110 Chalmers Court, Berryville, VA 22611 · Clarke County · (540) 955-9995
120 certified beds, about 115 residents a day · For profit - Corporation · Medicare and Medicaid since 1984
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495140 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 29, 2023, inspectors cited 19 health deficiencies (the Virginia average is 14.3, the national average 9.2).
None of its 75 health citations since March 2020 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.37 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.34 of those hours.
46.2% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Trio Healthcare, an affiliated group of 9 nursing homes.
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.
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 75 health citations on file.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement their policy to prevent misappropriation of resident property for three of thirteen residents in the survey sample, Residents #10, #11, and #12.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to report an allegation of misappropriation of resident property to the state agency for three of thirteen residents in the survey sample, Residents #10, #11, and #12.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to report an allegation of misappropriation of resident property to the state agency for two of thirteen residents in the survey sample, Residents #11 and #12.
Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to maintain infection control tracking logs for two of the three months requested.
Inspectors wroteBased on staff interview. facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner when medications were not available or administered for three of 13 residents in the survey sample, Residents #1, #10, and #11.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications for three of 13 residents in the survey sample, Residents #11, #2, and #7.
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 three of 13 residents in the survey sample, Residents #7, #11, and #10.
Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, it was determined the facility staff failed to review and revise the care plan for one of 13 residents in the survey sample, Resident #12.
Inspectors wroteBased on observation, resident interview, staff interview and facility document review, it was determined the facility staff failed to implement a physician order for supervision of a resident when the resident signs himself out of the building, for one of 13 residents in the survey sample, Resident #12.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide pharmacy services for one of 13 residents in the survey sample, Resident #1.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 13 residents were free of significant medication errors, Residents #7 and Resident #10.
Inspectors wroteBased on resident interview, staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 13 residents in the survey sample, Resident #3.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent with residents upon transfer to the hospital for four of 35 residents, Residents #45, #102, #43 and #89.
Inspectors wroteBased on staff interview, facility document review and clinical record review it was determined the facility staff failed to notify the Office of the State Long-Term Care Ombudsman and the resident and/or responsible party of a transfer to the hospital for four of 35 residents in the survey sample, Residents #45, #102, #43, and #89.
Inspectors wrote3. For Resident #76 (R76), the facility staff failed to develop a care plan to address the resident's smoking. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 5/3/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as only requiring supervision after set up assistance if needed. An interview was conducted with R76 on 6/27/2023 at approximately 1:30 p.m. When asked if he goes out to smoke, R76 stated he goes out about three times a day for smoking and does go out other times just to walk. [...]
Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete smoking assessments for four of 35 residents in the survey sample, Residents #76, #38, #67, and #307.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to inform a resident/resident representative of the risks and benefits of medication treatment for one of 35 residents in the survey sample, Resident #5.
Inspectors wroteBased on family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to invite the responsible party to the care plan meeting for one of 35 residents in the survey sample, Resident #100.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to conduct a periodic review of advance directives with residents and/or their RRs (resident representatives) to determine if they wished to make changes to their existing advance directives or maintain them as written, for two of 35 residents in the survey sample, Residents #36 and #2.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a possible need to alter treatment for two of 35 residents in the survey sample, Residents #51 and #2.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for one of 35 residents in the survey sample, Resident #51.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer to the hospital for two of 35 residents in the survey sample, Residents #45 and #89.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 35 residents in the survey sample, Resident #5.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to clarify a physician order for the diagnosis for the use of Seroquel, for one of 35 residents in the survey sample, Resident #157.
