VCU Health Tappahannock Hospital
An acute care hospital in Tappahannock, Virginia 22560
618 Hospital Road, Tappahannock, Virginia 22560. (804) 443-3311.
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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
- 67 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 Mar 2, 2026: 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 Mar 2026. 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.
Mar 2, 2026: complaint inspection1 deficiency
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Staffing And Delivery Of Care
The inspectors’ words, 711 words
“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 45736 Based on medical record review, interview and document review, the facility failed to document pain reassessments and intervention assessments, as indicated for six (6) of 6 (six) patients (Medical Records: 1, 2, 3, 4, 5 and 6). The findings include: During medical record review, the afternoon of March 2, 2026 with Employee 3 and Employee 8, the surveyor determined that six (6) of six (6) medical records reviewed during the survey process did not contain evidence of pain reassessments and intervention assessments as indicated by Employee 3, of every two (2) hours for reassessments and every one (1) hour after interventions. The emergency department (ED) medical records evidenced the following pain assessments: Medical Record 1- ED arrival time on December 10, 2025 at 1:27 PM. Initial pain assessment 1:30 PM: pain of zero (0). Medical Record 1 left AMA at 5:19 PM. No pain reassessments were completed for Medical Record 1. Medical Record 2- ED arrival time on December 26, 2025 at 1:27 PM. Initial pain assessment 4:15 PM: pain of zero (0). Medical Record 2 left AMA at 10:19 PM. No pain reassessments were completed for Medical Record 2. Medical Record 3- ED arrival time on December 1, 2025 at 10:52 AM. Initial pain assessment 11:02 AM: pain of six (6). Medical Record 3 left AMA at 3:25 PM. No interventions were given to Medical Record 3 for their pain of six (6) and no pain reassessments were completed for Medical Record 3. Medical Record 4- ED arrival time on December 30, 2025 at 2:15 PM. Initial pain assessment 2:19 PM: pain of nine (9). Medical Record 4 left AMA at 7:40 PM. Medical Record 4 was administered Tylenol 975 mg and Fentanyl 50 mcg IV (intravenous) at 2:47 PM. Additional pain reassessments were completed for Medical Record 4 at 3:10 PM: pain of eight (8) and 3:47 PM: pain of eight (8). Medical Record 4 was administered Robaxin 750 mg, Roxicodone 5 mg and Lidocaine patch 5% at 5:01 PM. There was no pain reassessment completed prior to administration of these medications and a pain interventions assessment one (1) hour after administration of interventions was not completed for Medical Record 4. Medical Record 5- ED arrival time on December 18, 2025 at 6:37 PM. Initial pain assessment 6:44 PM: pain of three (3). Medical Record 5 left AMA on December 19, 2025 at 3:12 AM. No interventions were given to Medical Record 5 for their pain of three (3) and no pain reassessments were completed for Medical Record 5. Medical Record 6- ED arrival time on December 1, 2025 at 2:41 PM. Initial pain assessment 2:58 PM: pain of zero (0). Medical Record 6 left AMA at 10:10 PM. Medical Record 6 had a pain assessment at 8:42 PM: pain of five (5). Medical Record 6 was administered Tylenol 975 mg at 8:43 PM. A pain interventions assessment one (1) hour after administration was not completed for Medical Record 6. During an interview with Employee 3, the afternoon of March 2, 2026. The surveyor asked what the facility’s expectation was related to pain assessments and intervention assessments in the ED. Employee 3 indicated that pain assessments should be completed with vital signs, which are completed typically every hour or two hours, depending on the patient’s acuity. If interventions are given to the patient, the pain should be assessed at least one (1) hour after the intervention or it is considered a “miss.” Employee 3 further indicated that they audit thirty (30) random ED charts per month to audit pain assessments, reassessments and intervention assessments. The facility did not have a policy that provided guidance on pain assessments, reassessments and assessments after interventions in the ED. The following policies were reviewed related to the deficiency: Assessment-Reassessment, last revised August 6, 2024 Pain Management, last revised January 27, 2022”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Mar 2, 2026 | Complaint inspection | 1 deficiency cited |
| Jun 4, 2025 | Complaint inspection | No deficiencies 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 5; safety of care, 0 better and 0 worse of 2; readmission, 1 better and 1 worse of 8.
- Patients rate it 4 of 5 in CMS’s patient survey (303 surveys completed, Oct 1, 2024 to Sep 30, 2025): 65% rated it 9 or 10 out of 10, and 69% 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.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 9.9%, pneumonia 14.5%, COPD 7.9%, stroke 12.3%. 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 21.3%, pneumonia 16.8%, COPD 19.7%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 186 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 50% 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 0.96 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 DNV, 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 4 of 5.
- 70% 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?
- Virginia Commonwealth University Health System Authority owns 100% directly since Jan 1, 2021.
- 16 owners or officers are people: Iris Lane (corporate director); Lisa Marie Dodd (corporate director); Alice G Burgess (corporate director); Darryl Fisher (corporate director); Christopher Brett Mcmillan (corporate officer); Joshua Hammond (corporate officer); Alexander F Dillard (corporate director); Patricia Gallagher (corporate director); William Gregory Hundley (corporate director); Sandra Noel (managing employee (on the payroll)); George Merl Longest (corporate director); Garfield Parker (corporate director); Nancy Weakley (corporate director); Richard Farmar (corporate director); James Siegel (corporate officer); Elizabeth Harlan (managing employee (on the payroll)).
- CMS’s Provider of Services file records 4 changes of ownership.
- 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 |
|---|---|---|---|
| Virginia Commonwealth University Health System Authority | Owns 5% or more directly | 100% | Jan 1, 2021 |
How does it compare nearby?
- No other hospital CMS lists is in Essex 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.