Danville, VA

Piney Forest Health And Rehabilitation Center

2-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

450 Piney Forest Rd, Danville, VA

(434) 799-1565

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

113

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lifeworks Rehab

Operator or chain grouping

Approved since

1978-01-01

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

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

0.38

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.98

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

1.81

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

3.16

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.36

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

2.85

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.16

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.32

CMS adjusted RN staffing hours

Adjusted total hours

2.69

CMS adjusted total nurse staffing hours

Case-mix index

1.61

Higher values indicate more complex resident acuity

RN turnover

23%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

59%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,853

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.87

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.17

Baseline 19.17% · Performance 20.43% · Measure score 2.17 · Achievement 2.17 · Improvement 0

Healthcare-associated infections

4.19

Baseline 7.58% · Performance 6.58% · Measure score 4.19 · Achievement 4.19 · Improvement 3.37

Total nurse turnover

1.19

Performance 58.82% · Measure score 1.19 · Achievement 1.19 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

Baseline 2.81 hours · Performance 2.67 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.27%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 78 · Observed rate 14.1% · Lower 95% interval 8.19%
Discharge to community	47.22%	50.57% 3.4 pts worse	No Different than the National Rate · Eligible stays 81 · Observed rate 37.04% · Lower 95% interval 35.81%
Medicare spending per beneficiary	1.08	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 59 · Denominator 59
Falls with major injury	3.39%	0.77% 2.6 pts worse	Numerator 2 · Denominator 59
Discharge self-care score	60.53%	53.69% 6.8 pts better	Numerator 23 · Denominator 38
Discharge mobility score	63.16%	50.94% 12.2 pts better	Numerator 24 · Denominator 38
Pressure ulcers or injuries, new or worsened	3.39%	2.29% 1.1 pts worse	Numerator 2 · Denominator 59 · Adjusted rate 3.21%
Healthcare-associated infections requiring hospitalization	6.58%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 3.59%
Staff COVID-19 vaccination coverage	1.94%	8.2% 6.3 pts worse	Numerator 3 · Denominator 155
Staff flu vaccination coverage	5.26%	42% 36.7 pts worse	Numerator 8 · Denominator 152
Discharge function score	63.16%	56.45% 6.7 pts better	Numerator 24 · Denominator 38
Transfer of health information to provider	60%	95.95% 36 pts worse	Numerator 12 · Denominator 20
Transfer of health information to patient	78.26%	96.28% 18 pts worse	Numerator 18 · Denominator 23
Resident COVID-19 vaccinations up to date	10.26%	25.2% 14.9 pts worse	Numerator 4 · Denominator 39

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.1	1.5 0.4 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.4 0.2 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.5%	91.2% 7.3 pts better	93.4% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 97.9% · Q4 97.0% · 4Q avg 98.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.0% 6 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.6% 0.3 pts better	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 1.1% · Q4 6.0% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	36.9%	15.7% 21.2 pts worse	11.4% 25.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 43.4% · Q2 27.0% · Q3 29.2% · Q4 46.8% · 4Q avg 36.9%
Percentage of long-stay residents who lose too much weight	5.2%	5.7% 0.5 pts better	5.4% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 7.0% · Q3 7.4% · Q4 2.3% · 4Q avg 5.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.1%	20.2% 4.9 pts worse	19.6% 5.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 28.1% · Q3 22.9% · Q4 27.6% · 4Q avg 25.1%
Percentage of long-stay residents who received an antipsychotic medication	25.7%	15.0% 10.7 pts worse	16.7% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 27.0% · Q3 23.7% · Q4 22.5% · 4Q avg 25.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	3.7%	17.5% 13.8 pts better	16.3% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 4.8% · Q4 4.6% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.0%	15.7% 9.7 pts better	14.9% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 8.9% · Q4 5.0% · 4Q avg 6.0% · 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 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	1.6% 0.6 pts better	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.0%	22.2% 2.2 pts better	19.8% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 18.6% · Q3 19.3% · Q4 19.4% · 4Q avg 20.0%
Percentage of long-stay residents with pressure ulcers	3.8%	5.2% 1.4 pts better	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.1% · Q3 4.0% · Q4 4.6% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	92.6%	74.6% 18 pts better	81.7% 10.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 94.4% · Q3 91.8% · Q4 89.8% · 4Q avg 92.6%
Percentage of short-stay residents who had an outpatient emergency department visit	21.0%	11.7% 9.3 pts worse	12.0% 9 pts worse	Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 21.1% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.2% 0.2 pts worse	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.8%	73.6% 19.2 pts better	79.7% 13.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.3%	22.0% 1.7 pts better	23.9% 3.6 pts better	Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 21.1% · Expected 24.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2022-04-15 · Fire 2022-04-15

16 health deficiencies

Top issue: Pharmacy Service (5 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-02-07 · Fire 2019-02-07

7 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-01-30

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-01-30

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-03-17

D · Potential for more than minimal harm 2025-01-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-14

F · Potential for more than minimal harm 2022-04-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-04-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-31

F · Potential for more than minimal harm 2022-04-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-04-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-06-24

F · Potential for more than minimal harm 2022-04-15

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-10-31

E · Potential for more than minimal harm 2022-04-15

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-10-31

E · Potential for more than minimal harm 2022-04-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-12-30

F · Potential for more than minimal harm 2019-02-07

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-04-16

F · Potential for more than minimal harm 2019-02-07

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-04-16

D · Potential for more than minimal harm 2019-02-07

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2019-04-16

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-01-30

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 2025-02-25

E · Potential for more than minimal harm 2025-01-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-25

D · Potential for more than minimal harm 2025-01-30

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 2025-01-10

D · Potential for more than minimal harm 2025-01-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-02-25

D · Potential for more than minimal harm 2025-01-30

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 2025-02-25

D · Potential for more than minimal harm 2025-01-30

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 2025-02-25

D · Potential for more than minimal harm 2023-06-16

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 2023-08-07

E · Potential for more than minimal harm 2022-04-15

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 2022-05-17

E · Potential for more than minimal harm 2022-04-15

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

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 2022-05-17

D · Potential for more than minimal harm 2022-04-15

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 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

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 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

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 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

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 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

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 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-05-17

D · Potential for more than minimal harm 2022-04-15

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2022-05-17

F · Potential for more than minimal harm 2019-02-07

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2019-03-18

E · Potential for more than minimal harm 2019-02-07

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 2019-03-18

D · Potential for more than minimal harm 2019-02-07

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 2019-03-18

D · Potential for more than minimal harm 2019-02-07

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2019-03-18

D · Potential for more than minimal harm 2019-02-07

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 2019-03-18

D · Potential for more than minimal harm 2019-02-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-18

Penalties and ownership

What sits behind the stars

Ownership

Piney Forest Holdings I LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2021-05-28

Charles 1994 Family Grantor Trust