Cycle 1
Health 2023-06-29 · Fire 2023-06-29
19 health deficiencies
Top issue: Resident Rights (8 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Berryville, VA
Rose Hill Health And Rehab
1-star overall rating with 2-star inspections with $24,921 in total fines with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
110 Chalmers Court, Berryville, VA
(540) 955-9995
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trio Healthcare
Operator or chain grouping
Approved since
1984-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 1 overall / 2 health / 1 staffing / 3 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
0.41
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,283
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.37
Baseline 24.24% · Performance 22.18% · Measure score 2.37 · Achievement 0 · Improvement 2.37
Healthcare-associated infections
0
Baseline 6.56% · Performance 12.30% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.34
Baseline 83.97% · Performance 67.20% · Measure score 2.34 · Achievement 0 · Improvement 2.34
Adjusted total nurse staffing
0.52
Baseline 2.78 hours · Performance 3.09 hours · Measure score 0.52 · Achievement 0 · Improvement 0.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 148 · Observed rate 12.16% · Lower 95% interval 7.78% |
| Discharge to community | 49.82% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 145 · Observed rate 42.07% · Lower 95% interval 41.6% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.71% |
95.27%
2.6 pts worse
|
Numerator 89 · Denominator 96 |
| Falls with major injury | 1.04% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 96 |
| Discharge self-care score | 44.83% |
53.69%
8.9 pts worse
|
Numerator 26 · Denominator 58 |
| Discharge mobility score | 31.03% |
50.94%
19.9 pts worse
|
Numerator 18 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 96 · Adjusted rate 2.13% |
| Healthcare-associated infections requiring hospitalization | 12.3% |
7.12%
5.2 pts worse
|
Worse than the National Rate · Eligible stays 96 · Observed rate 17.71% · Lower 95% interval 8.85% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 114 |
| Staff flu vaccination coverage | 2.65% |
42%
39.4 pts worse
|
Numerator 3 · Denominator 113 |
| Discharge function score | 37.93% |
56.45%
18.5 pts worse
|
Numerator 22 · Denominator 58 |
| Transfer of health information to provider | 97.56% |
95.95%
1.6 pts better
|
Numerator 40 · Denominator 41 |
| Transfer of health information to patient | 93.75% |
96.28%
2.5 pts worse
|
Numerator 30 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 28.95% |
25.2%
3.8 pts better
|
Numerator 11 · Denominator 38 |
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 | 1.3 |
1.4
0.1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.3% |
3.6%
0.7 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.8% · Q3 5.6% · Q4 5.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 46.6% |
15.7%
30.9 pts worse
|
11.4%
35.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.1% · Q2 45.7% · Q3 38.2% · Q4 42.2% · 4Q avg 46.6% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.7%
3.2 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 4.2% · Q4 1.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
20.2%
7.1 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.8% · Q3 14.0% · Q4 13.2% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
15.0%
6.7 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.3% · Q3 10.7% · Q4 11.9% · 4Q avg 8.3% · 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 | 29.1% |
17.5%
11.6 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 35.9% · Q3 29.4% · Q4 15.8% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.1% |
15.7%
14.4 pts worse
|
14.9%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 29.8% · Q3 37.1% · Q4 26.6% · 4Q avg 30.1% · 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 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.6%
1.4 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
22.2%
7.2 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 29.0% · Q3 29.6% · Q4 33.2% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.2%
3.9 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.8% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
74.6%
18.3 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 95.5% · Q3 94.7% · Q4 90.6% · 4Q avg 92.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.7%
3.9 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.6% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.0% |
73.6%
20.4 pts better
|
79.7%
14.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
22.0%
4.8 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 26.6% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-02 · Fire 2021-12-02
25 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-03-10 · Fire 2020-03-10
45 health deficiencies
Top issue: Resident Assessment and Care Planning (11 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-06-29
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 2023-09-21
D · Potential for more than minimal harm
2023-06-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-21
D · Potential for more than minimal harm
2021-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-27
D · Potential for more than minimal harm
2021-12-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-27
C · Minimal harm
2020-03-10
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-04-08
C · Minimal harm
2020-03-10
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-04-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-08-14
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 2024-10-30
D · Potential for more than minimal harm
2024-08-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-16
E · Potential for more than minimal harm
2023-12-13
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 2024-01-16
E · Potential for more than minimal harm
2023-12-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-13
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 2024-01-16
D · Potential for more than minimal harm
2023-12-13
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 2024-01-16
D · Potential for more than minimal harm
2023-12-13
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 2024-01-16
D · Potential for more than minimal harm
2023-12-13
