Tyler's Retreat At Iron Bridge
12001 Iron Bridge Rd, Chesterfield, VA 23831
Tyler's Retreat At Iron Bridge is a nursing home in Chesterfield, Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (804) 706-1023
- Last standard health inspection
- August 13, 2025 (1 year ago)
- Certified beds
- 90
- Residents per day, on average
- 83.4
- Ownership type
- For profit - Corporation
- Legal business name
- Chesterfield Healthcare Group, INC.
- Chain
- Saber Healthcare Group
- Takes part in
- Medicare and Medicaid
More health citations than the Virginia average (45 vs 39).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of January 14, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
4 citations
Health inspection on August 13, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0700. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS lists it as corrected on September 18, 2025.
CMS has cited this home for F0700 2 times since 2021.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 18, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 18, 2025.
CMS has cited this home for F0695 3 times since 2021.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on September 18, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
6 citations
Health inspection on June 12, 2024
CMS lists this as a complaint inspection.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 16, 2024.
CMS has cited this home for F0580 2 times since 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 16, 2024.
CMS has cited this home for F0656 4 times since 2021.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on July 16, 2024.
CMS has cited this home for F0658 2 times since 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on July 16, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 16, 2024.
Citation F0710. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
CMS lists it as corrected on July 16, 2024.
2 citations
Health inspection on October 17, 2023
CMS lists this as a complaint inspection.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 9, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 9, 2023.
17 citations
Health inspection on January 19, 2023
CMS lists this as a standard inspection.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on February 14, 2023.
CMS has cited this home for F0623 2 times since 2021.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 14, 2023.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on February 14, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on February 14, 2023.
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
CMS lists it as corrected on February 14, 2023.
CMS has cited this home for F0622 2 times since 2021.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on February 14, 2023.
CMS has cited this home for F0657 2 times since 2021.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on February 14, 2023.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on February 14, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on February 14, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 14, 2023.
CMS has cited this home for F0689 2 times since 2021.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on February 14, 2023.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on February 14, 2023.
Citation F0727. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS lists it as corrected on February 14, 2023.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on February 14, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on February 14, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 14, 2023.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on February 14, 2023.
16 citations
Health inspection on August 5, 2021
CMS lists this as a standard inspection.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 10, 2021.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 10, 2021.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 10, 2021.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on September 10, 2021.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on September 10, 2021.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 10, 2021.
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
CMS lists it as corrected on September 10, 2021.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on September 10, 2021.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on September 10, 2021.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on September 10, 2021.
Citation F0675. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor each resident's preferences, choices, values and beliefs.
CMS lists it as corrected on September 10, 2021.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 10, 2021.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 10, 2021.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
CMS lists it as corrected on September 10, 2021.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on September 10, 2021.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on September 10, 2021.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- SABER GOVERNANCE LLCOperational/managerial control · not applicable · since 03/01/2019
- SHG MANAGEMENT LLCOperational/managerial control · not applicable · since 09/01/2019
- HOLMES, ANDREAOperational/managerial control · not applicable · since 03/17/2025
- HOPKINS, JOSEPHOperational/managerial control · not applicable · since 05/08/2023
Questions
When was Tyler's Retreat At Iron Bridge last inspected?
CMS lists August 13, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Tyler's Retreat At Iron Bridge have?
CMS lists 45 health citations since August 5, 2021. CMS also calls these deficiencies.
Has Tyler's Retreat At Iron Bridge been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Tyler's Retreat At Iron Bridge?
Its CMS overall star rating is 4 of 5.
Is Tyler's Retreat At Iron Bridge a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.