Cycle 1
Health 2021-07-22 · Fire 2021-07-22
23 health deficiencies
Top issue: Resident Rights (8 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Chesapeake, VA
Deep Creek Health & Rehabilitation
1-star overall rating with 2-star inspections with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1017 George Washington Highway North, Chesapeake, VA
(757) 485-5500
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ark Post Acute Network
Operator or chain grouping
Approved since
1998-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 1 overall / 2 health / 2 staffing / 2 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
0.27
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.46
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
2.95
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.49
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,429
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.72
Baseline 19.57% · Performance 20.64% · Measure score 1.72 · Achievement 1.72 · Improvement 0
Healthcare-associated infections
5.99
Baseline 6.80% · Performance 6.05% · Measure score 5.99 · Achievement 5.99 · Improvement 3.70
Total nurse turnover
3.74
Baseline 83.33% · Performance 58.54% · Measure score 3.74 · Achievement 1.26 · Improvement 3.74
Adjusted total nurse staffing
1.71
Baseline 3.18 hours · Performance 3.56 hours · Measure score 1.71 · Achievement 1.71 · Improvement 0.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 5.36% · Lower 95% interval 6.41% |
| Discharge to community | 50.41% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 40% · Lower 95% interval 37.32% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 82.61% |
95.27%
12.7 pts worse
|
Numerator 57 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 58.97% |
53.69%
5.3 pts better
|
Numerator 23 · Denominator 39 |
| Discharge mobility score | 48.72% |
50.94%
2.2 pts worse
|
Numerator 19 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 1.45% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 69 · Adjusted rate 1.49% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 2.27% · Lower 95% interval 2.79% |
| Staff COVID-19 vaccination coverage | 2.73% |
8.2%
5.5 pts worse
|
Numerator 3 · Denominator 110 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 48.72% |
56.45%
7.7 pts worse
|
Numerator 19 · Denominator 39 |
| Transfer of health information to provider | 86.36% |
95.95%
9.6 pts worse
|
Numerator 19 · Denominator 22 |
| Transfer of health information to patient | 90.32% |
96.28%
6 pts worse
|
Numerator 28 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 24.32% |
25.2%
0.9 pts worse
|
Numerator 9 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.4
1.3 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
91.2%
0.2 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 97.8% · Q3 90.9% · Q4 90.8% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.8% |
94.0%
11.2 pts worse
|
95.5%
12.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.6%
2.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 1.1% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
15.7%
12.5 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.8% · Q3 0.0% · Q4 6.3% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.7%
3.2 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 3.7% · Q4 3.7% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.8% |
20.2%
9.4 pts better
|
19.6%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.4% · Q3 8.6% · Q4 17.3% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
15.0%
1.7 pts worse
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 21.1% · Q3 16.4% · Q4 14.1% · 4Q avg 16.7% · 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 | 27.4% |
17.5%
9.9 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 18.6% · Q3 28.4% · Q4 31.2% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
15.7%
8.9 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 24.3% · Q3 27.6% · Q4 22.1% · 4Q avg 24.6% · 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 2.6% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.6%
1.8 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.3% · Q3 2.3% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
22.2%
4.9 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 31.9% · Q3 25.9% · Q4 25.5% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.2%
4.1 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 9.0% · Q3 8.1% · Q4 11.6% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.5% |
74.6%
15.1 pts worse
|
81.7%
22.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.3% · Q2 62.2% · Q3 61.6% · Q4 58.6% · 4Q avg 59.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
11.7%
4.7 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 17.0% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.2%
1.1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 1.6% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.2% |
73.6%
17.4 pts worse
|
79.7%
23.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
22.0%
2.6 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 18.9% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-16 · Fire 2019-04-16
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
26 fire-safety deficiencies
Top issue: Emergency Preparedness (22 deficiencies)
Cycle 3
Health 2017-07-27 · Fire 2017-07-27
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-07-22
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 2021-08-24
D · Potential for more than minimal harm
2021-07-22
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-08-24
D · Potential for more than minimal harm
2021-07-22
K400 · Miscellaneous Deficiencies
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2021-08-24
D · Potential for more than minimal harm
2021-07-22
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2021-08-24
C · Minimal harm
2021-07-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-09-05
C · Minimal harm
2021-07-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-09-05
C · Minimal harm
2021-07-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-09-05
F · Potential for more than minimal harm
2019-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-08-01
F · Potential for more than minimal harm
2019-04-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-01
E · Potential for more than minimal harm
2019-04-16
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2020-12-07
E · Potential for more than minimal harm
2019-04-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-08-01
C · Minimal harm
2019-04-16
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-05-31
C · Minimal harm
2019-04-16
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-05-31
F · Potential for more than minimal harm
