12001 Iron Bridge Rd, Chester, VA 23831 · Chesterfield County · (804) 706-1023
90 certified beds, about 87 residents a day · For profit - Corporation · Medicare and Medicaid since 2010
CMS Care Compare ratings, data as of September 1, 2026 · CCN 495401 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 13, 2025, inspectors cited 4 health deficiencies (the Virginia average is 14.3, the national average 9.2).
None of its 45 health citations since August 2021 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 3.85 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.77 of those hours.
50.0% of nursing staff left within the year CMS measured (Virginia average 48.1%).
CMS links it to Saber Healthcare Group, an affiliated group of 126 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 45 health citations on file.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for four of 36 residents in the survey sample, Residents #6, #100, #101, and #102.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement hospital transfer requirements for two of 36 residents in the survey sample, Residents #96 and #5.
Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for two of 36 residents in the survey sample, Residents #100, and #102.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement a pain management program consistent with professional standards of practice for one of 36 residents in the survey sample, Resident #63.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician of a change in condition for one of 11 residents in the survey sample, Resident #1.
Inspectors wroteBased on observations, staff interview, clinical record review, the facility staff failed to follow the comprehensive care plan for two of 11 residents in the survey sample, Resident #4 (R4) and R11.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of quality for one of 11 residents in the survey sample, Resident #1.
Inspectors wroteBased on observation, resident and/or representative interview, clinical record review, staff interview, and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for two of 11 residents in the survey sample, Resident #4 and Resident #11.
Inspectors wroteBased on clinical record review staff interview, and facility document review, it was determined that the facility staff failed to maintain the resident's highest level of well-being for 2 (two) of 11 residents in the survey sample, Resident #2 (R2) and R1.
Inspectors wroteBased on clinical record review staff interview, and facility document review, it was determined that the physician failed to oversee the resident's plan of care for 3 (three) of 5 (five) days for Resident #2.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow the comprehensive care plan for one of four residents in the survey sample; Resident #3.
Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor a resident's weight to ensure nutritional status was maintained for one of four residents in the survey sample; Resident #3.
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice of a hospital transfer to the Resident Representative and/or State Long Term Care Ombudsman office for four of 30 residents in the survey sample; Residents #1, #8, #35, and #72.
Inspectors wroteBased on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to develop and/or implement a comprehensive care plan for five of 30 residents in the survey sample, Residents #123, #23, #1, #21 and #68.
Inspectors wroteBased on clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide one of 30 residents in the survey sample the opportunity to formulate an advance directive (1); Resident #11.
Inspectors wroteBased on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician when physician ordered medications were not administered for one of 30 residents in the survey sample, Resident #123 (R123).
Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility for hospital transfers for three of 30 residents in the survey sample; Residents #1, #8, and #72.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for one of 30 residents in the survey sample, Resident #10.
Inspectors wroteBased on staff interview, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to follow professional standards of practice for medication administration. to clarify a physician order for one of 30 residents in the survey sample, Resident #123 (R123).
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence a complete discharge summary for one of 30 residents in the survey sample, Resident #70.
Inspectors wroteBased on clinical record review, staff interview and facility document review it was determined that the facility staff failed to obtain a physician order and provide treatment to promote non-recurrence of a healed pressure injury for one of 30 residents in the survey sample, Resident #23.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement fall interventions per the plan of care for two of 30 residents in the survey sample; Residents #21 and #23.
Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer oxygen per physician's orders for one of 30 residents in the survey sample; Resident #1.
Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 30 residents in the survey sample, Resident #68.
Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage on three of 34 days reviewed.
Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to ensure one of 30 residents in the survey sample was free of a significant mediation error, Resident #123 (R123).
Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 30 residents in the survey sample; Resident #21.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a bedpan in a clean and sanitary manner for one of 30 residents in the survey sample; Resident #35.
Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift for one of three days observed.
