Cycle 1
Health 2024-04-25 · Fire 2024-04-25
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Williamsburg, VA
Jamestown Health and Rehabilitation
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1811 Jamestown Road, Williamsburg, VA
(757) 229-9991
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1989-05-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.40
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,979
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.48
Baseline 18.73% · Performance 19.82% · Measure score 3.48 · Achievement 3.48 · Improvement 0
Healthcare-associated infections
3.46
Baseline 5.60% · Performance 6.80% · Measure score 3.46 · Achievement 3.46 · Improvement 0
Total nurse turnover
2.47
Baseline 57.14% · Performance 53.57% · Measure score 2.47 · Achievement 2.47 · Improvement 0.61
Adjusted total nurse staffing
1.87
Baseline 3.20 hours · Performance 3.61 hours · Measure score 1.87 · Achievement 1.87 · Improvement 1.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.08% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 15.57% · Lower 95% interval 9.82% |
| Discharge to community | 58.95% |
50.57%
8.4 pts better
|
No Different than the National Rate · Eligible stays 238 · Observed rate 51.68% · Lower 95% interval 50.27% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 156 · Denominator 156 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 156 |
| Discharge self-care score | 84.21% |
53.69%
30.5 pts better
|
Numerator 80 · Denominator 95 |
| Discharge mobility score | 75.79% |
50.94%
24.9 pts better
|
Numerator 72 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 3.21% |
2.29%
0.9 pts worse
|
Numerator 5 · Denominator 156 · Adjusted rate 3.21% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 6.67% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 32.18% |
8.2%
24 pts better
|
Numerator 28 · Denominator 87 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 80% |
56.45%
23.5 pts better
|
Numerator 76 · Denominator 95 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 96 · Denominator 96 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 40.24% |
25.2%
15 pts better
|
Numerator 33 · Denominator 82 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.2%
8.4 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
15.7%
14.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 1.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.7%
0.4 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 9.0% · Q3 4.6% · Q4 3.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
20.2%
4.4 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 27.5% · Q3 23.9% · Q4 23.4% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
15.0%
3.2 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 13.2% · Q3 9.3% · Q4 9.1% · 4Q avg 11.8% · 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 | 5.7% |
17.5%
11.8 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.1% · Q3 5.5% · Q4 8.2% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
15.7%
9.2 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.0% · Q3 4.6% · Q4 11.3% · 4Q avg 6.5% · 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 | 0.4% |
1.6%
1.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.9% |
22.2%
6.3 pts better
|
19.8%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 14.2% · Q3 15.1% · Q4 18.0% · 4Q avg 15.9% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.2%
3 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 0.0% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
74.6%
24.8 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 99.4% · Q4 99.4% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
11.7%
4.7 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
73.6%
25.2 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
22.0%
0.9 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 20.6% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-12 · Fire 2022-05-12
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-03-05 · Fire 2020-03-05
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-04-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-04-25
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-07-01
D · Potential for more than minimal harm
2022-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-30
B · Minimal harm
2020-03-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Not marked corrected
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-25
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 2024-06-03
D · Potential for more than minimal harm
2024-04-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-25
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 2024-06-03
D · Potential for more than minimal harm
2024-04-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-25
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-25
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-06-03
G · Actual harm
2022-05-12
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 2022-06-15
E · Potential for more than minimal harm
2022-05-12
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-06-15
E · Potential for more than minimal harm
2022-05-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-15
E · Potential for more than minimal harm
2022-05-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-12
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 2022-06-15
D · Potential for more than minimal harm
2022-05-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-12
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 2022-06-15
D · Potential for more than minimal harm
2022-05-12
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 2022-06-15
D · Potential for more than minimal harm
2022-05-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-05-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-12
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 2022-06-15
D · Potential for more than minimal harm
2022-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-06-15
D · Potential for more than minimal harm
2020-03-05
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 2020-04-14
D · Potential for more than minimal harm
2020-03-05
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 2020-04-14
D · Potential for more than minimal harm
2020-03-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-04-14
D · Potential for more than minimal harm
2020-03-05
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 2020-04-14
D · Potential for more than minimal harm
2020-03-05
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-04-14
D · Potential for more than minimal harm
2020-03-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-04-14
D · Potential for more than minimal harm
2020-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-14
B · Minimal harm
2020-03-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-04-14
B · Minimal harm
2020-03-05
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 2020-04-14
Penalties and ownership
What sits behind the stars
Ownership
Williamsburg Parentco LLC
5% Or Greater Direct Ownership Interest · Organization
Adams, Sebastian
Operational/Managerial Control · Individual
Hoback, Tiffany
Operational/Managerial Control · Individual
James City Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Jones, Tequilla
Operational/Managerial Control · Individual
Morgan, Daniel
Operational/Managerial Control · Individual
Nu C Ii Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nu C Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Reid, Lori
Operational/Managerial Control · Individual
Snf Care Centers LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Mgr LLC
Operational/Managerial Control · Organization
Vaop Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Walters, Robert
Operational/Managerial Control · Individual
Zenith Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Woodhaven Hall At Williamsburg Landing
Williamsburg, VA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Riverside Lifelong Health & Rehabilitation Patri
Williamsburg, VA
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Williamsburg Post Acute & Rehabilitation
Williamsburg, VA
3-star overall rating with 4-star inspections with 5 recent health deficiencies
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