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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.57

Registered nurse staffing

LPN hours / resident day

0.63

Licensed practical nurse staffing

Aide hours / resident day

1.84

Nurse aide staffing

Weekend hours

2.66

Weekend nurse staffing

RN turnover

33%

Annual RN turnover

Total nurse turnover

49%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

78% 5 facilities 2020-07-10

Ahc Acquisitions, LLC

5% Or Greater Direct Ownership Interest · Organization

12% 5 facilities 2020-07-10

Crc Blind Trust

5% Or Greater Direct Ownership Interest · Organization

7% 2 facilities 2020-07-10

American Healthcare LLC

Operational/Managerial Control · Organization

0% 14 facilities 2010-11-22

Cranwell, C.

5% Or Greater Direct Ownership Interest · Individual

0% 4 facilities 2020-07-10

Cranwell, Robert