Staffing
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.56 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
Also known publicly as Birchwood Park Rehabilitation and Nursing
VIRGINIA BEACH, VA
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 1-star staffing rating for this facility.
RN staffing was 0.56 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Dec 19, 2024 cited 25 deficiencies.
View inspection evidenceCMS-published records list 13 ownership or control parties.
CMS records show an ownership change effective March 2022.
View ownership evidenceCMS groups this facility with a chain covering 18 facilities across 1 states or territories.
View chain evidenceCMS records show a $131,178 fine in the loaded enforcement dataset.
View enforcement evidence →Ownership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
18 currently connected nursing homes share this CMS organization identity with YDI IRREVOCABLE TRUST.
These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jan 31, 2024
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · CORPORATE OFFICER
Association date reported to CMS: Mar 1, 2022
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Mar 1, 2022
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Mar 27, 2023
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 31, 2024
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 10 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jan 31, 2024
Other facilities connected through this exact CMS organization identity: 14 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Jan 31, 2024
Other facilities connected through this exact CMS organization identity: 16 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: Jan 31, 2024
Other facilities connected through this exact CMS organization identity: 17 across VA.
Individual · CORPORATE OFFICER
Association date reported to CMS: Mar 1, 2022
Individual · W-2 MANAGING EMPLOYEE
Published ownership percentage: 0%
Association date reported to CMS: Mar 1, 2022
Individual · W-2 MANAGING EMPLOYEE
Published ownership percentage: 0%
Association date reported to CMS: Mar 27, 2023
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across VA.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 608 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 18 | 1.5 | 1.5 |
| Mon Jun | 18 | 1.3 | 1.1 |
| Fri May | 18 | 1.3 | 1.1 |
| Wed Apr | 17 | 1.2 | 1.1 |
| Sun Mar | 17 | 1.3 | 1.4 |
| Sun Feb | 17 | 1.3 | 1.4 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Ensure each resident receives an accurate assessment.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Allow residents to self-administer drugs if determined clinically appropriate.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 14, 2025)
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Assess the resident when there is a significant change in condition
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
PASARR screening for Mental disorders or Intellectual Disabilities
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Provide activities to meet all resident's needs.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Ensure the activities program is directed by a qualified professional.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Provide safe, appropriate pain management for a resident who requires such services.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Employ staff that are licensed, certified, or registered in accordance with state laws.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
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 scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Hire a qualified full-time social worker in a facility with more than 120 beds.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
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 scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Provide training in compliance and ethics.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Feb 15, 2025)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 30, 2024)
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Past Non-Compliance (Apr 2, 2024)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 28, 2023)
No health-deficiency rows were deterministically linked to this inspection.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Keep residents' personal and medical records private and confidential.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
PASARR screening for Mental disorders or Intellectual Disabilities
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Assist a resident in gaining access to vision and hearing services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Observe each nurse aide's job performance and give regular training.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
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 scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Provide and implement an infection prevention and control program.
CMS scope/severity L: Widespread; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Implement a program that monitors antibiotic use.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Report COVID19 data to residents and families.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Perform COVID19 testing on residents and staff.
CMS scope/severity L: Widespread; Immediate jeopardy to resident health or safety.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Nov 5, 2021)
No health-deficiency rows were deterministically linked to this inspection.
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
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 scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
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 scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 10, 2020)
Penalties & enforcement
Published fine amount: $131,178.00
Questions to ask
Facility history
11 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
Total nurse staffing decreased from 3.29 to 3.06 hours per resident day between 2025Q4 and 2026Q1. Staffing declined across those reported periods.
3.29 → 3.06
CMS · Reported in a source release · View related evidence
Total nurse staffing increased from 3.04 to 3.41 hours per resident day between 2025Q2 and 2025Q3. Staffing improved across those reported periods.
3.04 → 3.41
CMS · Reported in a source release · View related evidence
6 deficiencies were recorded.
CMS · Recorded event date · View related evidence
7 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
25 deficiencies were recorded. That includes 2 higher-severity deficiencies.
CMS · Recorded event date · View related evidence
CMS recorded a $131,178 civil monetary penalty.
CMS · Recorded event date · View related evidence
2 deficiencies were recorded.
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1 deficiency was recorded.
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An ownership change was recorded. New organization: BIRCHWOOD PARK REHABILITATION AND NURSING LLC.
THE CITADEL VIRGINIA BEACH LLC → BIRCHWOOD PARK REHABILITATION AND NURSING LLC
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28 deficiencies were recorded. That includes 2 higher-severity deficiencies.
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24 deficiencies were recorded.
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Staffing
CMS staffing rating: 1 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.304 | 2.454 |
| RN categories | 0.63 | 0.384 |
Contract staff accounted for 8% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.047 higher than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.038 | 0.591 | 0.798 | 1.649 | 6.2% | 91 |
| 2025Q3 | 3.412 | 0.524 | 0.988 | 1.9 | 0.5% | 92 |
| 2025Q4 | 3.288 | 0.512 | 1.069 | 1.706 | 0% | 92 |
| 2026Q1 | 3.059 | 0.559 | 0.988 | 1.512 | 8% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
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Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.
Source register
No paid placements. Facilities cannot pay to rank higher. We cite. You decide.