Cycle 1
Health 2025-04-08 · Fire 2025-04-08
56 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rural Retreat, VA
Mountain Laurel Rehabilitation And Nursing
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $204,839 in total fines with 56 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
514 North Main Street, Rural Retreat, VA
(276) 686-7000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eastern Healthcare Group
Operator or chain grouping
Approved since
2015-01-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 1 overall / 2 health / 1 staffing / 3 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
0.48
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.22
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
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,618
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.47% · Performance 21.48% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.43% · Performance 9.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.80
Performance 60.40% · Measure score 0.80 · Achievement 0.80 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.31
Baseline 2.68 hours · Performance 2.93 hours · Measure score 0.31 · Achievement 0 · Improvement 0.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.07% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 14.05% · Lower 95% interval 8.78% |
| Discharge to community | 29.01% |
50.57%
21.6 pts worse
|
Worse than the National Rate · Eligible stays 105 · Observed rate 22.86% · Lower 95% interval 22.61% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 57 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 42.5% |
53.69%
11.2 pts worse
|
Numerator 17 · Denominator 40 |
| Discharge mobility score | 47.5% |
50.94%
3.4 pts worse
|
Numerator 19 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 1.62% |
| Healthcare-associated infections requiring hospitalization | 9.79% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 13.7% · Lower 95% interval 5.74% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 17.05% |
42%
24.9 pts worse
|
Numerator 37 · Denominator 217 |
| Discharge function score | 45% |
56.45%
11.5 pts worse
|
Numerator 18 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 86.21% |
96.28%
10.1 pts worse
|
Numerator 25 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 3.03% |
25.2%
22.2 pts worse
|
Numerator 1 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · 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 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 39.7% |
91.2%
51.5 pts worse
|
93.4%
53.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 29.6% · Q3 50.6% · Q4 49.4% · 4Q avg 39.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
94.0%
0.2 pts better
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.6%
0.4 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 1.1% · Q4 5.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.1% |
15.7%
0.4 pts worse
|
11.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 24.7% · Q3 10.4% · Q4 11.0% · 4Q avg 16.1% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.7%
0.3 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 7.2% · Q4 10.7% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.9% |
20.2%
20.7 pts worse
|
19.6%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 38.7% · Q3 41.2% · Q4 39.3% · 4Q avg 40.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
15.0%
3 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 9.5% · Q3 14.1% · Q4 12.5% · 4Q avg 12.0% · 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 | 16.1% |
17.5%
1.4 pts better
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 18.2% · Q3 9.7% · Q4 12.1% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
15.7%
5.5 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.6% · Q3 4.5% · Q4 7.0% · 4Q avg 10.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.6%
1.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.1% · Q3 1.1% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
22.2%
0.9 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 25.9% · Q3 23.8% · Q4 19.9% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.2%
3.4 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 7.4% |
74.6%
67.2 pts worse
|
81.7%
74.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.2% · Q3 13.8% · Q4 14.1% · 4Q avg 7.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.9% |
11.7%
11.2 pts worse
|
12.0%
10.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 20.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 16.5% |
73.6%
57.1 pts worse
|
79.7%
63.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 16.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
22.0%
0.5 pts worse
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 22.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-14 · Fire 2023-08-14
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-07-01 · Fire 2021-07-01
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-08
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-28
D · Potential for more than minimal harm
2023-08-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-13
F · Potential for more than minimal harm
2021-07-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-08-30
F · Potential for more than minimal harm
2021-07-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-08-30
E · Potential for more than minimal harm
2021-07-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-10-07
E · Potential for more than minimal harm
2021-07-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-10-07
E · Potential for more than minimal harm
2021-07-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-30
D · Potential for more than minimal harm
2021-07-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-30
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-08
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 2025-05-15
J · Immediate jeopardy
2025-04-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-24
J · Immediate jeopardy
2025-04-08
