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Home / Virginia / Virginia Beach

Birchwood Park Rehabilitation

340 Lynn Shores Drive, Virginia Beach, VA 23452 · Virginia Beach City County · (757) 340-6611

150 certified beds, about 136 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1984

CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 495150 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on December 19, 2024, inspectors cited 46 health deficiencies (the Virginia average is 14.3, the national average 9.2).

Of 114 health citations since March 2020, 7 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).

CMS lists 1 fine totaling $131,178 in the last three years; the largest was $131,178, and the latest is dated December 19, 2024.

Nurses and nurse aides worked 3.06 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.

63.6% of nursing staff left within the year CMS measured (Virginia average 48.1%).

CMS links it to Eastern Healthcare Group, an affiliated group of 18 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 114 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
2L
Actual harm
5G
0H
0I
Potential for more than minimal harm
58D
38E
11F
Potential for minimal harm
0A
0B
0C
April 4, 2025Complaint inspection · 6 citations
  1. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure that Residents are treated resident with respect and dignity for 1 Resident (#111) in a survey sample of 29 Residents.
  2. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to implement the abuse policy for reporting allegations of abuse for 1 Resident (#111) in a survey sample of 29 Residents.
  3. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility policy the facility staff failed to report allegations of abuse in a timely manner for 1 Resident (#111) in a survey sample of 29 Residents.
  4. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure allegations of abuse and neglect are thoroughly investigated for 1 Resident (#111) in a survey sample of 29 Residents.
  5. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observations, resident interviews, staff interview, and clinical record review the facility staff failed to provide needed oral care to a dependent resident receiving enteral feedings for 1 of 29 residents (Resident #123), in the survey sample.
  6. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for 2 of 29 residents (Resident 126 and Resident #128), in the survey sample.
December 19, 2024Standard inspection, Complaint inspection · 53 citations
  1. G
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    F603 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observations, Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff involuntarily secluded one (1) Resident (Resident #226) in a survey sample of 74 Residents, resulting in psychosocial harm.
  2. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent, assess, identify timely, and treat avoidable pressure ulcers resulting in harm for two Residents, (Resident #117, and Resident #379) in a survey sample of 74 Residents.
  3. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from accidents, hazards receive adequate supervision and assistance devices to prevent accidents, resulting in harm for two (2) Residents (#78 & 56) in a survey sample of 74 Residents. 1. For Resident #78 the facility staff failed to implement fall precautions for a Resident known to be a high fall risk resulting in Resident #78 sustaining a fractured hip after a fall from her wheelchair, this is harm. [...]
  4. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on a resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 74 residents (Resident #280), in the survey sample which resulted in harm.
  5. F
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain a safe, clean comfortable homelike environment for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of five Residents (Resident #226, #117, #91, #69, and #280) in a survey sample of 74 Residents, resulting in a Substandard Quality of Care.
  6. F
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an activities program to meet the needs and preferences of each resident to include the entire locked memory care unit and for four individual Residents (Resident #226, #117, #77, and #105) in a survey sample of 74 Residents, resulting in a Substandard Quality of care.
  7. F
    Ensure the activities program is directed by a qualified professional.
    F680 · Quality of Life and Care · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in Substandard Quality of Care.
  8. F
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    F839 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to employ a full time professional necessary to carry out the provisions of a licensed or certified Social worker in a 220 bed facility impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents.
  9. F
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    F850 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to maintain a qualified Social Worker in a 220 bed facility resulting in a Substandard Level of Care impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents.
  10. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an infection prevention and control program to include environmental concerns for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of four Residents (Resident #226, #117, #105, and #87) in a survey sample of 74 Residents.
  11. E
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    F565 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on interview, observation, and facility documentation the facility staff failed to promptly act upon the grievances and recommendations of regularly attending Resident council members.
  12. E
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission or shortly thereafter for 4 Residents (Residents #49, #24, #47, and #80) in a sample of 74 residents.
  13. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to develop and implement a comprehensive care plan for 4 Residents (Residents #117, #379, #91 and #39) in a survey sample of 74 Residents.
  14. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observation, interview, clinical record review and facility documentation, the facility staff failed to review and revise a care plan for two (2) Residents (#'s 78 and 105) in a survey sample of 74 Residents.
  15. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to four (4) dependant Residents (Resident #226, #117, #18, and #48) in a survey sample of 74 Residents.
