17 health deficiencies
Top issue: Resident Rights (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hampton, VA
3-star overall rating with 2-star inspections with 17 recent health deficiencies
2230 Executive Drive Revised, Hampton, VA
(757) 224-2230
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
86
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1994-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
RN hours / resident day
0.71
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
4,819
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.65
Baseline 19.49% · Performance 18.35% · Measure score 6.65 · Achievement 6.65 · Improvement 4.15
Healthcare-associated infections
3.94
Baseline 6.60% · Performance 6.66% · Measure score 3.94 · Achievement 3.94 · Improvement 0
Total nurse turnover
3.93
Baseline 76.14% · Performance 53.41% · Measure score 3.93 · Achievement 2.51 · Improvement 3.93
Adjusted total nurse staffing
0.86
Baseline 3.13 hours · Performance 3.32 hours · Measure score 0.86 · Achievement 0.86 · Improvement 0.22
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 14.49% · Lower 95% interval 8.35% |
| Discharge to community | 60.87% |
50.57%
10.3 pts better
|
Better than the National Rate · Eligible stays 230 · Observed rate 50% · Lower 95% interval 52.61% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.86% |
95.27%
2.4 pts worse
|
Numerator 91 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 63.16% |
53.69%
9.5 pts better
|
Numerator 48 · Denominator 76 |
| Discharge mobility score | 52.63% |
50.94%
1.7 pts better
|
Numerator 40 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 98 · Adjusted rate 0.93% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 6.19% · Lower 95% interval 4.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 35.33% |
42%
6.7 pts worse
|
Numerator 59 · Denominator 167 |
| Discharge function score | 60.53% |
56.45%
4.1 pts better
|
Numerator 46 · Denominator 76 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 98.46% |
96.28%
2.2 pts better
|
Numerator 64 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 10 · Denominator 60 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
91.2%
10.2 pts worse
|
93.4%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 80.7% · Q3 78.6% · Q4 80.8% · 4Q avg 81.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.0% |
94.0%
12 pts worse
|
95.5%
13.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.6%
1.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 1.8% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
15.7%
14.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 4.1% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 13.2% |
5.7%
7.5 pts worse
|
5.4%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.7% · Q3 12.5% · Q4 13.7% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.8% |
20.2%
13.4 pts better
|
19.6%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.4% · Q3 7.1% · Q4 7.8% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
15.0%
8.8 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.9% · Q3 4.5% · Q4 4.7% · 4Q avg 6.2% · 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 | 27.1% |
17.5%
9.6 pts worse
|
16.3%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
15.7%
0.1 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 27.7% · Q3 10.0% · Q4 4.3% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.6%
1.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
22.2%
8.5 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 12.2% · Q3 15.0% · Q4 13.8% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.2%
1.6 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.7% · Q3 4.4% · Q4 2.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 30.3% |
74.6%
44.3 pts worse
|
81.7%
51.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.0% · Q2 38.5% · Q3 26.7% · Q4 14.9% · 4Q avg 30.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.7%
4.4 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 15.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.2%
0.1 pts worse
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.6% · Q3 1.6% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.2% |
73.6%
39.4 pts worse
|
79.7%
45.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
22.0%
4.1 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.1% · Expected 22.7% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire Safety
Meet other general requirements.
Corrected 2019-07-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-07-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-31
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-07-31
Inspection history
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 2024-10-18
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-18
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 2024-10-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-18
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-18
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-10-18
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 2024-10-18
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 2024-10-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-18
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-10-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-18
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-10-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-07
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-06-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-05
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2021-05-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-30
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-08-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-05-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-05-20
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 2021-05-20
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 2021-05-20
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-05-20
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 2021-05-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-05-20
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 2021-05-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-08-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-30
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-08-30
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-08-05
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-30
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 2021-05-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-05-20
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-08-05
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-05-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-05-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-05-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-05-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-05-24
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 2019-05-24
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 2019-05-24
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 2019-05-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-05-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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