Cycle 1
Health 2023-10-04 · Fire 2023-10-04
38 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Highland Springs, VA
Henrico Health & Rehabilitation Center
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
561 North Airport Drive, Highland Springs, VA
(804) 737-0172
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
101
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1989-07-06
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
0.35
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.46
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
3.74
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.76
Higher values indicate more complex resident acuity
RN turnover
56%
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
10,794
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.67
Baseline 23.16% · Performance 19.99% · Measure score 4.67 · Achievement 3.11 · Improvement 4.67
Healthcare-associated infections
0.06
Baseline 7.96% · Performance 7.79% · Measure score 0.06 · Achievement 0 · Improvement 0.06
Total nurse turnover
2.39
Performance 53.92% · Measure score 2.39 · Achievement 2.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.52
Baseline 2.40 hours · Performance 2.74 hours · Measure score 0.52 · Achievement 0 · Improvement 0.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.87% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 181 · Observed rate 11.6% · Lower 95% interval 8.02% |
| Discharge to community | 58.65% |
50.57%
8.1 pts better
|
No Different than the National Rate · Eligible stays 188 · Observed rate 49.47% · Lower 95% interval 50.38% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.2% |
95.27%
2.1 pts worse
|
Numerator 96 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 27 · Denominator 66 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 24 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 0.65% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 9.35% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 21.71% |
42%
20.3 pts worse
|
Numerator 28 · Denominator 129 |
| Discharge function score | 40.91% |
56.45%
15.5 pts worse
|
Numerator 27 · Denominator 66 |
| Transfer of health information to provider | 97.14% |
95.95%
1.2 pts better
|
Numerator 68 · Denominator 70 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.69% |
25.2%
4.5 pts worse
|
Numerator 12 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.3 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.4
0.4 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
91.2%
4.3 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 94.0% · Q3 91.1% · Q4 97.8% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
94.0%
1 pts better
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.6%
1.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 1.1% · Q4 2.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 94.7% |
15.7%
79 pts worse
|
11.4%
83.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 93.2% · Q3 91.5% · Q4 97.7% · 4Q avg 94.7% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.7%
3 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.3% · Q3 2.4% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
20.2%
10.7 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 10.1% · Q3 10.6% · Q4 4.6% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
15.0%
2 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 10.6% · Q3 15.1% · Q4 11.4% · 4Q avg 13.0% · 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 | 7.2% |
17.5%
10.3 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.5% · Q3 10.5% · Q4 4.8% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
15.7%
9.5 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 9.1% · Q3 6.3% · Q4 7.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.5%
1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.2% · Q4 2.3% · 4Q avg 1.5% · 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 1.2% · Q3 2.3% · 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 | 24.4% |
22.2%
2.2 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 16.9% · Q3 23.0% · Q4 29.6% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.2%
0.5 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.4% · Q3 3.9% · Q4 4.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
74.6%
5.6 pts better
|
81.7%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 83.4% · Q3 68.4% · Q4 64.2% · 4Q avg 80.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
11.7%
3 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 9.2% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 4.8% · Q4 2.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.1% |
73.6%
9.5 pts better
|
79.7%
3.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
22.0%
3.4 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 26.4% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-10 · Fire 2021-09-10
23 health deficiencies
Top issue: Resident Rights (7 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2018-10-25 · Fire 2018-10-25
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-10-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-09
D · Potential for more than minimal harm
2023-10-04
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-02-09
D · Potential for more than minimal harm
2023-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-09
D · Potential for more than minimal harm
2021-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-04
D · Potential for more than minimal harm
2021-09-10
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-10-04
C · Minimal harm
2021-09-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-30
E · Potential for more than minimal harm
2018-10-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-01-14
E · Potential for more than minimal harm
2018-10-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-03-28
E · Potential for more than minimal harm
2018-10-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-10-25
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-10-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-03-28
D · Potential for more than minimal harm
2018-10-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-10-25
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 2019-01-14
D · Potential for more than minimal harm
2018-10-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-10-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-10-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-10-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-14
C · Minimal harm
2018-10-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-11-23
C · Minimal harm
2018-10-25
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-11-23
C · Minimal harm
2018-10-25
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2018-11-23
C · Minimal harm
2018-10-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2018-11-23
C · Minimal harm
2018-10-25
