Holly Manor Rehab and Nursing
2003 Cobb Street, Farmville, VA 23901 · Prince Edward County · (434) 392-6106
120 certified beds, about 112 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1999
Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495339 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on August 30, 2024, inspectors cited 31 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 95 health citations since June 2021, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.30 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.45 of those hours.
56.9% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Hill Valley Healthcare, an affiliated group of 43 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
706/21
3011/22
409/23
605/24
3108/24
1706/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 95 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
47D
35E
8F
Potential for minimal harm
0A
1B
3C
June 5, 2025Complaint inspection · 17 citations
- E Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to resolve grievances voiced regarding linen supplies in 10 of 11 months of resident council meetings reviewed.
- E Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 13 residents in the survey sample, Resident #10.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for three of 13 residents, Residents #12, #7, and #1.
- E Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for four of 13 residents in the survey sample, Residents #1, #5, #7, and #9.
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of 13 residents in the survey sample, Resident #8.
- E Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wrote2. For Resident #12(R12), the facility staff failed to manage the resident's pain. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 5/22/25, the residents scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The resident was admitted to the facility with diagnoses that included but were not limited to: muscle weakness, peripheral vascular disease, and an open arterial wound to the right ankle. An interview was conducted with R12 on 6/3/25 at 2:30 p.m. When asked if he had pain, R12 stated at that moment his pain level was a six out of 10. He stated the staff give him Tylenol for it. R12 stated it dulls the pain but doesn't take it away. A second interview was conducted with R12 on 6/4/25 at 8:43 a.m. [...]
- E Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure one of 13 residents in the survey sample was free of significant medication errors, Resident #1.
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of three units observed, [NAME] unit.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interview, it is determined that the facility staff failed to prepare and serve food in a sanitary manner in one of two facility kitchens.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to inform a resident/resident representative of the risks, benefits, and alternatives of medication treatment for one of 13 residents in the survey sample, Resident #10.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wrote2. For Resident #10 (R10), the facility staff failed to notify the resident representative the resident was vomiting and placed on contact precautions on 2/19/25. A review of R10's clinical record revealed a nurse's note dated 2/19/25 that documented the resident was placed on contact isolation precautions due to vomiting during the previous day. Further review of R10's clinical record failed to reveal the resident's representative was notified regarding this change in condition on 2/18/25 or 2/19/25. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated a resident's representative should be made aware of the resident's change in condition as soon as possible and this is evidenced by documenting a nurse's note. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. [...]
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to review or revise the comprehensive care plan for one of 13 residents, Residents in the survey sample, Resident #11 (R11).
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. For Resident #12, the facility staff failed to administer antibiotics, Flagyl and Cipro, per the physician orders. The physician orders dated 5/20/25, documented, Ciprofloxacin HCL (hydrochloride)(1) Oral Tablet 500 MG (milligrams); Give 1 tablet by mouth one time a day related to diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 4 days. The physician order dated, 5/21/25, documented, Flagyl Oral Tablet (2) 500 MG; Give 1 tablet by mouth three times a day related to Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 3 days. The May 2025 MAR (medication administration record) documented the above order. The medication was to be administered at 4:00 a.m. On 5/20/25 at 4:00 a.m. the space to sign off the medication was blank. The May 2025 MAR documented the above order. On 5/24/25 for the 10: [...]
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility, it was determined that facility staff failed to provide respiratory care and services for one of 13 residents in the survey sample, Resident #5 (R5). For R5, the facility staff failed to obtain a physician's order for the use of oxygen.
- D Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for three of 13 residents in the survey sample, Residents #1, #5, and #9.
- D Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide sufficient nursing staff for three of 13 residents in the survey sample, Residents #1, #5, and #9.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to post complete nurse staffing information for three of three reviewed days.
August 30, 2024Standard inspection, Complaint inspection · 31 citations
- F Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain the garbage areas in a sanitary manner for one of one trash compactor and two of ten trash bins.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain a complete infection control program and implement infection control practices for one of 50 residents in the survey sample, Resident #33.
- E Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview, facility staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a manner to promote resident dignity for four of 50 residents in the survey sample, Residents #96, #31, #67, and #157.
- E Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence written notification of a facility-initiated hospital transfer was provided to the resident and/or Ombudsman, for five of 50 residents in the survey sample; Residents #52, #69, #22, #45 and #11.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote7. The facility staff failed to implement the comprehensive care plan for wound care for Resident #116. Resident #116 was admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, sacral ulcer and ASCVD (atherosclerotic cardiovascular disease). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/6/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 9/14/22 revealed, FOCUS: Resident has a skin tear to her right shin. INTERVENTIONS: Treatment as ordered. [...]
