Cycle 1
Health 2025-08-13 · Fire 2025-08-13
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Chester, VA
Tyler's Retreat At Iron Bridge
3-star overall rating with 3-star inspections with 4 recent health deficiencies
12001 Iron Bridge Rd, Chester, VA
(804) 706-1023
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
2010-01-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 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
0.90
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,152
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.64
Baseline 21.89% · Performance 21.34% · Measure score 0.64 · Achievement 0 · Improvement 0.64
Healthcare-associated infections
7.33
Baseline 7.97% · Performance 5.64% · Measure score 7.33 · Achievement 7.33 · Improvement 7.32
Total nurse turnover
1.49
Baseline 56.47% · Performance 57.61% · Measure score 1.49 · Achievement 1.49 · Improvement 0
Adjusted total nurse staffing
1.61
Baseline 3.26 hours · Performance 3.54 hours · Measure score 1.61 · Achievement 1.61 · Improvement 0.61
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.29% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 254 · Observed rate 7.48% · Lower 95% interval 6.81% |
| Discharge to community | 60.02% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 258 · Observed rate 55.81% · Lower 95% interval 54.54% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.1% |
95.27%
2.2 pts worse
|
Numerator 135 · Denominator 145 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 145 |
| Discharge self-care score | 56.88% |
53.69%
3.2 pts better
|
Numerator 62 · Denominator 109 |
| Discharge mobility score | 47.71% |
50.94%
3.2 pts worse
|
Numerator 52 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 10 · Denominator 145 · Adjusted rate 6.38% |
| Healthcare-associated infections requiring hospitalization | 5.65% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 3.6% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 143 |
| Staff flu vaccination coverage | 9.02% |
42%
33 pts worse
|
Numerator 12 · Denominator 133 |
| Discharge function score | 50.46% |
56.45%
6 pts worse
|
Numerator 55 · Denominator 109 |
| Transfer of health information to provider | 88.24% |
95.95%
7.7 pts worse
|
Numerator 30 · Denominator 34 |
| Transfer of health information to patient | 88.46% |
96.28%
7.8 pts worse
|
Numerator 92 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 8 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 15.8% |
91.2%
75.4 pts worse
|
93.4%
77.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.7% · Q3 21.5% · Q4 27.4% · 4Q avg 15.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.4% |
94.0%
5.6 pts worse
|
95.5%
7.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.6%
2.3 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.6% · Q3 9.2% · Q4 9.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
15.7%
4.3 pts better
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 12.1% · Q4 34.5% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.7%
1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.6% · Q3 5.0% · Q4 6.7% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
20.2%
1 pts better
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 17.5% · Q3 18.3% · Q4 25.0% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
15.0%
11.8 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 6.2% · Q4 4.0% · 4Q avg 3.2% · 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 | 18.4% |
17.5%
0.9 pts worse
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 14.2% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.7%
2.9 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 22.2% · Q3 7.1% · Q4 3.7% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.6%
0.8 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 3.1% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
22.2%
2.3 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 17.4% · Q3 24.8% · Q4 18.5% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.2%
2.5 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 1.7% · Q4 3.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 11.7% |
74.6%
62.9 pts worse
|
81.7%
70 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 9.8% · Q3 13.8% · Q4 19.1% · 4Q avg 11.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
11.7%
5.8 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 16.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 33.5% |
73.6%
40.1 pts worse
|
79.7%
46.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 33.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
22.0%
1.9 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 24.1% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-19 · Fire 2023-01-19
23 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-08-05 · Fire 2021-08-05
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-13
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-18
D · Potential for more than minimal harm
2024-06-12
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 2024-07-16
D · Potential for more than minimal harm
2024-06-12
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 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
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 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-12
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-07-16
D · Potential for more than minimal harm
2023-10-17
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 2023-11-09
D · Potential for more than minimal harm
2023-10-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-01-19
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 2023-02-14
E · Potential for more than minimal harm
2023-01-19
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 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
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 2023-02-14
D · Potential for more than minimal harm
2023-01-19
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 2023-02-14
D · Potential for more than minimal harm
2023-01-19
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 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
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 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-19
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 2023-02-14
D · Potential for more than minimal harm
2023-01-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-14
C · Minimal harm
2023-01-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-02-14
E · Potential for more than minimal harm
2021-08-05
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 2021-09-10
E · Potential for more than minimal harm
2021-08-05
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 2021-09-10
E · Potential for more than minimal harm
2021-08-05
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 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
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 2021-09-10
D · Potential for more than minimal harm
2021-08-05
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 2021-09-10
D · Potential for more than minimal harm
2021-08-05
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 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
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 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-10
D · Potential for more than minimal harm
2021-08-05
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 2021-09-10
Penalties and ownership
What sits behind the stars
Ownership
Saber Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Holmes, Andrea
Operational/Managerial Control · Individual
Hopkins, Joseph
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Shg Management LLC
Operational/Managerial Control · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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#3
Hiram W Davis Medical Ctr
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