Cycle 1
Health 2021-04-29 · Fire 2021-04-29
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Norton, VA
Norton Community Hospital SNF Unit
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
100 15th St Nw, Norton, VA
(276) 679-9100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
7
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
4.32
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.24
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
8.31
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
5.07
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
7.06
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
3.29
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
1.38
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
4.22
CMS adjusted RN staffing hours
Adjusted total hours
8.14
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
19%
Annual nurse turnover · state 48% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 97.37% |
95.27%
2.1 pts better
|
Numerator 37 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 77.42% |
53.69%
23.7 pts better
|
Numerator 24 · Denominator 31 |
| Discharge mobility score | 67.74% |
50.94%
16.8 pts better
|
Numerator 21 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 39 |
| Staff flu vaccination coverage | 95.65% |
42%
53.7 pts better
|
Numerator 22 · Denominator 23 |
| Discharge function score | 74.19% |
56.45%
17.7 pts better
|
Numerator 23 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
74.6%
12 pts better
|
81.7%
4.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.5% · Q2 83.6% · Q3 90.6% · Q4 93.8% · 4Q avg 86.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
11.7%
0.3 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.5% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.9% · Q4 3.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.5% |
73.6%
11.9 pts better
|
79.7%
5.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.3% |
22.0%
11.3 pts worse
|
23.9%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.3% · Observed 34.6% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2018-09-06 · Fire 2018-09-06
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2017-06-08 · Fire 2017-06-08
21 health deficiencies
Top issue: Administration (4 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-04-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-04-29
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 2021-06-01
D · Potential for more than minimal harm
2021-04-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-06-01
F · Potential for more than minimal harm
2018-09-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2018-11-30
F · Potential for more than minimal harm
2017-06-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
Inspection history
Recent health citations
F · Potential for more than minimal harm
2021-04-29
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 2021-06-18
D · Potential for more than minimal harm
2021-04-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-18
D · Potential for more than minimal harm
2021-04-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-18
D · Potential for more than minimal harm
2021-04-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-06-18
D · Potential for more than minimal harm
2021-04-29
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 2021-06-18
D · Potential for more than minimal harm
2021-04-29
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 2021-06-18
D · Potential for more than minimal harm
2021-04-29
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2021-06-18
D · Potential for more than minimal harm
2021-04-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-18
D · Potential for more than minimal harm
2018-09-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-09-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-09-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-09-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-09-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-09-06
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 2018-10-05
D · Potential for more than minimal harm
2018-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-05
F · Potential for more than minimal harm
2017-06-08
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-07-21
F · Potential for more than minimal harm
2017-06-08
F372 · Environmental Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2017-07-21
F · Potential for more than minimal harm
2017-06-08
F520 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Corrected 2017-07-21
E · Potential for more than minimal harm
2017-06-08
F272 · Resident Assessment and Care Planning Deficiencies
Health
Conduct initial and periodic assessments of each resident's functional capacity.
Corrected 2017-07-21
E · Potential for more than minimal harm
2017-06-08
F329 · Pharmacy Service Deficiencies
Health
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Corrected 2017-07-21
E · Potential for more than minimal harm
2017-06-08
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 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F157 · 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 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F164 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F241 · Resident Rights Deficiencies
Health
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F279 · Resident Assessment and Care Planning Deficiencies
Health
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F280 · Resident Assessment and Care Planning Deficiencies
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F281 · Quality of Life and Care Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
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 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F500 · 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 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F502 · Administration Deficiencies
Health
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.
Corrected 2017-07-21
D · Potential for more than minimal harm
2017-06-08
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2017-07-21
C · Minimal harm
2017-06-08
F167 · Resident Rights Deficiencies
Health
Allow residents to easily view the results of the nursing home's most recent inspection.
Corrected 2017-07-21
C · Minimal harm
2017-06-08
F334 · Quality of Life and Care Deficiencies
Health
Develop policies and procedures for influenza and pneumococcal immunizations.
Corrected 2017-07-21
C · Minimal harm
2017-06-08
F356 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information/data on a daily basis.
Corrected 2017-07-21
Penalties and ownership
What sits behind the stars
Ownership
Ballad Health
5% Or Greater Indirect Ownership Interest · Organization
Wellmont Health System
5% Or Greater Direct Ownership Interest · Organization
Bennett, Julie
Corporate Director · Individual
Bennett, Julie
Corporate Officer · Individual
Deaton, Buford
Corporate Director · Individual
Deaton, Buford
Corporate Officer · Individual
Eichorn, Marvin
Corporate Director · Individual
Eichorn, Marvin
Corporate Officer · Individual
Hilton, Shane
Corporate Director · Individual
Hilton, Shane
Corporate Officer · Individual
Levine, Alan
Corporate Director · Individual
Levine, Alan
Corporate Officer · Individual
Newberry, Brian
Operational/Managerial Control · Individual
Showalter, Shannon
Operational/Managerial Control · Individual
Wilgocki, Gregory
Corporate Director · Individual
Nearby options
Other facilities in reach
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Heritage Hall Wise
Wise, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Heritage Hall Big Stone Gap
Big Stone Gap, VA
3-star overall rating with 3-star inspections with $71,620 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Letcher Manor
Whitesburg, KY
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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