Cycle 1
Health 2024-07-24 · Fire 2023-06-23
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pulaski, VA
Pulaski Hlth & Rehab Cntr
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2401 Lee Highway, Pulaski, VA
(540) 980-3111
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1995-01-01
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
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
0.63
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.58
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
2.61
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,121
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.42
Baseline 19.12% · Performance 18.46% · Measure score 6.42 · Achievement 6.42 · Improvement 2.67
Healthcare-associated infections
2.64
Baseline 9.79% · Performance 8.28% · Measure score 2.64 · Achievement 0 · Improvement 2.64
Total nurse turnover
3.21
Baseline 75.89% · Performance 56.94% · Measure score 3.21 · Achievement 1.65 · Improvement 3.21
Adjusted total nurse staffing
0
Baseline 2.70 hours · Performance 2.47 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 256 · Observed rate 10.94% · Lower 95% interval 7.98% |
| Discharge to community | 62.74% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 253 · Observed rate 57.31% · Lower 95% interval 55.11% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 146 · Denominator 146 |
| Falls with major injury | 1.37% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 146 |
| Discharge self-care score | 66.33% |
53.69%
12.6 pts better
|
Numerator 65 · Denominator 98 |
| Discharge mobility score | 72.45% |
50.94%
21.5 pts better
|
Numerator 71 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 4.11% |
2.29%
1.8 pts worse
|
Numerator 6 · Denominator 146 · Adjusted rate 4.35% |
| Healthcare-associated infections requiring hospitalization | 8.28% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 8.86% · Lower 95% interval 5.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 84.24% |
42%
42.2 pts better
|
Numerator 171 · Denominator 203 |
| Discharge function score | 72.45% |
56.45%
16 pts better
|
Numerator 71 · Denominator 98 |
| Transfer of health information to provider | 85.06% |
95.95%
10.9 pts worse
|
Numerator 74 · Denominator 87 |
| Transfer of health information to patient | 85.71% |
96.28%
10.6 pts worse
|
Numerator 30 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 42.17% |
25.2%
17 pts better
|
Numerator 35 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.5
1.1 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
91.2%
4.3 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 89.1% · Q3 97.1% · Q4 98.4% · 4Q avg 95.5% |
| 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 | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.6% · Q3 4.4% · Q4 7.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 54.5% |
15.7%
38.8 pts worse
|
11.4%
43.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.9% · Q2 41.3% · Q3 79.7% · Q4 60.3% · 4Q avg 54.5% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
5.7%
4.6 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 12.9% · Q3 14.1% · Q4 11.5% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
20.2%
2.8 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 20.3% · Q3 28.1% · Q4 20.6% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
15.0%
2.7 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 16.7% · Q3 15.7% · Q4 17.9% · 4Q avg 17.7% · 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 | 11.5% |
17.5%
6 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
15.7%
3.2 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.2% · Q3 15.0% · Q4 22.6% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.6%
0.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.8% |
22.2%
3.4 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 17.7% · Q3 15.2% · Q4 19.1% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.2%
0.1 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.7% · Q3 4.4% · Q4 5.1% · 4Q avg 5.3% · 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 87.8% · Q2 92.6% · Q3 93.2% · Q4 95.7% · 4Q avg 92.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.7%
1.4 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 12.3% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 2.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
73.6%
22.3 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.2% |
22.0%
12.8 pts better
|
23.9%
14.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.1% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-23 · Fire 2021-11-19
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-11-19 · Fire 2019-01-03
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-04
F · Potential for more than minimal harm
2023-06-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-04
E · Potential for more than minimal harm
2023-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-04
E · Potential for more than minimal harm
2023-06-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-06-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-06-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-21
F · Potential for more than minimal harm
2021-11-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-25
F · Potential for more than minimal harm
2021-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-10
F · Potential for more than minimal harm
2021-11-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-16
F · Potential for more than minimal harm
2021-11-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-10
F · Potential for more than minimal harm
2021-11-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-02-25
F · Potential for more than minimal harm
2021-11-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-17
F · Potential for more than minimal harm
2021-11-19
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 2022-02-25
E · Potential for more than minimal harm
2021-11-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-10
E · Potential for more than minimal harm
2021-11-19
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-02-25
E · Potential for more than minimal harm
2021-11-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-25
D · Potential for more than minimal harm
2021-11-19
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 2022-06-10
E · Potential for more than minimal harm
2019-01-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-02-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-06
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 2025-11-21
D · Potential for more than minimal harm
2025-11-06
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 2025-11-21
E · Potential for more than minimal harm
2024-07-24
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 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
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 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
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 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
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 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-24
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-08-26
E · Potential for more than minimal harm
2023-06-23
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 2023-08-04
D · Potential for more than minimal harm
2023-06-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-04
E · Potential for more than minimal harm
2021-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-27
D · Potential for more than minimal harm
2021-11-19
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 2021-12-27
D · Potential for more than minimal harm
2021-11-19
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 2021-12-27
D · Potential for more than minimal harm
2021-11-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-12-27
D · Potential for more than minimal harm
2021-11-19
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 2021-12-27
D · Potential for more than minimal harm
2021-11-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-27
D · Potential for more than minimal harm
2021-11-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-12-27
Penalties and ownership
What sits behind the stars
Ownership
Pulaski Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
America West LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Charles 1994 LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 LLC
5% Or Greater Indirect Ownership Interest · Organization
Kss 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Ml 2000 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mrv West LLC
5% Or Greater Indirect Ownership Interest · Organization
Rczbm West Manager LLC
Operational/Managerial Control · Organization
Redrock West LLC
5% Or Greater Indirect Ownership Interest · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Turner, Terressa
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Highland Ridge Rehab Center
Dublin, VA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Radford Health And Rehab Center
Radford, VA
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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
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