  16. E
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on a resident interview, staff interview, and clinical record review, the facility staff failed to have ongoing records of communication between the facility and the dialysis center for one (1) of 74 residents (Resident 13), in the survey sample.
  17. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observation, interview and clinical record review the facility staff failed to ensure medications were acquired and available to meet the needs of one (1) of 74 residents in the survey sample, Resident #327.
  18. E
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure pharmacy recommendations were obtained and acted upon for five Residents (Residents #117, #226, #51, #33 and #78), in the survey sample of 74 Residents.
  19. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to label with expiration date and store medications appropriately for 3 Residents ( Resident #8, #74 and #103) and for the facility stock multi use vial medications, in a survey sample of 74 residents, and the facility failed to ensure that narcotic medications no longer in use by residents were properly locked away, accounted for and disposed of in a timely manner.
  20. E
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of the residents who resided on the Memory unit were available.
  21. E
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    F940 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview and facility documentation the facility failed to maintain a training program for all new and existing staff based on the facility's assessment.
  22. E
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    F941 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview, and facility documentation, the facility failed to ensure that all direct care staff complete mandatory Effective Communication training.
  23. E
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    F942 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview, and facility documentation, the facility failed to ensure that all staff members are educated in the rights of the residents and responsibilities of the facility.
  24. E
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    F944 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview and facility documents the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement
  25. E
    Provide training in compliance and ethics.
    F946 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Compliance and Ethics.
  26. E
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurse's Aides (CNA) completed the mandatory twelve (12) hours of education each year.
  27. E
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    F949 · Administration · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview, and facility documentation, the facility failed to ensure that all staff members had completed mandatory Behavioral Health Training.
  28. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure there was a self-administration of medication assessment prior to leaving medications at the bedside for one (1) of 74 residents (Resident #91) in survey sample.
  29. D
    Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
    F560 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to afford a resident the ability to refuse a transfer affecting one (1) resident (Resident #226) in a survey sample of 74 Residents.
  30. D
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    F568 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on a resident personal funds review, the resident interview, staff interview and facility document review, the facility staff failed to ensure that one (1) resident out of 74 residents in the survey sample, Resident #24, was afforded the right to receive quarterly statements.
  31. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on staff interview, clinical record review, the facility staff failed to ensure the physician was notified of pertinent information regarding two (2) residents (Resident # 327 and # 326) in a survey sample of 74 residents.
  32. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to maintain the confidentiality of medical records for two residents (Residents #'s 39, 74) in a survey sample of 74 residents.
  33. D
    Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
    F586 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on resident interview and staff interview, the facility staff prohibited and discouraged a resident from communicating with the state surveyor for one (1) of 74 residents (Resident #226), in the survey sample.
  34. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to report an accident hazard which resulted in bodily harm, to the State Survey and Certification Agency for one (1) or 74 residents, (Resident #56) in the survey summary.
  35. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for one (1) resident (Resident #32) in the sample of 74 residents.
  36. D
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    F636 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview, facility documentation review, and clinical record review the facility staff failed to complete a Comprehensive 14 day full admission assessment and submit it to CMS (Centers for Medicare and Medicaid Services) in a timely manner for one (1) Resident (Residents #117) in a survey sample of 74 Residents.
  37. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interview, facility documentation review, and clinical record review the facility staff failed to complete a correct Significant Change full MDS assessment for two (2) Residents (Residents #117 & #105) in a survey sample of 74 Residents.
  38. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow the professional standards of quality for four (4)residents (Resident #'s 326, 91, 128 and 48) in survey sample of 74 residents.
  39. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent a significant weight loss and dehydration for one (1) Resident (Residents #117) in a survey sample of 74 Residents.
  40. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents are free from significant medication errors for three (3) Residents (378, 109, and 327) in a survey sample of 74 Residents.
  41. D
    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.
    F840 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on staff interviews, the facility staff failed to obtain agreements for dental services and audiology services.