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for dependent residents for four of 50 residents in the survey sample, Residents #96, #108, #32, and #67.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of well-being for eight of 50 residents in the survey sample, Residents #157, #34, #114, #113, #108, #112, #117 and #53.
- E Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of pressure injuries for three of 50 residents in the survey sample, Residents #67, #111 and #116.
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for 2 of 50 residents, Resident #108 and #407.
- E Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 50 residents in the survey sample, Residents #96 and #72.
- E Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services related to dialysis for five of 50 residents in the survey sample, Residents #101, #109, #56, #63 and #22.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on staff interview and facility document review, the facility failed to provide adequate nursing staff for two of 50 residents in the survey sample, Residents #107 and #112.
- E Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for two of 50 residents in the survey sample, Resident #113 and Resident #26.
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to serve palatable food for five of 33 residents in the survey sample, Residents #24, #96, #34, #157, and #32.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on staff interview, and facility document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required in-services trainings for three of five CNA record reviews.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for three of 50 residents in the survey sample, Resident #92, Resident #50 and Resident #91.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to notify the physician and/or the resident's representative of a change in condition or treatment, for three of 50 residents in the survey sample; Residents #53, #101, and #110.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to issue a beneficiary notice of non-coverage in a timely manner for one of three beneficiary notice reviews, Resident #257.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 50 residents in the survey sample, Resident # 115.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan for two of 50 residents in the survey sample, Resident #113 and Resident #407.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for three of 50 residents in the survey sample, Residents #11, #114 and #110.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for three of 50 residents in the survey sample, Residents #157, #34 and #72.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for an indwelling catheter for two of 50 residents in the survey sample, Residents #67 and #24.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to complete nutritional assessments and obtain daily weights for one of 50 residents in the survey sample, Resident #34.
- D 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.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to perform safety assessments for the use of side rails for one of 50 residents in the survey sample, Resident #93.
- D Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide physician oversight for the care of four of 50 residents in the survey sample, Residents #96, #72, #112, and #117.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide a physician ordered medication for administration to two of 50 residents in the survey sample, Residents #96 and #34.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure the physician reviewed and acted upon a pharmacy recommendation for one of five residents reviewed for the monthly pharmacy regimen review task.
- D 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.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure that one of five residents reviewed for the monthly pharmacy regimen review task was free of an unnecessary psychoactive medication; Resident #22.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in a safe and sanitary manner in one of one kitchen, and one of three nourishment rooms (the grace unit), and failed to maintain the dishwasher in good repair in one of one kitchen.
- D Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to provide a sanitary environment for one of one kitchen.
May 7, 2024Complaint inspection · 6 citations
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, resident interview, facility document review, and clinical record review, the facility staff failed to treat a resident with dignity by not answering a call bell for one of six residents in the survey sample, Resident #6.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for two of six residents in the survey sample, Residents #5 and #6.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer and/or accurately document administration of medications according to professional standards of practice for one of six residents in the survey sample, Resident #5.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order for one of six residents in the survey, Resident #4.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory services in a timely manner for one of six residents in the survey sample, Resident #5.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, resident interview, facility document review, and clinical record review, the facility staff failed to store equipment in a manner to prevent infection for one of six residents in the survey sample, Resident #5.
September 12, 2023Complaint inspection · 4 citations
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to serve food at a palatable texture and appetizing temperature, on one of three facility units, the [NAME] unit.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for two of six residents in the survey sample, Residents #3 and #2.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications according to the provider's orders and professional standards of medication administration for two of six residents in the survey sample, Residents #3 and #2.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications in a manner to prevent significant medication errors for two of six residents in the survey sample, Residents #3 and #2.
November 17, 2022Standard inspection · 30 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide adequate supervision to prevent injury for one of 33 residents in the survey sample, Resident #61, resulting in harm of past non-compliance.
- F Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to continuously employ a registered dietitian (RD) or qualified nutritional professional.
- F Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement a QAPI (Quality Assurance and Performance Improvement) program potentially affecting all residents in the survey sample.
- F Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement policies and procedures for QAPI (Quality Assurance and Performance Improvement) program feedback, data systems and monitoring potentially affecting all residents in the survey sample.
- F Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to conduct required QAPI (Quality Assurance and Performance Improvement) meetings potentially affecting all residents in the survey sample.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to implement an ongoing infection prevention and control program (IPCP) potentially affecting all residents in the survey sample.
- F Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to continuously employ an infection preventionist (IP) potentially affecting all residents in the survey sample.
- E Reasonably accommodate the needs and preferences of each resident.