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2018-11-23
C · Minimal harm
2018-10-25
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 2019-01-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-22
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 2025-11-04
D · Potential for more than minimal harm
2025-07-22
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 2025-11-04
G · Actual harm
2025-05-13
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 2025-06-11
D · Potential for more than minimal harm
2025-05-13
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 2025-06-11
D · Potential for more than minimal harm
2025-05-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-05-13
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 2025-06-11
E · Potential for more than minimal harm
2025-02-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-24
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-24
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 2025-03-21
D · Potential for more than minimal harm
2025-02-24
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
J · Immediate jeopardy
2024-09-06
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 2024-10-01
E · Potential for more than minimal harm
2024-09-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-09-06
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-06
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 2024-10-01
D · Potential for more than minimal harm
2024-05-08
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 2024-07-16
D · Potential for more than minimal harm
2024-05-08
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 2024-07-16
D · Potential for more than minimal harm
2024-05-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-16
D · Potential for more than minimal harm
2023-12-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-12
K · Immediate jeopardy
2023-10-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-19
G · Actual harm
2023-10-04
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 2023-11-19
G · Actual harm
2023-10-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-11-19
G · Actual harm
2023-10-04
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 2023-11-19
G · Actual harm
2023-10-04
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-11-19
G · Actual harm
2023-10-04
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-11-19
F · Potential for more than minimal harm
2023-10-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-11-19
F · Potential for more than minimal harm
2023-10-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-19
F · Potential for more than minimal harm
2023-10-04
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 2023-11-19
E · Potential for more than minimal harm
2023-10-04
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 2023-11-19
E · Potential for more than minimal harm
2023-10-04
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 2023-11-19
E · Potential for more than minimal harm
2023-10-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-04
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-19
E · Potential for more than minimal harm
2023-10-04
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
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 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
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 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
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 2023-11-19
D · Potential for more than minimal harm
2023-10-04
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 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-10-04
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 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-10-04
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-04
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 2023-11-19
D · Potential for more than minimal harm
2023-10-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-07-25
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 2023-08-15
G · Actual harm
2023-03-15
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 2022-11-11
D · Potential for more than minimal harm
2023-03-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-03-28
L · Immediate jeopardy
2021-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-12
L · Immediate jeopardy
2021-09-10
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-01-12
F · Potential for more than minimal harm
2021-09-10
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-01-12
E · Potential for more than minimal harm
2021-09-10
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 2021-10-14
E · Potential for more than minimal harm
2021-09-10
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 2022-01-12
D · Potential for more than minimal harm
2021-09-10
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2021-10-14
D · Potential for more than minimal harm
2021-09-10
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-09-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-09-10
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 2022-01-12
D · Potential for more than minimal harm
2021-09-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-11-30
D · Potential for more than minimal harm
2021-09-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-11-30
E · Potential for more than minimal harm
2018-10-25
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 2018-11-23
D · Potential for more than minimal harm
2018-10-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-25
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 2018-11-23
D · Potential for more than minimal harm
2018-10-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-25
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 2018-11-23
D · Potential for more than minimal harm
2018-10-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-10-25
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 2018-11-23
D · Potential for more than minimal harm
2018-10-25
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 2018-11-23
D · Potential for more than minimal harm
2018-10-25
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 2018-11-23
D · Potential for more than minimal harm
2018-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-23
Penalties and ownership
What sits behind the stars
$131,571
2025-02-24
Fine
Fine · fine $131,571
Fine
$23,196
2024-09-06
Fine
Fine · fine $23,196
Fine
$104,310
2023-10-04
Fine
Fine · fine $104,310
Fine
Ownership
Henrico Holdings 1 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
Matt 2002 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Matt 2002 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
Wilson, Lakeshia
Corporate Director · Individual
Wilson, Lakeshia
W-2 Managing Employee · Individual
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