Birchwood Park Rehabilitation
340 Lynn Shores Drive, Virginia Beach, VA 23452
Birchwood Park Rehabilitation is a nursing home in Virginia Beach, Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionDecember 19, 2024 (1 year ago)
- Health citations since March 5, 2020114 (Virginia average 39)
- Fines in the past three years1, $131,178 in total
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of March 25, 2026
Fine
CMS changed the fine from December 19, 2024 from $130,094 to $131,178.
CMS update of February 25, 2026
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Fine
CMS changed the fine from December 19, 2024 from $127,257 to $130,094.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health citation
CMS changed citation F0657 from severity D to E. It is from the health inspection on December 19, 2024. Severity E: potential for more than minimal harm, pattern.
CMS update of June 25, 2025
Health citation
CMS removed citation F0661 from the health inspection on December 19, 2024.
Health citation
CMS removed citation F0623 from the health inspection on December 19, 2024.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on April 4, 2025
6 citationsCMS lists this as a complaint inspection.
Show the 6 citations
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0550 2 times since 2024.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0607 3 times since 2020.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0609 3 times since 2020.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0610 3 times since 2020.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0677 2 times since 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0698 2 times since 2024.
Health inspection on December 19, 2024
53 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
33 of 289 Virginia homes (11%) got a citation at the actual harm level in 2024.
CMS fine of $131,178 on December 19, 2024.
Show the 53 citations
Citation F0603. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS lists it as corrected on February 15, 2025.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0684 2 times since 2021.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0686 2 times since 2023.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0689 2 times since 2020.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on February 15, 2025.
Citation F0584. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0584 3 times since 2020.
Citation F0679. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on February 15, 2025.
Citation F0680. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure the activities program is directed by a qualified professional.
CMS lists it as corrected on February 15, 2025.
Citation F0839. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Employ staff that are licensed, certified, or registered in accordance with state laws.
CMS lists it as corrected on February 15, 2025.
Citation F0850. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Hire a qualified full-time social worker in a facility with more than 120 beds.
CMS lists it as corrected on February 15, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0880 2 times since 2021.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on February 15, 2025.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0641 2 times since 2020.
Citation F0645. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0645 2 times since 2021.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0656 2 times since 2020.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0657 3 times since 2020.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 14, 2025.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on May 14, 2025.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0755 2 times since 2020.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0756 2 times since 2020.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0761 2 times since 2020.
Citation F0835. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on February 15, 2025.
Citation F0940. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on February 15, 2025.
Citation F0941. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on February 15, 2025.
Citation F0942. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on February 15, 2025.
Citation F0944. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on February 15, 2025.
Citation F0946. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on February 15, 2025.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on February 15, 2025.
Citation F0949. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on February 15, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 14, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on May 14, 2025.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on February 15, 2025.
Citation F0560. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
CMS lists it as corrected on February 15, 2025.
Citation F0568. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
CMS lists it as corrected on February 15, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0580 2 times since 2021.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0583 2 times since 2021.
Citation F0586. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
CMS lists it as corrected on February 15, 2025.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on May 14, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 14, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on May 14, 2025.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0623 2 times since 2021.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on February 15, 2025.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on February 15, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on February 15, 2025.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on February 15, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on February 15, 2025.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on February 15, 2025.
Citation F0840. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0840 2 times since 2021.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on May 14, 2025.
CMS has cited this home for F0842 3 times since 2020.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 15, 2025.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0883 3 times since 2020.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 15, 2025.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on February 15, 2025.
CMS has cited this home for F0921 2 times since 2021.
Fire safety inspection on December 19, 2024
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on February 20, 2025.
Citation K0932. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on February 20, 2025.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 20, 2025.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on February 20, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 20, 2025.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 20, 2025.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on February 20, 2025.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of August 29, 2024
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Health inspection on April 15, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on May 30, 2024.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on April 2, 2024.
Health inspection on November 3, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0686. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 28, 2023.
Health inspection on September 30, 2021
28 citationsCMS lists this as a standard inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
7 of 289 Virginia homes (2%) got a citation at the immediate jeopardy level in 2021.