Inspectors wrote4. For Resident #15 (R15), the facility staff failed to honor a resident's preferences for bed rails to maintain their level of ADL (activities of daily living) self-performance and promote their sense of self-determination and independence. R15 used the bed rails on their bed to increase their ADL self-performance with staff assistance in transferring and bed mobility and requested their use however they were removed from the bed causing R15 to require more physical assistance from staff when transferring to the recliner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/30/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. [...]
- E Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to maintain grievance logs from 7/20/2022 through 11/15/2022 potentially affecting most of the 33 residents in the survey sample.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 33 residents in the survey sample, Residents #53, #51, #63 and #54.
- E Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to facilitate communication with the dialysis center for one of 33 residents in the survey sample, Resident #63 (R63).
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for three of five CNA's (certified nursing assistants) reviewed CNA #2, #3, and #5.
- E Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on staff interview, facility document review, and clinical record review it was determined that the facility staff failed to ensure one of 33 residents in the survey sample was free of unnecessary medications, Resident #16.
- E Ensure that residents are free from significant medication errors.
Inspectors wroteBased on staff interview, facility document review, and clinical record review it was determined that the facility staff failed to administer medications in a manner free of significant errors for one of 33 residents in the survey sample, Resident #16.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to properly store food products in the walk in refrigerator, discard expired food, and maintain the dishwasher in good repair in one of two kitchens in the facility.
- E Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for five of five CNA (certified nursing assistant) record reviews.
- E Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to provide abuse and dementia management training for five of six agency employee reviews.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, resident interview, responsible party interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to honor a resident's right to make choices about their bathing preferences for two of 33 residents in the survey sample, Resident #47 and Resident #29.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review it was determined that the facility failed to ensure one of 33 residents were free of misappropriation of property, Resident #10.
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on staff interview, facility document review, and clinical record review it was determined that the facility failed to implement the facility abuse policy for screening staff for one of four agency staff reviewed, LPN (licensed practical nurse) #3.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 33 residents in the survey sample, Resident #206.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain weights as ordered by the physician, for one of 33 residents in the survey sample, Resident #22.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care for two of 33 residents in the survey sample, Residents #61 and #22.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide incontinence care in a timely manner for one of 33 residents in the survey sample, Resident #51 (R51).
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice for three of 33 residents in the survey sample, Residents #53, #98 and #206.
- D 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.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement bed rail requirements for two of 33 residents in the survey sample, Residents #68 and #20.
- D Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on staff interview, resident observation, facility document review and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet resident needs for one of 33 residents, Resident #22.
- D Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to maintain an effective training program for two of 5 employee reviews.
- C Implement a program that monitors antibiotic use.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to conduct an ongoing antibiotic stewardship program.
- C Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on staff interview and facility document review, the facility staff failed implement their COVID-19 policy to track and document the COVID-19 vaccination status for contract employees.
June 30, 2021Standard inspection · 7 citations
- E Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure pain management was provided consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 38 residents in the survey sample, Resident #27. The facility staff failed to complete a pain assessment of Resident #27's pain, prior to the administration of a pain medication on multiple occasions in April, May and June 2021.
- E Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one of 38 residents in the survey sample was free of unnecessary medications, Resident #27. On multiple occasions during April, May and June 2021, the facility staff failed to ensure Resident #27 was free from unnecessary medication, as evidenced by the staffs failure to complete a pain assessment, and failure to attempt/offer non-pharmacological interventions prior to administering the physician prescribed as needed pain medication Norco to Resident #27, and as evidenced by staff administering the medication for documented/reported pain levels of 7, which were below the physician ordered parameter of eight (8) for administration of the medication.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 38 residents in the survey sample, Resident #27 and Resident #89. 1. The facility staff failed to implement Resident 327's comprehensive care plan for the management of pain. Facility staff administer a as needed pain medication when the residents pain level rating was below the physician parameter of eight, without a pain assessment and without attempting non-pharmacological interventions on multiple occasions during April, May and June 2021. 2. a. The facility staff failed to implement Resident #89's comprehensive care plan for treatment of a pressure injury. [...]
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide wound care in a manner to promote healing and prevent infection for one of 38 residents in the survey sample, Resident #89. LPN #6 failed to change gloves between cleaning Resident #89's right and left buttock wound and wiped down the left buttock wound from top to bottom and then wiped back up the wound using the same gauze.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an indwelling catheter consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 38 residents in the survey sample, Resident # 89. The nurse failed to maintain the indwelling catheter collection bag below the resident's bladder. Observation revealed the staff placed Resident #89's Foley catheter bag on the bed while the resident received wound care. Urine was observed flowing up towards the resident and not towards the collection bag.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to store, and prepare, food in accordance with professional standards for food service. The facility staff failed to maintain the fryer in a sanitary manner after use the previous evening and failed to dispose of expired or opened food during the facility task- kitchen observation on 6/28/21 at 11:30 AM.
