Cycle 1
Health 2023-01-26 · Fire 2023-01-26
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Louisa, VA
Louisa Health & Rehabilitation Center
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
210 Elm Street, Louisa, VA
(540) 967-2250
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1993-10-01
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
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,136
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.70% · Performance 21.61% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.34
Baseline 8.02% · Performance 7.46% · Measure score 1.34 · Achievement 1.24 · Improvement 1.34
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.80
Baseline 2.43 hours · Performance 2.87 hours · Measure score 0.80 · Achievement 0 · Improvement 0.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 7.41% · Lower 95% interval 5.89% |
| Discharge to community | 50.44% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 170 · Observed rate 45.29% · Lower 95% interval 44.3% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.27% |
95.27%
2 pts better
|
Numerator 107 · Denominator 110 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 110 |
| Discharge self-care score | 65.43% |
53.69%
11.7 pts better
|
Numerator 53 · Denominator 81 |
| Discharge mobility score | 60.49% |
50.94%
9.6 pts better
|
Numerator 49 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 5 · Denominator 110 · Adjusted rate 4.26% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 6.96% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 61.86% |
42%
19.9 pts better
|
Numerator 73 · Denominator 118 |
| Discharge function score | 54.32% |
56.45%
2.1 pts worse
|
Numerator 44 · Denominator 81 |
| Transfer of health information to provider | 93.44% |
95.95%
2.5 pts worse
|
Numerator 57 · Denominator 61 |
| Transfer of health information to patient | 88.89% |
96.28%
7.4 pts worse
|
Numerator 32 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 16.36% |
25.2%
8.8 pts worse
|
Numerator 9 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.7 · 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 0.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
91.2%
0.2 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.8% · Q2 88.7% · Q3 97.1% · Q4 98.6% · 4Q avg 91.0% |
| 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 | 4.9% |
3.6%
1.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.2% · Q3 5.8% · Q4 4.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.0% |
15.7%
19.3 pts worse
|
11.4%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 28.6% · Q3 40.0% · Q4 46.9% · 4Q avg 35.0% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.7%
0.7 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 16.7% · Q4 3.2% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.5% |
20.2%
2.7 pts better
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 15.3% · Q3 18.2% · Q4 19.0% · 4Q avg 17.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
15.0%
9.7 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 21.2% · Q3 25.9% · Q4 29.3% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.7% |
0.2%
0.5 pts worse
|
0.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
17.5%
2.9 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q3 8.5% · Q4 10.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
15.7%
4 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 3.6% · Q3 7.8% · Q4 16.7% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.6%
0.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 2.9% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.5% |
22.2%
12.3 pts worse
|
19.8%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 32.6% · Q3 40.9% · Q4 37.5% · 4Q avg 34.5% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.2%
1.8 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.4% · Q3 7.0% · Q4 6.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
74.6%
12.9 pts better
|
81.7%
5.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 86.1% · Q3 88.5% · Q4 95.9% · 4Q avg 87.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
11.7%
6.8 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
1.2%
3.6 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 7.0% · Q4 11.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.9% |
73.6%
9.3 pts better
|
79.7%
3.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
22.0%
4.5 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 16.5% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-22 · Fire 2021-04-22
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2018-10-04 · Fire 2018-10-04
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-01-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-01-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-01-26
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-03-27
C · Minimal harm
2021-04-22
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-05-28
C · Minimal harm
2021-04-22
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-05-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-05-28
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 2025-06-25
E · Potential for more than minimal harm
2023-01-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-01-26
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 2023-03-07
D · Potential for more than minimal harm
2023-01-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-07
D · Potential for more than minimal harm
2023-01-26
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 2023-03-07
D · Potential for more than minimal harm
2023-01-26
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 2023-03-07
D · Potential for more than minimal harm
2023-01-26
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 2023-03-07
E · Potential for more than minimal harm
2021-04-22
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 2021-05-28
E · Potential for more than minimal harm
2021-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-22
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-22
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 2021-05-28
D · Potential for more than minimal harm
2021-04-22
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 2021-05-28
D · Potential for more than minimal harm
2021-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-05-28
D · Potential for more than minimal harm
2018-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-19
C · Minimal harm
2018-10-04
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2018-10-19
B · Minimal harm
2018-10-04
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 2018-10-19
Penalties and ownership
What sits behind the stars
Ownership
Louisa Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Ak 2003 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Al 2003 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Central Bay LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Golden 2017 LLC
5% Or Greater Indirect Ownership Interest · Organization
Matt 2002 LLC
5% Or Greater Indirect Ownership Interest · Organization
Mrcz Central LLC
5% Or Greater Indirect Ownership Interest · Organization
Nathan 5604 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Nathan 5604 LLC
5% Or Greater Indirect Ownership Interest · Organization
Pivotal Central LLC
5% Or Greater Indirect Ownership Interest · Organization
Rybst Central Manager LLC
Operational/Managerial Control · Organization
Sas 1998 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Scholes, Monique
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Dogwood Village Of Orange County Health And Rehab
Orange, VA
3-star overall rating with 3-star inspections with 9 recent health deficiencies
#2
Chelsea Rehabilitation And Healthcare Center
Goochland, VA
3-star overall rating with 2-star inspections with abuse icon flag with $10,033 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Oakhurst Health & Rehabilitation
Fork Union, VA
1-star overall rating with 1-star inspections with abuse icon flag with $18,590 in total fines with 28 recent health deficiencies
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