Tyler's Retreat at Iron Bridge

Name: Tyler's Retreat at Iron Bridge
Address: 12001 IRON BRIDGE RD, Chester, VA, 23831, US
Telephone: 8047061023

12001 Iron Bridge Rd, Chester, VA 23831 · Chesterfield County · 90 certified beds · avg 87 residents/day · certified since Jan 13, 2010

Part of chain: SABER HEALTHCARE GROUP (126 facilities, chain avg rating 2.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.29

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (45)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Aug 13, 2025	E · Potential for harm, repeated	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Aug 13, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Aug 13, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Aug 13, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Jun 12, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. · from a complaint
Oct 17, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Oct 17, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Jan 19, 2023	E · Potential for harm, repeated	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jan 19, 2023	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jan 19, 2023	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jan 19, 2023	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 19, 2023	D · Potential for harm, one-off	When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jan 19, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 19, 2023	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Aug 5, 2021	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 5, 2021	E · Potential for harm, repeated	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Aug 5, 2021	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Aug 5, 2021	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Aug 5, 2021	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Aug 5, 2021	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (17 → 4).

Year	Citations	Worst severity that year
2021	16	E
2023	19	E
2024	6	D
2025	4	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Virginia avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.29	3.67	3.95	bottom 43% in Virginia; bottom 26% in the U.S.
Registered Nurse hours	0.66	0.66	0.69	top 28% in Virginia; top 41% in the U.S.
Weekend total nurse staffing	2.89	3.21	3.50	bottom 46% in Virginia; bottom 25% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.44	0.46	0.48	top 28% in Virginia; top 41% in the U.S.
Total nursing staff turnover (%)	50.0	48.1	45.8	bottom 46% in Virginia; bottom 38% in the U.S.
RN turnover (%)	45.0	48.2	42.9	top 44% in Virginia; bottom 44% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.85, RN 0.77, weekend 3.38. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Bundle Tenant LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/28/2026
Citrin Cooperman Advisors LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/13/2010
Holmes, Andrea	Individual	Operational/Managerial Control	NOT APPLICABLE	03/17/2025
Holmes, Andrea	Individual	ADP of the SNF	NOT APPLICABLE	03/17/2025
Hopkins, Joseph	Individual	Operational/Managerial Control	NOT APPLICABLE	05/08/2023
Hopkins, Joseph	Individual	ADP of the SNF	NOT APPLICABLE	05/08/2023
Ms Chesterfield LP	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2015
Mughal, Amjad	Individual	ADP of the SNF	NOT APPLICABLE	01/13/2010
Nicoluzakis, Gregory	Individual	Corporate Officer	NOT APPLICABLE	03/01/2019
Nicoluzakis, Gregory	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2019
Saber Governance LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	03/01/2019
Saber Governance LLC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2019
Saber Healthcare Group LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/13/2010
SHG Management LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2019
SHG Management LLC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2019
TCF National Bank	Organization	ADP of the SNF	NOT APPLICABLE	07/19/2019
Volpe, Benjamin	Individual	Corporate Director	NOT APPLICABLE	03/01/2019
Volpe, Benjamin	Individual	Corporate Officer	NOT APPLICABLE	03/01/2019
Volpe, Benjamin	Individual	ADP of the SNF	NOT APPLICABLE	03/01/2019
Walker & Associates PC	Organization	ADP of the SNF	NOT APPLICABLE	01/13/2010

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What alternatives do you try before using bed rails, and how do you involve families in that decision?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"How do you assess and manage residents' pain, especially for those who have trouble communicating?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Health Care Center Lucy Corr	2.4 mi	Chesterfield, VA	★★☆☆☆	2/5
Colonial Heights Rehabilitation and Nursing Center	7.7 mi	Colonial Heights, VA	★☆☆☆☆	1/5
Hiram W Davis Medical Ctr	9.7 mi	Petersburg, VA	★★★★☆	4/5
Sitter and Barfoot Veterans Care Center	9.8 mi	Richmond, VA	★★★★★	3/5
Wonder City Rehabilitation and Nursing Center	10.6 mi	Hopewell, VA	★☆☆☆☆	1/5	SFF
Beaufont Health and Rehabilitation Center	10.8 mi	Richmond, VA	★★☆☆☆	3/5
The Laurels of Bon Air	10.8 mi	Bon Air, VA	★★★☆☆	2/5
Forest Hill Health & Rehabilitation	11.5 mi	Richmond, VA	★☆☆☆☆	1/5
Petersburg Healthcare Center	11.6 mi	Petersburg, VA	★★☆☆☆	2/5	abuse
River View on the Appomattox Health & Rehab Center	11.7 mi	Hopewell, VA	★☆☆☆☆	1/5	abuse
Dinwiddie Health and Rehab Center	11.7 mi	Petersburg, VA	★★☆☆☆	3/5
The Haven at Brandermill Woods	12.4 mi	Midlothian, VA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Chester →

Facility data as of CMS processing date 2026-08-01. CCN 495401.

The Care File

Visit checklist — Tyler's Retreat at Iron Bridge

12001 Iron Bridge Rd, Chester, VA 23831 · 8047061023

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 495401 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)