  42. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain accurate and readily accessible medical records for one (1) resident (Resident # 327) in a sample size of 74 residents.
  43. D
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on Observation, staff interview, clinical record review, and facility document review the facility staff failed to provide services for two Residents receiving hospice care (Resident #117, and #78) in a survey sample of 74 Residents.
  44. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on clinical record review and staff interviews, the facility staff failed to administer the influenza vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of 74 Residents.
  45. D
    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.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on clinical record review and staff interviews, the facility staff failed to administer the Covid-19 vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of 74 Residents.
  46. D
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to ensure functional, and sanitary environment for the residents, staff and the public.
  47. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview clinical record review and facility documentation the facility staff failed to ensure residents receive treatment and care in accordance with professional standards of practice for one (1) Resident (#376) in a survey sample of 74 Residents, which resulted in harm.
  48. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased a clinical record review and staff interview the facility staff failed to accurately code the Minimum Data Set (MDS) assessment and trackings for 1 of 29 residents (Resident #123), in the survey sample.
  49. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure that Residents are treated resident with respect and dignity for 1 Resident (#111) in a survey sample of 29 Residents.
  50. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were transported to outside medical appointments, for two (2) Residents (#'s 378 and 381) in a survey sample of 74 Residents.
  51. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to implement the abuse policy for reporting allegations of abuse for 1 Resident (#111) in a survey sample of 29 Residents.
  52. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 14, 2025
    Inspectors wroteBased on interview, clinical record review and facility documentation the facility staff failed to ensure allegations of abuse and neglect are thoroughly investigated for 1 Resident (#111) in a survey sample of 29 Residents.
  53. D
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    F661 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2025
    Inspectors wroteBased on a clinical record review and staff interview the facility staff failed to provide a resident with as much discharge information as possible at the time of discharge for one (1) of 74 residents (Resident #278), in the survey sample.
April 15, 2024Complaint inspection · 2 citations
  1. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 30, 2024
    Inspectors wroteBased on interview, clinical record review and facility documentation, the facility staff failed to develop and implement a baseline care plan that includes the instructions needed to provide immediate and effective and person-centered care of the resident, for 1 Resident (#1) in a survey sample of 5 Residents.
  2. D
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interviews, clinical record review, and facility documentation, the facility staff failed to provide nutrition in a form designed to meet the individual needs of the Resident, for 1 Resident (#1) in a survey sample of 5 Residents.
November 3, 2023Complaint inspection · 1 citation
  1. E
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 28, 2023
    Inspectors wroteBased on staff interviews, clinical record review, and facility documentation review, the facility staff failed to consistently assess, track, monitor, and treat a stage II pressure ulcer timely for 1 of 5 residents (Resident #5) in the survey sample.
September 30, 2021Standard inspection · 28 citations
  1. L
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · Immediate jeopardy to resident health or safety, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wrote9. The facility staff failed to ensure infections control measures were consistently implemented to prevent the development and/or transmission of a communicable disease (COVID-19), and other infectious diseases by not wearing the required N95 masks or improperly wearing the required facial coverings. A. On 09/20/21 at approximately 7:05 p.m., upon facility entrance Dietary Staff member #3 was observed sitting in a chair in the dining room with no facial covering on. Sitting less than four feet near him was dietary staff member #4 with no facial covering. They appeared to be playing a video game. The surveyor was screened at the entrance then entered into the dining area where the two facility staff were seen. She asked Dietary staff member #4 where was his mask. He stated, that he didn't think he needed to wear his mask because he wasn't around residents. B. [...]
  2. L
    Perform COVID19 testing on residents and staff.
    F886 · Infection Control · Immediate jeopardy to resident health or safety, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observations, resident interviews, staff interviews and review of facility documentation, the facility's staff failed to adhere to the following Centers for Disease Control and Prevention (CDC) guidance to have an established and effective COVID-19 testing program in place during a major SARS-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalizations and deaths which constituted Immediate Jeapardy at a scope and severity level of 4 widespread (L): The facility failed to ascertain the vaccination status of all Healthcare Personnel (HCP) to determine who was unvaccinated and required expanded screening testing and the facility failed to conduct unvaccinated HCP testing for SARS-CoV-2 infection based on the level of community transmission (high/Red). The facility was broad based testing two times a week. [...]
  3. F
    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
    F837 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on facility policy, and staff interview, the facility staff failed to have a governing body of persons to ensure policies regarding the management and operations of the facility during COVID-19 outbreak.
  4. F
    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.
