Cycle 1
Health 2023-04-19 · Fire 2023-04-19
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lynchburg, VA
Tate Springs Health & Rehab
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2200 Landover Place, Lynchburg, VA
(434) 846-4626
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hill Valley Healthcare
Operator or chain grouping
Approved since
1970-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.66
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,099
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.41% · Performance 21.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.95% · Performance 7.75% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Baseline 53.95% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.86
Adjusted total nurse staffing
0
Baseline 3.26 hours · Performance 2.86 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.68% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 155 · Observed rate 16.13% · Lower 95% interval 9.24% |
| Discharge to community | 65.36% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 145 · Observed rate 58.62% · Lower 95% interval 58.71% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.63% |
95.27%
1.4 pts better
|
Numerator 86 · Denominator 89 |
| Falls with major injury | 2.25% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 89 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 31 · Denominator 62 |
| Discharge mobility score | 40.32% |
50.94%
10.6 pts worse
|
Numerator 25 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 5.62% |
2.29%
3.3 pts worse
|
Numerator 5 · Denominator 89 · Adjusted rate 5.8% |
| Healthcare-associated infections requiring hospitalization | 7.74% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 8.97% · Lower 95% interval 5.07% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 129 |
| Staff flu vaccination coverage | 11.63% |
42%
30.4 pts worse
|
Numerator 20 · Denominator 172 |
| Discharge function score | 48.39% |
56.45%
8.1 pts worse
|
Numerator 30 · Denominator 62 |
| Transfer of health information to provider | 66.67% |
95.95%
29.3 pts worse
|
Numerator 20 · Denominator 30 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 40 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 19.61% |
25.2%
5.6 pts worse
|
Numerator 10 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| 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 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
91.2%
8.8 pts worse
|
93.4%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 76.1% · Q3 75.0% · Q4 96.6% · 4Q avg 82.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.1% |
94.0%
8.9 pts worse
|
95.5%
10.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.6%
0.3 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 5.0% · Q4 5.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 28.2% |
15.7%
12.5 pts worse
|
11.4%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 42.2% · Q3 19.2% · Q4 24.7% · 4Q avg 28.2% |
| Percentage of long-stay residents who lose too much weight | 12.8% |
5.7%
7.1 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 12.5% · Q3 16.2% · Q4 17.6% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
20.2%
0.3 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 18.2% · Q3 21.1% · Q4 26.8% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
15.0%
2.4 pts better
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.3% · Q3 16.9% · Q4 11.9% · 4Q avg 12.6% · 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 | 5.1% |
17.5%
12.4 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.0% · Q4 9.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
15.7%
8.8 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.4% · Q3 7.4% · Q4 9.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.6%
0.5 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 6.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
22.2%
1.7 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 23.3% · Q3 25.8% · Q4 18.3% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
5.2%
4.6 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 12.4% · Q3 13.6% · Q4 4.6% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.7% |
74.6%
17.9 pts worse
|
81.7%
25 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.9% · Q2 55.0% · Q3 61.2% · Q4 60.3% · 4Q avg 56.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.7%
2.9 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.4% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.8% · Q3 0.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 39.3% |
73.6%
34.3 pts worse
|
79.7%
40.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 39.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
22.0%
0.3 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 23.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-18 · Fire 2021-11-18
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-02-21 · Fire 2019-02-21
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-04-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-21
F · Potential for more than minimal harm
2023-04-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-21
E · Potential for more than minimal harm
2023-04-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-21
E · Potential for more than minimal harm
2023-04-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-21
E · Potential for more than minimal harm
2023-04-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-21
E · Potential for more than minimal harm
2023-04-19
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-04-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-04-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-04-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-21
D · Potential for more than minimal harm
2021-11-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-18
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-12-10
F · Potential for more than minimal harm
2019-02-21
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2019-05-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-27
D · Potential for more than minimal harm
2023-04-19
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 2023-05-23
D · Potential for more than minimal harm
2023-04-19
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 2023-05-23
D · Potential for more than minimal harm
2023-04-19
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 2023-05-23
E · Potential for more than minimal harm
2021-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-18
E · Potential for more than minimal harm
2021-11-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-18
E · Potential for more than minimal harm
2021-11-18
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 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
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 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
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 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
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 2021-12-18
E · Potential for more than minimal harm
2019-02-21
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-02-21
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 2019-04-05
D · Potential for more than minimal harm
2019-02-21
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 2019-04-05
C · Minimal harm
2019-02-21
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 2019-04-05
B · Minimal harm
2019-02-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-05
B · Minimal harm
2019-02-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-04-05
Penalties and ownership
What sits behind the stars
Ownership
Va Pro 7 SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Crg Va Pro 7 SNF Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hvh Va Pro 7 SNF Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Idels, Shimon
Corporate Officer · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ph Va LLC
5% Or Greater Indirect Ownership Interest · Organization
Rogers, Delisa
W-2 Managing Employee · Individual
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Seven Hills Rehabilitation And Nursing
Lynchburg, VA
1-star overall rating with 1-star inspections with abuse icon flag with $235,850 in total fines with 29 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Forest Health & Rehab Center
Lynchburg, VA
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Guggenheimer Health And Rehab Center
Lynchburg, VA
2-star overall rating with 1-star inspections with $76,681 in total fines with 31 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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