Cycle 1
Health 2023-09-22 · Fire 2023-09-22
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Franklin, VA
Southampton Memorial Hosp
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
100 Fairview Dr, Franklin, VA
(757) 569-6287
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
88
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-12-02
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
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,491
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0034
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.75
Performance 18.30% · Measure score 6.75 · Achievement 6.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.19
Baseline 5.91% · Performance 6.28% · Measure score 5.19 · Achievement 5.19 · Improvement 0
Total nurse turnover
6.29
Baseline 27.78% · Performance 37.97% · Measure score 6.29 · Achievement 6.29 · Improvement 0
Adjusted total nurse staffing
1.55
Baseline 3.98 hours · Performance 3.52 hours · Measure score 1.55 · Achievement 1.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 7.75% · Lower 95% interval 7.31% |
| Discharge to community | 57.32% |
50.57%
6.8 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 57.89% · Lower 95% interval 49.83% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 76 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 63.24% |
53.69%
9.6 pts better
|
Numerator 43 · Denominator 68 |
| Discharge mobility score | 70.59% |
50.94%
19.7 pts better
|
Numerator 48 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 3.95% |
2.29%
1.7 pts worse
|
Numerator 3 · Denominator 76 · Adjusted rate 5.74% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 3.23% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 70.59% |
56.45%
14.1 pts better
|
Numerator 48 · Denominator 68 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 2 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.4
1.6 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
91.2%
10.2 pts worse
|
93.4%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.5% · Q2 92.0% · Q3 81.0% · Q4 75.0% · 4Q avg 81.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.0%
3.7 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.6%
2.1 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.7% · Q3 7.6% · Q4 5.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
15.7%
13.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 1.4% · Q4 4.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 11.0% |
5.7%
5.3 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 18.8% · Q3 15.3% · Q4 5.6% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
20.2%
13.1 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 37.1% · Q3 31.5% · Q4 34.7% · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
15.0%
3.7 pts better
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.8% · Q3 8.2% · Q4 8.6% · 4Q avg 11.3% · 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 | 9.9% |
17.5%
7.6 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.9% · Q3 19.0% · Q4 11.9% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
15.7%
6.6 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.3% · Q3 9.2% · Q4 16.7% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.5%
1.1 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.8% · Q3 1.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.6%
0.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
22.2%
1.2 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 10.0% · Q3 34.8% · Q4 24.5% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
5.2%
3.5 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.8% |
74.6%
45.8 pts worse
|
81.7%
52.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.9% · Q2 22.7% · Q3 25.0% · Q4 24.7% · 4Q avg 28.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
11.7%
4.6 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.2% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.2%
0.4 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.1% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.6% |
73.6%
22 pts worse
|
79.7%
28.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
22.0%
0.5 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 17.5% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-12 · Fire 2020-02-12
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-10-18 · Fire 2018-10-18
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 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
2023-09-22
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-10-09
D · Potential for more than minimal harm
2018-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-10-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-01-04
D · Potential for more than minimal harm
2018-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-09-22
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 2023-10-31
D · Potential for more than minimal harm
2023-09-22
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 2023-10-31
D · Potential for more than minimal harm
2023-09-22
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2023-10-31
E · Potential for more than minimal harm
2020-02-12
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 2020-03-27
E · Potential for more than minimal harm
2020-02-12
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 2020-03-27
D · Potential for more than minimal harm
2020-02-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-12
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 2020-03-27
D · Potential for more than minimal harm
2020-02-12
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 2020-03-27
D · Potential for more than minimal harm
2020-02-12
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 2020-03-27
D · Potential for more than minimal harm
2020-02-12
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2020-03-27
D · Potential for more than minimal harm
2018-10-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-18
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 2018-11-30
D · Potential for more than minimal harm
2018-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-18
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 2018-11-30
D · Potential for more than minimal harm
2018-10-18
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 2018-11-30
D · Potential for more than minimal harm
2018-10-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-18
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 2018-11-30
D · Potential for more than minimal harm
2018-10-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-11-30
Penalties and ownership
What sits behind the stars
Ownership
Bon Secours Hampton Roads Health System Inc
5% Or Greater Direct Ownership Interest · Organization
Bon Secours Mercy Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Beale, Teresa
Corporate Director · Individual
Cannady, David
Corporate Director · Individual
Davis-Hagens, Patricia
Corporate Director · Individual
Fairchild, Charlette
Corporate Director · Individual
Gerardo, Edward
Corporate Director · Individual
Glynn, Dawn
Corporate Director · Individual
Hajimomenian, Amir
Corporate Officer · Individual
Haynes, Jonathan
Operational/Managerial Control · Individual
Haynes, Jonathan
Corporate Director · Individual
Haynes, Jonathan
Corporate Officer · Individual
Jefferson, Joy
Corporate Director · Individual
Kirk, Ann
Corporate Director · Individual
Mccray, Corey
Corporate Director · Individual
Romero, Cynthia
Corporate Director · Individual
Russell, Deborah
Corporate Director · Individual
Rutledge, Carolyn
Corporate Director · Individual
Suber, Diane
Corporate Director · Individual
Yanofchick, Brian
Corporate Director · Individual
Zawoloka, Alex
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Courtland Rehabilitation And Healthcare Center
Courtland, VA
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
Windsor Grove Health and Rehabilitation
Windsor, VA
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Lake Prince Woods, Inc
Suffolk, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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