Cycle 1
Health 2024-04-24 · Fire 2024-04-24
15 health deficiencies
Top issue: Infection Control (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lexington, VA
Kendal At Lexington
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
160 Kendal Drive, Lexington, VA
(540) 463-1910
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Kendal
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.46
Nurse aide staffing
Weekend hours
3.78
Weekend nurse staffing
RN turnover
14%
Annual RN turnover
Total nurse turnover
21%
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 | 2.6 |
1.4
1.2 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.2%
8.1 pts better
|
93.4%
5.9 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 | 7.5% |
3.6%
3.9 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.7%
2.1 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
20.2%
3.2 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.3% |
15.0%
8.7 pts better
|
16.7%
10.4 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 | 28.0% |
17.5%
10.5 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
15.7%
8.9 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.5%
0.4 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.6%
1.6 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
22.2%
2.1 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.2%
2.5 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
74.6%
18.5 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
11.7%
0.5 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.2%
2.5 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.6%
26.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.4% |
22.0%
4.6 pts better
|
23.9%
6.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-17 · Fire 2021-11-17
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-04-04 · Fire 2019-04-04
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-04-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-04-24
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-28
D · Potential for more than minimal harm
2021-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-09
F · Potential for more than minimal harm
2019-04-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-05-21
Inspection history
Recent health citations
G · Actual harm
2024-04-24
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 2024-06-07
F · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-04-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-04-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-04-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-24
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 2024-06-07
D · Potential for more than minimal harm
2024-04-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-23
D · Potential for more than minimal harm
2024-04-24
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 2024-06-07
D · Potential for more than minimal harm
2024-04-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-24
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 2024-06-07
D · Potential for more than minimal harm
2024-04-24
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 2024-07-23
D · Potential for more than minimal harm
2024-04-24
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 2024-07-23
D · Potential for more than minimal harm
2024-04-24
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 2024-07-23
D · Potential for more than minimal harm
2024-04-24
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-06-07
E · Potential for more than minimal harm
2021-11-17
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 2021-12-20
D · Potential for more than minimal harm
2021-11-17
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 2021-12-20
D · Potential for more than minimal harm
2021-11-17
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 2021-12-20
B · Minimal harm
2021-11-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-20
E · Potential for more than minimal harm
2019-04-04
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 2019-05-10
D · Potential for more than minimal harm
2019-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-10
D · Potential for more than minimal harm
2019-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-10
D · Potential for more than minimal harm
2019-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-10
Penalties and ownership
What sits behind the stars
$10,033
2024-04-24
Fine
Fine · fine $10,033
Fine
Ownership
Baker, Priscilla
Corporate Director · Individual
Baroco, Patrick
Operational/Managerial Control · Individual
Branner, Elizabeth
Corporate Director · Individual
Brooke, George
Corporate Director · Individual
Bryd, Vassar
Operational/Managerial Control · Individual
Bush, Felicia
Operational/Managerial Control · Individual
Bush, Felicia
Corporate Officer · Individual
Day, Adam
Operational/Managerial Control · Individual
Day, Adam
Corporate Officer · Individual
Feldbauer, Adam
Operational/Managerial Control · Individual
Gosse, Thomas
Corporate Director · Individual
Grizzle, James
Corporate Director · Individual
Guill, Noelle
Operational/Managerial Control · Individual
Hare, Randolph
Corporate Director · Individual
Hare, Randolph
Corporate Officer · Individual
Hentz, Michele
Corporate Director · Individual
Herrick, Dianne
Corporate Director · Individual
Huch, Robert
Corporate Director · Individual
Keeley, Mark
Corporate Director · Individual
Luecke, Pamela
Corporate Director · Individual
Luecke, Pamela
Corporate Officer · Individual
Moliterno, Valerie
Corporate Director · Individual
Reid, Colin
Corporate Director · Individual
Ross, Bennett
Corporate Director · Individual
Ross, Bennett
Corporate Officer · Individual
Summers, Bruce
Corporate Director · Individual
Walsh, Natasha
Corporate Director · Individual
Warner, Harry
Corporate Director · Individual
Wilder, Linda
Corporate Director · Individual
Wilder, Linda
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Heritage Hall Lexington
East Lexington, VA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 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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