Cycle 1
Health 2023-02-23 · Fire 2023-02-23
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Buena Vista, VA
Shenandoah Valley Health And Rehab
2-star overall rating with 2-star inspections with $61,692 in total fines with 6 recent health deficiencies
3737 Catalpa Ave, Buena Vista, VA
(540) 261-7444
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trio Healthcare
Operator or chain grouping
Approved since
1987-01-27
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
0.45
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.12
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
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,457
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.89
Baseline 18.13% · Performance 18.70% · Measure score 5.89 · Achievement 5.89 · Improvement 0
Healthcare-associated infections
0
Baseline 8.07% · Performance 10.34% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.76
Baseline 94.07% · Performance 57.65% · Measure score 4.76 · Achievement 1.48 · Improvement 4.76
Adjusted total nurse staffing
1.23
Baseline 3.17 hours · Performance 3.43 hours · Measure score 1.23 · Achievement 1.23 · Improvement 0.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.12% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 11.45% · Lower 95% interval 7.93% |
| Discharge to community | 60.04% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 154 · Observed rate 56.49% · Lower 95% interval 52.69% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 92.75% |
95.27%
2.5 pts worse
|
Numerator 64 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 37.25% |
53.69%
16.4 pts worse
|
Numerator 19 · Denominator 51 |
| Discharge mobility score | 13.73% |
50.94%
37.2 pts worse
|
Numerator 7 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 69 · Adjusted rate 5.44% |
| Healthcare-associated infections requiring hospitalization | 10.34% |
7.12%
3.2 pts worse
|
Worse than the National Rate · Eligible stays 87 · Observed rate 13.79% · Lower 95% interval 7.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 50 |
| Staff flu vaccination coverage | 3.28% |
42%
38.7 pts worse
|
Numerator 2 · Denominator 61 |
| Discharge function score | 23.53% |
56.45%
32.9 pts worse
|
Numerator 12 · Denominator 51 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.89% |
25.2%
16.3 pts worse
|
Numerator 4 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.4
0.8 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · 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 | 98.6% |
94.0%
4.6 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.0% |
3.6%
8.4 pts worse
|
3.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.1% · Q3 12.7% · Q4 5.6% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.9% |
15.7%
3.8 pts better
|
11.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 16.1% · Q3 14.9% · Q4 5.7% · 4Q avg 11.9% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
5.7%
4.9 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.1% |
20.2%
3.9 pts worse
|
19.6%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 23.3% · Q3 22.2% · Q4 29.9% · 4Q avg 24.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
15.0%
11.2 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.0% · Q3 3.6% · Q4 3.6% · 4Q avg 3.8% · 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 | 29.2% |
17.5%
11.7 pts worse
|
16.3%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 31.0% · Q3 31.7% · Q4 18.6% · 4Q avg 29.2% · 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 32.8% · Q2 19.3% · Q3 24.6% · Q4 25.0% · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.5%
1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.6% · Q3 2.2% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
22.2%
3.8 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 19.3% · Q3 27.9% · Q4 29.7% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.2%
1.1 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.0% · Q3 9.9% · Q4 6.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
74.6%
20.9 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 95.2% · Q3 96.3% · Q4 96.4% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
11.7%
3.2 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.5% · 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 | 92.9% |
73.6%
19.3 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
22.0%
4.5 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 17.7% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-27 · Fire 2021-05-27
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-03-14 · Fire 2019-03-14
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-05-27
K321 · Smoke Deficiencies
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 2021-08-05
D · Potential for more than minimal harm
2021-05-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-08-05
D · Potential for more than minimal harm
2021-05-27
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-08-05
D · Potential for more than minimal harm
2021-05-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-05
E · Potential for more than minimal harm
2019-03-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-05-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-17
D · Potential for more than minimal harm
2025-01-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-17
G · Actual harm
2024-01-31
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 2024-04-01
G · Actual harm
2024-01-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-01-31
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-01-31
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-01-31
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-04-01
F · Potential for more than minimal harm
2024-01-31
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-01-31
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-01-31
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 2024-04-01
D · Potential for more than minimal harm
2024-01-31
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 2024-04-01
G · Actual harm
2023-05-31
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 2023-05-24
F · Potential for more than minimal harm
2023-02-23
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-02-23
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 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-23
G · Actual harm
2021-05-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-06-25
E · Potential for more than minimal harm
2021-05-27
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-06-25
E · Potential for more than minimal harm
2021-05-27
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 2021-07-20
E · Potential for more than minimal harm
2021-05-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-27
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 2021-06-25
D · Potential for more than minimal harm
2021-05-27
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 2021-06-25
D · Potential for more than minimal harm
2021-05-27
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 2021-06-25
D · Potential for more than minimal harm
2021-05-27
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 2021-06-25
D · Potential for more than minimal harm
2021-05-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-05-27
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 2021-06-25
D · Potential for more than minimal harm
2021-05-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-27
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-06-25
E · Potential for more than minimal harm
2019-03-14
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 2019-04-03
E · Potential for more than minimal harm
2019-03-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-04-03
E · Potential for more than minimal harm
2019-03-14
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 2019-04-03
D · Potential for more than minimal harm
2019-03-14
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 2019-04-03
D · Potential for more than minimal harm
2019-03-14
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 2019-04-03
D · Potential for more than minimal harm
2019-03-14
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 2019-04-03
Penalties and ownership
What sits behind the stars
$50,635
2024-01-31
Fine
Fine · fine $50,635
Fine
$11,057
2023-05-31
Fine
Fine · fine $11,057
Fine
Ownership
Gl Virginia Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Gentry, Boyd
5% Or Greater Indirect Ownership Interest · Individual
Gentry, Boyd
Corporate Officer · Individual
Lam, Angela
W-2 Managing Employee · 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
Other facilities in reach
#1
Heritage Hall Lexington
East Lexington, VA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Kendal At Lexington
Lexington, VA
3-star overall rating with 2-star inspections with $10,033 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Fairmont Crossing Health And Rehab Center
Amherst, VA
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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