Cycle 1
Health 2023-02-08 · Fire 2023-02-08
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lynchburg, VA
Westminster-Canterbury Of Lynchburg Inc
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
501 Ves Rd, Lynchburg, VA
(434) 386-3500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-07-14
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
1.02
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.60
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.91
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.31
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
5.68
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
6.81
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
14%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
101
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
85.61
Composite VBP score used to determine payment impact.
Payment multiplier
1.0268
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.75
Baseline 18.65% · Performance 18.30% · Measure score 6.75 · Achievement 6.75 · Improvement 1.65
Healthcare-associated infections
7.49
Baseline 6.09% · Performance 5.60% · Measure score 7.49 · Achievement 7.49 · Improvement 4.02
Total nurse turnover
10
Baseline 41.27% · Performance 19.61% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
10
Baseline 6.89 hours · Performance 6.68 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.73% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 3.25% · Lower 95% interval 5.58% |
| Discharge to community | 45.3% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 49.15% · Lower 95% interval 39.2% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 111 · Denominator 111 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 111 |
| Discharge self-care score | 79.49% |
53.69%
25.8 pts better
|
Numerator 62 · Denominator 78 |
| Discharge mobility score | 71.79% |
50.94%
20.9 pts better
|
Numerator 56 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 1.8% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 111 · Adjusted rate 2.64% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 1.05% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 5.93% |
8.2%
2.3 pts worse
|
Numerator 15 · Denominator 253 |
| Staff flu vaccination coverage | 94.15% |
42%
52.2 pts better
|
Numerator 451 · Denominator 479 |
| Discharge function score | 70.51% |
56.45%
14.1 pts better
|
Numerator 55 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 80 · Denominator 80 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.59% |
25.2%
2.4 pts better
|
Numerator 16 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.4
0.2 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.2 · 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 | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.9% · Q3 4.5% · Q4 6.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
15.7%
13.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.5% · Q3 1.6% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
5.7%
4.8 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
20.2%
13.2 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.8% · Q3 1.8% · Q4 5.1% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
15.0%
2.1 pts worse
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 20.5% · Q3 15.9% · Q4 8.9% · 4Q avg 17.1% · 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 | 5.6% |
17.5%
11.9 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 0.0% · Q3 8.0% · Q4 2.6% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
15.7%
9.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.7% · Q3 5.8% · Q4 7.3% · 4Q avg 6.6% · 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 | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 13.3% |
22.2%
8.9 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 28.7% · Q3 6.0% · Q4 3.0% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.2%
0.7 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.0% · Q3 6.1% · Q4 6.6% · 4Q avg 4.5% · 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 | 15.8% |
11.7%
4.1 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 13.0% · Expected 9.2% · 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 | 100.0% |
73.6%
26.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
22.0%
2.6 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 15.7% · Expected 15.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-05 · Fire 2021-05-05
3 health deficiencies
Top issue: Administration (1 deficiency)
8 fire-safety deficiencies
Top issue: Services (3 deficiencies)
Cycle 3
Health 2019-06-05 · Fire 2019-06-05
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
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
2023-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-10
E · Potential for more than minimal harm
2023-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-10
E · Potential for more than minimal harm
2021-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-28
E · Potential for more than minimal harm
2021-05-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-28
D · Potential for more than minimal harm
2021-05-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-06-28
D · Potential for more than minimal harm
2021-05-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-06-28
D · Potential for more than minimal harm
2021-05-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-28
D · Potential for more than minimal harm
2021-05-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-06-28
D · Potential for more than minimal harm
2021-05-05
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-06-28
D · Potential for more than minimal harm
2021-05-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-02-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-03
E · Potential for more than minimal harm
2021-05-05
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 2021-05-21
D · Potential for more than minimal harm
2021-05-05
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2021-05-21
D · Potential for more than minimal harm
2021-05-05
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 2021-05-21
D · Potential for more than minimal harm
2019-06-05
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 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
Westminster-Canterbury Of Lynchburg, Inc.
5% Or Greater Direct Ownership Interest · Organization
Ames, Pattie
Corporate Director · Individual
Borel, Marcus
Corporate Director · Individual
Bradford, Pamela
Corporate Director · Individual
Conzen, Elizabeth
Corporate Director · Individual
Frantz, David
Corporate Director · Individual
Frazier, Daniel
Corporate Director · Individual
Giles, Becky
Corporate Director · Individual
Huyett, Sean
Corporate Officer · Individual
Huyett, Sean
W-2 Managing Employee · Individual
Johnson, Melissa
Corporate Director · Individual
Jones, Angela
Corporate Officer · Individual
Laundon, Elizabeth
Corporate Director · Individual
Lockridge, Robert
Corporate Director · Individual
Mcveigh, Anne
Corporate Director · Individual
O'brian, Robert
Corporate Director · Individual
Perkins, William
Corporate Director · Individual
Sanford, Marianne
Corporate Officer · Individual
Shelton, Paul
Corporate Officer · Individual
Shelton, Paul
W-2 Managing Employee · Individual
Stevens, Thomas
Corporate Director · Individual
Strosnider, Mark
Corporate Director · Individual
Sweeney, Lori
Corporate Officer · Individual
Turpin, Melinda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Seven Hills Rehabilitation And Nursing
Lynchburg, VA
1-star overall rating with 1-star inspections with abuse icon flag with $235,850 in total fines with 29 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Tate Springs Health & Rehab
Lynchburg, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Forest Health & Rehab Center
Lynchburg, VA
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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