2081 Langhorne Road, Lynchburg, VA 24501 · Lynchburg City County · (434) 846-8437
120 certified beds, about 77 residents a day · For profit - Corporation · Medicare and Medicaid since 1984
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495151 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 2, 2023, inspectors cited 29 health deficiencies (the Virginia average is 14.3, the national average 9.2).
Of 83 health citations since February 2019, 6 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 3 fines totaling $108,801 in the last three years; the largest was $85,700, and the latest is dated April 30, 2026.
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 0.46 of those hours.
50.6% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Eastern Healthcare Group, an affiliated group of 18 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 83 health citations on file.
Inspectors wroteBased on staff interviews, resident interviews, observations and facility documentation, the facility staff failed to ensure adequate linen to meet the needs of the residents and provide a homelike environment for four of four nursing units.
Inspectors wroteBased on staff interviews, and facility documentation reviews, the facility staff failed to ensure that residents were protected during an allegation of abuse investigation and failed to investigate an allegation of verbal abuse involving one resident (Resident #1) in a survey sample of 10 residents. Resident #1 (R1) was the victim of two different abuse allegations and during the investigations on 5/30/25 and 10/30/25 the perpetrator was allowed to work to the end of their shift and worked their schedule days following, and while the investigation was being conducted. By allowing the perpetrator to continue to work, the facility did not protect the victim, and the perpertrator had unrestricted access to other residents; this noncompliance resulted in the identification of immediate jeopardy (IJ), and subsequent substandard quality of care. [...]
Inspectors wroteBased on staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure resident #2 (R2) was free from significant medication error, which resulted in harm for one of ten residents in the survey sample.
Inspectors wroteBased on staff interviews, resident interviews, observations and facility documentation, the facility staff failed to ensure adequate linen to meet the needs of the residents and provide a homelike envornment for four of four nursing units.
Inspectors wroteBased on staff interviews, clinical reviews, and facility documentation the facility staff failed to ensure medications were administered according to professional standards of nursing practice. Specifically, nursing staff administered an incorrect medication dose over an extended period of time for one resident (Resident #2-R2) out of a survey sample of 10 residents.
Inspectors wroteBased on staff interviews, clinical record review, and facility documentation review the facility staff failed to ensure effective pain management on multiple occassions, for one resident (Resident #1-R1) in a survey sample of 10 residents.
Inspectors wroteBased on staff interviews and facility documentation review, the facility staff failed to effectively administer the facility by failure of the administrator, who was the abuse coordinator to effectively implement the facility's abuse policy to ensure measures were taken to protect residents when an allegation of abuse and/or neglect is being investigated and failure to conduct thorough investigations into allegations for one resident, Resident #1 (R1) out of a survey sample of 10 residents.
Inspectors wroteBased on staff interviews, employee record review, and facility documentation review the facility staff failed to implement their abuse policy by failure to ensure that one employee, CNA #3 (CNA3) was trained on the Abuse, Neglect, and Exploitation training out of a survey sample of five employee records.
Inspectors wroteBased on facility document review, clinical record review, and staff interviews the facility failed to develop a complete and thorough comprehensive care plan to ensure person-centered interventions were present for one of 10 residents in the sample, Resident #1 (R1).
Inspectors wroteBased on staff interview, clinical record review, and facility documentation review the facility staff failed to ensure that pharmacy regimen reviews were completed and implemented timely for one resident, Resident #1 (R1) out of a survey sample of 10 residents.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive plan of care for one of two residents in the survey sample (Resident #1).
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to implement physician ordered interventions for pressure ulcer prevention for one of two residents in the survey sample (Resident #1).
Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure misappropriation of medications did not occur for one of nine residents, resident # 7 (R7).
Inspectors wrote2. For Resident #6 (R6), who verbalized having feelings/thoughts of self-harm and/or being better off dead, the facility staff failed to respond and implement interventions to address the resident's behavioral health needs. On 2/12/24 at approximately 4:30 p.m., a review of R6's clinical record was conducted. R6's most recent MDS (minimum data set - an assessment tool) with an ARD (assessment reference date) of 12/20/23, was a quarterly assessment. R6 was coded in section D0150, question I, which asked if the resident has Thoughts that you would be better off dead, or of hurting yourself in some way. R6 reported having these feelings 2-6 days (several days), out of 14 days. There was no evidence within the clinical record that the facility responded to or implemented any interventions to address R6's mental/behavioral health needs. [...]