Inspectors wroteBased on family interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to consistently provide ADL (activities of daily living) care for one of 35 residents in the survey sample, Resident #100.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to monitor a resident's weight for one of 35 residents in the survey sample, Resident #12.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of communication to the dialysis center for one of 35 residents in the survey sample, Resident #45.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure residents were assessed for, informed of risk and benefits of, and signed a consent for the use of siderails/bedrails for two of 35 residents in the survey sample; Residents #40 and #96.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration for two of 35 residents in the survey sample, Residents #51 and #2.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 35 residents in the survey sample was free from a significant medication error; Resident #51.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to serve food in a sanitary manner in one of one resident dining rooms.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence physician documentation of the rationale for and/or failed to provide all required documentation to the receiving facility for transfer to the hospital for five of 46 residents in the survey sample; Residents #91, #49, #26, #29 and #13. 1. The facility staff failed to evidence the physician wrote a note regarding the reason for Resident #91's hospital transfer on 10/26/21, and that all required documentation was provided to the receiving facility. 2. The facility staff failed to evidence the physician wrote a note regarding the reason for Resident #49's hospital transfer on 8/19/21 and 9/1/21, and that all required documentation was provided to the receiving facility for both transfers. 3. [...]
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the Ombudsman and/or Resident Representative upon a hospital transfer for six of 46 residents in the survey sample; Residents #91, #49, #26, #29, #13 and #100. The facility staff failed to evidence that written notification was provided to the resident representative and Ombudsman for Resident #91's hospital transfer on 10/26/21, Resident #49's hospital transfers on 8/19/21 and 9/1/21, Resident #26's hospital transfer on 9/15/21 and 11/4/21, Resident #29's hospital transfer on 10/23/2021, Resident #13's hospital transfer on 8/19/21, and Resident #100's hospital transfer on 11/1/2021.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or resident representative prior to and or at the time of transfer to the hospital for three of 46 residents in the survey sample; Residents #49, #26 and #68. The facility staff failed to evidence that a written bed hold notice was provided to the resident and or resident representative for the hospital transfers of Resident #49 on 8/19/21 and 9/1/21, Resident #26 on 9/2/2021 and Resident #68 on 10/27/21.
Inspectors wroteBased on observation, staff interview and facility document review it was determined that the facility staff failed to ensure medications were labeled and stored in a secure manner in two of four medication carts, (South Wing medication cart-one and South Wing medication cart-three). Observation of the South wing medication cart-one revealed two half-loose unidentified pills in drawer one, three whole-loose unidentified pills in drawer three and one whole-loose unidentified pill in drawer four of the medication cart. Observation of the South wing-cart three revealed, one whole-loose unidentified pill in drawer two, two half and one-loose unidentified pills in drawer three of the medication cart.
Inspectors wroteBased on observation, staff interview, and facility document review it was determined that the facility staff failed to store food in two of two nourishment rooms in accordance with professional standards for food service safety.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to maintain an effective Quality Assurance program. The facility staff failed to ensure the physician attended quarterly quality assurance meetings for three of three quarters
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to respond to a grievance expressed during a resident council meeting for one of three resident council meetings reviewed. The facility staff failed to ensure a concern expressed regarding laundry during the August 2021 resident council meeting was responded to and addressed.
Inspectors wroteBased on clinical record review, facility document review and staff interview it was determined that the facility staff failed to notify the physician that a resident's medications were not available for administration for one of 46 residents in the survey sample, Resident # 201. The facility staff failed to notify Resident # 201's physician that the medications, metoprolol, zestoretic, gabapentin, glimepiride, and ozempic, were not available for administration on 05/22/2021 and 05/23/2021.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for one of 46 residents in the survey sample, Resident #7. The facility staff failed to implement the facility abuse policy for investigating and reporting an injury of unknown origin when Resident #7 sustained a bruise on 8/5/21.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report an injury of unknown origin for one of 46 residents in the survey sample, Resident #7. Resident #7 sustained a bruise of unknown origin on the right arm extending from the shoulder to elbow that was found on 8/5/21. The facility staff failed to report this injury of unknown origin to the SA (state agency) and other required agencies.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to investigate an injury of unknown origin for one of 46 residents in the survey sample, Resident #7. Resident #7 sustained a bruise of unknown origin on the right arm extending from the shoulder to elbow on 8/5/21. The facility staff failed to complete a thorough investigation to determine the cause of the bruise.
Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility staff failed to ensure an accurate MDS [minimum data set] assessment for one of 46 residents in the survey sample, Resident # 86. The facility staff failed to code Resident # 86 for the use of oxygen in Section O Special Treatments on the residents 5 day MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/05/2021.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 46 residents in the survey sample, Resident # 62. The facility staff failed implement Resident # 62's comprehensive care plan to keep the catheter collection bag off the floor and failed implement Resident # 62's comprehensive care plan to administer oxygen at two liters per minute.
Inspectors wroteBased on observation, staff interview and facility document review it was determined facility staff failed to review and revise the comprehensive care plan for three of 46 residents in the survey sample, Resident #3, Resident #31 and Resident #15. 1. The facility staff failed to revise the Resident #3's comprehensive care plan to address the resident beginning a restorative program following completion of physical therapy on 3/26/21. 2. The facility staff failed to review and revise Resident #15's comprehensive care plan to address the administration of an anticoagulant prescribed by the physician on 05/27/2021. 3. The facility staff failed to review and revise Resident #31's comprehensive care plan for the use of bed rails.
Inspectors wroteBased on clinical record review, facility document review and staff interview it was determined that the facility staff failed to ensure treatment and care in accordance with professional standards of practice, and the comprehensive plan of care for one of 46 residents in the survey sample, Resident # 201. The facility staff failed to administer Gabapentin to Resident #201 on 05/22/2021, according to the physician's orders.
Inspectors wroteBased on observation, resident interview staff interview and facility document review it was determined that the facility staff failed to provide treatment and services to maintain or improve mobility for one of 46 residents in the survey sample, Resident #3. The facility staff failed to implement a RNP (restorative nursing program) for Resident #3 following completion of physical therapy 3/26/21.
Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that facility staff failed to ensure care and services for an indwelling catheter to prevent infection for one of 46 residents in the survey sample, Residents # 62. The facility staff failed to keep Resident # 62's catheter collection bag off the floor.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory services according to the physician's orders one of 46 residents in the survey sample, Residents # 62. The facility staff failed to administer Resident # 62's oxygen at two liters per minute according to the physician's orders.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for two of five CNA record reviews, CNA #6 and CNA #7. The facility staff failed to complete an annual performance review for CNA #6, hired on 8/29/19 and CNA #7, hired on 1/7/20.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to provide pharmacy services for one of 46 residents in the survey sample, Resident # 201. The facility staff failed to ensure the medications, Metoprolol [1] Zestoretic [2], Glimepiride [3] and Ozempic [4] were available for administration to Resident # 201 as ordered by the physician on 5/22/21, 5/23/21 and 5/24/21.
Inspectors wroteBased on observation, clinical record review and facility staff interview it was determined that the facility staff failed to maintain a complete and accurate record for one of 46 residents in the survey sample, Resident #29.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure CNAs (certified nursing aides) completed required annual in-service training for two of five CNA record reviews, CNA #2 and CNA #8. The facility staff failed to ensure CNA #2 and CNA #8 completed annual dementia training.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to notify the physician and/or responsible party of resident to resident incidents or the need to alter treatment for one of 50 residents in the survey sample, Residents #18. The facility staff failed to notify the physician and/or the nurse practitioner when Resident #18's medications were not administered on 12/31/19.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain the resident right to be free from abuse for nine of 50 residents in the survey sample, Residents #69, #67, #650, #652, #7, #651, #22, #41, and #39. - On 1/22/19, facility staff failed to ensure that Resident #69 and Resident #67 were free from abuse from each other. Resident #67 hit Resident #69, and then Resident #69 hit Resident #67 back. - On 2/26/19, facility staff failed to ensure that Resident #650 was free from abuse, when Resident #69 hit Resident #650 in the face on the nose and forehead. - On 2/15/19, facility staff failed to ensure that Resident #652 was free from abuse, when Resident #69 grabbed Resident #652 by the neck. [...]
