Cycle 1
Health 2022-06-15 · Fire 2022-06-15
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Martinsville, VA
Martinsville Health And Rehab
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1607 Spruce Street, Martinsville, VA
(276) 632-7146
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trio Healthcare
Operator or chain grouping
Approved since
1984-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.4
1.3 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
91.2%
2.4 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
94.0%
0.6 pts better
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
15.7%
9.6 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.7%
4.5 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
20.2%
3 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.6% |
15.0%
1.6 pts worse
|
16.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.2%
0.1 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.8% |
17.5%
10.3 pts worse
|
16.3%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
15.7%
11.1 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.6%
1.1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
22.2%
2.4 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.2%
2.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.2% |
74.6%
46.4 pts worse
|
81.7%
53.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.2% |
11.7%
5.5 pts worse
|
12.0%
5.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.8% |
1.2%
4.6 pts worse
|
1.6%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 10.6% |
73.6%
63 pts worse
|
79.7%
69.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
22.0%
6.2 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-18 · Fire 2019-10-18
35 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2018-06-04 · Fire 2018-06-04
35 health deficiencies
Top issue: Resident Rights (9 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-06-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-22
F · Potential for more than minimal harm
2022-06-15
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-08-22
F · Potential for more than minimal harm
2022-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-22
F · Potential for more than minimal harm
2022-06-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-22
F · Potential for more than minimal harm
2022-06-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-06-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-06-15
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 2022-08-22
E · Potential for more than minimal harm
2022-06-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-06-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-06-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-06-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-06-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-08-22
F · Potential for more than minimal harm
2019-10-18
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 2019-12-12
F · Potential for more than minimal harm
2019-10-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-12
F · Potential for more than minimal harm
2019-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-12
F · Potential for more than minimal harm
2018-06-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2018-08-07
F · Potential for more than minimal harm
2018-06-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-08-07
F · Potential for more than minimal harm
2018-06-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-08-07
F · Potential for more than minimal harm
2018-06-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-08-07
F · Potential for more than minimal harm
2018-06-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-08-07
D · Potential for more than minimal harm
2018-06-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-08-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-15
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 2026-02-24
E · Potential for more than minimal harm
2024-01-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-01-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-01-31
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 2024-04-19
D · Potential for more than minimal harm
2024-01-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-01-31
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 2024-04-19
D · Potential for more than minimal harm
2024-01-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-01-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-19
E · Potential for more than minimal harm
2022-06-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-12
E · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-07-12
C · Minimal harm
2022-06-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-07-12
G · Actual harm
2019-10-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2020-01-03
G · Actual harm
2019-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-15
G · Actual harm
2019-10-18
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 2020-01-03
F · Potential for more than minimal harm
2019-10-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-03-15
E · Potential for more than minimal harm
2019-10-18
F622 · Resident Rights Deficiencies
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 2020-01-03
E · Potential for more than minimal harm
2019-10-18
F625 · Resident Rights Deficiencies
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 2020-01-03
E · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-02-26
D · Potential for more than minimal harm
2019-10-18
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 2020-03-15
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-03-15
D · Potential for more than minimal harm
2019-10-18
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 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-02-26
D · Potential for more than minimal harm
2019-10-18
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
F826 · Quality of Life and Care Deficiencies
Health
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-18
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 2020-03-15
D · Potential for more than minimal harm
2019-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-15
D · Potential for more than minimal harm
2019-10-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2020-02-26
G · Actual harm
2018-06-04
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 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-08-24
E · Potential for more than minimal harm
2018-06-04
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 2018-07-26
E · Potential for more than minimal harm
2018-06-04
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 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-08-24
E · Potential for more than minimal harm
2018-06-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-07-26
E · Potential for more than minimal harm
2018-06-04
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 2018-08-24
E · Potential for more than minimal harm
2018-06-04
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 2018-08-24
E · Potential for more than minimal harm
2018-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-26
E · Potential for more than minimal harm
2018-06-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-06-04
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 2018-08-24
D · Potential for more than minimal harm
2018-06-04
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2018-07-26
D · Potential for more than minimal harm
2018-06-04
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-06-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-07-26
D · Potential for more than minimal harm
2018-06-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-07-26
D · Potential for more than minimal harm
2018-06-04
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 2018-07-26
D · Potential for more than minimal harm
2018-06-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2018-07-26
D · Potential for more than minimal harm
2018-06-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-06-04
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 2018-07-26
D · Potential for more than minimal harm
2018-06-04
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 2018-08-24
D · Potential for more than minimal harm
2018-06-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-07-26
D · Potential for more than minimal harm
2018-06-04
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-06-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2018-08-24
Penalties and ownership
What sits behind the stars
Ownership
Gl Virginia Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Davis, Duane
W-2 Managing Employee · Individual
Gentry, Boyd
5% Or Greater Indirect Ownership Interest · Individual
Gentry, Boyd
Corporate Officer · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
Corporate Officer · Individual
Trio Health Care - East, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trio Healthcare Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trio Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
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