Inspectors wrote5. The facility failed to develop a comprehensive care plan to address the use of bed rails for Resident #67. Resident #67 was admitted to the facility on [DATE]. Resident #67s diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function often accompanied by personality changes) (1), fracture of left femur (break in left thighbone) (2) and degeneration of discs (physical decline that involves tissue and cellular changes of the cushioning tissue between the vertebrae) (3). Resident #67's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/25/21, coded the resident as scoring 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. MDS Section G- Functional Status: [...]
Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for four of 37 residents in the survey sample, Residents #31, #25, #37 and #21.
Inspectors wroteBased on observation, staff interview, and facility document review it was determined facility staff failed to store food and failed to to maintain dietary equipment in a sanitary manner. The facility failed to dispose of tomatoes in the walk-in refrigerator with visible black spots and signs of spoilage and observation of the round blade on the kitchens electric food slicer revealed a rust-colored area on the surface and edging of the blade approximately one-quarter inch in size.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the accommodation of needs for one of 37 residents in the survey sample, Resident #29. The facility staff failed to place Resident #29's call bell within reach on 8/3/21 and 8/4/21.
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 immediately report an allegation of abuse to the administrator/ abuse coordinator for one of 37 residents in the survey sample, Resident #31. Resident #31 reported an allegation of abuse to facility staff on 1/16/21. The facility staff failed to immediately report this allegation to the facility administrator, ASM #1. ASM #1 stated he did not report Resident #31's allegation of abuse to the SA (state agency) and other officials until 1/19/21, because he was not made aware of the allegation until that date.
Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report an allegation of abuse was reported immediately but no later than two hours for one of 37 residents in the survey sample, Resident #31. Resident #31 reported an allegation of abuse on 1/16/21. The facility staff failed to report this allegation to the SA (state agency) until 1/19/21.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide all required documents to the receiving facility upon transfer for two of 37 residents in the survey sample, Residents #64 and #25. 1. The facility staff failed to evidence Resident #64's comprehensive care plan goals and other documents required to care for the resident were sent to the hospital when Resident #64 was transferred and discharged there on 7/23/21. 2. The facility staff failed to provide evidence Resident #25's comprehensive care plan goals were provided to receiving hospital staff when the resident was transferred to the hospital on 6/26/21.
Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the resident and or RR (resident representative), and ombudsman in writing of the resident's discharge to the hospital for three of 37 residents in the survey sample, Residents #69, #64, and #25.
Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 37 residents in the survey sample, Resident #21. The facility staff failed to complete assessments for sections B0700, B0800 and section C of Resident #21's quarterly MDS with an ARD (assessment reference date) of 6/12/21.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for two of 37 residents in the survey sample, (Residents #59 and #69). For Resident #59, the facility staff failed to develop a base line care plan for the use of side rails. For Resident #69, the facility staff failed to develop a care plan for the use of side rails.
Inspectors wroteBased on observation, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to promote a resident's quality of life for one of 37 residents in the survey sample, Resident #59. The facility staff failed to get Resident #59 out of bed into a chair from her admission on [DATE] through 8/3/21.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement interventions to prevent a resident's injury from a fall for one of 37 residents in the survey staff, Resident #29. The facility staff failed to place Resident #29's call bell within reach and to place fall mats beside the resident's bed on 8/3/21 and 8/4/21.
Inspectors wroteThe facility staff failed to provide respiratory care, consistent with professional standards of practice, and the comprehensive person-centered plan of care for one of 37 residents in the survey sample, Resident #17. The facility staff failed to replace Resident #17's nebulizer tubing (1) as ordered by the physician.
Inspectors wrote2. The facility staff failed to evidence Resident #67 was assessed for risk of entrapment, failed to review risks / benefits and failed to obtain informed consent prior to the use of bed rails. Resident #67 was admitted to the facility on [DATE]. Resident #67's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function often accompanied by personality changes) (1), fracture of left femur (break in left thighbone) (2) and degeneration of discs (physical decline that involves tissue and cellular changes of the cushioning tissue between the vertebrae) (3). [...]
Inspectors wroteBased on resident interview, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to ensure one of 37 residents in the survey sample was free of unnecessary medications, Resident #58. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication for Resident #58.
Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a resident did not receive an unnecessary psychotropic medication for one of 37 residents in the survey sample, Resident #59. The facility staff failed to document adequate indications for the use of the anti-anxiety medication Alprazolam, failed to offer non-pharmacological interventions prior to the administration of the medication to Resident #59 and failed to monitor Resident #59 for side effects of the Alprazolam(1).
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) | 3.85 | 3.76 | 3.86 |
| Registered nurses | 0.77 | 0.69 | 0.69 |
| All nursing staff on weekends | 3.38 | 3.29 | 3.42 |
| Nurse aides | 2.11 | ||
| Licensed practical nurses | 0.97 | ||
| Nursing staff turnover (share who left in a year) | 50.0% | 48.1% | 45.8% |
| Registered nurse turnover | 45.0% | 48.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.49 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 4.03 on weekdays and 3.38 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.48 in April to June 2025 to 3.85 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 | 3.85 | 0.77 | 4.03 | 3.38 | 0.3% | 0 of 90 | 87 |
| Oct to Dec 2025 | 3.67 | 0.79 | 3.80 | 3.32 | 0.1% | 0 of 92 | 86 |
| Jul to Sep 2025 | 3.69 | 0.90 | 3.85 | 3.28 | 0.3% | 0 of 92 | 84 |
| Apr to Jun 2025 | 3.48 | 0.62 | 3.67 | 3.00 | 0.9% | 0 of 91 | 85 |
| 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 | 5.4 | 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 | 1.2 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 9.4 | 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 | 9.1 | 15.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.9 | 4.7 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 4.2 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.1 | 22.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.6 | 11.5 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Tyler's Retreat at Iron Bridge's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (60.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
60.0% this home
Better than 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. 258 eligible stays.
9.3% 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. 254 eligible stays.
5.7% this home
No different from 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. 139 eligible stays.
56.3% 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. 112 residents counted.
0.6% 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. 167 residents counted.
4.1% 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. 167 residents counted.
88.8% this home
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. 98 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: CHESTERFIELD HEALTHCARE GROUP, INC.. CMS links this home to Saber Healthcare Group, a group of 126 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Volpe, Benjamin | Corporate director | Individual | 03/01/2019 | |
| Weisberg, William | Corporate director | Individual | 03/01/2019 | |
| Nicoluzakis, Gregory | Corporate officer | Individual | 03/01/2019 | |
| Volpe, Benjamin | Corporate officer | Individual | 03/01/2019 | |
| Weisberg, William | Corporate officer | Individual | 03/01/2019 | |
| Saber Governance LLC | Operational/managerial control | Organization | 03/01/2019 | |
| Shg Management LLC | Operational/managerial control | Organization | 09/01/2019 | |
| Holmes, Andrea | Operational/managerial control | Individual | 03/17/2025 | |
| Hopkins, Joseph | Operational/managerial control | Individual | 05/08/2023 | |
| Weisberg, William | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/28/2026 | |
| Bundle Tenant LLC | Adp of the SNF | Organization | 01/28/2026 | |
| Citrin Cooperman Advisors LLC | Adp of the SNF | Organization | 01/13/2010 | |
| Ms Chesterfield LP | Adp of the SNF | Organization | 08/01/2015 | |
| Saber Governance LLC | Adp of the SNF | Organization | 09/01/2019 | |
| Saber Healthcare Group LLC | Adp of the SNF | Organization | 01/13/2010 | |
| Shg Management LLC | Adp of the SNF | Organization | 09/01/2019 | |
| Tcf National Bank | Adp of the SNF | Organization | 07/19/2019 | |
| Walker & Associates PC | Adp of the SNF | Organization | 01/13/2010 | |
| Holmes, Andrea | Adp of the SNF | Individual | 03/17/2025 | |
| Hopkins, Joseph | Adp of the SNF | Individual | 05/08/2023 | |
| Mughal, Amjad | Adp of the SNF | Individual | 01/13/2010 | |
| Nicoluzakis, Gregory | Adp of the SNF | Individual | 03/01/2019 | |
| Volpe, Benjamin | Adp of the SNF | Individual | 03/01/2019 | |
| Weisberg, William | Adp of the SNF | Individual | 10/27/2009 |
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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