15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gainesville, VA
4-star overall rating with 3-star inspections with 15 recent health deficiencies
14935 Holly Knoll Lane, Gainesville, VA
(703) 743-3999
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
Beds
120
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
2017-10-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
RN hours / resident day
0.81
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
2.95
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
7,383
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.10
Baseline 17.52% · Performance 17.68% · Measure score 8.10 · Achievement 8.10 · Improvement 0
Healthcare-associated infections
1.93
Baseline 6.88% · Performance 7.26% · Measure score 1.93 · Achievement 1.93 · Improvement 0
Total nurse turnover
1.93
Baseline 66.67% · Performance 56.52% · Measure score 1.93 · Achievement 1.75 · Improvement 1.93
Adjusted total nurse staffing
0
Baseline 3.40 hours · Performance 3.18 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.56% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 801 · Observed rate 11.11% · Lower 95% interval 9.59% |
| Discharge to community | 65.65% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 846 · Observed rate 60.28% · Lower 95% interval 61.75% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 519 · Denominator 519 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 5 · Denominator 519 |
| Discharge self-care score | 74.56% |
53.69%
20.9 pts better
|
Numerator 255 · Denominator 342 |
| Discharge mobility score | 69.3% |
50.94%
18.4 pts better
|
Numerator 237 · Denominator 342 |
| Pressure ulcers or injuries, new or worsened | 3.28% |
2.29%
1 pts worse
|
Numerator 17 · Denominator 519 · Adjusted rate 3.02% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 527 · Observed rate 7.02% · Lower 95% interval 5.16% |
| Staff COVID-19 vaccination coverage | 0.58% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 171 |
| Staff flu vaccination coverage | 19.41% |
42%
22.6 pts worse
|
Numerator 33 · Denominator 170 |
| Discharge function score | 78.07% |
56.45%
21.6 pts better
|
Numerator 267 · Denominator 342 |
| Transfer of health information to provider | 90.96% |
95.95%
5 pts worse
|
Numerator 332 · Denominator 365 |
| Transfer of health information to patient | 99.26% |
96.28%
3 pts better
|
Numerator 135 · Denominator 136 |
| Resident COVID-19 vaccinations up to date | 12.45% |
25.2%
12.8 pts worse
|
Numerator 34 · Denominator 273 |
Quality measures
| 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 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.6% |
91.2%
23.6 pts worse
|
93.4%
25.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.0% · Q2 71.1% · Q3 62.5% · Q4 66.7% · 4Q avg 67.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.8% |
94.0%
6.2 pts worse
|
95.5%
7.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.6%
2.5 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.6% · Q3 9.4% · Q4 8.3% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.5% |
15.7%
1.2 pts better
|
11.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 12.1% · Q3 9.7% · Q4 11.1% · 4Q avg 14.5% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.7%
4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
20.2%
7.7 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 12.1% · Q3 10.7% · Q4 10.0% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
15.0%
9.6 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.9% · Q3 4.0% · Q4 3.7% · 4Q avg 5.4% · 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 | 3.3% |
17.5%
14.2 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
15.7%
9 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.1% · Q3 4.0% · Q4 10.7% · 4Q avg 6.7% · 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 | 0.7% |
1.6%
0.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.1% |
22.2%
12.1 pts better
|
19.8%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.8% · Q3 13.1% · Q4 18.1% · 4Q avg 10.1% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.2%
0.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.0% · Q3 3.3% · Q4 2.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 48.5% |
74.6%
26.1 pts worse
|
81.7%
33.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.4% · Q2 54.3% · Q3 33.6% · Q4 26.9% · 4Q avg 48.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
11.7%
4.1 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.0% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 0.7% · Q2 0.3% · Q3 0.7% · Q4 0.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.1% |
73.6%
20.5 pts worse
|
79.7%
26.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
22.0%
3.9 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 17.4% · Expected 22.8% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Meet other general requirements.
Corrected 2022-08-26
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-26
Inspection history
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-19
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-19
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-31
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-31
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-31
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-07-31
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 2024-07-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-31
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 2024-07-31
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-31
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-31
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-31
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-31
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2024-07-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-31
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-11
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-08-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-22
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 2022-08-22
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-08-22
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-08-22
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-08-22
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 2022-08-22
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-22
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 2022-08-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-22
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-22
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 2022-08-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-22
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-08-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-16
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-16
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2020-03-16
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-03-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-16
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-03-16
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-03-16
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2020-03-16
Health
Dispose of garbage and refuse properly.
Corrected 2020-03-16
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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