12 health deficiencies
Top issue: Infection Control (5 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Williamsburg, VA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5500 Williamsburg Landing Dr, Williamsburg, VA
(757) 258-2196
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
73
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-11-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.95
Registered nurse staffing
LPN hours / resident day
1.15
Licensed practical nurse staffing
Aide hours / resident day
2.50
Nurse aide staffing
Weekend hours
4.08
Weekend nurse staffing
RN turnover
81%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.4
1.2 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
91.2%
7.9 pts worse
|
93.4%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 72.7% |
94.0%
21.3 pts worse
|
95.5%
22.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.8% |
3.6%
5.2 pts worse
|
3.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.7%
3.1 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
20.2%
10.2 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
15.0%
10.7 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.1% |
17.5%
5.6 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
15.7%
1.4 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
1.6%
3.9 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
22.2%
2.7 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.2%
2.4 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
74.6%
3 pts worse
|
81.7%
10.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
11.7%
0.4 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.1% |
73.6%
7.5 pts better
|
79.7%
1.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
22.0%
3 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (5 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (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)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Meet fire sprinkler requirement for tall buildings.
Corrected 2023-01-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-16
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-09-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-09-05
Inspection history
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-20
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-09-20
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-09-20
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-09-20
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 2022-09-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-20
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 2022-09-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-20
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-20
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-09-20
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 2022-09-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-07-12
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-12
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-07-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-07-12
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-07-12
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-07-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-07-12
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 2019-07-12
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-07-12
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-07-12
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-07-12
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-07-12
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2019-07-12
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-07-12
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-05-27
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-05-27
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 2018-05-20
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-05-27
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 2018-05-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-05-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-05-15
Penalties and ownership
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Nearby options
Williamsburg, VA
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Williamsburg, VA
3-star overall rating with 4-star inspections with 5 recent health deficiencies
Williamsburg, VA
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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