Cycle 1
Health 2023-03-16 · Fire 2023-03-16
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Warsaw, VA
Northern Neck Senior Care Community
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
20 Delfae Drive, Warsaw, VA
(804) 313-2568
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-10-10
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
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,912
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.72
Baseline 17.44% · Performance 18.78% · Measure score 5.72 · Achievement 5.72 · Improvement 0
Healthcare-associated infections
4.01
Baseline 5.12% · Performance 6.64% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Total nurse turnover
3.18
Baseline 58.06% · Performance 50.67% · Measure score 3.18 · Achievement 3.18 · Improvement 1.73
Adjusted total nurse staffing
0.94
Baseline 4.08 hours · Performance 3.34 hours · Measure score 0.94 · Achievement 0.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 181 · Observed rate 9.94% · Lower 95% interval 7.87% |
| Discharge to community | 62.69% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 179 · Observed rate 60.34% · Lower 95% interval 56.71% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 58.59% |
95.27%
36.7 pts worse
|
Numerator 75 · Denominator 128 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 128 |
| Discharge self-care score | 73.24% |
53.69%
19.5 pts better
|
Numerator 52 · Denominator 71 |
| Discharge mobility score | 74.65% |
50.94%
23.7 pts better
|
Numerator 53 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 128 · Adjusted rate 1.24% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 4.92% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 1.89% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 106 |
| Staff flu vaccination coverage | 52.03% |
42%
10 pts better
|
Numerator 64 · Denominator 123 |
| Discharge function score | 73.24% |
56.45%
16.8 pts better
|
Numerator 52 · Denominator 71 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 50 · Denominator 51 |
| Transfer of health information to patient | 95.16% |
96.28%
1.1 pts worse
|
Numerator 59 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 12 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| 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 0.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.4
1 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.0%
2.8 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.6%
0.5 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 3.6% · Q4 2.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.6% |
15.7%
0.1 pts better
|
11.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 20.4% · Q3 23.3% · Q4 9.5% · 4Q avg 15.6% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
5.7%
5.2 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
20.2%
3 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.2% · Q3 11.8% · Q4 16.0% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
15.0%
2.8 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 20.9% · Q3 15.0% · Q4 14.0% · 4Q avg 17.8% · 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 | 5.6% |
17.5%
11.9 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
15.7%
6.7 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.6% · Q3 6.1% · Q4 10.6% · 4Q avg 9.0% · 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 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 | 25.7% |
22.2%
3.5 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 23.1% · Q3 24.6% · Q4 32.2% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.2%
2.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 3.0% · Q4 3.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
74.6%
20.1 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 93.9% · Q3 97.4% · Q4 97.5% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
11.7%
1.2 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 11.6% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.2% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.4% |
73.6%
16.2 pts worse
|
79.7%
22.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
22.0%
0.3 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 19.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-03-05 · Fire 2021-03-05
12 health deficiencies
Top issue: Administration (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-06-01 · Fire 2018-06-01
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-08-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-08-01
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 2023-08-21
D · Potential for more than minimal harm
2023-08-01
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-08-21
E · Potential for more than minimal harm
2023-03-16
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 2023-04-20
D · Potential for more than minimal harm
2023-03-16
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 2023-04-20
D · Potential for more than minimal harm
2023-03-16
F580 · 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 2023-04-20
D · Potential for more than minimal harm
2023-03-16
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 2023-04-20
D · Potential for more than minimal harm
2023-03-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-16
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 2023-04-20
D · Potential for more than minimal harm
2023-03-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-20
F · Potential for more than minimal harm
2021-03-05
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 2021-04-26
F · Potential for more than minimal harm
2021-03-05
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-05-19
E · Potential for more than minimal harm
2021-03-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-04-26
E · Potential for more than minimal harm
2021-03-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2021-04-26
E · Potential for more than minimal harm
2021-03-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2021-04-26
E · Potential for more than minimal harm
2021-03-05
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-05
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 2021-04-26
D · Potential for more than minimal harm
2021-03-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-03-05
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-05-19
C · Minimal harm
2021-03-05
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2021-05-19
C · Minimal harm
2021-03-05
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2021-05-19
E · Potential for more than minimal harm
2018-06-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-07-06
E · Potential for more than minimal harm
2018-06-01
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 2018-07-06
D · Potential for more than minimal harm
2018-06-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-07-06
D · Potential for more than minimal harm
2018-06-01
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 2018-07-06
D · Potential for more than minimal harm
2018-06-01
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 2018-07-06
Penalties and ownership
What sits behind the stars
Ownership
Va 3 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bsd Eom Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Hlhk Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
South East Virginia Hold Co LLC
5% Or Greater Indirect Ownership Interest · Organization
Vogue Nhc LLC
5% Or Greater Indirect Ownership Interest · Organization
Hallback, Erikka
W-2 Managing Employee · Individual
Hartstein, Jake
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Carrington Place Of Tappahannock
Tappahannock, VA
1-star overall rating with 2-star inspections with $31,445 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Westmoreland Rehabilitation & Healthcare Center
Colonial Beach, VA
2-star overall rating with 2-star inspections with $27,885 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
St. Mary's Nursing Center Inc
Leonardtown, MD
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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