Inspectors wroteBased on clinical record review, staff interview, and review of facility documents, the facility failed to ensure adequate supervision and implement interventions for non-compliance with smoking materials for one of seven residents (Resident #3). Multiple occurences of non-compliance with smoking materials, designated smoking times, designated smoking areas, and smoking supervision was revealed in Resident #3's clinical record, as well as through staff interviews. No evidence was found that the facility implemented interventions to address the unsecured smoking materials repeatedly observed in R3's possession. While R3 was in therapy on 2/1/24, a fire occurred in R3's room and unsecured smoking materials were again retrieved from the room, which had been accessible to other residents. [...]
Inspectors wroteBased on facility documentation and staff interviews, the facility staff failed to review and update a facility-wide assessment to care for the resident population during day-to-day operations and emergencies, which had the potential to affect all 82 residents residing in the facility.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of seven residents in the survey sample (Residents #2, #3 and #6).
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services in response to statements of self-harm for three of seven residents in the survey sample (Residents #2, #6 and #7).
Inspectors wroteBased on observation, staff and resident interviews, clinical record reviews and facility documentation reviews, the facility staff failed to provide effective administration regarding behavioral health services and smoking safety, resulting in the identification of two immediate jeopardy situations and substandard quality of care being identified, which had the potential to affect multiple residents on all 3 of the nursing units.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an effective quality assurance program with regards to smoking safety, which had the potential to affect many residents on one of three nursing units.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to notify the physician and/or nurse practitioner of significant changes in condition for three of seven residents in the survey sample (Residents #2, #6 and #7).
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow physician orders for four of fifteen residents in the survey sample (Residents #101, #105, #107 and #108).
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 fifteen residents in the survey sample (Residents #107 and #108).
Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to ensure laboratory services were obtained for one of 15 residents in the survey sample: Resident # 105. A urine specimen was not picked up by the contracted lab, and a Valproic acid (Depakote) level was not obtained as ordered by the physician.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to offer, educate, and document the status of pneumococcal immunizations for three of five residents reviewed during the infection control survey task (Residents #105, #109 and #111).
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to offer, educate, and document the status of COVID-19 immunizations for two of five residents reviewed during the infection control survey task (Residents #109 and #112) and failed to develop an infection control policy to address offering/provision of COVID-19 immunizations to all residents.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure hazardous smoking materials were secured for three of forty residents in the survey sample (Residents #43, #24 and #75). The facility experienced a centrally located fire on [DATE] with heavy smoke requiring evacuation of the facility with three of forty residents in the survey sample hospitalized for assessment/treatment related to the smoke/evacuation event (Residents #19, #23 and #239). Resident #43 was found with a lighter immediately after the [DATE] fire that started in her room. There was no protocol implemented after finding the lighter, to ensure all smoking materials including lighters, were securely stored. [...]
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide transportation to the hemodialysis center for two consecutive appointments for one of one (Resident (R)59) reviewed for dialysis out of a total sample of 41 residents. This failure caused harm when R59 required emergent dialysis and hospital admission for chest pain, fluid overload and critically high blood potassium levels.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to effectively manage and use resources to ensure resident safety following changes to the facility's smoking protocols. New smoking protocols transferred responsibility to secure smoking materials from staff to residents. Three days after implementing the policy, the facility experienced a centrally located fire resulting in evacuation and three residents (Residents #19, #23 and #239) sent to the hospital for assessment/treatment related to the fire. An unsecured lighter was associated with the start of the facility fire. Unsecured hazardous smoking materials, including lighters were found during the survey resulting in the identification of immediate jeopardy and substandard quality of care.
Inspectors wroteBased on facility document review and staff interview, the facility staff failed to provide advanced notice of discontinued Medicare Part A services for two of three residents sampled (Residents #70 and #77).
