Cycle 1
Health 2022-06-09 · Fire 2022-06-09
14 health deficiencies
Top issue: Resident Rights (6 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Virginia Beach, VA
Thalia Gardens Rehabilitation And Nursing
1-star overall rating with 1-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4142 Bonney Road, Virginia Beach, VA
(757) 340-0620
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eastern Healthcare Group
Operator or chain grouping
Approved since
1991-06-01
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
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.36
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
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,721
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.16
Baseline 18.30% · Performance 19.50% · Measure score 4.16 · Achievement 4.16 · Improvement 0
Healthcare-associated infections
0
Baseline 6.50% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.07
Performance 55.21% · Measure score 2.07 · Achievement 2.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.02 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.53% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 6.78% · Lower 95% interval 5.88% |
| Discharge to community | 47.45% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 39.13% · Lower 95% interval 34.02% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 65.22% |
95.27%
30 pts worse
|
Numerator 30 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 35.48% |
53.69%
18.2 pts worse
|
Numerator 11 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 46 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 12.12% · Lower 95% interval 4.41% |
| 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 | 60.52% |
42%
18.5 pts better
|
Numerator 164 · Denominator 271 |
| Discharge function score | 41.94% |
56.45%
14.5 pts worse
|
Numerator 13 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 5 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.4% |
91.2%
29.8 pts worse
|
93.4%
32 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.0% · Q2 56.7% · Q3 58.7% · Q4 64.1% · 4Q avg 61.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.8% |
94.0%
11.2 pts worse
|
95.5%
12.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| 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 0.9% · Q2 2.9% · Q3 4.6% · Q4 3.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.2% |
15.7%
9.5 pts worse
|
11.4%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 44.8% · Q3 30.0% · Q4 0.0% · 4Q avg 25.2% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.7%
2.1 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.0% · Q3 6.9% · Q4 2.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
20.2%
9.2 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 11.1% · Q3 10.5% · Q4 7.2% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
15.0%
9 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.3% · Q3 8.2% · Q4 6.5% · 4Q avg 6.0% · 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 | 25.7% |
17.5%
8.2 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 18.8% · Q3 11.9% · Q4 46.6% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
15.7%
6.7 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 26.4% · Q3 17.6% · Q4 28.4% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.5%
1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.8% · Q3 2.6% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.6%
0.8 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.8% · Q3 2.8% · Q4 1.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
22.2%
4.8 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 24.6% · Q3 27.3% · Q4 30.3% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.2%
3.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.0% · Q3 1.1% · Q4 1.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.5% |
74.6%
49.1 pts worse
|
81.7%
56.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 27.7% · Q3 28.5% · Q4 22.0% · 4Q avg 25.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
11.7%
1.9 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 10.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 30.4% |
73.6%
43.2 pts worse
|
79.7%
49.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 30.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.0%
0.6 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 24.2% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-29 · Fire 2019-08-29
21 health deficiencies
Top issue: Resident Rights (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-05-04 · Fire 2018-05-04
24 health deficiencies
Top issue: Resident Rights (7 deficiencies)
27 fire-safety deficiencies
Top issue: Emergency Preparedness (19 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-06-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-08-23
E · Potential for more than minimal harm
2022-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-06-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-23
C · Minimal harm
2022-06-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-07-24
C · Minimal harm
2022-06-09
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-07-24
C · Minimal harm
2022-06-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-07-24
C · Minimal harm
2022-06-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-07-24
E · Potential for more than minimal harm
2019-08-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-29
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-29
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-11-07
E · Potential for more than minimal harm
2019-08-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-29
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 2019-11-07
D · Potential for more than minimal harm
2019-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-07
D · Potential for more than minimal harm
2019-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-11-07
F · Potential for more than minimal harm
2018-05-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-06-07
F · Potential for more than minimal harm
2018-05-04
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 2018-06-07
D · Potential for more than minimal harm
2018-05-04
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-06-07
D · Potential for more than minimal harm
2018-05-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2018-06-07
D · Potential for more than minimal harm
2018-05-04
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 2018-06-07
D · Potential for more than minimal harm
