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Nursing Home Inspect > Virginia > Virginia Beach City Data as of October 2024

    Birchwood Park Rehabilitation

    For profit - Limited Liability company  ·  340 Lynn Shores Drive, Virginia Beach, VA 23452  ·  See home’s Medicare page

    Inspections Delayed
    The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 9 to 15 months.
    Affiliated With Eastern Healthcare Group
    People or companies with an ownership interest in or managerial control of this home, according to CMS data.
    2.96
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 3.7
    61.2%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 52.1%
    150
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    140
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    Va Snf Operations Holdings Llc (100%)
    Indirect owners
    Jj United Tr
    Ydi Eastern Holdco Llc
    Ydi Irrevocable Trust
    Managerial control
    No information available
    Managing employee(s)
    Akiva Shapiro since Mar, 2022
    Nakia Whitley since Mar, 2023

    Inspection Reports

    67

    total deficiencies

    6

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    Sep 30, 2021
    Standard report
    28 deficiencies
    (5 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to L
    L
    Full report
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Many people affected
    Seriousness
    L
    Infection Control Deficiency — F0886
    Failure to: Perform COVID19 testing on residents and staff.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Many people affected
    Seriousness
    L
    Administration Deficiency — F0837
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0838
    Failure to: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0840
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Environmental Deficiency — F0925
    Failure to: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0727
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0881
    Failure to: Implement a program that monitors antibiotic use.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0883
    Failure to: Develop and implement policies and procedures for flu and pneumonia vaccinations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0885
    Failure to: Report COVID19 data to residents and families.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Environmental Deficiency — F0921
    Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0582
    Failure to: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0583
    Failure to: Keep residents' personal and medical records private and confidential.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0584
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0626
    Failure to: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0645
    Failure to: PASARR screening for Mental disorders or Intellectual Disabilities
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0685
    Failure to: Assist a resident in gaining access to vision and hearing services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0712
    Failure to: Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Mar 5, 2020
    Standard report
    24 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to E
    E
    Full report
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0727
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0755
    Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0756
    Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Environmental Deficiency — F0925
    Failure to: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0578
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0584
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0640
    Failure to: Encode each resident's assessment data and transmit these data to the State within 7 days of assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0757
    Failure to: Ensure each resident's drug regimen must be free from unnecessary drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0804
    Failure to: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0883
    Failure to: Develop and implement policies and procedures for flu and pneumonia vaccinations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0582
    Failure to: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
    Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Apr 5, 2019
    Standard report
    15 deficiencies
    B

     to F
    F
    Full report
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0645
    Failure to: PASARR screening for Mental disorders or Intellectual Disabilities
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0550
    Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0582
    Failure to: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0583
    Failure to: Keep residents' personal and medical records private and confidential.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
    Failure to: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0770
    Failure to: Provide timely, quality laboratory services/tests to meet the needs of residents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0814
    Failure to: Dispose of garbage and refuse properly.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Environmental Deficiency — F0924
    Failure to: Put firmly secured handrails on each side of hallways.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Some people affected
    Seriousness
    B

    Penalties

    $650

    total fines

    A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
    Nov 15, 2021
    $650 fine
    No corresponding inspection report.