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure complete and accurate minimum data set (MDS) assessments for four of forty residents in the survey sample (Residents #41, #48, #50 and #189).
Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to complete a nursing assessment and/or incontinent care for one (Resident (R)90) of 41 sampled residents.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to perform weekly skin assessments for pressure ulcer prevention for one of forty residents in the survey sample (Resident #55).
Inspectors wroteBased on interviews and the staffing pattern, the facility failed to ensure that there was a Registered Nurse (RN) on duty at least eight consecutive hours a day, seven days a week for five of the 30 days reviewed for staffing patterns, and two of the Payroll Based Data (PBJ) days reviewed. This failure had the potential to impact all residents present in the building.
Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to properly store food in a sanitary manner for 36 of 40 residents that received meals from the kitchen. This failure increased the risk for food borne illnesses.
Inspectors wroteBased on facility document review and staff interview, the facility staff failed to conduct quality assessment and assurance meetings at least quarterly.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide appropriate tuberculin testing per policy for four of forty residents (Residents #79, #68, #80, #90), failed to perform proper hand hygiene during care of one of forty residents (Resident #239), and failed to follow infection control protocols on one of four units (Brookside) regarding handling of linen.
Inspectors wroteBased on observation, staff interview, group interview, the facility failed to ensure an effective pest control program. Flies were observed in multiple areas of the facility. The Findings Include: Observations during initial tour of the facility on 7/30/23 included multiple sightings of flies throughout the facility, including residents' rooms and common areas. During a group interview meeting conducted on 7/31/23 at 1:37 PM, one of the concerns brought up by the group of residents were the flies throughout the facility. On 8/2/23, the facility's pest control logs were reviewed for the past 3 months. [...]
Inspectors wroteBased on facility document review and staff interview, the facility staff failed to track and show evidence that nurse aides received at least 12 hours of in-service training per year.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the maintenance of residents' dignity for two of two residents (Residents (R)239 and R240) with an indwelling urinary catheter by failing to provide a privacy cover for their urinary catheter drainage bags and one resident (R44) when the curtain and door were not closed during personal care out of a total sample of 41 residents.
Inspectors wroteBased on record review, observations, interviews, and policy review, the facility failed to ensure safe positioning for one (Resident (R)140) of two residents reviewed for positioning in a total sample of 41 residents. This deficient practice had the potential to cause respiratory issues for residents who require assistance with positioning for meals.
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to notify the guardian of significant weight loss, of a significant event and/or potential for abuse for one (Resident (R)80) of two residents reviewed for notification of a pool of 41 residents. Specifically, the guardian was not notified of a fire in the building on 07/21/23 which required evacuation of residents in the building, and was not notified allegation of abuse involving R80.
Inspectors wroteBased on observation, interviews, document review, and facility policy review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one unit (Brookside) of four units.
Inspectors wroteBased on resident interview, staff interviews, clinical record review, and facility document review, the facility failed to ensure that three of 41 residents of the survey sample (Resident (R) #1, R80, R189) were free from abuse.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility failed to prevent misappropriation of personal property for one of 40 residents in the survey sample. Resident #88's (R88) Klonopin (medication for anxiety) had been misplaced. The Findings Include: Diagnoses for Resident #88 included: Hypothyroidism, malnutrition, anxiety, and chronic pain. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/16/23. Resident #88 was not cognitively assessed at the time of the 5 day assessment. A facility reported incident (FRI) for R88 dated 5/26/23 indicated a concern regarding misappropriation of personal property. On 7/31/23 R88's clinical record was reviewed. A physician's order documented Klonopin 1 MG [milligram] Give 1 tablet by mouth three times a day for anxiety. [...]
Inspectors wroteBased on staff interview, and facility document review, the facility failed to ensure an employee background check was completed for one of 20 employees reviewed. The Findings Include: During an employee record review conducted on 8/2/23 there was no documentation to indicate an employee hired on 4/28/23 had completed a required background check. On 8/1/23 at 4:00 PM the business manager (other staff, OS #5) was interviewed. OS #5 verbalized recently taking over the position and after going through employee records realized that the previous business manager had not been completing some of the required documentation on new employees and she (OS #5) had been trying to catch everything up to date. [...]
Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure three of three residents (Residents (R)1, R8, and R59) reviewed for care planning out of 41 sample residents were invited to participate in their quarterly care plan meetings.
Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL) assistance received services for three of four residents (Resident (R)50, R31, and R140 ) reviewed for shaving and/or fingernail care in a total sample of 41 residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues.
Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to assess and monitor the nutritional status of one of five residents (Resident (R)80) reviewed for weight loss in a total sample of 41 residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the oxygen units for two of two residents (Resident (R)50 and R23) reviewed for respiratory care were clean and sanitary in a sample of 41 residents. This failed practice has the potential to cause respiratory and other infections for residents.
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 fifteen residents in the survey sample (Residents #107 and #108).
Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed properly store liquid narcotics in one of two refrigerators and failed to ensure medications were labeled appropriately in one of two medication carts reviewed.
Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure a urinalysis (UA) and urine culture and sensitivity (C&S) tests were processed and reported to the provider for one of one (Resident (R)68) resident reviewed for urinary tract infections in a total sample size of 41. Specifically, R68's abnormal UA C&S results were not reported to the physician until 08/02/23, delaying the treatment for recurrent urinary tract infection.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to offer, educate and document the status of pneumococcal and/or influenza immunizations for two of five residents reviewed during the infection control survey task (Residents #48 and #79).
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to offer and record the status of COVID-19 immunizations for one of five residents reviewed during the infection control survey task (Resident #79).
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide security of all resident personal funds deposited with the facility. The facility did not have a surety bond in an amount to cover resident fund balances. The facility's surety bond was for $55,000 and resident funds equaled $146,285.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure routine COVID-19 testing for unvaccinated staff was conducted based on level of community transmission rates, for two of four weeks in the month of November.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for reporting and thoroughly investigating an allegation of abuse for one of 23 residents in the survey sample, Resident #67. Allegations by Resident #67 of inappropriate sexual comments from another resident that made the resident uncomfortable were not reported or thoroughly investigated as required by the facility's abuse prevention policies.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to report to the state agency and adult protective services, an allegation of inappropriate sexual comments toward one of 23 residents in the survey sample. Allegations by Resident #67 of inappropriate sexual comments from another resident that made the resident uncomfortable were not reported to the state agency or local adult protective services.
Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to thoroughly investigate allegations of potential verbal abuse for one of 23 residents in the survey sample. Allegations by Resident #67 of inappropriate sexual comments from another resident that made the resident uncomfortable were not thoroughly investigated.
Inspectors wroteBased on observation, resident interview, and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) for one of 23 residents in the survey sample. Resident #49's 5-day and significant change MDS both documented an inaccurate assessment of bladder function.
Inspectors wroteBased on observation, resident interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for 2 of 23 residents in the survey sample, Resident #49 and Resident #47. Resident #49's care plans were not reviewed and revised for discontinuation of a foley catheter. Resident #47's care plans were not reviewed and revised for code status change.
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to obtain a physician's order prior to use of a topical medication for one of 23 residents in the survey sample. Resident #72 had topical Nystatin powder applied to her skin without a physician's order for its use.
Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 23 residents in the survey sample, Resident #30, was provided care and treatment to promote healing and prevent infection of a pressure ulcer.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide appropriate catheter care for two of 23 residents in the survey sample. Resident #72 had a urinary catheter in use with the tubing unsecured to prevent pulling/tugging at the insertion site. Resident #50's catheter bag was observed in the floor under the resident's bed.
Inspectors wroteBased on observation, resident interview, staff interview and facility document review, the facility staff failed to ensure oxygen equipment was maintained in sanitary manner for one of 23 residents, Resident #44.
Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to properly store medications for two of 23 residents in the survey sample, Resident # 28 and #72.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure infection control practices were maintained during a dressing change for one of 23 residents (Resident #30), and during a medication pass and pour observation on one of two nursing units.
