Cycle 1
Health 2023-03-09 · Fire 2023-03-09
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Virginia Beach, VA
Westminster-Canterbury On Chesapeake Bay
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3100 Shore Drive, Virginia Beach, VA
(757) 496-1158
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-04-15
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
0.80
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.42
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.53
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
5.13
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.50
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
0.96
CMS adjusted RN staffing hours
Adjusted total hours
6.67
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,209
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9987
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.39% · Performance 22.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.45
Baseline 4.94% · Performance 6.21% · Measure score 5.45 · Achievement 5.45 · Improvement 0
Total nurse turnover
2.74
Baseline 58.21% · Performance 52.47% · Measure score 2.74 · Achievement 2.74 · Improvement 1.22
Adjusted total nurse staffing
10
Baseline 5.77 hours · Performance 6.28 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 624 · Observed rate 9.13% · Lower 95% interval 8.5% |
| Discharge to community | 67.5% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 646 · Observed rate 65.33% · Lower 95% interval 64.63% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 373 · Denominator 373 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 373 |
| Discharge self-care score | 84.97% |
53.69%
31.3 pts better
|
Numerator 260 · Denominator 306 |
| Discharge mobility score | 62.42% |
50.94%
11.5 pts better
|
Numerator 191 · Denominator 306 |
| Pressure ulcers or injuries, new or worsened | 2.68% |
2.29%
0.4 pts worse
|
Numerator 10 · Denominator 373 · Adjusted rate 3.92% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 373 · Observed rate 4.56% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 8.72% |
8.2%
0.5 pts better
|
Numerator 26 · Denominator 298 |
| Staff flu vaccination coverage | 90.06% |
42%
48.1 pts better
|
Numerator 308 · Denominator 342 |
| Discharge function score | 76.47% |
56.45%
20 pts better
|
Numerator 234 · Denominator 306 |
| Transfer of health information to provider | 97.95% |
95.95%
2 pts better
|
Numerator 143 · Denominator 146 |
| Transfer of health information to patient | 99.41% |
96.28%
3.1 pts better
|
Numerator 169 · Denominator 170 |
| Resident COVID-19 vaccinations up to date | 45.51% |
25.2%
20.3 pts better
|
Numerator 81 · Denominator 178 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
91.2%
3.9 pts better
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 100.0% · Q3 98.7% · Q4 98.8% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.3% · Q3 3.9% · Q4 6.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
5.7%
4.2 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.7% · Q3 3.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
20.2%
0.7 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 18.8% · Q3 17.9% · Q4 20.3% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
15.0%
3.5 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.6% · Q3 10.6% · Q4 9.1% · 4Q avg 11.5% · 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 | 7.0% |
17.5%
10.5 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.8% · Q3 12.9% · Q4 5.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
15.7%
3.3 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 15.9% · Q3 13.6% · Q4 12.3% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.6%
1.7 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
22.2%
2.6 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 19.8% · Q3 19.6% · Q4 15.3% · 4Q avg 19.6% |
| 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 0.0% · Q2 3.6% · Q3 3.2% · Q4 3.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
74.6%
22.8 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 97.1% · Q3 97.6% · Q4 96.2% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.7%
3.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 13.6% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
73.6%
25.9 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.0%
2.2 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 18.2% · Expected 17.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-16 · Fire 2020-01-16
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-11-30 · Fire 2018-11-30
4 health deficiencies
Top issue: Resident Assessment and Care Planning (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
2023-03-09
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-04-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-03-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-12
D · Potential for more than minimal harm
2020-01-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-02-17
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2020-01-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-02-17
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2020-01-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-03-30
D · Potential for more than minimal harm
2020-01-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-02-17
D · Potential for more than minimal harm
2020-01-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-03-30
D · Potential for more than minimal harm
2020-01-16
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 2020-02-17
D · Potential for more than minimal harm
2018-11-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-01-11
D · Potential for more than minimal harm
2018-11-30
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 2019-01-11
D · Potential for more than minimal harm
2018-11-30
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 2019-01-11
D · Potential for more than minimal harm
2018-11-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-01-11
Penalties and ownership
What sits behind the stars
Ownership
Boone, Elwood
Corporate Director · Individual
Burroughs, Richard
Corporate Director · Individual
Cavanaugh, John
Corporate Director · Individual
Ccl Hospitality Group
Operational/Managerial Control · Organization
Compo, George
Corporate Director · Individual
Crenshaw, Victoria
Operational/Managerial Control · Individual
Damuth, Thomas
Corporate Director · Individual
Fretwell, Julia
Operational/Managerial Control · Individual
Functional Pathways Of Tennessee LLC
Operational/Managerial Control · Organization
Haji Medical Services, Pllc
Operational/Managerial Control · Organization
Hajimomenian, Amir
Operational/Managerial Control · Individual
Haynes, Susan
Corporate Director · Individual
Holder, Ian
Corporate Director · Individual
Myers, David
Corporate Officer · Individual
Ripley, Ronald
Corporate Director · Individual
Robison, Charles
Corporate Director · Individual
Smith, Lisa
Corporate Director · Individual
Taylor, Robert
Corporate Director · Individual
Unkle, Joseph
Corporate Officer · Individual
Wall, Alvin
Corporate Director · Individual
Westminster-Canterbury On Chesapeake Bay
Operational/Managerial Control · Organization
Whibley, Theresa
Corporate Director · Individual
Williams, Armistead
Corporate Director · Individual
Wong, George
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bay Pointe Rehabilitation And Nursing
Virginia Beach, VA
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Bayside Health & Rehabilitation Center
Virginia Beach, VA
1-star overall rating with 1-star inspections with $113,068 in total fines with 42 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Virginia Beach Healthcare And Rehab Center
Virginia Beach, VA
1-star overall rating with 1-star inspections with $131,313 in total fines with 38 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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