Cycle 1
Health 2024-08-29 · Fire 2024-08-29
22 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Poquoson, VA
Bayside Of Poquoson Health And Rehab
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1 Vantage Drive, Poquoson, VA
(757) 868-9960
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trio Healthcare
Operator or chain grouping
Approved since
1992-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 1 overall / 2 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,931
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.12
Baseline 84.51% · Performance 50.98% · Measure score 5.12 · Achievement 3.11 · Improvement 5.12
Adjusted total nurse staffing
1.79
Baseline 3.14 hours · Performance 3.59 hours · Measure score 1.79 · Achievement 1.79 · Improvement 1.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 7% |
| Discharge to community | 38.97% |
50.57%
11.6 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 26.92% · Lower 95% interval 28.22% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 68 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.4
1.5 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
91.2%
4.2 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 97.9% · Q3 93.5% · Q4 94.1% · 4Q avg 95.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
94.0%
2.4 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.6%
2.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.3% |
15.7%
1.4 pts better
|
11.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 18.8% · Q3 9.7% · Q4 9.4% · 4Q avg 14.3% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
5.7%
5.5 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 19.0% · Q3 12.2% · Q4 6.7% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
20.2%
2.6 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 19.0% · Q3 12.2% · Q4 15.6% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
15.0%
0.3 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 18.5% · Q3 7.1% · Q4 10.7% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.1% |
17.5%
7.6 pts worse
|
16.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.4% |
15.7%
12.7 pts worse
|
14.9%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 31.6% · Q3 38.5% · Q4 14.0% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.5%
0.4 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.6%
0.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
22.2%
5 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 16.7% · Q3 29.4% · Q4 35.8% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.2%
0.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 8.7% · Q4 5.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.4% |
74.6%
17.2 pts worse
|
81.7%
24.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 78.7% · Q3 48.9% · Q4 20.0% · 4Q avg 57.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.1% |
73.6%
2.5 pts better
|
79.7%
3.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-11 · Fire 2021-05-11
36 health deficiencies
Top issue: Resident Rights (10 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2019-08-16 · Fire 2019-08-16
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-29
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-29
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-16
C · Minimal harm
2021-05-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-07-29
C · Minimal harm
2021-05-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-07-29
E · Potential for more than minimal harm
2019-08-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-02-12
E · Potential for more than minimal harm
2019-08-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-02-12
E · Potential for more than minimal harm
2019-08-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-02-12
E · Potential for more than minimal harm
2019-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-08-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-08-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2020-02-12
D · Potential for more than minimal harm
2019-08-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-02-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-08-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-03
D · Potential for more than minimal harm
2023-04-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-19
G · Actual harm
2021-05-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-05-11
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-07-29
E · Potential for more than minimal harm
2019-08-16
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-16
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2019-09-16
Penalties and ownership
What sits behind the stars
Ownership
Gl Virginia Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Gentry, Boyd
5% Or Greater Indirect Ownership Interest · Individual
Gentry, Boyd
Corporate Officer · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
Corporate Officer · Individual
Schlaikowski, Amanda
W-2 Managing Employee · Individual
Trio Health Care - East, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trio Healthcare Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trio Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
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The Chesapeake
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5-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Regency Health And Rehabilitation Center
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2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Hampton Health & Rehab Center, LLC
Hampton, VA
3-star overall rating with 2-star inspections with 17 recent health deficiencies
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