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
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 5 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
0.97
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.64
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
1.13
CMS adjusted RN staffing hours
Adjusted total hours
5.08
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
370
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
71.60
Composite VBP score used to determine payment impact.
Payment multiplier
1.0231
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.20
Baseline 20.06% · Performance 18.56% · Measure score 6.20 · Achievement 6.20 · Improvement 4.45
Healthcare-associated infections
7.53
Baseline 7.48% · Performance 5.59% · Measure score 7.53 · Achievement 7.53 · Improvement 7.12
Total nurse turnover
6.91
Baseline 29.54% · Performance 35.42% · Measure score 6.91 · Achievement 6.91 · Improvement 0
Adjusted total nurse staffing
8
Baseline 5.07 hours · Performance 5.35 hours · Measure score 8 · Achievement 8 · Improvement 3.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 9.52% · Lower 95% interval 7.47% |
| Discharge to community | 61.57% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 80 · Observed rate 62.5% · Lower 95% interval 51.16% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.63% |
95.27%
3.4 pts better
|
Numerator 72 · Denominator 73 |
| Falls with major injury | 2.74% |
0.77%
2 pts worse
|
Numerator 2 · Denominator 73 |
| Discharge self-care score | 61.11% |
53.69%
7.4 pts better
|
Numerator 33 · Denominator 54 |
| Discharge mobility score | 64.81% |
50.94%
13.9 pts better
|
Numerator 35 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 73 · Adjusted rate 1.64% |
| Healthcare-associated infections requiring hospitalization | 5.59% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 0% · Lower 95% interval 2.95% |
| Staff COVID-19 vaccination coverage | 7.55% |
8.2%
0.6 pts worse
|
Numerator 12 · Denominator 159 |
| Staff flu vaccination coverage | 36.89% |
42%
5.1 pts worse
|
Numerator 38 · Denominator 103 |
| Discharge function score | 64.81% |
56.45%
8.4 pts better
|
Numerator 35 · Denominator 54 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 44.19% |
25.2%
19 pts better
|
Numerator 19 · Denominator 43 |
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 0.7 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 2.6 · Observed 2.3 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 96.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 7.5% |
3.6%
3.9 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.4% · Q3 5.7% · Q4 5.9% · 4Q avg 7.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 8.3% · Q2 13.8% · Q3 6.5% · Q4 3.2% · 4Q avg 7.8% |
| 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 · Q1 13.8% · Q2 25.8% · Q3 24.2% · Q4 29.0% · 4Q avg 23.4% |
| 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 · Q1 5.0% · Q2 8.0% · Q3 4.2% · Q4 7.7% · 4Q avg 6.3% · 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 | 28.0% |
17.5%
10.5 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.0% · Used in QM five-star |
| 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 · Q1 21.4% · Q2 36.7% · Q3 21.9% · Q4 17.9% · 4Q avg 24.6% · Used in QM five-star |
| 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 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 6.7% · Q3 3.0% · Q4 2.9% · 4Q avg 3.2% · Used in QM five-star |
| 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 · Q1 17.6% · Q2 31.3% · Q3 11.3% · Q4 21.0% · 4Q avg 20.1% |
| 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 · Q1 9.3% · Q2 4.7% · Q3 6.6% · Q4 9.9% · 4Q avg 7.7% · Used in QM five-star |
| 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 · Q1 91.3% · Q2 95.2% · Q3 91.7% · Q4 94.3% · 4Q avg 93.1% |
| 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 · Adjusted 11.2% · Observed 11.3% · Expected 11.3% · Used in QM five-star |
| 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 · Q1 3.2% · Q2 6.5% · Q3 4.0% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
| 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 · Adjusted 17.4% · Observed 16.1% · Expected 22.0% · Used in QM five-star |
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
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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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