Cycle 1
Health 2023-10-18 · Fire 2023-10-18
10 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Culpeper, VA
The Culpeper
4-star overall rating with 3-star inspections with 10 recent health deficiencies
12425 Village Loop, Culpeper, VA
(540) 825-2411
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-02-01
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
1.08
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.21
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.19
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
5.66
CMS adjusted total nurse staffing hours
Case-mix index
1.26
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
3,924
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9950
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.19% · Performance 21.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.17
Baseline 9.17% · Performance 8.05% · Measure score 2.17 · Achievement 0 · Improvement 2.17
Total nurse turnover
5.73
Baseline 46.03% · Performance 40.28% · Measure score 5.73 · Achievement 5.73 · Improvement 2.22
Adjusted total nurse staffing
8.94
Baseline 4.84 hours · Performance 5.62 hours · Measure score 8.94 · Achievement 8.94 · Improvement 7.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 9.19% · Lower 95% interval 7.6% |
| Discharge to community | 57.54% |
50.57%
7 pts better
|
Better than the National Rate · Eligible stays 178 · Observed rate 55.62% · Lower 95% interval 50.58% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.09% |
95.27%
3.8 pts better
|
Numerator 109 · Denominator 110 |
| Falls with major injury | 0.91% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 110 |
| Discharge self-care score | 50.59% |
53.69%
3.1 pts worse
|
Numerator 43 · Denominator 85 |
| Discharge mobility score | 51.76% |
50.94%
0.8 pts better
|
Numerator 44 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 4 · Denominator 110 · Adjusted rate 4.68% |
| Healthcare-associated infections requiring hospitalization | 8.05% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 7.75% · Lower 95% interval 5.24% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 105 |
| Staff flu vaccination coverage | 29.03% |
42%
13 pts worse
|
Numerator 36 · Denominator 124 |
| Discharge function score | 64.71% |
56.45%
8.3 pts better
|
Numerator 55 · Denominator 85 |
| Transfer of health information to provider | 94.92% |
95.95%
1 pts worse
|
Numerator 56 · Denominator 59 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 12 · Denominator 48 |
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 2.2 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.4
0.3 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.0 · 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 | 6.4% |
3.6%
2.8 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.1% · Q3 3.3% · Q4 6.5% · 4Q avg 6.4% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.7%
0.7 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.9% · Q3 7.4% · Q4 3.8% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
20.2%
5.5 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 30.0% · Q3 25.9% · Q4 17.9% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
15.0%
0.2 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.3% · Q4 12.5% · 4Q avg 14.8% · 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 | 19.4% |
17.5%
1.9 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
15.7%
3.7 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 24.1% · Q3 15.4% · Q4 14.3% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.5%
1.9 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
1.6%
4.2 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 12.5% · Q3 3.3% · Q4 3.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.4% |
22.2%
13.2 pts worse
|
19.8%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.3% · Q2 38.6% · Q3 34.3% · Q4 23.1% · 4Q avg 35.4% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.2%
0.4 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 10.2% · Q4 3.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
74.6%
25.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.6% |
11.7%
13.9 pts worse
|
12.0%
13.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 23.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
73.6%
14.3 pts better
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
22.0%
0.7 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 19.5% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-07 · Fire 2022-04-07
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-02-18 · Fire 2021-02-18
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-10-18
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-18
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 2023-12-01
D · Potential for more than minimal harm
2023-10-18
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 2023-12-01
D · Potential for more than minimal harm
2023-10-18
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 2023-12-01
D · Potential for more than minimal harm
2023-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
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 2023-12-01
D · Potential for more than minimal harm
2023-10-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-18
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 2023-12-01
B · Minimal harm
2023-10-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-12-01
F · Potential for more than minimal harm
2022-04-07
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 2022-04-22
E · Potential for more than minimal harm
2022-04-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-04-07
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 2022-04-22
D · Potential for more than minimal harm
2022-04-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-04-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-22
G · Actual harm
2021-02-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-03-22
D · Potential for more than minimal harm
2021-02-18
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 2021-03-22
D · Potential for more than minimal harm
2021-02-18
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 2021-03-22
D · Potential for more than minimal harm
2021-02-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-03-22
Penalties and ownership
What sits behind the stars
Ownership
Albritton, Tracey
Corporate Officer · Individual
Bales, James
Corporate Director · Individual
Brooks, Sharon
Corporate Director · Individual
Browning, Herbert
Corporate Director · Individual
Carlton, Daniel
Corporate Officer · Individual
Carter, Valerie
Corporate Director · Individual
Cave, R
Corporate Director · Individual
Cook, Jonathan
Corporate Officer · Individual
Franks, Tiffany
Corporate Director · Individual
Harris, Charles
Corporate Director · Individual
Hawthorne, Lisa
Corporate Officer · Individual
Jacobsen, James
W-2 Managing Employee · Individual
Jung, John
Corporate Director · Individual
Keck, Michael
Corporate Director · Individual
Marchello, Sallie
Corporate Director · Individual
Markwith, Christopher
Corporate Officer · Individual
Moran, Christine
Corporate Officer · Individual
Oakey, Samuel
Corporate Director · Individual
Owens, Arne
Corporate Director · Individual
Poats, Jim
Corporate Director · Individual
Poma, John
Corporate Director · Individual
Robinson, John
Corporate Officer · Individual
Scott, Matthew
Corporate Director · Individual
Thomson, Gary
Corporate Director · Individual
Virginia Baptist Homes Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Culpeper Health & Rehabilitation Center
Culpeper, VA
2-star overall rating with 1-star inspections with $16,298 in total fines with 30 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Mountain View Nursing Home
Aroda, VA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Dogwood Village Of Orange County Health And Rehab
Orange, VA
3-star overall rating with 3-star inspections with 9 recent health deficiencies
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