    F838 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteThe facility staff failed to conduct and document a facility wide assessment to determine what resources were necessary to assist in the prevention of the spread of COVID -19.
  5. F
    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.
    F840 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteThe facility staff failed to utilize outside resource to assist in the prevention of the spread of COVID -19 which resulted in hospitalizations and deaths.
  6. F
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on deficiencies determined during this survey the QAA (Quality Assessment and Assurance) and Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement corrective plans of action and monitoring to ensure the necessary systems were in place and correct identified quality deficiencies during a major outbreak of SARS-CoV-2 in the facility beginning 08/28/2021. Immediate Jeopardy to the resident health and safety was identified on 09/23/21 in the area of Infection Control at (F-880 and F886) at a scope and severely level 4 Widespread (L) which constituted Substandard Quality of Care.
  7. F
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observations, record review, and staff interview, the facility staff failed to maintain an effective pest control program.
  8. E
    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.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan for 3 out of 42 residents (Resident #33, Resident #42 and Resident #21) after being transferred to the hospital.
  9. E
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on staff interview, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for 4 of 42 resident's (Resident #33, Resident #42, Resident #21 and Resident #92) after being transferred to the hospital.
  10. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on clinical record review, facility document review and staff interviews the facility staff failed to revise a care plan to include an indwelling foley catheter upon re-admission for 1 or 42 residents in the survey sample, Resident #21.
  11. E
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on clinical record review, facility document review and staff interviews the facility staff failed to obtain physician orders upon re-admission for an indwelling foley catheter for 1 or 42 residents in the survey sample, Resident #21.
  12. E
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on staff interviews and facility information, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.
  13. E
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on information gleamed during the Antibiotic Stewardship task, staff interview, and clinical record review, the facility's staff failed to have a system to ensure that an antibiotic was prescribed based on laboratory results and/or clinical signs and symptoms of true infections when prescribing an antibiotic for 1 of 42 residents (Resident #75), in the survey sample.
  14. E
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the immunization and the administration or the refusal of or medical contraindications to vaccines for 3 of 42 residents (Resident #50, 24 and 5 ), in the survey sample.
  15. E
    Report COVID19 data to residents and families.
    F885 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on resident interview, clinical record review, and review of facility documents, the facility staff failed to provide cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.
  16. E
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observations, record reviews and staff interviews, the facility staff failed to ensure resident rooms who were identified as COVID-19 positive (Resident #16, #27 and #53) were cleaned and sanitized.
  17. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to notify the physician and/or responsible party of missed COVID-19 vaccination for Resident #24 and failed to notify the resident's representative of weight loss for Resident #22 in a survey sample of 42 residents.
  18. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 2 residents (Resident #5 and Resident #80) in the survey sample.
  19. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, the facility's staff failed to ensure personal privacy of a resident's physical body during personal care for 1 of 42 residents (Resident #90), in the survey sample.
  20. D
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide reasonable care for the protection of residents' property from loss for 2 of 42 residents (Resident #7 and #22) in the survey sample.
  21. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for two residents (Resident #22, #21) in the sample of 42 residents.
  22. D
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    F626 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on a closed record review, staff interviews, and a complaint investigation, the facility staff failed to re-admit one resident Resident # 92 in the survey sample of 42 residents after they were hospitalized .
  23. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on clinical record review, facility document review and staff interviews the facility staff failed to initiate a Level II Preadmission Screening and Annual Resident Review (PASARR) after a positive Level I PASARR screening was completed for 2 of 42 residents in the survey sample, Resident #21 and Resident #71.
  24. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to monitor daily weights per physician's orders for 1 of 42 residents (Resident #22) in the survey sample.
  25. D
    Assist a resident in gaining access to vision and hearing services.
    F685 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain assistive devices to include hearing aids and dentures for 1 of 42 residents (Resident #22) in the survey sample. Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. [...]
  26. D
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    F712 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on record review and staff interviews the facility staff failed to provide physician services for two residents in the survey sample (Residents #28 and #83) of 42 residents.
  27. D
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on extended survey task, staff interview and documentation review the facility staff failed to ensure 3 out of 3 Certified Nursing Assistant (CNA) received their required 12 hours of mandatory annual competencies and 1 out of 3 CNA's completed her mandatory Dementia training.