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy to report and investigate allegations of abuse to the required State agency for eight of 50 residents in the survey sample, (Residents #69, #67, #7, #41, #22, #39, #650, and #652). On 1/22/19, Resident #67 hit Resident #69, and then Resident #69 hit Resident #67 back. On 3/18/19, Resident #69 hit Resident #7 in the face. On 1/12/20, Resident #69 hit Resident #41 in the right side of her face with a closed fist. The facility staff failed to implement the facility abuse policy to investigate and report the incident to the required state agency and failed to notify Resident #67's, #7's and #41's physicians and responsible parties per the policy. On 10/17/19, Resident #69 hit Resident #22 in the left arm with a closed fist. [...]
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse, for eight of 50 residents in the survey sample, (Residents #69, #67, #7, #41, #22, #39, #650, and #652). On 1/22/19, Resident #67 hit by Resident #69 and then Resident #69 hit Resident #67 back. On 3/18/19, Resident #69 hit Resident #7 in the face. On 1/12/20, Resident #69 hit Resident #41 in the right side of her face with a closed fist. On 10/17/19, Resident #69 hit Resident #22 in the left arm with a closed fist. On 3/6/20, Resident #69 pulled Resident #39 out of his chair to the floor. On 2/26/19, Resident #69 hit Resident #650 in the face. On 2/15/19, Resident #69 grabbed Resident #652 by the neck. [...]
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to investigate allegations of abuse, for seven of 50 residents in the survey sample, Residents #69, #67, #7, #41, #22, #650, and #652. On 1/22/19, Resident #67 hit by Resident #69 and then Resident #69 hit Resident #67 back. On 3/18/19, Resident #69 hit Resident #7 in the face. On 1/12/20, Resident #69 hit Resident #41 in the right side of her face with a closed fist. On 10/17/19, Resident #69 hit Resident #22 in the left arm with a closed fist. On 2/26/19, Resident #69 hit Resident #650 in the face. On 2/15/19, Resident #69 grabbed Resident #652 by the neck. The facility staff failed to investigate the allegations of abuse for Residents# 69, #67, #7, #41, #22, #650 and #652.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the required information to the receiving facility at the time of facility initiated transfers for six of 50 residents in the survey sample, Residents #114, #60, #36, #7, #59 and #40. The facility staff failed to evidence that the comprehensive care plan goals were provided to the receiving facility for: Resident # 114 transferred on 01/03/2020; Resident # 60 transferred on 02/27/2020 and for Resident # 36 transferred on 01/09/2020. For Resident #7's transfer on 1/3/2020, for Resident #59's hospital transfer on 1/13/20 and for Resident #40's hospital transfer on 12/29/19.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification to the ombudsman and/or the resident and the resident's representative of a facility/resident-initiated transfer for six of 50 residents in the survey sample, Residents #114, #60, #36, #7, #59 and #40. The facility staff failed to evidence that written notification of the reason for transfer was provided to resident # 114 and Resident # 114's responsible party for the resident hospital transfer on 01/03/2020. To Resident # 60, Resident # 60's representative and /or the ombudsman for the facility-initiated transfer of Resident # 60 on 02/27/2020, and to Resident # 36, Resident # 36's representative and the ombudsman for the facility-initiated transfer of Resident # 36 on 01/09/2020. [...]
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for five of 50 residents in the survey sample, (Residents #313, 18, 11, 87, and 61). The facility staff failed to develop and implement a comprehensive care plan to address Resident #313's fall risk. The facility staff failed to implement Resident #18's comprehensive care plan for medication administration, failed to implement Resident #11's comprehensive care plan for oxygen administration, and failed to implement Resident # 87's comprehensive care plan for the use of oxygen. The facility staff failed to develop a comprehensive care plan to address Resident # 61's use of a C-PAP [Continuous Positive Airway Pressure].
