Cycle 1
Health 2022-02-03 · Fire 2022-02-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Suffolk, VA
Lake Prince Woods, Inc
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
100 Anna Goode Way, Suffolk, VA
(757) 923-5500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
25
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Everyage Senior Living
Operator or chain grouping
Approved since
2003-01-14
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
4 facilities
Chain averages 5 overall / 5 health / 5 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
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.93
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.65
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.83
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
5.57
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.91
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
5.67
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.63% · Performance 23.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.77% · Performance 8.16% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.42
Baseline 47.37% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 5.73
Adjusted total nurse staffing
8.99
Performance 5.63 hours · Measure score 8.99 · Achievement 8.99 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 7.84% · Lower 95% interval 6.56% |
| Discharge to community | 56.17% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 55.49% · Lower 95% interval 47.58% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 61.73% |
53.69%
8 pts better
|
Numerator 50 · Denominator 81 |
| Discharge mobility score | 60.49% |
50.94%
9.6 pts better
|
Numerator 49 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 1.19% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 84 · Adjusted rate 1.21% |
| Healthcare-associated infections requiring hospitalization | 8.16% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 8.33% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 20.9% |
8.2%
12.7 pts better
|
Numerator 14 · Denominator 67 |
| Staff flu vaccination coverage | 38.41% |
42%
3.6 pts worse
|
Numerator 53 · Denominator 138 |
| Discharge function score | 49.38% |
56.45%
7.1 pts worse
|
Numerator 40 · Denominator 81 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.65% |
96.28%
2.4 pts better
|
Numerator 73 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 29.27% |
25.2%
4.1 pts better
|
Numerator 12 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.9% |
91.2%
15.3 pts worse
|
93.4%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 75.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
94.0%
1 pts better
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.6%
0.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.7%
5.7 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.7% |
20.2%
13.5 pts better
|
19.6%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
15.7%
2.4 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.8% |
1.6%
10.2 pts worse
|
1.7%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
22.2%
0.3 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 25.9% |
5.2%
20.7 pts worse
|
5.1%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.2% |
74.6%
13.4 pts worse
|
81.7%
20.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.6% · Q2 57.6% · Q3 52.7% · Q4 63.2% · 4Q avg 61.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
11.7%
0.9 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 9.8% · Expected 10.2% · Used in QM five-star |
| 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% · Q3 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 | 71.2% |
73.6%
2.4 pts worse
|
79.7%
8.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
22.0%
2.5 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 21.6% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-29 · Fire 2019-08-29
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2017-11-16 · Fire 2017-11-16
10 health deficiencies
Top issue: Environmental (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-02-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-25
E · Potential for more than minimal harm
2022-02-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-03-25
E · Potential for more than minimal harm
2019-08-29
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 2020-02-11
D · Potential for more than minimal harm
2019-08-29
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2020-02-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-02-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-02-16
D · Potential for more than minimal harm
2022-02-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-02-16
D · Potential for more than minimal harm
2019-08-29
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 2019-08-30
F · Potential for more than minimal harm
2017-11-16
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-12-25
F · Potential for more than minimal harm
2017-11-16
F465 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2017-12-25
E · Potential for more than minimal harm
2017-11-16
F157 · 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 2017-12-25
E · Potential for more than minimal harm
2017-11-16
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 2017-12-25
D · Potential for more than minimal harm
2017-11-16
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-12-25
D · Potential for more than minimal harm
2017-11-16
F279 · Resident Assessment and Care Planning Deficiencies
Health
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2017-12-25
D · Potential for more than minimal harm
2017-11-16
F314 · Quality of Life and Care Deficiencies
Health
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Corrected 2017-12-25
D · Potential for more than minimal harm
2017-11-16
F323 · Environmental Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Corrected 2017-12-25
D · Potential for more than minimal harm
2017-11-16
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-12-25
D · Potential for more than minimal harm
2017-11-16
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2017-12-25
Penalties and ownership
What sits behind the stars
Ownership
Abernethy, Julius
Corporate Director · Individual
Alcorn, Gregory
Corporate Director · Individual
Bolick, Lawrence
Corporate Director · Individual
Branch, Anthony
Corporate Director · Individual
Clapp, Kenneth
Corporate Director · Individual
Erdman, Charles
Corporate Director · Individual
Everyage
5% Or Greater Direct Ownership Interest · Organization
Everyage
Operational/Managerial Control · Organization
Everyage
5% Or Greater Security Interest · Organization
Gilliam, Jeffrey J
Corporate Director · Individual
Gray, Paul
Corporate Director · Individual
Horton, Michelle
Corporate Director · Individual
Howell, Parker
Corporate Director · Individual
Jones, Tammy
Corporate Officer · Individual
Maddox, Lamont
Corporate Director · Individual
March, Mills
Corporate Director · Individual
Reimann, Aimee
Corporate Officer · Individual
Smith, Shane
Corporate Director · Individual
Stone, Susan
Corporate Director · Individual
Street, Jody
Corporate Director · Individual
Sullivan, Diana
Corporate Director · Individual
Syria, Lee
Operational/Managerial Control · Individual
Syria, Lee
Corporate Officer · Individual
Thie, Ronald
Corporate Director · Individual
Tobin, Cory
Corporate Director · Individual
Wiley, Margaret
Corporate Director · Individual
Wood, Kathy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Autumn Care Of Suffolk
Suffolk, VA
2-star overall rating with 3-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Nans Pointe Rehabilitation And Nursing
Suffolk, VA
2-star overall rating with 1-star inspections with $5,293 in total fines with 29 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Windsor Grove Health and Rehabilitation
Windsor, VA
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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