Cycle 1
Health 2021-10-15 · Fire 2021-10-15
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Norfolk, VA
Lake Taylor Hosp
3-star overall rating with 2-star inspections with $59,150 in total fines with 11 recent health deficiencies
1309 Kempsville Rd, Norfolk, VA
(757) 461-5001
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
192
Certified beds
Average residents
164
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
2.52
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.94
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.93
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.26
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
5.30
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,252
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0136
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.95
Baseline 21.00% · Performance 19.14% · Measure score 4.95 · Achievement 4.95 · Improvement 4.20
Healthcare-associated infections
7.43
Baseline 5.88% · Performance 5.61% · Measure score 7.43 · Achievement 7.43 · Improvement 2.48
Total nurse turnover
4.52
Baseline 52.97% · Performance 45.19% · Measure score 4.52 · Achievement 4.52 · Improvement 2.27
Adjusted total nurse staffing
6.43
Baseline 4.57 hours · Performance 4.91 hours · Measure score 6.43 · Achievement 6.43 · Improvement 2.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.45% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 929 · Observed rate 10.01% · Lower 95% interval 8.88% |
| Discharge to community | 61.69% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 986 · Observed rate 57.3% · Lower 95% interval 59% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.92% |
95.27%
3.7 pts better
|
Numerator 549 · Denominator 555 |
| Falls with major injury | 1.26% |
0.77%
0.5 pts worse
|
Numerator 7 · Denominator 555 |
| Discharge self-care score | 61.31% |
53.69%
7.6 pts better
|
Numerator 263 · Denominator 429 |
| Discharge mobility score | 62.94% |
50.94%
12 pts better
|
Numerator 270 · Denominator 429 |
| Pressure ulcers or injuries, new or worsened | 2.16% |
2.29%
0.1 pts better
|
Numerator 12 · Denominator 555 · Adjusted rate 2.77% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
Better than the National Rate · Eligible stays 535 · Observed rate 4.67% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 8.42% |
8.2%
0.2 pts better
|
Numerator 32 · Denominator 380 |
| Staff flu vaccination coverage | 37.55% |
42%
4.5 pts worse
|
Numerator 178 · Denominator 474 |
| Discharge function score | 56.64% |
56.45%
0.2 pts better
|
Numerator 243 · Denominator 429 |
| Transfer of health information to provider | 98.9% |
95.95%
3 pts better
|
Numerator 270 · Denominator 273 |
| Transfer of health information to patient | 99.18% |
96.28%
2.9 pts better
|
Numerator 242 · Denominator 244 |
| Resident COVID-19 vaccinations up to date | 3.83% |
25.2%
21.4 pts worse
|
Numerator 11 · Denominator 287 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.4
0.6 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
91.2%
6.9 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 98.1% · Q4 95.6% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.0%
5.1 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.1% · Q3 4.9% · Q4 4.4% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
15.7%
15 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.9% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.7%
2.5 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.3% · Q3 2.2% · Q4 4.2% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
20.2%
9.1 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.4% · Q3 9.8% · Q4 9.2% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
15.0%
1.8 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 18.3% · Q3 12.0% · Q4 9.9% · 4Q avg 13.2% · 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 | 8.7% |
17.5%
8.8 pts better
|
16.3%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 7.7% · Q3 5.9% · Q4 5.1% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
15.7%
4.9 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 11.9% · Q3 8.0% · Q4 8.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.5%
1.2 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 2.3% · Q4 2.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 12.9% |
22.2%
9.3 pts better
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 18.4% · Q3 7.9% · Q4 9.3% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.2%
1.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.6% · Q3 5.6% · Q4 3.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
74.6%
23.8 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 99.1% · Q3 98.4% · Q4 97.1% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
11.7%
1.1 pts worse
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 11.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.3% · Q3 0.0% · Q4 0.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
73.6%
22.6 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
22.0%
0.9 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 19.2% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2018-11-01 · Fire 2018-11-01
10 health deficiencies
Top issue: Environmental (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Cycle 3
Health 2017-04-06 · Fire 2017-04-06
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2018-11-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-01-24
D · Potential for more than minimal harm
2018-11-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-24
C · Minimal harm
2018-11-01
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2018-12-16
C · Minimal harm
2018-11-01
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2018-12-16
F · Potential for more than minimal harm
2017-04-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2017-06-06
F · Potential for more than minimal harm
2017-04-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-06-06
F · Potential for more than minimal harm
2017-04-06
