Lancashire Post Acute Inspection Report, Violations & Safety Grade (KILMARNOCK, Virginia)

287 SCHOOL STREET, KILMARNOCK, Virginia 22482

Phone: 8044351684

CMS Overall:3/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

105.6

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Lancaster

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health3/5

Staffing1/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	Virginia Avg	Difference
RN Hours per Resident per Day	0.59	0.71	-0.11
Total Nurse Hours per Resident per Day	2.76	3.88	-1.12
CMS Staffing Rating	1/5	2.5/5	-
Nursing Staff Turnover	58.9%	47.5%	-

Health Citation History

28 health citations on record

Date	Category	Description	Severity
2026-02-20	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2026-02-20	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2026-02-20	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	E – Moderate Harm Potential
2026-02-20	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-02-20	Resident Rights Deficiencies	Ensure that residents are fully informed and understand their health status, care and treatments.	D – Moderate Harm Potential
2026-02-20	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2026-02-20	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2026-02-20	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	D – Moderate Harm Potential
2026-02-20	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2026-02-20	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2026-02-20	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-02-20	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2026-02-20	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	D – Moderate Harm Potential
2022-02-03	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	E – Moderate Harm Potential
2022-02-03	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2022-02-03	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2022-02-03	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2022-02-03	Quality of Life and Care Deficiencies	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.	D – Moderate Harm Potential
2022-02-03	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2022-02-03	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2022-02-03	Quality of Life and Care Deficiencies	Provide or obtain dental services for each resident.	D – Moderate Harm Potential
2022-02-03	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2022-02-03	Infection Control Deficiencies	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.	D – Moderate Harm Potential
2019-01-25	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2019-01-25	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	G – Actual Harm
2019-01-25	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	D – Moderate Harm Potential
2019-01-25	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2019-01-25	Resident Assessment and Care Planning Deficiencies	Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.	D – Moderate Harm Potential

Fire Safety Citation History

4 fire safety citations on record

Date	Category	Description	Severity
2026-02-20	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	D – Moderate Harm Potential
2026-02-20	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential
2022-02-03	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	D – Moderate Harm Potential
2022-02-03	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper power supply for life support equipment.	D – Moderate Harm Potential

Total Penalties & Fines

$26,189

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-02-20	Fine	$26,189	-

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