6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Danville, VA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2526 North Main Street, Danville, VA
(434) 836-9510
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
312
Certified beds
Average residents
220
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
Staffing
RN hours / resident day
0.65
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
2.46
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
10,305
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.31% · Performance 21.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.50% · Performance 9.80% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.14
Baseline 27.75% · Performance 42.69% · Measure score 5.14 · Achievement 5.14 · Improvement 0
Adjusted total nurse staffing
3.2
Baseline 3.70 hours · Performance 3.99 hours · Measure score 3.2 · Achievement 3.2 · Improvement 0.89
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.57% |
10.72%
2.2 pts better
|
Better than the National Rate · Eligible stays 435 · Observed rate 6.9% · Lower 95% interval 6.57% |
| Discharge to community | 54.11% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 469 · Observed rate 49.25% · Lower 95% interval 50.22% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 78.21% |
95.27%
17.1 pts worse
|
Numerator 201 · Denominator 257 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 4 · Denominator 257 |
| Discharge self-care score | 61.93% |
53.69%
8.2 pts better
|
Numerator 109 · Denominator 176 |
| Discharge mobility score | 63.07% |
50.94%
12.1 pts better
|
Numerator 111 · Denominator 176 |
| Pressure ulcers or injuries, new or worsened | 5.84% |
2.29%
3.5 pts worse
|
Numerator 15 · Denominator 257 · Adjusted rate 6.25% |
| Healthcare-associated infections requiring hospitalization | 9.8% |
7.12%
2.7 pts worse
|
Worse than the National Rate · Eligible stays 287 · Observed rate 10.8% · Lower 95% interval 7.34% |
| Staff COVID-19 vaccination coverage | 2.22% |
8.2%
6 pts worse
|
Numerator 7 · Denominator 315 |
| Staff flu vaccination coverage | 17.17% |
42%
24.8 pts worse
|
Numerator 57 · Denominator 332 |
| Discharge function score | 61.93% |
56.45%
5.5 pts better
|
Numerator 109 · Denominator 176 |
| Transfer of health information to provider | 23.19% |
95.95%
72.8 pts worse
|
Numerator 16 · Denominator 69 |
| Transfer of health information to patient | 71.74% |
96.28%
24.5 pts worse
|
Numerator 99 · Denominator 138 |
| Resident COVID-19 vaccinations up to date | 17.91% |
25.2%
7.3 pts worse
|
Numerator 24 · Denominator 134 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.8 · 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 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
91.2%
5.4 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.3% · Q3 97.3% · Q4 92.4% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.5% |
94.0%
5.5 pts better
|
95.5%
4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 3.2% · Q4 3.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
15.7%
15.5 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.7%
1.8 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.6% · Q3 6.4% · Q4 9.4% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
20.2%
1.8 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 22.9% · Q3 21.6% · Q4 20.1% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.1% |
15.0%
13.1 pts worse
|
16.7%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 26.2% · Q3 28.4% · Q4 30.7% · 4Q avg 28.1% · 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 | 24.7% |
17.5%
7.2 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 30.7% · Q3 28.3% · Q4 21.5% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.6% |
15.7%
9.9 pts worse
|
14.9%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 25.2% · Q3 28.9% · Q4 25.7% · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 0.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
1.6%
3.2 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.5% · Q3 2.2% · Q4 2.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
22.2%
3.2 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 21.0% · Q3 18.6% · Q4 17.2% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.2%
0.3 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 4.3% · Q3 5.6% · Q4 3.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
74.6%
20.1 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 96.2% · Q3 95.1% · Q4 91.0% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.1% |
11.7%
6.4 pts worse
|
12.0%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 17.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.2%
2.1 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 3.6% · Q3 5.5% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
73.6%
20.2 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
22.0%
0.8 pts worse
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 22.6% · Expected 23.7% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
11 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Top issue: Resident Rights (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-16
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-16
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-05-16
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-05-16
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-01-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-04-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-04-01
Fire Safety
Use approved construction type or materials.
Corrected 2022-01-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-01
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-04-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-20
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-01-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-12-28
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-12-28
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-12-28
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-12-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-12-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-12-28
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2018-12-28
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-12-28
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2018-12-28
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-12-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-28
Inspection history
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-27
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-27
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 2023-04-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-27
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-01-14
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-14
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 2022-01-14
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-01-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-12-14
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2018-12-14
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-12-14
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-12-14
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 2018-12-14
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 2018-12-14
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-12-14
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2018-12-14
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 2018-12-14
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-12-14
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 2018-12-14
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2018-12-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-12-14
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 2018-12-14
Health
Provide activities to meet all resident's needs.
Corrected 2018-12-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-12-14
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 2018-12-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-12-14
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-14
Penalties and ownership
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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