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Lancashire Nursing & Rehabilitation Center

For profit - Corporation  ·  287 School Street, Kilmarnock, VA 22482  ·  See home’s Medicare page

Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 18 months.
Affiliated With Virginia Health Services
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
2.86
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.6
51.4%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 56.6%
120
Certified beds
Qualifying beds in the certified provider or supplier facility.
73
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Harry Wason (9%)
George S Mitchell Jr Rvoc Tr (7%)
Indirect owners
No indirect owner information
Managerial control
No information available
Managing employee(s)
Nicole Boldy since Jan, 2009
Michael Harrison since Sep, 2022
Mark Klyczek since Apr, 2020
Donald Lundin since Mar, 2021
Robert Walters since Oct, 2013

Inspection Reports

24

total deficiencies

2

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Feb 3, 2022
Standard report
10 deficiencies
(2 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

$5,000 Fine
D

to E
E

Resident Rights Deficiency — F0582
Failure to: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0584
Failure to: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0688
Failure to: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0692
Failure to: Provide enough food/fluids to maintain a resident's health.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0791
Failure to: Provide or obtain dental services for each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0887
Failure to: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Jan 25, 2019
Standard report
7 deficiencies
D

to J
J

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to: Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Rights Deficiency — F0623
Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0644
Failure to: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0646
Failure to: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 12, 2017
Standard report
7 deficiencies
D

Resident Rights Deficiency — F0246
Failure to: Reasonably accommodate the needs and preferences of each resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0278
Failure to: Ensure each resident receives an accurate assessment by a qualified health professional.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0280
Failure to: Allow residents the right to participate in the planning or revision of care and treatment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0309
Failure to: Provide necessary care and services to maintain or improve the highest well being of each resident .
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0425
Failure to: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Environmental Deficiency — F0441
Failure to: Have a program that investigates, controls and keeps infection from spreading.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0518
Failure to: Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

$6,637

total fines

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
Mar 14, 2022
$987 fine
No corresponding inspection report.
Feb 3, 2022
Dec 6, 2021
$650 fine
No corresponding inspection report.