Inspectors wroteBased on observation, clinical record review, and staff interview, the facility staff failed to obtain a physician order for the administration of supplemental oxygen for one of 31 residents in the survey sample: Resident # 102.
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain and administer pain medications as ordered by the physician for one of 31 residents in the survey sample. Resident #46, assessed with ongoing pain related to cancer, was not administered the pain medication Morphine Sulfate as ordered by the physician for five consecutive days.
Inspectors wroteBased on resident interview, group interview, facility document review, and in the course of a complaint investigation, facility staff failed to answer call bells in a timely manner throughout the facility. Facility staff failed to answer call bells in a timely manner as evidenced by individual resident interviews, family interview, group resident interview, and as documented in past resident council meeting minutes.
Inspectors wroteBased on staff interview and facility document review, the facility staff failed to treat one of 31 residents in the survey sample with respect and dignity. The facility administrator yelled and talked over Resident #455 during a conversation regarding the patient pay.
Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure a safe, clean and homelike environment on two of four living units. On the Brookside unit, there was a damaged access cover in the hallway creating a trip hazard and a damaged over-bed table in room [ROOM NUMBER]. On the Pondside unit, water was leaking into the floor around the ice machine with resulting floor damage. The louvered air return panel on the Pondside unit was dirty with heavy lint accumulation.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement written policies and procedures for the prevention of abuse, neglect and exploitation for one of 31 residents in the survey sample, Resident #42. The facility staff failed to investigate an injury of unknown origin, involving Resident #42. The resident was found with a knot and small laceration over his left eye, in addition to a broken front tooth. The facility failed to investigate, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred, the extent, and cause; and failed to provide a complete and thorough documentation of the investigation.
Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 31 residents in the survey sample, Resident #77 and #46. 1. Resident #77's care plan was not revised to reflect discontinuation of dialysis and shunt. 2. Resident #46's plan of care was not revised to include problems, goals and/or interventions regarding chronic nausea. The Findings Include: 1. Resident #77 was admitted to the facility on [DATE] with the most current readmission on [DATE]. Diagnoses for Resident #77 included: Depression, end stage renal disease, diabetes. The current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/1/19. Resident #77 was assessed as being cognitively intact with a score of 15 of 15. On 02/24/19 at 4:30 PM, Resident #77 was interviewed. [...]
Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide activities of daily living (ADL) care for two of 31 residents in the survey sample. Resident #98's teeth were not brushed/cleaned. Resident #104 was observed with long, dirty fingernails. 1. Resident #98, totally dependent upon staff for ADL care, was observed with unclean teeth. 2. The facility staff failed to ensure Resident #104 was provided ADL (activities of daily living) care to assist with nail care, and meal consumption.
Inspectors wroteBased on observation, staff interview, and clinical record review the facility staff failed to ensure medications were available for 2 of thirty-one in the survey sample, Resident #29 and Resident #104. 1. The facility staff failed to ensure medications were available for Resident #29 during a medication pass and pour observation, per the physician's order. 2. The facility staff failed to ensure the medications, Aricept and Vitamin D were available for administration for Resident # 104.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, facility staff failed to act upon pharmacy recommendations for one of 31 residents in the survey sample, Resident #81. Facility staff failed to respond to a pharmacy request dated 02/01/2019 and 02/18/2019 for Resident #81.
Inspectors wroteBased on medication administration observation, staff interview and clinical record review, facility staff failed to ensure a medication error rate of less than five percent in the facility. There were two medication administration errors out of 30 opportunities total, resulting in an overall medication error rate of 6.67 %. The Findings Include: During medication pass and pour observation conducted on 02/25/19 at 8:12 AM, Resident #37 was observed receving medications. The labels on two medications were observed. One label instructed Carvedilol (Coreg) 3.125 MG (millagrams) give two tablets twice a day (given for hypertension); the second instructed Allopurinol 100 MG give two tablets twice a day (given for hyperuricemia). Registered nurse (RN) #2 was observed putting one of each tablet into a dispense cup. Then RN #2 picked up the medication cup and began to enter Resident #37's room. [...]