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-05-15
G · Actual harm
2025-04-08
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-05-15
G · Actual harm
2025-04-08
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 2025-05-15
G · Actual harm
2025-04-08
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2025-05-15
G · Actual harm
2025-04-08
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-08
F578 · Resident Rights Deficiencies
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 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-05-15
E · Potential for more than minimal harm
2025-04-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-06-24
E · Potential for more than minimal harm
2025-04-08
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 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-06-24
E · Potential for more than minimal harm
2025-04-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-05-15
E · Potential for more than minimal harm
2025-04-08
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-06-24
E · Potential for more than minimal harm
2025-04-08
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 2025-06-24
E · Potential for more than minimal harm
2025-04-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-08
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 2025-06-24
E · Potential for more than minimal harm
2025-04-08
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-08
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-06-24
D · Potential for more than minimal harm
2025-04-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-04-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-06-24
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F840 · Administration Deficiencies
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 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-24
D · Potential for more than minimal harm
2025-04-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-15
C · Minimal harm
2025-04-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-15
G · Actual harm
2024-12-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-04
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 2025-01-31
D · Potential for more than minimal harm
2024-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-04
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 2025-01-31
D · Potential for more than minimal harm
2024-12-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
E · Potential for more than minimal harm
2023-08-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-14
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 2023-09-13
E · Potential for more than minimal harm
2023-08-14
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-14
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 2023-09-13
D · Potential for more than minimal harm
2023-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-14
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 2023-09-13
D · Potential for more than minimal harm
2023-08-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-14
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-14
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 2023-09-13
D · Potential for more than minimal harm
2023-08-14
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 2023-09-13
D · Potential for more than minimal harm
2023-08-14
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-14
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-09-13
F · Potential for more than minimal harm
2021-07-01
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 2021-07-31
E · Potential for more than minimal harm
2021-07-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-31
E · Potential for more than minimal harm
2021-07-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F578 · Resident Rights Deficiencies
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 2021-07-31
D · Potential for more than minimal harm
2021-07-01
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 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
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 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-07-31
Penalties and ownership
What sits behind the stars
$170,017
2025-04-08
Fine
Fine · fine $170,017
Fine
$8,357
2024-12-04
Fine
Fine · fine $8,357
Fine
$4,235
2023-09-25
Fine
Fine · fine $4,235
Fine
$3,882
2023-09-18
Fine
Fine · fine $3,882
Fine
$3,529
2023-09-11
Fine
Fine · fine $3,529
Fine
$3,176
2023-09-05
Fine
Fine · fine $3,176
Fine
$2,823
2023-08-28
Fine
Fine · fine $2,823
Fine
$2,470
2023-08-21
Fine
Fine · fine $2,470
Fine
$2,117
2023-08-14
Fine
Fine · fine $2,117
Fine
$4,233
2023-07-24
Fine
Fine · fine $4,233
Fine
Ownership
Va SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Lyam Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ydi Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Capital Funding Group
Operational/Managerial Control · Organization
Capital Funding Group
5% Or Greater Mortgage Interest · Organization
Gittleson, Yehuda
Operational/Managerial Control · Individual
Hajimomenian, Amir
Operational/Managerial Control · Individual
Hartman, Aaron
Operational/Managerial Control · Individual
Shapiro, Akiva
Operational/Managerial Control · Individual
Shapiro, Akiva
Corporate Officer · Individual
Sommer, Nechama
Operational/Managerial Control · Individual
Va SNF Master Consulting LLC
Operational/Managerial Control · Organization
Va SNF Operations Holdings 3 LLC
Operational/Managerial Control · Organization
Ydi Eastern Holdco LLC
Operational/Managerial Control · Organization
Nearby options
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4-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#2
Holston Health and Rehabilitation
Wytheville, VA
1-star overall rating with 1-star inspections with $111,911 in total fines with 32 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Francis Marion Manor Health & Rehabilitation
Marion, VA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
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