Inspectors wrote6. The facility staff failed to review and revise Resident #39's comprehensive care plan for the use of halo assist bar bed rails. Resident #39 was admitted to the facility on [DATE]. Resident #39's diagnoses included but were not limited to seizures, high blood pressure and muscle weakness. Resident #39's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/14/20, coded the resident's cognition as severely impaired. Section G coded Resident #39 as requiring extensive assistance of two or more staff with bed mobility. Resident #39's comprehensive care plan dated 11/5/19 failed to document information regarding the resident's use of halo assist bar bed rails. On 3/9/20 at 8:21 a.m., Resident #39 was observed in bed with bilateral halo assist bars up. [...]
Inspectors wroteBased on observation, staff interview and clinical record review it was determined facility staff failed to follow professional standards of practice for two of 50 residents in the survey sample, Resident #99 and Resident #61. The facility staff failed to follow medication administration standards of practice during the administration of Protonix delayed release tablet on 3/9/20. RN (registered nurse) #1 crushed, opened and mixed the contents of one 40 mg (milligram) Protonix delayed release capsule with pudding and administered the medication to Resident #99. The facility staff failed to obtain an order for Resident #61 use of a CPAP [continuous positive airway pressure].
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services in accordance with professional standards of practice and the comprehensive plan of care for two of 50 residents in the survey sample, (Residents #18 and #40). The facility staff failed to administer physician prescribed medications to Resident #18 on 12/31/19. The facility staff failed to maintain a current physician's order for Resident #4 to received Hospice care and services.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for four of 50 residents in the survey sample, Residents #11, #87, #99 and #61. The facility staff failed to administer oxygen to Resident #11, #87 and #99, at flow rate prescribed by the physician. The facility staff failed to store Resident # 61's C-PAP [Continuous Positive Airway Pressure] mask in a sanitary manner.
Inspectors wroteBased on observation and staff interview it was determined facility staff failed to ensure expired medications and biological's were not available for use in two of four medication carts observed, (North Unit yellow and North Unit one medication cart), and one of one medication rooms observed, (South Unit medication room). On the North Unit yellow medication cart 2 bottles of medication expired were observed available for use a bottle of zinc sulfate (mineral supplement) 220mg (milligram) with Best by 12/19 labeled on the bottle, and a 10 (ten) oz. (ounce) bottle of Geri-mucil fiber laxative and dietary supplement with 09/19 printed on the bottle. On the North Unit Medication cart 1 (one) eleven plastic vials of Albuterol Sulfate inhalation solution 0.083% (percent) 2.5mg (milligram)/3ml (milliliter), labeled, Exp [expire]: Sep 2019, were available for resident use. [...]
Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to prepare food in the facility's kitchen in a sanitary manner and store food in a sanitary manner in two of two nutritional rooms.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement infection control practices for the storage of a C-PAP mask for one of 50 residents in the survey sample, Residents # 61; in the laundry room and in one of two dining rooms, (the facility's main dining room). The facility staff failed to store Resident #61's CPAP [continuous positive airway pressure] mask in a manner to prevent infection. The facility staff failed to maintain the clean laundry area in a clean and sanitary manner. Dust, dirt and lint were observed on the metal overhead conduit piping, vents and support beams. [...]
Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for one of 50 residents in the survey sample, Resident #18. Multiple brown stains were observed on the resident's privacy curtain.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to provide treatment and services to maintain and/or restore a resident's bladder function for one of 50 residents in the survey sample, Resident #78. The facility staff failed to identify and address Resident #8's decline in urinary continence between a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/9/19 and a quarterly MDS assessment with an ARD of 2/12/20.
