Cycle 1
Health 2024-06-12 · Fire 2024-06-12
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Richmond, VA
Westminster-Canterbury Of Richmond
5-star overall rating with 4-star inspections with 4 recent health deficiencies
1600 Westbrook Ave, Richmond, VA
(804) 264-6000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
158
Certified beds
Average residents
133
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-10-01
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
1.18
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.90
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
1.32
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
198
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
78.47
Composite VBP score used to determine payment impact.
Payment multiplier
1.0255
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.24
Baseline 16.82% · Performance 17.15% · Measure score 9.24 · Achievement 9.24 · Improvement 0
Healthcare-associated infections
10
Baseline 5.45% · Performance 4.80% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
5.61
Baseline 36.23% · Performance 40.76% · Measure score 5.61 · Achievement 5.61 · Improvement 0
Adjusted total nurse staffing
6.54
Baseline 4.88 hours · Performance 4.94 hours · Measure score 6.54 · Achievement 6.54 · Improvement 0.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 368 · Observed rate 8.7% · Lower 95% interval 8.33% |
| Discharge to community | 65.87% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 313 · Observed rate 67.41% · Lower 95% interval 61.11% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.29% |
95.27%
2 pts better
|
Numerator 287 · Denominator 295 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 295 |
| Discharge self-care score | 58.51% |
53.69%
4.8 pts better
|
Numerator 110 · Denominator 188 |
| Discharge mobility score | 62.77% |
50.94%
11.8 pts better
|
Numerator 118 · Denominator 188 |
| Pressure ulcers or injuries, new or worsened | 2.71% |
2.29%
0.4 pts worse
|
Numerator 8 · Denominator 295 · Adjusted rate 3.82% |
| Healthcare-associated infections requiring hospitalization | 4.8% |
7.12%
2.3 pts better
|
No Different than the National Rate · Eligible stays 233 · Observed rate 1.72% · Lower 95% interval 2.71% |
| Staff COVID-19 vaccination coverage | 8.9% |
8.2%
0.7 pts better
|
Numerator 29 · Denominator 326 |
| Staff flu vaccination coverage | 98.44% |
42%
56.4 pts better
|
Numerator 441 · Denominator 448 |
| Discharge function score | 66.49% |
56.45%
10 pts better
|
Numerator 125 · Denominator 188 |
| Transfer of health information to provider | 58.2% |
95.95%
37.8 pts worse
|
Numerator 71 · Denominator 122 |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 124 · Denominator 126 |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 63 · Denominator 168 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.4
1 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
91.2%
5.6 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 100.0% · Q3 96.2% · Q4 93.4% · 4Q avg 96.8% |
| 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 | 4.3% |
3.6%
0.7 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.4% · Q3 3.8% · Q4 2.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
15.7%
15.5 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.7%
0.7 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.4% · Q3 7.5% · Q4 5.4% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.9% |
20.2%
17.7 pts worse
|
19.6%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 38.8% · Q3 40.9% · Q4 39.4% · 4Q avg 37.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
15.0%
7.9 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 19.2% · Q3 23.1% · Q4 25.6% · 4Q avg 22.9% · 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 | 34.3% |
17.5%
16.8 pts worse
|
16.3%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 39.5% · Q3 31.2% · Q4 35.4% · 4Q avg 34.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 40.1% |
15.7%
24.4 pts worse
|
14.9%
25.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 43.9% · Q3 28.2% · Q4 50.0% · 4Q avg 40.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.6%
0.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
22.2%
6.1 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 29.9% · Q3 29.6% · Q4 33.0% · 4Q avg 28.3% |
| 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 4.5% · Q2 5.9% · Q3 6.8% · Q4 6.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
74.6%
21.4 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 94.6% · Q3 97.3% · Q4 97.3% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.7%
5 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 1.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
73.6%
23.1 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
22.0%
3.2 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 14.0% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-03-25 · Fire 2021-03-25
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-05-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-04
F · Potential for more than minimal harm
2021-03-25
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-06-02
F · Potential for more than minimal harm
2021-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-08
D · Potential for more than minimal harm
2024-10-30
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 2024-12-08
D · Potential for more than minimal harm
2024-06-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-27
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 2024-07-27
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 2024-07-27
D · Potential for more than minimal harm
2024-06-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-27
D · Potential for more than minimal harm
2023-05-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-25
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 2023-06-30
B · Minimal harm
2023-05-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-30
B · Minimal harm
2023-05-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-30
F · Potential for more than minimal harm
2021-03-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-05-09
F · Potential for more than minimal harm
2021-03-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2021-05-09
F · Potential for more than minimal harm
2021-03-25
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 2021-05-09
D · Potential for more than minimal harm
2021-03-25
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 2021-05-09
Penalties and ownership
What sits behind the stars
Ownership
Branch Banking And Trust Company
5% Or Greater Mortgage Interest · Organization
Burns, John
Corporate Director · Individual
Gardner, Russell
Corporate Officer · Individual
Mackall, Tyler
Operational/Managerial Control · Individual
The Bank Of New York Mellon Trust Company
5% Or Greater Mortgage Interest · Organization
Westminster Canterbury Corporation
5% Or Greater Direct Ownership Interest · Organization
Westminster Canterbury Corporation
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Rosedale Health & Rehabilitation
Richmond, VA
1-star overall rating with 1-star inspections with $73,788 in total fines with 51 recent health deficiencies
#2
Lakeside Health & Rehabilitation
Richmond, VA
2-star overall rating with 1-star inspections with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Vcu Health Children's Services At Brook Road
Richmond, VA
5-star overall rating with 5-star inspections
Jump out