  28. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 5, 2021
    Inspectors wroteBased on a clinical record review, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to ensure a complete and accurate clinical record for 2 of 42 residents in the survey sample, Resident #8 and Resident #93.
March 5, 2020Standard inspection · 24 citations
  1. E
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on clinical record review, staff interviews and review of facility documentation, the facility staff failed to implement the advance directive policy by not sending a resident's advance directive to the receiving hospital, and/or provide acknowledgement that allowed an opportunity to formulate an advance directive for 3 of 57 residents (#82, #63 and #109) in the survey sample.
  2. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure a homelike environment on 3 units.
  3. E
    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.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to send the comprehensive care plan goals upon transfer to the hospital for 4 out of 57 residents in the survey sample, Residents #119, #53, #82, and #21.
  4. E
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on clinical record review, staff interviews and facility documentation review, the facility staff failed to issue a bedhold notice to the resident or resident representative at time of transfer to the hospital for 3 of 57 Residents (#89, #82 and #21) in the survey sample.
  5. E
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview and information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week potentially affecting all residents in the facility.
  6. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications for 4 of 57 residents (Residents #22, #37, #168 and #418), in a survey sample.
  7. E
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure monthly medication reviews were readily available for review for 3 residents (Residents #21, #61, #71) and to ensure the physician reviewed pharmacy recommendations for 1 resident (Resident #112) of 57 residents in the survey sample.
  8. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on general observations of the nursing facility and staff interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and stored according to manufacture guidelines in 3 out of 5 medication carts
  9. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observations, staff interviews and facility document review the facility staff failed to store and prepare food in accordance with professional standards for food service safety.
  10. E
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observations, staff interviews and facility document review the facility staff failed to maintain an effective pest control program.
  11. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview, clinical record review and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #3 and #87) in the survey sample.
  12. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observation, staff interviews and facility document review, the facility staff failed to implement their Abuse Investigation and Reporting Policy after a witnessed allegation of abuse/mistreatment for 1 of 57 Residents in the survey sample, Resident #64.
  13. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observation, staff interviews and facility document review the facility staff failed to report an allegation of abuse/mistreatment to the State Survey Agency and Adult Protective Services within the required time frame for 1 of 57 Residents in the survey sample, Resident #64.
  14. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observation, staff interviews and facility document review the facility staff failed to thoroughly investigate a witnessed allegation of abuse/mistreatment for 1 of 57 Residents in the survey sample, Resident #64.
  15. D
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    F640 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a discharge assessment (MDS) was submitted for 2 of 57 residents (Residents #91 and Resident #1), in the survey sample.
  16. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on clinical record review and staff interviews, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 57 residents (Resident #76), in the survey sample.
  17. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to develop a person centered care plan to include depression and anxiety for 1 of 57 residents in the survey sample, Resident #100.
  18. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on clinical record review staff interview and review of facility documentation, the facility staff failed to revise the care plan for 1 of 57 residents (Resident #96) in the survey sample.
  19. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on record review and staff interview the facility staff failed to provide supervision for one resident (Resident #167) in the survey sample of 57 to prevent an elopement.
  20. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on family interview, medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 57 Residents in the survey sample, Resident #77, was free from unnecessary medications.
  21. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview, clinical record review and facility documentation review the facility staff failed to indicate the duration for an as needed psychotropic medication for 1 resident (Resident #100) and failed to perform a gradual dose reduction for 1 resident (Resident #20) of 57 residents in the survey sample.
  22. D
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to prepare food by methods that conserves nutritive value and provide and present food that is palatable and attractive for 1 of 57 residents (Resident #89) in the survey sample.
  23. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on staff interview, clinical record review, review of facility documentation, and in the course of a complaint investigation, the facility failed to maintain complete and accurately documented medical records for 2 out of 57 resident records reviewed, Resident #53 and Resident #77.
  24. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 10, 2020
    Inspectors wroteBased on family interview, medical record review, staff interviews and facility document review the facility staff failed to follow the informed consent for the administration of the influenza vaccine for 1 of 57 Residents in the survey sample, Resident #77.

