32 health deficiencies
Top issue: Resident Rights (7 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Wytheville, VA
1-star overall rating with 1-star inspections with $111,911 in total fines with 32 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
990 Holston Rd, Wytheville, VA
(276) 228-5595
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
137
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.23
Registered nurse staffing
LPN hours / resident day
1.10
Licensed practical nurse staffing
Aide hours / resident day
1.82
Nurse aide staffing
Weekend hours
2.79
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
70%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.4
1.4 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 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 | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 27.5% |
15.7%
11.8 pts worse
|
11.4%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.7%
0.9 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
20.2%
7.4 pts worse
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
15.0%
5.6 pts better
|
16.7%
7.3 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 | 33.5% |
17.5%
16 pts worse
|
16.3%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
15.7%
14.9 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.6%
1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
22.2%
2.4 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.2%
2.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
74.6%
24.6 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.6% |
11.7%
9.9 pts worse
|
12.0%
9.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
73.6%
20.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.4% |
22.0%
10.4 pts worse
|
23.9%
8.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Rights (7 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Infection Control (1 deficiency)
13 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (12 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-06
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-06-06
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-06
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-06
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-06
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-25
Fire Safety
Meet other general requirements.
Corrected 2025-09-25
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-30
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-19
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2022-10-03
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 2022-12-30
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-10-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-03
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-30
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-10-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-30
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-03
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 2019-07-29
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-07-29
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 2019-07-29
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-07-29
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-04
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-06
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-06-06
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-06-06
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-06
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 2025-06-06
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 2025-06-06
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-04
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-06-06
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-09-04
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-06
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-06
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-06-06
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-06-06
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 2025-06-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-04
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 2025-06-06
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-06
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-04
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-04
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-06-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-04
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 2025-06-06
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-04
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 2025-06-06
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-06-06
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-06-06
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-06-06
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2025-06-06
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-04
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-06-06
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-03-13
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-13
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-13
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 2024-03-13
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-13
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-13
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-13
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-03-13
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-13
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-13
Health
Keep all essential equipment working safely.
Corrected 2024-03-13
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 2022-05-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-05-13
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-05-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-19
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 2019-07-19
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 2019-07-19
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-07-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-07-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-07-19
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 2019-07-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-07-19
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 2019-07-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-07-19
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 2019-07-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2019-07-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-07-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-07-19
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-07-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-07-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-07-19
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-19
Penalties and ownership
Fine · fine $111,911
Fine
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