Cycle 1
Health 2022-02-03 · Fire 2022-02-03
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Kilmarnock, VA
Lancashire Nursing & Rehabilitation Center
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
287 School Street, Kilmarnock, VA
(804) 435-1684
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
120
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Virginia Health Services
Operator or chain grouping
Approved since
2000-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 3 health / 3 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
0.50
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
2.97
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.47
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
2.92
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,260
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.68
Baseline 19.11% · Performance 18.34% · Measure score 6.68 · Achievement 6.68 · Improvement 3.23
Healthcare-associated infections
3.32
Baseline 5.68% · Performance 6.84% · Measure score 3.32 · Achievement 3.32 · Improvement 0
Total nurse turnover
6.26
Baseline 42.47% · Performance 38.09% · Measure score 6.26 · Achievement 6.26 · Improvement 1.98
Adjusted total nurse staffing
0
Baseline 2.9 hours · Performance 2.75 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 10% · Lower 95% interval 7.26% |
| Discharge to community | 56.44% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 52.38% · Lower 95% interval 46.31% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 14.29% |
53.69%
39.4 pts worse
|
Numerator 3 · Denominator 21 |
| Discharge mobility score | 38.1% |
50.94%
12.8 pts worse
|
Numerator 8 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 34 · Adjusted rate 3.92% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 40.61% |
42%
1.4 pts worse
|
Numerator 67 · Denominator 165 |
| Discharge function score | 28.57% |
56.45%
27.9 pts worse
|
Numerator 6 · Denominator 21 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
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 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.4
0.4 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.6% |
3.6%
About the same
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.6% · Q3 2.5% · Q4 2.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
15.7%
4.7 pts better
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 10.3% · Q3 11.7% · Q4 11.9% · 4Q avg 11.0% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
5.7%
3.9 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 1.4% · Q4 2.5% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.0% |
20.2%
8.8 pts worse
|
19.6%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 22.7% · Q3 27.8% · Q4 39.2% · 4Q avg 29.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.7% |
15.0%
10.7 pts worse
|
16.7%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 23.2% · Q3 24.6% · Q4 33.3% · 4Q avg 25.7% · 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 | 11.8% |
17.5%
5.7 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.3% · Q3 14.0% · Q4 9.0% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
15.7%
6.8 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 1.6% · Q3 17.4% · Q4 7.9% · 4Q avg 8.9% · 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 | 1.0% |
1.6%
0.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
22.2%
2.8 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 13.0% · Q3 19.5% · Q4 27.8% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.2%
3.7 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
74.6%
22.4 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 97.7% · Q4 94.9% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
11.7%
1.6 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 8.3% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · 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 | 5.3% |
22.0%
16.7 pts better
|
23.9%
18.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 4.2% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-01-25 · Fire 2019-01-25
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2017-10-12 · Fire 2017-10-12
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-02-03
K222 · Egress Deficiencies
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 2022-02-28
D · Potential for more than minimal harm
2022-02-03
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-02-28
D · Potential for more than minimal harm
2017-10-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-02-26
D · Potential for more than minimal harm
2017-10-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-02-26
D · Potential for more than minimal harm
2017-10-12
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2018-02-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-02-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-03-18
E · Potential for more than minimal harm
2022-02-03
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 2022-03-18
D · Potential for more than minimal harm
2022-02-03
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 2022-03-18
D · Potential for more than minimal harm
2022-02-03
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 2022-03-18
D · Potential for more than minimal harm
2022-02-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-03
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 2022-03-18
D · Potential for more than minimal harm
2022-02-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-03
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-03
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 2022-03-18
J · Immediate jeopardy
2019-01-25
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 2019-03-01
G · Actual harm
2019-01-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-25
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2019-03-01
D · Potential for more than minimal harm
2017-10-12
F246 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2017-11-13
D · Potential for more than minimal harm
2017-10-12
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-11-13
D · Potential for more than minimal harm
2017-10-12
F280 · Resident Assessment and Care Planning Deficiencies
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-11-13
D · Potential for more than minimal harm
2017-10-12
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-11-13
D · Potential for more than minimal harm
2017-10-12
F425 · Pharmacy Service Deficiencies
Health
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Corrected 2017-11-13
D · Potential for more than minimal harm
2017-10-12
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-11-13
D · Potential for more than minimal harm
2017-10-12
F518 · Administration Deficiencies
Health
Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Corrected 2017-11-13
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Rappahannock Westminster Canterbury
Irvington, VA
4-star overall rating with 3-star inspections with 10 recent health deficiencies
#2
Dockside Health & Rehab Center
Locust Hill, VA
4-star overall rating with 3-star inspections with $14,740 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Riverside Lifelong Health & Rehabilitation Salud
Saluda, VA
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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