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Deep Creek Health & Rehabilitation Inspection Report, Violations & Safety Grade (CHESAPEAKE, Virginia)

1017 GEORGE WASHINGTON HIGHWAY NORTH, CHESAPEAKE, Virginia 23323

Phone: 7574855500

CMS Overall:3/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Chesapeake City

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health3/5

StaffingN/A

Quality3/5

Nurse Staffing Check

Metric	This Facility	Virginia Avg	Difference
RN Hours per Resident per Day	0.00	0.71	-0.71
Total Nurse Hours per Resident per Day	0.00	3.88	-3.88
CMS Staffing Rating	N/A	2.5/5	-
Nursing Staff Turnover	68.0%	47.5%	-

Health Citation History

44 health citations on record

Date	Category	Description	Severity
2025-09-19	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2025-09-19	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	F – Moderate Harm Potential
2025-09-19	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	E – Moderate Harm Potential
2025-09-19	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	D – Moderate Harm Potential
2025-09-19	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2025-09-19	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2025-09-19	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	E – Moderate Harm Potential
2025-09-19	Administration Deficiencies	Administer the facility in a manner that enables it to use its resources effectively and efficiently.	E – Moderate Harm Potential
2025-09-19	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-11-16	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2021-07-22	Resident Assessment and Care Planning Deficiencies	Assure that each resident’s assessment is updated at least once every 3 months.	E – Moderate Harm Potential
2021-07-22	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	E – Moderate Harm Potential
2021-07-22	Nursing and Physician Services Deficiencies	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.	E – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.	D – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	D – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	D – Moderate Harm Potential
2021-07-22	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2021-07-22	Resident Assessment and Care Planning Deficiencies	Assess the resident when there is a significant change in condition	D – Moderate Harm Potential
2021-07-22	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2021-07-22	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2021-07-22	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2021-07-22	Pharmacy Service Deficiencies	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.	D – Moderate Harm Potential
2021-07-22	Nutrition and Dietary Deficiencies	Dispose of garbage and refuse properly.	D – Moderate Harm Potential
2021-07-22	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	D – Moderate Harm Potential
2019-04-16	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2019-04-16	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	E – Moderate Harm Potential
2019-04-16	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2019-04-16	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	E – Moderate Harm Potential
2019-04-16	Nursing and Physician Services Deficiencies	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.	E – Moderate Harm Potential
2019-04-16	Administration Deficiencies	Provide timely, quality laboratory services/tests to meet the needs of residents.	E – Moderate Harm Potential
2019-04-16	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	D – Moderate Harm Potential
2019-04-16	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2019-04-16	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2019-04-16	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2019-04-16	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2019-04-16	Quality of Life and Care Deficiencies	Provide appropriate foot care.	D – Moderate Harm Potential
2019-04-16	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential
2019-04-16	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2019-04-16	Nutrition and Dietary Deficiencies	Provide special eating equipment and utensils for residents who need them and appropriate assistance.	D – Moderate Harm Potential
2019-04-16	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2019-04-16	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	B – Minimal Harm Potential

Fire Safety Citation History

43 fire safety citations on record

Date	Category	Description	Severity
2025-09-19	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	F – Moderate Harm Potential
2025-09-19	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2025-09-19	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2025-09-19	Smoke Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2025-09-19	Construction Deficiencies	Meet other general requirements.	D – Moderate Harm Potential
2025-09-19	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential
2025-09-19	Smoke Deficiencies	Have properly installed hallway dispensers for alcohol-based hand rub.	D – Moderate Harm Potential
2025-09-19	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	D – Moderate Harm Potential
2025-09-19	Emergency Preparedness Deficiencies	Provide a means of sharing information on occupancy/needs.	C – Minimal Harm Potential
2025-09-19	Emergency Preparedness Deficiencies	Provide family notifications of emergency plan.	C – Minimal Harm Potential
2021-07-22	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	D – Moderate Harm Potential
2021-07-22	Smoke Deficiencies	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	D – Moderate Harm Potential
2021-07-22	Miscellaneous Deficiencies	Meet fire sprinkler requirement for tall buildings.	D – Moderate Harm Potential
2021-07-22	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper power supply for life support equipment.	D – Moderate Harm Potential
2021-07-22	Emergency Preparedness Deficiencies	Conduct risk assessment and an All-Hazards approach.	C – Minimal Harm Potential
2021-07-22	Emergency Preparedness Deficiencies	Establish emergency prep training and testing.	C – Minimal Harm Potential
2021-07-22	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential
2019-04-16	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2019-04-16	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2019-04-16	Construction Deficiencies	Meet other general requirements.	E – Moderate Harm Potential
2019-04-16	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	E – Moderate Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Address patient/client population and determine types of services needed.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Include a process for Emergency Preparedness collaboration.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Develop Emergency Preparedness policies and procedures.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish procedures for tracking staff and patients during an emergency.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish policies and procedures including evacuation.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish policies and procedures for sheltering.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish policies and procedures for medical documentation.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish policies and procedures for volunteers.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Create arrangements with other facilities to receive patients.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish roles under a Waiver declared by secretary.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Develop a communication plan.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	List the names and contact information of those in the facility.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Provide emergency officials' contact information.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish methods for sharing information.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Provide a means of sharing information on occupancy/needs.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Provide family notifications of emergency plan.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish emergency prep training and testing.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	C – Minimal Harm Potential
2019-04-16	Emergency Preparedness Deficiencies	Implement emergency and standby power systems.	C – Minimal Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the CHESAPEAKE area at no cost.

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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

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