Cycle 1
Health 2022-09-21 · Fire 2022-09-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
East Lexington, VA
Heritage Hall Lexington
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
205 Houston Street, East Lexington, VA
(540) 464-8181
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
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Heritage Hall
Operator or chain grouping
Approved since
1997-06-01
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
0.57
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,305
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 19.55% · Performance 19.71% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Healthcare-associated infections
5.51
Baseline 5.54% · Performance 6.19% · Measure score 5.51 · Achievement 5.51 · Improvement 0
Total nurse turnover
2.84
Baseline 58.00% · Performance 52.08% · Measure score 2.84 · Achievement 2.84 · Improvement 1.28
Adjusted total nurse staffing
0
Baseline 2.95 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.85% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 13.4% · Lower 95% interval 8.67% |
| Discharge to community | 47.54% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 43.9% · Lower 95% interval 38.11% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 67.74% |
53.69%
14 pts better
|
Numerator 21 · Denominator 31 |
| Discharge mobility score | 54.84% |
50.94%
3.9 pts better
|
Numerator 17 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 2% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 9.86% |
8.2%
1.7 pts better
|
Numerator 7 · Denominator 71 |
| Staff flu vaccination coverage | 29.27% |
42%
12.7 pts worse
|
Numerator 24 · Denominator 82 |
| Discharge function score | 58.06% |
56.45%
1.6 pts better
|
Numerator 18 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.2%
7.8 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.9% · 4Q avg 99.0% |
| 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 | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.8% · Q3 2.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
15.7%
13.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 4.0% · Q4 2.1% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.7%
1.7 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.9% · Q3 2.0% · Q4 4.1% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
20.2%
6.9 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 22.6% · Q3 32.0% · Q4 30.6% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
15.0%
8.3 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.5% · Q3 4.8% · Q4 4.8% · 4Q avg 6.7% · 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 | 20.5% |
17.5%
3 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 31.5% · Q3 8.1% · Q4 14.3% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
15.7%
5.4 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 21.3% · Q3 11.1% · Q4 23.3% · 4Q avg 21.1% · 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 | 1.9% |
1.6%
0.3 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.0% · Q4 4.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
22.2%
3.7 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 48.6% · Q3 14.4% · Q4 20.5% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.2%
5.2 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
74.6%
16.8 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 96.6% · Q4 77.4% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
11.7%
3.1 pts worse
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 15.6% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
73.6%
22.2 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.0%
0.6 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 21.9% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-12 · Fire 2021-05-12
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2019-02-14 · Fire 2019-02-14
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-28
F · Potential for more than minimal harm
2022-09-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-09-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-06
B · Minimal harm
2021-05-12
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2021-06-15
B · Minimal harm
2021-05-12
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-06-15
F · Potential for more than minimal harm
2019-02-14
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2019-04-17
F · Potential for more than minimal harm
2019-02-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-04-17
F · Potential for more than minimal harm
2019-02-14
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-04-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-16
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.
Not marked corrected
D · Potential for more than minimal harm
2024-10-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
G · Actual harm
2022-09-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-31
G · Actual harm
2022-09-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-31
E · Potential for more than minimal harm
2021-05-12
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-06-15
B · Minimal harm
2021-05-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-15
G · Actual harm
2019-02-14
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 2019-03-18
F · Potential for more than minimal harm
2019-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-18
E · Potential for more than minimal harm
2019-02-14
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 2019-03-18
D · Potential for more than minimal harm
2019-02-14
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 2019-03-18
D · Potential for more than minimal harm
2019-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-03-18
Penalties and ownership
What sits behind the stars
Ownership
Wcc Third Blind Trust
5% Or Greater Direct Ownership Interest · Organization
Ahc Acquisitions, LLC
5% Or Greater Direct Ownership Interest · Organization
Crc Blind Trust
5% Or Greater Direct Ownership Interest · Organization
American Healthcare LLC
Operational/Managerial Control · Organization
Cranwell, C.
5% Or Greater Direct Ownership Interest · Individual
Cranwell, Robert
Operational/Managerial Control · Individual
Dalton, Brad
Operational/Managerial Control · Individual
Dalton, Robert
Operational/Managerial Control · Individual
Dalton, Robert
Corporate Officer · Individual
East, Thomas
Operational/Managerial Control · Individual
East, Thomas
Corporate Officer · Individual
Gallant, Cassandra
Operational/Managerial Control · Individual
Hopkins, William
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kendal At Lexington
Lexington, VA
3-star overall rating with 2-star inspections with $10,033 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Shenandoah Valley Health And Rehab
Buena Vista, VA
2-star overall rating with 2-star inspections with $61,692 in total fines with 6 recent health deficiencies
#3
Alleghany Health And Rehab
Clifton Forge, VA
1-star overall rating with 1-star inspections with $108,698 in total fines with 17 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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