Waynesboro, VA

Summit Square

4-star overall rating with 3-star inspections with $50,021 in total fines with 5 recent health deficiencies

501 Oak Avenue, Waynesboro, VA

(540) 941-3100

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2010-08-02

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

2.35

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

1.48

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

4.79

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

8.61

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

3.83

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

7.09

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.91

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.44

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

2.56

CMS adjusted RN staffing hours

Adjusted total hours

9.39

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,976

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

41.88

Composite VBP score used to determine payment impact.

Payment multiplier

0.9948

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.61

Baseline 21.35% · Performance 19.76% · Measure score 3.61 · Achievement 3.61 · Improvement 3.18

Healthcare-associated infections

4.59

Baseline 5.94% · Performance 6.46% · Measure score 4.59 · Achievement 4.59 · Improvement 0

Total nurse turnover

4.37

Baseline 44.44% · Performance 45.83% · Measure score 4.37 · Achievement 4.37 · Improvement 0

Adjusted total nurse staffing

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.43%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 90 · Observed rate 3.33% · Lower 95% interval 5.3%
Discharge to community	63.59%	50.57% 13 pts better	Better than the National Rate · Eligible stays 80 · Observed rate 71.25% · Lower 95% interval 55.36%
Medicare spending per beneficiary	0.77	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 56 · Denominator 56
Falls with major injury	1.79%	0.77% 1 pts worse	Numerator 1 · Denominator 56
Discharge self-care score	63.27%	53.69% 9.6 pts better	Numerator 31 · Denominator 49
Discharge mobility score	63.27%	50.94% 12.3 pts better	Numerator 31 · Denominator 49
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 56 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.46%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 49 · Observed rate 2.04% · Lower 95% interval 3.02%
Staff COVID-19 vaccination coverage	11.18%	8.2% 3 pts better	Numerator 18 · Denominator 161
Staff flu vaccination coverage	18.92%	42% 23.1 pts worse	Numerator 35 · Denominator 185
Discharge function score	61.22%	56.45% 4.8 pts better	Numerator 30 · Denominator 49
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 39 · Denominator 39
Resident COVID-19 vaccinations up to date	62.86%	25.2% 37.7 pts better	Numerator 22 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.2%	91.2% 1 pts worse	93.4% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 90.2%
Percentage of long-stay residents experiencing one or more falls with major injury	9.8%	3.6% 6.2 pts worse	3.3% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	15.7% 15.7 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	3.4%	5.7% 2.3 pts better	5.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.4%	20.2% 14.2 pts worse	19.6% 14.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 34.4%
Percentage of long-stay residents who received an antipsychotic medication	11.1%	15.0% 3.9 pts better	16.7% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · 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 · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	27.6%	15.7% 11.9 pts worse	14.9% 12.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 27.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.6%	1.6% 1 pts worse	1.7% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.0%	22.2% 0.2 pts better	19.8% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0%
Percentage of long-stay residents with pressure ulcers	9.7%	5.2% 4.5 pts worse	5.1% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.3%	74.6% 20.7 pts better	81.7% 13.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 90.0% · Q4 91.4% · 4Q avg 95.3%
Percentage of short-stay residents who had an outpatient emergency department visit	13.6%	11.7% 1.9 pts worse	12.0% 1.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 11.7% · Expected 9.6% · 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	46.3%	73.6% 27.3 pts worse	79.7% 33.4 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 46.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.2%	22.0% 3.2 pts worse	23.9% 1.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 18.3% · Expected 17.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-11-15 · Fire 2023-11-15

5 health deficiencies

Top issue: Infection Control (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2022-03-10 · Fire 2022-03-10

17 health deficiencies

Top issue: Administration (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-02-10 · Fire 2021-02-10

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

J · Immediate jeopardy 2025-02-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-05-02

G · Actual harm 2025-02-07

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-05-02

G · Actual harm 2025-02-07

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2025-05-02

F · Potential for more than minimal harm 2025-02-07

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected 2025-03-20

E · Potential for more than minimal harm 2025-02-07

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-02-07

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-02-07

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-02-07

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-03-20

D · Potential for more than minimal harm 2025-02-07

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-02-07

F949 · Administration Deficiencies

Health

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected 2025-05-02

E · Potential for more than minimal harm 2023-11-15

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-11-15

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-12-13

E · Potential for more than minimal harm 2022-03-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-04-01

E · Potential for more than minimal harm 2022-03-10

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-04-01

E · Potential for more than minimal harm 2022-03-10

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 2022-04-01

E · Potential for more than minimal harm 2022-03-10

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 2022-04-01

D · Potential for more than minimal harm 2022-03-10

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-04-01

D · Potential for more than minimal harm 2022-03-10

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 2022-04-01

D · Potential for more than minimal harm 2022-03-10

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2022-04-01

E · Potential for more than minimal harm 2021-02-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-03-08

D · Potential for more than minimal harm 2021-02-10

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 2021-03-08

D · Potential for more than minimal harm 2021-02-10

F756 · Pharmacy Service Deficiencies

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 2021-03-08

D · Potential for more than minimal harm 2021-02-10