Cycle 1
Health 2023-02-28 · Fire 2023-02-28
3 health deficiencies
Top issue: Environmental (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Grundy, VA
Heritage Hall Grundy
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2966 Slate Creek Road, Grundy, VA
(276) 935-8144
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Heritage Hall
Operator or chain grouping
Approved since
1991-12-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 4 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
0.55
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.63
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
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,340
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.62
Baseline 18.66% · Performance 20.68% · Measure score 1.62 · Achievement 1.62 · Improvement 0
Healthcare-associated infections
0
Baseline 7.31% · Performance 8.13% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.34
Baseline 39.25% · Performance 33.68% · Measure score 7.34 · Achievement 7.34 · Improvement 3.37
Adjusted total nurse staffing
0.61
Baseline 2.70 hours · Performance 3.04 hours · Measure score 0.61 · Achievement 0 · Improvement 0.61
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 9.52% · Lower 95% interval 6.9% |
| Discharge to community | 31.14% |
50.57%
19.4 pts worse
|
Worse than the National Rate · Eligible stays 57 · Observed rate 19.3% · Lower 95% interval 20.96% |
| Medicare spending per beneficiary | 1.47 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 93.62% |
95.27%
1.6 pts worse
|
Numerator 44 · Denominator 47 |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 47 |
| Discharge self-care score | 56.67% |
53.69%
3 pts better
|
Numerator 17 · Denominator 30 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 14 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 1.75% |
| Healthcare-associated infections requiring hospitalization | 8.13% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 11.32% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 139 |
| Staff flu vaccination coverage | 12.78% |
42%
29.2 pts worse
|
Numerator 29 · Denominator 227 |
| Discharge function score | 46.67% |
56.45%
9.8 pts worse
|
Numerator 14 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 18.52% |
25.2%
6.7 pts worse
|
Numerator 5 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
91.2%
5.2 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 94.4% · Q3 98.1% · Q4 98.0% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
94.0%
2.5 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| 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 5.6% · Q2 7.4% · Q3 5.8% · Q4 8.2% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
15.7%
9.5 pts better
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 6.9% · Q3 2.1% · Q4 4.4% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.7%
2.2 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.9% · Q3 1.0% · Q4 3.1% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.2% |
20.2%
7 pts worse
|
19.6%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 27.9% · Q3 27.5% · Q4 28.9% · 4Q avg 27.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
15.0%
3.6 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.0% · Q3 14.1% · Q4 11.1% · 4Q avg 11.4% · 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 | 13.4% |
17.5%
4.1 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 16.0% · Q3 10.9% · Q4 10.5% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
15.7%
6.3 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.5% · Q3 12.4% · Q4 6.5% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.6%
0.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
22.2%
0.9 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 26.6% · Q3 21.6% · Q4 18.4% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.2%
1 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.8% · Q3 1.1% · Q4 5.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.7% |
74.6%
5.9 pts worse
|
81.7%
13 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.0% · Q2 69.4% · Q3 67.6% · Q4 67.4% · 4Q avg 68.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.7%
5 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 7.7% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.2%
1.3 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.7% · Q3 3.3% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.9% |
73.6%
16.7 pts worse
|
79.7%
22.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
22.0%
1.8 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 23.1% · Expected 27.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-03-18 · Fire 2021-03-18
6 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-03-21 · Fire 2019-03-21
15 health deficiencies
Top issue: Resident Rights (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-02-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-02-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-02-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-09
E · Potential for more than minimal harm
2021-03-18
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 2021-05-26
E · Potential for more than minimal harm
2021-03-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-05-26
E · Potential for more than minimal harm
2021-03-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-26
E · Potential for more than minimal harm
2021-03-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-05-26
E · Potential for more than minimal harm
2021-03-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-02-28
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 2023-04-26
D · Potential for more than minimal harm
2023-02-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-02-28
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 2023-04-26
E · Potential for more than minimal harm
2021-03-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-18
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 2021-04-26
D · Potential for more than minimal harm
2021-03-18
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 2021-04-26
E · Potential for more than minimal harm
2019-03-21
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-05-05
E · Potential for more than minimal harm
2019-03-21
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 2019-05-05
E · Potential for more than minimal harm
2019-03-21
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 2019-05-05
E · Potential for more than minimal harm
2019-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-05-05
E · Potential for more than minimal harm
2019-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-05
D · Potential for more than minimal harm
2019-03-21
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 2019-05-05
D · Potential for more than minimal harm
2019-03-21
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 2019-05-05
D · Potential for more than minimal harm
2019-03-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-05-05
D · Potential for more than minimal harm
2019-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-05
D · Potential for more than minimal harm
2019-03-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-05
D · Potential for more than minimal harm
2019-03-21
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 2019-05-05
D · Potential for more than minimal harm
2019-03-21
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 2019-05-05
D · Potential for more than minimal harm
2019-03-21
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 2019-05-05
C · Minimal harm
2019-03-21
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-05-05
C · Minimal harm
2019-03-21
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 2019-05-05
Penalties and ownership
What sits behind the stars
Ownership
Wcc Third Blind Trust
5% Or Greater Direct Ownership Interest · Organization
Cranwell, Robert
5% Or Greater Direct Ownership Interest · Individual
Ahc Acquisitions, LLC
5% Or Greater Direct Ownership Interest · Organization
Cranwell, C.
5% Or Greater Direct Ownership Interest · Individual
American Healthcare LLC
Operational/Managerial Control · Organization
Dalton, Robert
W-2 Managing Employee · Individual
East, Thomas
Corporate Director · Individual
East, Thomas
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Good Shepherd Health and Rehabilitation
Phelps, KY
1-star overall rating with 1-star inspections with $43,646 in total fines with 2 recent health deficiencies
#2
Elkhorn Health & Rehabilitation
Elkhorn City, KY
3-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#3
Clinch Valley Medical Center
Richlands, VA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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