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 2024-01-16
D · Potential for more than minimal harm
2023-12-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-13
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 2024-01-16
E · Potential for more than minimal harm
2023-06-29
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-29
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 2023-07-27
E · Potential for more than minimal harm
2023-06-29
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 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
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 2023-07-27
D · Potential for more than minimal harm
2023-06-29
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 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F584 · Resident Rights Deficiencies
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 2023-07-27
D · Potential for more than minimal harm
2023-06-29
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 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
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 2023-07-27
D · Potential for more than minimal harm
2023-06-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
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 2023-07-27
G · Actual harm
2023-03-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-29
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 2023-05-19
E · Potential for more than minimal harm
2023-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-29
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 2023-05-19
D · Potential for more than minimal harm
2023-03-29
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 2023-05-19
D · Potential for more than minimal harm
2023-03-29
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-09-14
D · Potential for more than minimal harm
2023-03-29
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 2023-04-26
D · Potential for more than minimal harm
2023-03-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-29
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 2023-04-26
D · Potential for more than minimal harm
2023-03-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-03-29
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 2023-05-05
D · Potential for more than minimal harm
2023-03-29
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 2023-05-19
D · Potential for more than minimal harm
2023-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-26
E · Potential for more than minimal harm
2021-12-02
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-01-04
E · Potential for more than minimal harm
2021-12-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-01-04
E · Potential for more than minimal harm
2021-12-02
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 2022-01-04
E · Potential for more than minimal harm
2021-12-02
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 2022-01-04
E · Potential for more than minimal harm
2021-12-02
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 2022-01-04
E · Potential for more than minimal harm
2021-12-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F690 · Quality of Life and Care Deficiencies
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-01-04
D · Potential for more than minimal harm
2021-12-02
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
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 2022-01-04
D · Potential for more than minimal harm
2021-12-02
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-01-04
E · Potential for more than minimal harm
2020-03-10
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 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
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 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
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 2020-04-08
E · Potential for more than minimal harm
2020-03-10
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 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-10
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 2020-04-08
E · Potential for more than minimal harm
2020-03-10
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 2020-04-08
E · Potential for more than minimal harm
2020-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-08
D · Potential for more than minimal harm
2020-03-10
F584 · Resident Rights Deficiencies
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 2020-04-08
D · Potential for more than minimal harm
2020-03-10
F690 · Quality of Life and Care Deficiencies
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 2020-04-08
D · Potential for more than minimal harm
2020-03-10
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2020-04-08
D · Potential for more than minimal harm
2020-03-10
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 2020-04-08
D · Potential for more than minimal harm
2020-03-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-04-08
C · Minimal harm
2020-03-10
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2020-04-08
C · Minimal harm
2020-03-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2020-04-08
Penalties and ownership
What sits behind the stars
$24,921
2023-03-29
Fine
Fine · fine $24,921
Fine
Ownership
Gl Virginia Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Fields, Joseph
W-2 Managing Employee · Individual
Gentry, Boyd
5% Or Greater Indirect Ownership Interest · Individual
Gentry, Boyd
Corporate Officer · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
Corporate Officer · Individual
Trio Health Care - East, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trio Healthcare Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trio Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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Evergreen Health And Rehabilitation Center
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2-star overall rating with 2-star inspections with $8,190 in total fines with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Winchester Health & Rehabilitation
Winchester, VA
2-star overall rating with 1-star inspections with 31 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Shenandoah Valley Westminster Canterbury
Winchester, VA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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