2017-07-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2017-10-02
F · Potential for more than minimal harm
2017-07-27
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 2017-10-02
F · Potential for more than minimal harm
2017-07-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2017-10-02
F · Potential for more than minimal harm
2017-07-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2017-10-02
F · Potential for more than minimal harm
2017-07-27
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 2017-10-02
F · Potential for more than minimal harm
2017-07-27
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2017-10-02
D · Potential for more than minimal harm
2017-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-10-02
D · Potential for more than minimal harm
2017-07-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2017-10-02
D · Potential for more than minimal harm
2017-07-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2017-10-02
D · Potential for more than minimal harm
2017-07-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2017-10-02
D · Potential for more than minimal harm
2017-07-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2017-10-02
D · Potential for more than minimal harm
2017-07-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2017-10-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-27
F · Potential for more than minimal harm
2025-09-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-27
E · Potential for more than minimal harm
2025-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-27
E · Potential for more than minimal harm
2025-09-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-27
D · Potential for more than minimal harm
2025-09-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-10-27
D · Potential for more than minimal harm
2025-09-19
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 2025-10-27
D · Potential for more than minimal harm
2023-11-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-03-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-25
E · Potential for more than minimal harm
2021-07-22
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 2021-09-05
E · Potential for more than minimal harm
2021-07-22
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2021-09-05
E · Potential for more than minimal harm
2021-07-22
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-09-05
E · Potential for more than minimal harm
2021-07-22
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 2021-09-05
D · Potential for more than minimal harm
2021-07-22
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 2021-09-05
D · Potential for more than minimal harm
2021-07-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
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 2021-09-05
D · Potential for more than minimal harm
2021-07-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
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 2021-09-05
D · Potential for more than minimal harm
2021-07-22
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
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 2021-06-21
D · Potential for more than minimal harm
2021-07-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
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 2021-09-05
D · Potential for more than minimal harm
2021-07-22
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-09-05
D · Potential for more than minimal harm
2021-07-22
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 2021-09-05
E · Potential for more than minimal harm
2019-04-16
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 2019-05-31
E · Potential for more than minimal harm
2019-04-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-05-31
E · Potential for more than minimal harm
2019-04-16
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 2019-05-31
E · Potential for more than minimal harm
2019-04-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-05-31
E · Potential for more than minimal harm
2019-04-16
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 2019-05-31
E · Potential for more than minimal harm
2019-04-16
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
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 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
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 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-05-31
D · Potential for more than minimal harm
2019-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-31
B · Minimal harm
2019-04-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-05-31
E · Potential for more than minimal harm
2017-07-27
F250 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F280 · Resident Assessment and Care Planning Deficiencies
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F285 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F287 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F323 · Environmental Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Corrected 2017-09-06
E · Potential for more than minimal harm
2017-07-27
F469 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F159 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F241 · Resident Rights Deficiencies
Health
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F281 · Quality of Life and Care Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F314 · Quality of Life and Care Deficiencies
Health
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F332 · Pharmacy Service Deficiencies
Health
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F425 · Pharmacy Service Deficiencies
Health
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-09-06
D · Potential for more than minimal harm
2017-07-27
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2017-09-06
Penalties and ownership
What sits behind the stars
Ownership
West Coast Commonwealth LLC
5% Or Greater Direct Ownership Interest · Organization
Bridges, Roy
Corporate Officer · Individual
Bryant, Tameika
W-2 Managing Employee · Individual
Justiniano, Kimberly
Corporate Officer · Individual
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3-star overall rating with 2-star inspections with $8,018 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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Autumn Care Of Portsmouth
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4-star overall rating with 3-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Portsmouth Health And Rehab
Portsmouth, VA
1-star overall rating with 1-star inspections with $156,213 in total fines with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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