Inspectors wroteBased on observation, and staff interview, the facility staff failed to ensure expired over the counter medications were not available for distribution on one of 4 medication carts. Four bulk over the counter (OTC) medications were expired and available for distribution on the Brookside medication cart. The Findings Include: On 02/25/19 at 2:14 PM, the Brookside medication cart was reviewed and evidenced the following expired medications: Vitamin C 1000 MG (Milligrams) expiration 12/2018, Antihistamine Allergy relief expiration 8/2018, Multivitamin expiration date 9/2018, and Vit B-12 500 MCG (Micrograms) expiration date 11/2018. License practical nurse (LPN) #3 was present during the observation and confirmed the medications were expired and available for distribution. [...]
Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of 31 residents in the survey sample. 1. Resident #46's clinical record failed to document a physician's order for hospice services. 2. Resident #78's clinical record inaccurately documented physician orders for contact precautions.
Inspectors wroteBased on staff interview and clinical record review the facility staff failed to provide written notification of a facility initiated hospital transfer for one of 31 residents in the survey sample: Residents #77. Resident #77 was discharged to hospital and the facility did not notify the Ombudsman or the responsible party (RP) in writing. The Findings Include: Resident #77 was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Diagnoses for Resident #77 included: Depression, end stage renal disease, diabetes. Resident #77 is his own responsible person (RP). The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/1/19. Resident #77 was assessed as being cognitively intact with a score of 15 of 15. [...]
Inspectors wroteBased on complaint investigation, staff interview, and review of facility documents, the facility failed to maintain an effective pest control program. Between 7/31/18 and 12/11/18, there were 20 Service Request Log entries for cockroaches in various areas of the facility.
13 fire safety citations on file: 8 on August 2, 2023, 2 on December 1, 2021, 3 on February 26, 2019.
| Date | Penalty | Amount or length |
|---|---|---|
| April 30, 2026 | Fine | $85,700 |
| February 14, 2024 | Fine | $19,819 |
| December 26, 2023 | Fine | $3,282 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
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 | 0.46 | 0.69 | 0.69 |
| All nursing staff on weekends | 2.89 | 3.29 | 3.42 |
| Nurse aides | 1.77 | ||
| Licensed practical nurses | 1.08 | ||
| Nursing staff turnover (share who left in a year) | 50.6% | 48.1% | 45.8% |
| Registered nurse turnover | 69.2% | 48.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.64 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 3.47 on weekdays and 2.89 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.89 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 | 0.46 | 3.47 | 2.89 | 4.6% | 2 of 90 | 77 |
| Oct to Dec 2025 | 3.45 | 0.40 | 3.63 | 3.00 | 3.0% | 0 of 92 | 81 |
| Jul to Sep 2025 | 3.16 | 0.39 | 3.35 | 2.67 | 6.6% | 0 of 92 | 96 |
| Apr to Jun 2025 | 2.89 | 0.35 | 3.05 | 2.49 | 12.2% | 0 of 91 | 96 |
| 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. If you work here, your report helps start one.
| 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 | 13.3 | 14.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.1 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.0 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.1 | 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 | 19.9 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.4 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 5.5 | 11.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Seven Hills Rehabilitation and Nursing's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (38.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
38.4% 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. 45 eligible stays.
11.5% 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. 74 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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. 23 eligible stays.
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: 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. 19 residents counted.
3.1% 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. 32 residents counted.
12.7% 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. 32 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. 12 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: SEVEN HILLS REHABILITATION AND NURSING LLC. CMS links this home to Eastern Healthcare Group, a group of 18 nursing homes averaging 1.5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| VA SNF Operations Holdings 2 LLC | 5% or greater direct ownership interest | Organization | 100% | 02/01/2024 |
| Jj United Tr | 5% or greater indirect ownership interest | Organization | 50% | 02/01/2024 |
| Baker, Kevin | W-2 managing employee | Individual | 02/01/2024 | |
| Shapiro, Akiva | Corporate officer | Individual | 02/01/2024 | |
| Sommer, Nechama | Corporate officer | Individual | 02/01/2024 |
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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