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
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
0.95
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.09
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
81%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
4,263
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.29% · Performance 21.80% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.74
Baseline 6.08% · Performance 6.72% · Measure score 3.74 · Achievement 3.74 · Improvement 0
Total nurse turnover
5.97
Baseline 59.09% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 5.28
Adjusted total nurse staffing
6.55
Baseline 4.08 hours · Performance 4.94 hours · Measure score 6.55 · Achievement 6.55 · Improvement 4.57
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.32% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 8.25% · Lower 95% interval 7.54% |
| Discharge to community | 61.62% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 182 · Observed rate 61.54% · Lower 95% interval 54.81% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 125 · Denominator 130 |
| Falls with major injury | 2.31% |
0.77%
1.5 pts worse
|
Numerator 3 · Denominator 130 |
| Discharge self-care score | 29.59% |
53.69%
24.1 pts worse
|
Numerator 29 · Denominator 98 |
| Discharge mobility score | 16.33% |
50.94%
34.6 pts worse
|
Numerator 16 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 4 · Denominator 130 · Adjusted rate 4.41% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 4.92% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 8.02% |
8.2%
0.2 pts worse
|
Numerator 34 · Denominator 424 |
| Staff flu vaccination coverage | 17.88% |
42%
24.1 pts worse
|
Numerator 91 · Denominator 509 |
| Discharge function score | 17.35% |
56.45%
39.1 pts worse
|
Numerator 17 · Denominator 98 |
| Transfer of health information to provider | 76.67% |
95.95%
19.3 pts worse
|
Numerator 23 · Denominator 30 |
| Transfer of health information to patient | 98.65% |
96.28%
2.4 pts better
|
Numerator 73 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 51.95% |
25.2%
26.8 pts better
|
Numerator 40 · Denominator 77 |
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 · Adjusted 1.7 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 2.6 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 89.7% · Q2 86.2% · Q3 80.0% · Q4 76.9% · 4Q avg 83.3% |
| 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 · 4Q avg 72.7% |
| 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 · Q1 3.4% · Q2 10.3% · Q3 10.0% · Q4 11.5% · 4Q avg 8.8% · 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 | 2.6% |
5.7%
3.1 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.6% |
| 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 · Q1 13.6% · Q4 10.0% · 4Q avg 10.0% |
| 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 · 4Q avg 4.3% · 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 | 23.1% |
17.5%
5.6 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · Used in QM five-star |
| 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 · Q1 27.3% · 4Q avg 17.1% · Used in QM five-star |
| 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 · 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 a urinary tract infection | 5.5% |
1.6%
3.9 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star |
| 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 · Q1 30.7% · Q2 33.3% · Q3 19.1% · Q4 14.5% · 4Q avg 24.9% |
| 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 · Q1 5.4% · Q2 2.8% · Q3 2.5% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| 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 · Q1 78.9% · Q2 75.0% · Q3 68.4% · Q4 64.5% · 4Q avg 71.6% |
| 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 · Adjusted 12.1% · Observed 10.0% · Expected 9.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 81.1% |
| 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 · Adjusted 25.0% · Observed 18.5% · Expected 17.6% · Used in QM five-star |
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
Jump out