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
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
0.79
Licensed practical nurse staffing
Aide hours / resident day
1.99
Nurse aide staffing
Weekend hours
3.28
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
54%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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#3
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