Cycle 1
Health 2022-10-26 · Fire 2022-10-26
14 health deficiencies
Top issue: Infection Control (3 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Bristol, VA
The Rehab Center At Bristol
1-star overall rating with 2-star inspections with $10,358 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
301 Village Circle, Bristol, VA
(276) 594-0032
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2019-05-11
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
0.88
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,641
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.63% · Performance 24.05% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.53
Baseline 9.30% · Performance 8.43% · Measure score 1.53 · Achievement 0 · Improvement 1.53
Total nurse turnover
5.07
Baseline 77.54% · Performance 48.19% · Measure score 5.07 · Achievement 3.79 · Improvement 5.07
Adjusted total nurse staffing
1.26
Baseline 3.04 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0.94
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 200 · Observed rate 14% · Lower 95% interval 8.53% |
| Discharge to community | 56.06% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 214 · Observed rate 48.13% · Lower 95% interval 49.7% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.9% |
95.27%
2.6 pts better
|
Numerator 140 · Denominator 143 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 142 |
| Discharge self-care score | 48.42% |
53.69%
5.3 pts worse
|
Numerator 46 · Denominator 95 |
| Discharge mobility score | 36.84% |
50.94%
14.1 pts worse
|
Numerator 35 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 2.84% |
2.29%
0.5 pts worse
|
Numerator 4 · Denominator 141 · Adjusted rate 2.6% |
| Healthcare-associated infections requiring hospitalization | 8.43% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 9.45% · Lower 95% interval 5.23% |
| Staff COVID-19 vaccination coverage | 4.69% |
8.2%
3.5 pts worse
|
Numerator 6 · Denominator 128 |
| Staff flu vaccination coverage | 7.1% |
42%
34.9 pts worse
|
Numerator 12 · Denominator 169 |
| Discharge function score | 46.32% |
56.45%
10.1 pts worse
|
Numerator 44 · Denominator 95 |
| Transfer of health information to provider | 98.44% |
95.95%
2.5 pts better
|
Numerator 63 · Denominator 64 |
| Transfer of health information to patient | 94.83% |
96.28%
1.5 pts worse
|
Numerator 55 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 67.95% |
25.2%
42.8 pts better
|
Numerator 53 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.5
1.5 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.4
About the same
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
91.2%
6.9 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.3% · Q3 96.2% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
94.0%
2.8 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.6%
2.5 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.4% · Q3 5.8% · Q4 7.3% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.2% |
15.7%
0.5 pts worse
|
11.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 20.4% · Q3 13.3% · Q4 13.7% · 4Q avg 16.2% |
| Percentage of long-stay residents who lose too much weight | 9.9% |
5.7%
4.2 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 10.9% · Q3 14.0% · Q4 7.5% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
20.2%
7.1 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 22.9% · Q3 19.6% · Q4 43.5% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
15.0%
7 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.2% · Q3 20.6% · Q4 22.9% · 4Q avg 22.0% · 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 | 42.4% |
17.5%
24.9 pts worse
|
16.3%
26.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 60.5% · 4Q avg 42.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
15.7%
11.2 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.5% · Q3 43.6% · Q4 23.7% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.5%
0.6 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.6%
0.4 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.1% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
22.2%
2.4 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 25.9% · Q3 30.3% · Q4 17.8% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.9% · Q3 3.8% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
74.6%
15.2 pts better
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 90.1% · Q3 92.1% · Q4 92.5% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
11.7%
0.7 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 10.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.2%
1.4 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.8% · Q3 2.6% · Q4 2.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.7% |
73.6%
14.9 pts worse
|
79.7%
21 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
22.0%
6 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 28.1% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-10 · Fire 2019-05-10
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-10-26
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-03-10
F · Potential for more than minimal harm
2022-10-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2022-10-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-10-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-10
E · Potential for more than minimal harm
2022-10-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-10
E · Potential for more than minimal harm
2022-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-10
E · Potential for more than minimal harm
2022-10-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-10
E · Potential for more than minimal harm
2022-10-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-10-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-10-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-23
Inspection history
Recent health citations
G · Actual harm
2025-10-01
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 2025-10-24
E · Potential for more than minimal harm
2025-10-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-10-01
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 2025-10-24
D · Potential for more than minimal harm
2025-02-25
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-25
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 2025-03-28
D · Potential for more than minimal harm
2025-02-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-25
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-03-27
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 2024-05-31
D · Potential for more than minimal harm
2024-03-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-31
E · Potential for more than minimal harm
2022-10-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-10-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-26
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 2022-12-08
D · Potential for more than minimal harm
2022-10-26
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 2022-12-08
D · Potential for more than minimal harm
2022-10-26
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 2022-12-08
D · Potential for more than minimal harm
2022-10-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-26
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 2022-12-08
D · Potential for more than minimal harm
2022-10-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-26
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 2022-12-08
D · Potential for more than minimal harm
2022-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-08
E · Potential for more than minimal harm
2019-05-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-05-11
E · Potential for more than minimal harm
2019-05-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-11
E · Potential for more than minimal harm
2019-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-11
D · Potential for more than minimal harm
2019-05-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-05-11
D · Potential for more than minimal harm
2019-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-11
D · Potential for more than minimal harm
2019-05-10
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 2019-05-11
D · Potential for more than minimal harm
2019-05-10
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 2019-05-11
D · Potential for more than minimal harm
2019-05-10
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 2019-05-11
Penalties and ownership
What sits behind the stars
$10,358
2025-10-01
Fine
Fine · fine $10,358
Fine
Ownership
Giberstien, Baruch
5% Or Greater Direct Ownership Interest · Individual
Giberstien, Baruch
Operational/Managerial Control · Individual
Giberstien, Baruch
5% Or Greater Mortgage Interest · Individual
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#3
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