Russell County Hospital
An acute care hospital in Lebanon, Virginia 24266
58 Carroll Street, Lebanon, Virginia 24266. (276) 883-8000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 4of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 1 deficiency cited in the last three years
- 78 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Aug 28, 2024: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Aug 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
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| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Aug 28, 2024: complaint inspection1 deficiency
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Administration Of Drugs
The inspectors’ words, 1,120 words
“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 33906 Based on interviews and review of documents it was determined hospital staff failed to complete CIWA-Ar assessments and administer medications in accordance with the orders of the practitioner for two (2) of eight (8) sampled patients. (Patient #7 and Patient #8) The findings include: 1. Patient #7 was admitted to the hospital’s intensive care unit (ICU) on 8/28/23 with diagnoses to include acute kidney injury, encephalopathy, acute on chronic respiratory failure with hypoxia and hypercapnia, and elevated troponin. Patient #7’s medical record was reviewed on 8/26/24. An order was placed on 8/28/23 at 4:29 AM to calculate CIWA (Clinical Institute Withdrawal Assessment from Alcohol) score. The following was found in the “Comments” section of the order: “Every 4 hours while awake for CIWA score of less than or equal to 10. Every 2 hours while awake for CIWA score of 11-19. Every 1 hour while awake for score equal to or greater than 20. Notify physician if score greater than 20 and for transfer to cardiorespiratory-monitored bed”. The CIWA score is used to determine the initiation of symptom triggered dosing ordered by the physician. The following orders for Lorazepam (aka Ativan, a benzodiazepine sometimes used for the treatment of acute alcohol withdrawal) oral or IV were placed on 8/28/23 at 4:29 AM and discontinued at discharge on 9/9/23 at 5:26 PM: · CIWA-Ar score less than 10: give 0.5mg every 4 hours PRN until CIWA score is less than 8 or RASS -1 to 0 · CIWA-Ar score 10-12: give 1 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0 · CIWA-Ar score 13-15: give 2 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0 · CIWA-Ar score 16-17: give 3 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0 · CIWA-Ar score 18-19: give 4 mg every 2 hours PRN until CIWA score is less than 8 or RASS -1 to 0 An order addressing scores of 20 to 67 was placed at the same time for lorazepam (Ativan) oral or IV as follows: · CIWA-Ar score 20-30: Give Ativan 2 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0 · CIWA-Ar score 31-40: Give Ativan 3 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0 · CIWA-Ar score 41-50: Give Ativan 4 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0 · CIWA-Ar score 61-67: Give Ativan 6 mg every 15 minutes until CIWA score less than 8 or RASS -1 to 0 Hospital policy “Alcohol Withdrawal, Management” dated 12/11/23, indicates team members will use the CIWA-Ar scale to assess the severity of alcohol withdrawal and provide treatment to the patients. A nurse will complete the scale assessment and follow the CIWA-Ar provider orders. The CIWA-Ar score will be documented in the medical record. Reassessment of the score will occur based on the initial and subsequent patient score. Scores of 10-19 indicate mild to moderate withdrawal and scores of 20 or above indicate severe withdrawal. The provider should be notified as needed based on the patient’s response to treatment. Use of the RASS (Richmond Agitation-Sedation Scale) may be indicated when the patient is unable to communicate or respond. Optional sedation for AWS using the RASS tool is suggested to be 0-2 with monitoring frequency every 15-30 minutes to every hour with effective dosing. Review of the medical record found more than 45 documented CIWA-Ar scores between 8/28/23 at 4:29 AM and discharge on 9/9/23. Multiple scores were equal to or greater than 20. Orders for scores 20 and above indicate administration of Ativan 2mg every 15 minutes until the score is below 8. This would require the reassessment 15 minutes after the administration of the prescribed amount of Ativan to determine the new score; if the score remains 8 or above Ativan would be administered based on the prescribed amount for that score. On multiple occasions, the clinical record failed to reveal evidence of reassessments after 15 minutes to determine the need for more medication and failed to provide documentation of why a reassessment was not completed. 2. Patient #8 was admitted to the hospital’s intensive care unit (ICU) on 7/29/24 with diagnoses to include alcohol withdrawal hallucinations, alcoholic hepatitis and hypertension. Patient #8’s medical record was reviewed on 8/26/24. On 7/29/24 at 9:17 PM, orders were placed to calculate the CIWA-Ar score, (same parameters as noted above) and for Ativan using the same scale and parameters as noted above. Review of the medical record found more than 50 documented CIWA-Ar scores between 7/29/24 at 9:18 PM and discharge on 8/7/24. Multiple scores were equal to or greater than 20. Orders for scores 20 and above indicate administration of Ativan 2mg every 15 minutes until the score is below 8. This would require the reassessment 15 minutes after the administration of the prescribed amount of Ativan to determine a new score; if the score remains 8 or above Ativan would be administered based on the prescribed amount for that score. On multiple occasions, the clinical record failed to reveal evidence of reassessments after 15 minutes to determine the need for more medication and/or failed to provide documentation of why a reassessment was not completed. Interviews conducted the afternoon of 8/28/24 with Staff #11 and Staff #12 (providers) related to the CIWA-Ar protocol indicate the expectation is that nursing staff will follow the orders as they are written. Nursing staff are to contact provider with questions. The failure to follow the CIWA-Ar protocol as it is written places the patient at increased risk of delirium tremens, respiratory difficulties, seizure, etc. and may result in the need to order additional medications or make medication changes to control withdrawal symptoms.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Aug 28, 2024 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 4 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 4; safety of care, 0 better and 0 worse of 1; readmission, 0 better and 0 worse of 4.
- Patients rate it 4 of 5 in CMS’s patient survey (134 surveys completed, Oct 1, 2024 to Sep 30, 2025): 73% rated it 9 or 10 out of 10, and 72% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): C. diff infections, no different than national benchmark.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 11.4%, pneumonia 15.7%, COPD 8.5%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 22.1%, pneumonia 19.1%, COPD 20.6%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate.
- Emergency department patients spent a median of 130 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 75% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.91 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 5 of 5.
- 92% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Mountain States Health Alliance owns 100% directly since Feb 1, 2008.
- 12 owners or officers are people: Shane Hilton (corporate officer, 0%); Shane Hilton (corporate director, 0%); Gregory Wilgocki (corporate director, 0%); Gregory Wilgocki (managing employee (on the payroll), 0%); Marvin Eichorn (corporate officer, 0%); Marvin Eichorn (corporate director, 0%); Buford Deaton (corporate officer, 0%); Buford Deaton (corporate director, 0%); Alan Levine (corporate officer, 0%); Alan Levine (corporate director, 0%); Julie Bennett (corporate officer, 0%); Julie Bennett (corporate director, 0%).
- CMS’s Provider of Services file records 3 changes of ownership, the latest on Feb 1, 2008.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Ballad Health | Owns 5% or more through other companies | 100% | Feb 1, 2018 |
| Mountain States Health Alliance | Owns 5% or more directly | 100% | Feb 1, 2008 |
How does it compare nearby?
- No other hospital CMS lists is in Russell County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.