- B Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop a policy for the monthly drug regimen reviews with times frames for the different steps in the process, in order to address recommendations from the pharmacist for four residents reviewed for medications, (Residents #22, #24, #45 and #77), in the survey sample of 38 residents. The facility, Medication Monitoring policy failed to include any documentation regarding the timeframe that a pharmacy recommendation is required to be provided to the physician and acted upon by the physician. The policy did not meet regulatory requirements of specifying those time frames for the different steps.
Fire safety inspections
7 fire safety citations on file: 1 on November 17, 2022, 6 on June 30, 2021.
Every fire safety citation7 citations
- E Inspect, test, and maintain automatic sprinkler systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have properly installed electrical wiring and gas equipment.
- E Have exits that are accessible at all times.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- D Use approved construction type or materials.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Virginia | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.30 | 3.76 | 3.86 |
| Registered nurses | 0.45 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.89 | 3.29 | 3.42 |
| Nurse aides | 1.84 | ||
| Licensed practical nurses | 1.01 | ||
| Nursing staff turnover (share who left in a year) | 56.9% | 48.1% | 45.8% |
| Registered nurse turnover | 60.9% | 48.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.71 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.46 on weekdays and 2.89 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 7.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.36 in April to June 2025 to 3.30 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.30 | 0.45 | 3.46 | 2.89 | 7.4% | 0 of 90 | 112 |
| Oct to Dec 2025 | 3.19 | 0.63 | 3.35 | 2.78 | 5.6% | 0 of 92 | 109 |
| Jul to Sep 2025 | 3.27 | 0.62 | 3.44 | 2.83 | 3.9% | 0 of 92 | 108 |
| Apr to Jun 2025 | 3.36 | 0.69 | 3.56 | 2.84 | 5.5% | 0 of 91 | 105 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Virginia, Jan to Mar 2026 | 3.58 | 0.56 | 3.76 | 3.12 | 5.7% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Virginia | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.0 | 14.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.3 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.9 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.0 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.4 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.3 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.6 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 18.5 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.5 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 1.5 | 1.8 |
Owners and operators
Legal business name: HOLLY MANOR SNF OPERATIONS LLC. CMS links this home to Hill Valley Healthcare, a group of 43 nursing homes averaging 1.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Holly Manor SNF Operations Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 05/01/2022 |
| Farmville Operations Holdings LLC | 5% or greater indirect ownership interest | Organization | 100% | 05/01/2022 |
| Preston, Zach | W-2 managing employee | Individual | 05/01/2022 | |
| Idels, Shimon | Corporate officer | Individual | 05/01/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 24 problems in this area, most recently on June 5, 2025: "Provide care and assistance to perform activities of daily living for any resident who is unable."
- When is the care plan meeting, and can family attend it?Inspectors cited 16 problems in this area, most recently on June 5, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 12 problems in this area, most recently on June 5, 2025: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 10 problems in this area, most recently on June 5, 2025: "Ensure that residents are free from significant medication errors."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.89 hours per resident per day, below the Virginia average of 3.29.
Other nursing homes nearby
- Farmville Health & Rehab Center Farmville, 1.8 mi · 3 of 5 stars · 44 citations
- Heritage Hall Dillwyn Dillwyn, 16.3 mi · 3 of 5 stars · 25 citations
- Appomattox Health & Rehabilitation Center Appomattox, 22.3 mi · 1 of 5 stars · 39 citations
- Amelia Rehabilitation and Healthcare Center Amelia, 24.1 mi · 1 of 5 stars · 57 citations
- Wayland Nursing and Rehabilitation Center Keysville, 24.7 mi · 4 of 5 stars · 38 citations
Virginia contacts for a concern about a nursing home
These are the official offices in Virginia. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Virginia Department of Health, Office of Licensure and Certification, Division of Long-Term Care Services, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Virginia Office of the State Long-Term Care Ombudsman, 800-552-5019. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: VDH Nursing Home and ICF/IID Inspections and Surveys, where Virginia publishes its own records on licensed homes.
Common questions
- What is Holly Manor Rehab and Nursing's Medicare star rating?
- CMS rates Holly Manor Rehab and Nursing 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Holly Manor Rehab and Nursing get at its last inspection?
- 31 health deficiencies at the standard inspection on August 30, 2024. The Virginia average is 14.3.
- Has Holly Manor Rehab and Nursing been fined?
- CMS lists no fines in the last three years.
- Does Holly Manor Rehab and Nursing accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Holly Manor Rehab and Nursing?
- CMS lists 4 owners and managers, and links the home to Hill Valley Healthcare. Legal business name: HOLLY MANOR SNF OPERATIONS LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.