minimal harm
2022-04-28
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-28
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 2022-06-07
J · Immediate jeopardy
2019-08-07
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 2019-09-21
J · Immediate jeopardy
2019-08-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-09-21
J · Immediate jeopardy
2019-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-09-21
J · Immediate jeopardy
2019-08-07
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 2019-09-21
J · Immediate jeopardy
2019-08-07
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2019-09-21
F · Potential for more than minimal harm
2019-08-07
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 2019-09-21
E · Potential for more than minimal harm
2019-08-07
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 2019-09-21
E · Potential for more than minimal harm
2019-08-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-09-21
E · Potential for more than minimal harm
2019-08-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-09-21
E · Potential for more than minimal harm
2019-08-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-09-21
E · Potential for more than minimal harm
2019-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
F690 · Quality of Life and Care Deficiencies
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-09-21
D · Potential for more than minimal harm
2019-08-07
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 2019-10-24
E · Potential for more than minimal harm
2018-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-04-06
E · Potential for more than minimal harm
2018-03-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-04-06
E · Potential for more than minimal harm
2018-03-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-04-06
D · Potential for more than minimal harm
2018-03-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-04-06
D · Potential for more than minimal harm
2018-03-05
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 2018-04-06
D · Potential for more than minimal harm
2018-03-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-04-06
D · Potential for more than minimal harm
2018-03-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-04-06
D · Potential for more than minimal harm
2018-03-05
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 2018-04-06
D · Potential for more than minimal harm
2018-03-05
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 2018-04-06
Penalties and ownership
What sits behind the stars
$22,925
2025-10-09
Fine
Fine · fine $22,925
Fine
Ownership
Hanover Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Ak 2003 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Al 2003 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Central Bay LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Golden 2017 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Golden 2017 LLC
5% Or Greater Indirect Ownership Interest · Organization
Holmes, Andrea
Corporate Director · Individual
Holmes, Andrea
W-2 Managing Employee · Individual
Matt 2002 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Matt 2002 LLC
5% Or Greater Indirect Ownership Interest · Organization
Mrcz Central LLC
5% Or Greater Indirect Ownership Interest · Organization
Nathan 5604 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Nathan 5604 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Nathan 5604 LLC
5% Or Greater Indirect Ownership Interest · Organization
Pivotal Central LLC
5% Or Greater Indirect Ownership Interest · Organization
Rybst Central Manager LLC
Operational/Managerial Control · Organization
Sas 1998 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Covenant Woods Nursing Home
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4-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Autumn Care Of Mechanicsville
Mechanicsville, VA
3-star overall rating with 2-star inspections with $10,358 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Henrico Health & Rehabilitation Center
Highland Springs, VA
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $259,077 in total fines with 38 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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