29 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Nassawadox, VA
1-star overall rating with 1-star inspections with abuse icon flag with 29 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
9468 Hospital Road, Nassawadox, VA
(757) 442-5600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
145
Certified beds
Average residents
123
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eastern Healthcare Group
Operator or chain grouping
Approved since
1993-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 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
RN hours / resident day
0.33
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
2.98
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.53
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
3,395
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9977
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.73
Baseline 20.60% · Performance 19.24% · Measure score 4.73 · Achievement 4.73 · Improvement 3.31
Healthcare-associated infections
5.48
Baseline 10.70% · Performance 7.29% · Measure score 5.48 · Achievement 1.84 · Improvement 5.48
Total nurse turnover
7.33
Performance 33.72% · Measure score 7.33 · Achievement 7.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.28
Baseline 2.80 hours · Performance 3.04 hours · Measure score 0.28 · Achievement 0 · Improvement 0.28
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 74 · Observed rate 10.81% · Lower 95% interval 7.09% |
| Discharge to community | 48.88% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 41.94% · Lower 95% interval 34.55% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 25 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 30% |
53.69%
23.7 pts worse
|
Numerator 6 · Denominator 20 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 9 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 1 · Denominator 27 · Adjusted rate 2.9% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 8 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
| 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 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.4
0.6 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.2% |
91.2%
6 pts worse
|
93.4%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.4% · Q2 88.3% · Q3 83.6% · Q4 83.6% · 4Q avg 85.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.9% |
94.0%
11.1 pts worse
|
95.5%
12.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.6%
1.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.0% · Q3 4.1% · Q4 4.9% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
15.7%
7.6 pts better
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.9% · Q3 12.7% · Q4 6.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
5.7%
4.7 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.6% · Q3 15.5% · Q4 7.9% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
20.2%
4.6 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 15.5% · Q3 14.7% · Q4 13.3% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.1% |
15.0%
8.1 pts worse
|
16.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 23.8% · Q3 19.0% · Q4 23.3% · 4Q avg 23.1% · 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 | 17.5% |
17.5%
About the same
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 14.1% · Q3 18.4% · Q4 17.3% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
15.7%
9.1 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 18.3% · Q3 30.0% · Q4 23.9% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.6%
1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.8% · 4Q avg 0.6% · 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 29.4% · Q2 33.9% · Q3 20.2% · Q4 25.6% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.2%
2.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.0% · Q3 8.2% · Q4 6.1% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.4% |
74.6%
10.2 pts worse
|
81.7%
17.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.3% · Q2 70.5% · Q3 72.5% · Q4 68.2% · 4Q avg 64.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
11.7%
8.9 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.8% · Observed 2.8% · Expected 11.2% · 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 | 32.8% |
73.6%
40.8 pts worse
|
79.7%
46.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
22.0%
9.8 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 30.6% · Expected 22.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-10
Inspection history
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-10-13
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-10-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-31
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-07-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-18
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-18
Health
Provide or obtain dental services for each resident.
Corrected 2022-07-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-18
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-07-18
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 2022-07-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-18
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-09-18
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-07-18
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2022-07-18
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 2022-07-18
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-07-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-18
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 2022-07-18
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-07-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-18
Health
Provide appropriate foot care.
Corrected 2022-07-18
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-07-18
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-18
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 2022-07-18
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-18
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-07-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-07-18
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 2022-07-18
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 2022-07-18
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 2019-09-20
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 2019-09-20
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 2019-09-20
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 2019-09-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-20
Health
Dispose of garbage and refuse properly.
Corrected 2019-09-20
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2019-09-20
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 2019-09-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-20
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-09-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-09-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-09-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-09-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-09-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-09-20
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2017-12-24
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-12-24
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-12-24
Health
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Corrected 2017-12-24
Health
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Corrected 2017-12-24
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-12-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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