Cycle 1
Health 2023-03-30 · Fire 2023-03-30
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Midlothian, VA
The Haven At Brandermill Woods
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2100 Brandermill Pkwy, Midlothian, VA
(804) 379-7100
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-11-02
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
0.98
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.79
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
5.29
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.90
Composite VBP score used to determine payment impact.
Payment multiplier
1.0087
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.86% · Performance 24.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.78
Baseline 6.20% · Performance 6.11% · Measure score 5.78 · Achievement 5.78 · Improvement 0.29
Total nurse turnover
6.79
Baseline 36.36% · Performance 35.94% · Measure score 6.79 · Achievement 6.79 · Improvement 0
Adjusted total nurse staffing
8.99
Baseline 5.25 hours · Performance 5.64 hours · Measure score 8.99 · Achievement 8.99 · Improvement 6.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 5.78% · Lower 95% interval 6.61% |
| Discharge to community | 64.01% |
50.57%
13.4 pts better
|
Better than the National Rate · Eligible stays 222 · Observed rate 66.22% · Lower 95% interval 58.39% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.16% |
95.27%
2.1 pts worse
|
Numerator 177 · Denominator 190 |
| Falls with major injury | 1.58% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 190 |
| Discharge self-care score | 58.57% |
53.69%
4.9 pts better
|
Numerator 82 · Denominator 140 |
| Discharge mobility score | 74.29% |
50.94%
23.4 pts better
|
Numerator 104 · Denominator 140 |
| Pressure ulcers or injuries, new or worsened | 1.05% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 190 · Adjusted rate 1.4% |
| Healthcare-associated infections requiring hospitalization | 6.11% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 3.43% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 13.81% |
8.2%
5.6 pts better
|
Numerator 46 · Denominator 333 |
| Staff flu vaccination coverage | 16.36% |
42%
25.6 pts worse
|
Numerator 72 · Denominator 440 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 105 · Denominator 140 |
| Transfer of health information to provider | 92.73% |
95.95%
3.2 pts worse
|
Numerator 51 · Denominator 55 |
| Transfer of health information to patient | 96.69% |
96.28%
0.4 pts better
|
Numerator 117 · Denominator 121 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 26 · Denominator 104 |
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 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.4
0.8 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
91.2%
6.4 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 100.0% · Q3 94.1% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
94.0%
3 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 3.5% |
15.7%
12.2 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 10.7% · Q4 3.1% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.7%
2.8 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · Q3 0.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
20.2%
2.9 pts better
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q3 13.6% · Q4 10.0% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
15.0%
0.7 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · 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 | 23.5% |
17.5%
6 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
15.7%
4.4 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 11.3% · 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 · 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 a urinary tract infection | 2.5% |
1.6%
0.9 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.1% · Q3 2.9% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
22.2%
0.4 pts better
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 24.5% · Q3 14.0% · Q4 29.2% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.2%
0.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.3% · Q3 8.0% · Q4 4.2% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
74.6%
18.1 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 94.8% · Q3 93.5% · Q4 81.8% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.7%
0.6 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 9.6% · 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 | 90.8% |
73.6%
17.2 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.0%
3.5 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 14.4% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-01 · Fire 2021-04-01
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2018-08-02 · Fire 2018-08-02
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-03-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-03-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-16
D · Potential for more than minimal harm
2021-04-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-01
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-04-29
E · Potential for more than minimal harm
2018-08-02
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 2019-01-10
D · Potential for more than minimal harm
2018-08-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-01-10
D · Potential for more than minimal harm
2018-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-10-03
D · Potential for more than minimal harm
2018-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-03
C · Minimal harm
2018-08-02
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-01-10
C · Minimal harm
2018-08-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-10-03
C · Minimal harm
2018-08-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2018-10-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-03-30
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 2023-04-26
D · Potential for more than minimal harm
2023-03-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-30
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 2023-04-26
D · Potential for more than minimal harm
2023-03-30
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 2023-04-26
E · Potential for more than minimal harm
2021-04-01
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 2021-04-29
D · Potential for more than minimal harm
2021-04-01
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-04-29
F · Potential for more than minimal harm
2018-08-02
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 2018-09-05
Penalties and ownership
What sits behind the stars
Ownership
Brickhouse, Frasier
Corporate Director · Individual
Edmunds, Wayne
Corporate Director · Individual
Hammer, Bradford
Corporate Director · Individual
Llewellyn, Ellen
Corporate Director · Individual
Preiss, Lynda
Operational/Managerial Control · Individual
Preiss, Lynda
Corporate Officer · Individual
Saunders, Nelson
Corporate Director · Individual
Scott, Tomeka
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Laurels Of Willow Creek
Midlothian, VA
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Laurels Of Bon Air
Bon Air, VA
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Beaufont Health And Rehabilitation Center
Richmond, VA
2-star overall rating with 3-star inspections with $8,197 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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