Fire safety inspections

23 fire safety citations on file: 7 on December 19, 2024, 2 on September 30, 2021, 14 on March 5, 2020.

Every fire safety citation23 citations
  1. F
    Have a battery powered remote alarm panel in a location accessible by operating personnel.
    K 916 · December 19, 2024 · Corrected (the home has a date of correction)
  2. F
    Meet other general requirements.
    K 932 · December 19, 2024 · Waiver
  3. E
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · December 19, 2024 · Corrected (the home has a date of correction)
  4. D
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · December 19, 2024 · Corrected (the home has a date of correction)
  5. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · December 19, 2024 · Corrected (the home has a date of correction)
  6. D
    Have simulated fire drills held at unexpected times.
    K 712 · December 19, 2024 · Corrected (the home has a date of correction)
  7. D
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · December 19, 2024 · Corrected (the home has a date of correction)
  8. C
    Conduct risk assessment and an All-Hazards approach.
    E 6 · September 30, 2021 · Corrected (the home has a date of correction)
  9. C
    Address subsistence needs for staff and patients.
    E 15 · September 30, 2021 · Corrected (the home has a date of correction)
  10. D
    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
    K 741 · March 5, 2020 · Corrected (the home has a date of correction)
  11. C
    Address patient/client population and determine types of services needed.
    E 7 · March 5, 2020 · Corrected (the home has a date of correction)
  12. C
    Address subsistence needs for staff and patients.
    E 15 · March 5, 2020 · Corrected (the home has a date of correction)
  13. C
    Establish procedures for tracking staff and patients during an emergency.
    E 18 · March 5, 2020 · Corrected (the home has a date of correction)
  14. C
    Establish policies and procedures including evacuation.
    E 20 · March 5, 2020 · Corrected (the home has a date of correction)
  15. C
    Establish policies and procedures for medical documentation.
    E 23 · March 5, 2020 · Corrected (the home has a date of correction)
  16. C
    Establish roles under a Waiver declared by secretary.
    E 26 · March 5, 2020 · Corrected (the home has a date of correction)
  17. C
    List the names and contact information of those in the facility.
    E 30 · March 5, 2020 · Corrected (the home has a date of correction)
  18. C
    Provide primary/alternate means for communication.
    E 32 · March 5, 2020 · Corrected (the home has a date of correction)
  19. C
    Establish methods for sharing information.
    E 33 · March 5, 2020 · Corrected (the home has a date of correction)
  20. C
    Provide a means of sharing information on occupancy/needs.
    E 34 · March 5, 2020 · Corrected (the home has a date of correction)
  21. C
    Establish emergency prep training and testing.
    E 36 · March 5, 2020 · Corrected (the home has a date of correction)
  22. C
    Establish staff and initial training requirements.
    E 37 · March 5, 2020 · Corrected (the home has a date of correction)
  23. C
    Conduct testing and exercise requirements.
    E 39 · March 5, 2020 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
December 19, 2024Fine $131,178