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for three of 50 residents in the survey sample, (Residents #39, #107 and #43). The facility staff failed to assess Resident #39, #107 and #43 for the use of halo assist bar bed rails, failed to review risks and benefits with the residents (or the resident's representative) and failed to obtain informed consent for the use of halo assist bar bed rails.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure physician prescribed medication were available for administration as ordered for one of 50 residents in the survey sample, Resident #18. On 12/31/19, the facility staff failed to administer the medication trazadone (1) to Resident #18 because the medication was on order from the pharmacy.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to administer the pneumococcal immunization for one of five influenza and pneumococcal resident reviews, Resident #7. Consent for Resident #7 to receive the pneumococcal immunization was obtained on 10/5/19 and the facility staff failed to administer the immunization.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post notice of employee rights regarding the reporting of suspicious crimes.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to post the current nurse staffing information. Nurse staffing information for 3/8/20 was not posted on 3/8/20. Instead, nurse staffing information for 3/7/20 was posted.
6 fire safety citations on file: 2 on June 29, 2023, 2 on December 2, 2021, 2 on March 10, 2020.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
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) | 3.37 | 3.76 | 3.86 |
| Registered nurses | 0.34 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.85 | 3.29 | 3.42 |
| Nurse aides | 2.07 | ||
| Licensed practical nurses | 0.97 | ||
| Nursing staff turnover (share who left in a year) | 46.2% | 48.1% | 45.8% |
| Registered nurse turnover | 61.5% | 48.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.91 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
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 3.59 on weekdays and 2.85 on weekends, 21% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.40 in April to June 2025 to 3.37 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 | 3.37 | 0.34 | 3.59 | 2.85 | 1.5% | 0 of 90 | 115 |
| Oct to Dec 2025 | 3.33 | 0.35 | 3.47 | 2.96 | 0.0% | 0 of 92 | 116 |
| Jul to Sep 2025 | 3.30 | 0.41 | 3.43 | 2.97 | 0.0% | 0 of 92 | 116 |
| Apr to Jun 2025 | 3.40 | 0.46 | 3.59 | 2.92 | 0.0% | 0 of 91 | 116 |
| 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.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Virginia, all employers | |||
| CNAs (nursing assistants) | $20.77 | $17.80 to $22.56 | 40,580 |
| LPNs and LVNs | $31.21 | $28.66 to $35.84 | 15,550 |
| Registered nurses | $45.00 | $38.51 to $49.53 | 77,490 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
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 | 32.3 | 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 | 0.5 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.3 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.5 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 34.1 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.5 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.3 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 27.5 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 10.5 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 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 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Rose Hill Health and Rehab's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (49.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
49.8% this home
No different from the national rate
US median of homes 51.5% · Virginia: 101 better, 22 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 145 eligible stays.
11.4% this home
No different from the national rate
US median of homes 10.7% · Virginia: 1 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 148 eligible stays.
12.3% this home
Worse than the national rate
US median of homes 7.1% · Virginia: 2 better, 8 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 96 eligible stays.
59.3% this home
Median of homes: Virginia60.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 54 residents counted.
1.1% this home
Median of homes: Virginia0.7% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 87 residents counted.
3.4% this home
Median of homes: Virginia2.1% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 87 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Virginia97.8% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 18 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: GL VIRGINIA ROSE HILL LLC. CMS links this home to Trio Healthcare, a group of 9 nursing homes averaging 1.6 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Gl Virginia Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 12/16/2016 |
| Trio Health Care - East, LLC | 5% or greater indirect ownership interest | Organization | 05/24/2019 | |
| Trio Healthcare Investors LLC | 5% or greater indirect ownership interest | Organization | 12/16/2016 | |
| Trio Healthcare LLC | 5% or greater indirect ownership interest | Organization | 12/10/2019 | |
| Gentry, Boyd | 5% or greater indirect ownership interest | Individual | 12/16/2016 | |
| Rubenstein, David | 5% or greater indirect ownership interest | Individual | 12/16/2016 | |
| Fields, Joseph | W-2 managing employee | Individual | 12/04/2023 | |
| Gentry, Boyd | Corporate officer | Individual | 12/16/2016 | |
| Rubenstein, David | Corporate officer | Individual | 12/16/2016 |
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.
Chosen from this home's own inspection record.
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