2018-05-04
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-06-07
D · Potential for more than minimal harm
2018-05-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-06-07
D · Potential for more than minimal harm
2018-05-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-06-07
C · Minimal harm
2018-05-04
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2018-05-22
C · Minimal harm
2018-05-04
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2018-05-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-08-15
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 2023-12-05
F · Potential for more than minimal harm
2023-08-15
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 2023-12-05
F · Potential for more than minimal harm
2023-08-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-08-15
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 2023-09-29
E · Potential for more than minimal harm
2023-08-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-08-15
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 2023-12-05
F · Potential for more than minimal harm
2023-05-10
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 2023-06-17
F · Potential for more than minimal harm
2023-05-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-10
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 2023-06-30
D · Potential for more than minimal harm
2023-05-10
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-10
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 2023-06-06
D · Potential for more than minimal harm
2023-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-06
G · Actual harm
2022-06-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-26
F · Potential for more than minimal harm
2022-06-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-07-24
E · Potential for more than minimal harm
2022-06-09
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 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F578 · Resident Rights Deficiencies
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 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-07-24
D · Potential for more than minimal harm
2022-06-09
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 2022-07-24
D · Potential for more than minimal harm
2022-06-09
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 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-24
D · Potential for more than minimal harm
2022-06-09
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 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-24
D · Potential for more than minimal harm
2022-06-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-07-24
D · Potential for more than minimal harm
2022-06-09
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 2022-07-24
F · Potential for more than minimal harm
2019-08-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-10-07
E · Potential for more than minimal harm
2019-08-29
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2019-10-07
E · Potential for more than minimal harm
2019-08-29
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 2019-10-07
E · Potential for more than minimal harm
2019-08-29
F622 · Resident Rights Deficiencies
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 2019-10-07
E · Potential for more than minimal harm
2019-08-29
F625 · Resident Rights Deficiencies
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 2019-10-07
E · Potential for more than minimal harm
2019-08-29
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 2019-10-07
E · Potential for more than minimal harm
2019-08-29
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 2019-10-07
E · Potential for more than minimal harm
2019-08-29
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 2019-10-07
E · Potential for more than minimal harm
2019-08-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-10-07
E · Potential for more than minimal harm
2019-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-07
E · Potential for more than minimal harm
2019-08-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-29
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 2019-10-07
D · Potential for more than minimal harm
2019-08-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-29
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 2019-10-07
D · Potential for more than minimal harm
2019-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-29
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 2019-10-07
D · Potential for more than minimal harm
2019-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-08-29
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-10-07
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 2019-10-07
G · Actual harm
2018-05-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-05-22
G · Actual harm
2018-05-04
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 2018-05-22
E · Potential for more than minimal harm
2018-05-04
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 2018-05-22
E · Potential for more than minimal harm
2018-05-04
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 2018-05-22
D · Potential for more than minimal harm
2018-05-04
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2018-05-22
D · Potential for more than minimal harm
2018-05-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-05-22
D · Potential for more than minimal harm
2018-05-04
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 2018-05-22
D · Potential for more than minimal harm
2018-05-04
F625 · Resident Rights Deficiencies
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 2018-05-22
D · Potential for more than minimal harm
2018-05-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-05-22
D · Potential for more than minimal harm
2018-05-04
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 2018-05-22
D · Potential for more than minimal harm
2018-05-04
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 2018-05-22
D · Potential for more than minimal harm
2018-05-04
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 2018-05-22
Penalties and ownership
What sits behind the stars
Ownership
Va SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Jj United Tr
5% Or Greater Indirect Ownership Interest · Organization
Rogers, Kevin
W-2 Managing Employee · Individual
Shapiro, Akiva
Corporate Officer · Individual
Ydi Eastern Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ydi Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
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