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeVirginiaUnited States
All nursing staff (RN, LPN and aides)3.063.763.86
Registered nurses0.560.690.69
All nursing staff on weekends2.453.293.42
Nurse aides1.51
Licensed practical nurses0.99
Nursing staff turnover (share who left in a year)63.6%48.1%45.8%
Registered nurse turnover55.0%48.2%42.9%
Administrators who left2

CMS expects 4.03 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.30 on weekdays and 2.45 on weekends, 26% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.04 in April to June 2025 to 3.06 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.060.563.302.45 8.0%0 of 90136
Oct to Dec 20253.290.513.512.71 0.0%0 of 92140
Jul to Sep 20253.410.523.622.90 0.5%0 of 92140
Apr to Jun 20253.040.593.252.52 6.2%0 of 91137
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Virginia, Jan to Mar 20263.580.563.763.125.7%0.2% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeVirginiaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
6.414.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.61.61.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
5.93.63.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.51.31.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
6.115.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
5.84.74.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
9.714.215.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
27.922.323.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
16.911.512.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.81.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.11.51.8

Owners and operators

Legal business name: BIRCHWOOD PARK REHABILITATION AND NURSING LLC. CMS links this home to Eastern Healthcare Group, a group of 18 nursing homes averaging 1.5 stars overall.

NameRoleTypeShareSince
VA SNF Operations Holdings LLC5% or greater direct ownership interestOrganization100%01/31/2024
Jj United Tr5% or greater indirect ownership interestOrganization50%01/31/2024
Shapiro, AkivaW-2 managing employeeIndividual03/01/2022
Whitley, NakiaW-2 managing employeeIndividual03/27/2023
Shapiro, AkivaCorporate officerIndividual03/01/2022

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 26 problems in this area, most recently on April 4, 2025: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 18 problems in this area, most recently on December 19, 2024: "PASARR screening for Mental disorders or Intellectual Disabilities"
  3. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 16 problems in this area, most recently on April 4, 2025: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  4. Who is the administrator and director of nursing, and how long have they been in the job?Inspectors cited 14 problems in this area, most recently on December 19, 2024: "Employ staff that are licensed, certified, or registered in accordance with state laws."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.45 hours per resident per day, below the Virginia average of 3.29.
  6. How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.

Other nursing homes nearby

Virginia contacts for a concern about a nursing home

These are the official offices in Virginia. NursingHomeClear cannot take or act on complaints.

Common questions

What is Birchwood Park Rehabilitation's Medicare star rating?
CMS rates Birchwood Park Rehabilitation 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Birchwood Park Rehabilitation get at its last inspection?
46 health deficiencies at the standard inspection on December 19, 2024. The Virginia average is 14.3.
Has Birchwood Park Rehabilitation been fined?
Yes. CMS lists 1 fine totaling $131,178 in the last three years.
Does Birchwood Park Rehabilitation accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Birchwood Park Rehabilitation?
CMS lists 5 owners and managers, and links the home to Eastern Healthcare Group. Legal business name: BIRCHWOOD PARK REHABILITATION AND NURSING LLC.

Sources

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