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2017-06-06
E · Potential for more than minimal harm
2017-04-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2017-06-06
Inspection history
Recent health citations
G · Actual harm
2025-09-26
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 2025-11-28
D · Potential for more than minimal harm
2025-09-26
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 2025-11-28
G · Actual harm
2021-10-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-22
F · Potential for more than minimal harm
2021-10-15
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 2021-12-22
E · Potential for more than minimal harm
2021-10-15
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 2021-12-22
E · Potential for more than minimal harm
2021-10-15
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2021-12-22
E · Potential for more than minimal harm
2021-10-15
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2021-12-22
D · Potential for more than minimal harm
2021-10-15
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 2021-12-22
D · Potential for more than minimal harm
2021-10-15
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 2021-12-22
D · Potential for more than minimal harm
2021-10-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-12-22
C · Minimal harm
2021-10-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-22
E · Potential for more than minimal harm
2018-11-01
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 2018-12-16
E · Potential for more than minimal harm
2018-11-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-12-16
E · Potential for more than minimal harm
2018-11-01
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 2018-12-16
E · Potential for more than minimal harm
2018-11-01
F921 · 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 2018-12-16
E · Potential for more than minimal harm
2018-11-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-12-16
D · Potential for more than minimal harm
2018-11-01
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2018-12-16
D · Potential for more than minimal harm
2018-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-12-16
D · Potential for more than minimal harm
2018-11-01
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 2018-12-16
D · Potential for more than minimal harm
2018-11-01
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 2018-12-16
C · Minimal harm
2018-11-01
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2018-12-16
E · Potential for more than minimal harm
2017-04-06
F221 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Keep each resident free from physical restraints, unless needed for medical treatment.
Corrected 2017-05-19
E · Potential for more than minimal harm
2017-04-06
F311 · Quality of Life and Care Deficiencies
Health
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
Corrected 2017-05-19
D · Potential for more than minimal harm
2017-04-06
F224 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from mistreatment, neglect and misappropriation of personal property.
Corrected 2017-05-19
D · Potential for more than minimal harm
2017-04-06
F225 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Corrected 2017-05-19
D · Potential for more than minimal harm
2017-04-06
F332 · Pharmacy Service Deficiencies
Health
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Corrected 2017-05-19
C · Minimal harm
2017-04-06
F159 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2017-05-19
C · Minimal harm
2017-04-06
F167 · Resident Rights Deficiencies
Health
Allow residents to easily view the results of the nursing home's most recent inspection.
Corrected 2017-05-19
Penalties and ownership
What sits behind the stars
$59,150
2025-09-26
Fine
Fine · fine $59,150
Fine
Ownership
Hospital Authority Of Norfolk
5% Or Greater Direct Ownership Interest · Organization
Albert, Elizabeth
Operational/Managerial Control · Individual
Albert, Elizabeth
Corporate Director · Individual
Allen, Suzanne
Operational/Managerial Control · Individual
Aramark Healthcare Support Services LLC
Operational/Managerial Control · Organization
Armstrong, Melody
Operational/Managerial Control · Individual
Armstrong, Melody
Corporate Director · Individual
Bauman, Deborah
Corporate Director · Individual
Durham, Calvin
Operational/Managerial Control · Individual
Durham, Calvin
Corporate Director · Individual
Fogg, Robert
Operational/Managerial Control · Individual
Fogg, Robert
Corporate Officer · Individual
Hcare LLC
Operational/Managerial Control · Organization
Hospital Authority Of Norfolk
Operational/Managerial Control · Organization
Lehew, Willette
Corporate Director · Individual
Massey, Paul
Corporate Director · Individual
Orsini, Thomas
Operational/Managerial Control · Individual
Orsini, Thomas
Corporate Director · Individual
Poston, Anita
Operational/Managerial Control · Individual
Poston, Anita
Corporate Director · Individual
Roberts-Atwater, Beverly
Operational/Managerial Control · Individual
Roberts-Atwater, Beverly
Corporate Director · Individual
Robinson, Bradbury
Operational/Managerial Control · Individual
Robinson, Bradbury
Corporate Director · Individual
Ryan, John
Operational/Managerial Control · Individual
Ryan, John
Corporate Director · Individual
Ward, Willie
Operational/Managerial Control · Individual
Ward, Willie
Corporate Director · Individual
Wilhelm, Karen
Operational/Managerial Control · Individual
Wolford, Lorraine
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Autumn Care Of Norfolk
Norfolk, VA
4-star overall rating with 3-star inspections with 11 recent health deficiencies
#2
Cypress Pointe Rehabilitation And Nursing
Virginia Beach, VA
2-star overall rating with 2-star inspections with 26 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Waterside Health & Rehab Center
Norfolk, VA
3-star overall rating with 3-star inspections with $8,375 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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