Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

GRETNA HEALTH AND REHABILITATION CENTER

GRETNA, VA · 90 certified beds · Last Life Safety survey July 27, 2023

CMS Certification Number 495202 · first certified October 1989

Ownership

Operated by LIFEWORKS REHAB · For profit - Corporation

Ownership changed May 28, 2021 (change of ownership)to GRETNA HEALTH & REHABILITATION CENTER from MEDICAL FACILITIES OF AMERICA LIII

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within VA

18 citations — more than 78% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: February 2026 to February 2027. This facility’s last Life Safety survey was July 2023. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

How that compares

Citations on file over three years

Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	18
Median facility in VA	10
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 29, 2019	4
October 21, 2021	8
July 27, 2023	6

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2023-07-27
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2021-10-21
K-0293	Have properly located and lighted "Exit" signs.	2	2023-07-27
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2023-07-27
K-0363	Install corridor and hallway doors that block smoke.	1	2021-10-21
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	1	2023-07-27
K-0251	Conform to length requirements for dead end corridors.	1	2021-10-21
K-0511	Have properly installed electrical wiring and gas equipment.	1	2021-10-21

What the citations cover

Citations by CMS category

Egress Deficiencies 7
Smoke Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 3
Miscellaneous Deficiencies 2
Other 1

Citations by CMS category
Category	Citations
Egress Deficiencies	7
Smoke Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	3
Miscellaneous Deficiencies	2
Services Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 27, 2023 — 6 citations

Citations issued on July 27, 2023
Tag	What the surveyor checks	Status
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (September 18, 2023)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (September 18, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (September 18, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 18, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 18, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 24, 2023)

October 21, 2021 — 8 citations

Citations issued on October 21, 2021
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (December 10, 2021)
K-0251	Conform to length requirements for dead end corridors.	Deficient, Provider has date of correction (December 10, 2021)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (December 10, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 10, 2021)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 10, 2021)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (December 10, 2021)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (December 10, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (December 10, 2021)

August 29, 2019 — 4 citations

Citations issued on August 29, 2019
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 19, 2019)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (September 19, 2019)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (September 19, 2019)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (September 19, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.