Show the 28 citations
Citation F0880. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 5, 2021.
Citation F0886. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Perform COVID19 testing on residents and staff.
CMS lists it as corrected on November 5, 2021.
Citation F0837. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
Citation F0840. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on November 5, 2021.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on November 5, 2021.
CMS has cited this home for F0925 2 times since 2020.
Citation F0622. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
CMS has cited this home for F0622 2 times since 2020.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
CMS has cited this home for F0625 2 times since 2020.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 5, 2021.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 5, 2021.
Citation F0727. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
CMS has cited this home for F0727 2 times since 2020.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on November 5, 2021.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on November 5, 2021.
Citation F0885. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Report COVID19 data to residents and families.
CMS lists it as corrected on November 5, 2021.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on November 5, 2021.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 5, 2021.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on November 5, 2021.
CMS has cited this home for F0582 2 times since 2020.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on November 5, 2021.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 5, 2021.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on November 5, 2021.
Citation F0626. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
CMS lists it as corrected on November 5, 2021.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on November 5, 2021.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 5, 2021.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on November 5, 2021.
Citation F0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS lists it as corrected on November 5, 2021.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on November 5, 2021.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on November 5, 2021.
Fire safety inspection on September 30, 2021
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation E0006. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on November 5, 2021.
Citation E0015. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on November 5, 2021.
CMS has cited this home for E0015 2 times since 2020.
Health inspection on March 5, 2020
24 citationsCMS lists this as a standard inspection.
Show the 24 citations
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0622. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0727. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 10, 2020.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on April 10, 2020.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 10, 2020.
Citation F0925. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on April 10, 2020.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on April 10, 2020.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 10, 2020.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 10, 2020.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 10, 2020.
Citation F0640. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on April 10, 2020.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 10, 2020.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 10, 2020.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 10, 2020.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 10, 2020.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 10, 2020.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 10, 2020.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on April 10, 2020.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 10, 2020.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 10, 2020.
Fire safety inspection on March 5, 2020
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on March 25, 2020.
Citation E0007. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Address patient/client population and determine types of services needed.
CMS lists it as corrected on April 10, 2020.
Citation E0015. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on April 10, 2020.
Citation E0018. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on April 10, 2020.
Citation E0020. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures including evacuation.
CMS lists it as corrected on April 10, 2020.
Citation E0023. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on April 10, 2020.
Citation E0026. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on April 10, 2020.
Citation E0030. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on April 10, 2020.
Citation E0032. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide primary/alternate means for communication.
CMS lists it as corrected on April 10, 2020.
Citation E0033. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish methods for sharing information.
CMS lists it as corrected on April 10, 2020.
Citation E0034. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide a means of sharing information on occupancy/needs.
CMS lists it as corrected on April 10, 2020.
Citation E0036. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on April 10, 2020.
Citation E0037. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on April 10, 2020.
Citation E0039. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on April 10, 2020.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (757) 340-6611
- Last standard health inspection
- December 19, 2024 (1 year ago)
- Certified beds
- 150
- Residents per day, on average
- 131.4
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Birchwood Park Rehabilitation and Nursing LLC
- Chain
- Eastern Healthcare Group
- Takes part in
- Medicare and Medicaid
More health citations than the Virginia average (114 vs 39).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- VA SNF OPERATIONS HOLDINGS LLC5% or greater direct ownership interest · 100% · since 01/31/2024
- JJ UNITED TR5% or greater indirect ownership interest · 50% · since 01/31/2024
Questions
When was Birchwood Park Rehabilitation last inspected?
CMS lists December 19, 2024 as the date of its most recent standard health inspection.
How many citations (violations) does Birchwood Park Rehabilitation have?
CMS lists 114 health citations since March 5, 2020. CMS also calls these deficiencies.
Has Birchwood Park Rehabilitation been fined?
CMS lists 1 fine in the past three years, $131,178 in total.
What is the CMS star rating of Birchwood Park Rehabilitation?
Its CMS overall star rating is 1 of 5.
Is Birchwood Park Rehabilitation a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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