Cycle 1
Health 2024-02-08 · Fire 2024-02-08
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Yorktown, VA
Regency Health And Rehabilitation Center
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
112 N Constitution Dr, Yorktown, VA
(757) 890-0675
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1989-05-08
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
0.33
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,856
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.23% · Performance 22.25% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4
Baseline 7.75% · Performance 6.64% · Measure score 4 · Achievement 4 · Improvement 3.54
Total nurse turnover
0
Performance 75.39% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.46 hours · Performance 3.1 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 242 · Observed rate 11.98% · Lower 95% interval 8.43% |
| Discharge to community | 60.1% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 245 · Observed rate 55.1% · Lower 95% interval 53.44% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.56% |
95.27%
0.3 pts better
|
Numerator 172 · Denominator 180 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 180 |
| Discharge self-care score | 68.7% |
53.69%
15 pts better
|
Numerator 79 · Denominator 115 |
| Discharge mobility score | 63.48% |
50.94%
12.5 pts better
|
Numerator 73 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 10 · Denominator 180 · Adjusted rate 5.37% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 6.25% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 121 |
| Staff flu vaccination coverage | 19.87% |
42%
22.1 pts worse
|
Numerator 30 · Denominator 151 |
| Discharge function score | 57.39% |
56.45%
0.9 pts better
|
Numerator 66 · Denominator 115 |
| Transfer of health information to provider | 67.27% |
95.95%
28.7 pts worse
|
Numerator 74 · Denominator 110 |
| Transfer of health information to patient | 87.27% |
96.28%
9 pts worse
|
Numerator 48 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 19.54% |
25.2%
5.7 pts worse
|
Numerator 17 · Denominator 87 |
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 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.4
1.5 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
91.2%
7.6 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.1% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| 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 | 4.8% |
3.6%
1.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.3% · Q3 4.8% · Q4 4.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.8% |
15.7%
24.1 pts worse
|
11.4%
28.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 30.3% · Q3 31.4% · Q4 68.6% · 4Q avg 39.8% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.7%
0.1 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 2.7% · Q3 2.9% · Q4 2.7% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
20.2%
3.8 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 13.5% · Q3 17.1% · Q4 18.9% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
15.0%
2 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 16.1% · Q3 6.5% · Q4 13.3% · 4Q avg 13.0% · 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 | 7.1% |
17.5%
10.4 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
15.7%
7.4 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.7% · Q3 3.6% · Q4 12.9% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.5%
2.9 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.5% · Q3 2.7% · Q4 4.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.6%
1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
22.2%
2.3 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 21.9% · Q3 17.3% · Q4 25.2% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.2%
1.8 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.5% · Q3 7.2% · Q4 6.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.4% |
74.6%
9.2 pts worse
|
81.7%
16.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.4% · Q2 61.4% · Q3 72.6% · Q4 64.3% · 4Q avg 65.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.3% |
11.7%
7.6 pts worse
|
12.0%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 18.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.2%
0.8 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.9% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
73.6%
6.9 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
22.0%
0.9 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 20.3% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-15 · Fire 2021-07-15
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2018-11-01 · Fire 2018-11-01
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-23
F · Potential for more than minimal harm
2021-07-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-08-23
E · Potential for more than minimal harm
2021-07-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-15
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-07-29
F · Potential for more than minimal harm
2018-11-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-14
D · Potential for more than minimal harm
2018-11-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-01-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
D · Potential for more than minimal harm
2025-10-22
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.
Not marked corrected
F · Potential for more than minimal harm
2025-01-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-16
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 2025-02-28
D · Potential for more than minimal harm
2025-01-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-16
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 2025-02-28
D · Potential for more than minimal harm
2025-01-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-02-08
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-08
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 2024-03-12
D · Potential for more than minimal harm
2024-02-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-08
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 2024-03-12
D · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-12
D · Potential for more than minimal harm
2023-11-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-20
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 2023-12-20
E · Potential for more than minimal harm
2021-07-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-23
E · Potential for more than minimal harm
2021-07-15
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 2021-08-23
E · Potential for more than minimal harm
2021-07-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-07-15
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 2021-08-23
D · Potential for more than minimal harm
2021-07-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-08-23
E · Potential for more than minimal harm
2018-11-01
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 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-01
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 2018-12-12
Penalties and ownership
What sits behind the stars
Ownership
Regency Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Brown, Justin
Corporate Director · Individual
Brown, Justin
W-2 Managing Employee · Individual
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Chesapeake East LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Ek 2005 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Fay 2014 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Fay 2014 LLC
5% Or Greater Indirect Ownership Interest · Organization
Ll 2013 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mms 2008 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mzr East LLC
5% Or Greater Indirect Ownership Interest · Organization
Rylbss East Manager LLC
Operational/Managerial Control · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Silverstone East LLC
5% Or Greater Indirect Ownership Interest · Organization
Sol 2000 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Stevens 3920 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Stevens 3920 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Stevens 3920 LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
York Nursing & Rehabilitation Center
Yorktown, VA
3-star overall rating with 2-star inspections with abuse icon flag with $48,831 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Old Dominion Rehabilitation And Nursing
Newport News, VA
1-star overall rating with 2-star inspections with 31 recent health deficiencies with 25 fire-safety deficiencies in the latest cycle
#3
Bayside Of Poquoson Health And Rehab
Poquoson, VA
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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