Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.26 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
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 2-star staffing rating for this facility.
RN staffing was 0.26 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Feb 26, 2026 cited 20 deficiencies.
View inspection evidenceCMS-published records list 53 ownership or control parties.
CMS records show an ownership change effective June 2025.
View ownership evidenceCMS groups this facility with a chain covering 38 facilities across 4 states or territories.
View chain evidenceOwnership & 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:
38 currently connected nursing homes share this CMS organization identity with NU C II 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: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER SECURITY INTEREST
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 20, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2025
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2025
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2025
CMS classifications: Holding company
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: May 1, 2025
CMS classifications: Parent company, Holding company
Other facilities connected through this exact CMS organization identity: 37 across MS, NC, PA, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: May 1, 2025
CMS classifications: Parent company, Holding company
Other facilities connected through this exact CMS organization identity: 37 across MS, NC, PA, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2025
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 37 across MS, NC, PA, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2025
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: 100%
Association date reported to CMS: May 1, 2025
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 37 across MS, NC, PA, VA.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2025
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 37 across MS, NC, PA, VA.
Organization · 5% OR GREATER SECURITY INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2025
CMS classifications: Real estate investment trust (REIT)
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: Jun 1, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 26, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 26, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 20, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 21, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Individual · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
Organization · ADP OF THE SNF
Association date reported to CMS: May 1, 2025
CMS classifications: Real estate investment trust (REIT)
Other facilities connected through this exact CMS organization identity: 0 across VA.
Organization · ADP OF THE SNF
Association date reported to CMS: Apr 20, 2025
Other facilities connected through this exact CMS organization identity: 42 across MS, NC, PA, VA.
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: Jun 1, 2025
Individual · MANAGING CONTROL - GOVERNING BODY
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jun 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Organization · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 42 across MS, NC, PA, VA.
Organization · TRUSTEE OF THE SNF
Association date reported to CMS: May 1, 2025
Other facilities connected through this exact CMS organization identity: 0 across VA.
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 843 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 38 | 2 | 2.2 |
| Mon Jun | 38 | 2 | 2.4 |
| Fri May | 38 | 2 | 2.4 |
| Wed Apr | 33 | 2.1 | 2.4 |
| Sun Mar | 14 | 2.1 | 2.3 |
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.
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
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 (Apr 5, 2026)
Ensure residents have reasonable access to and privacy in their use of communication methods.
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 5, 2026)
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 (Apr 5, 2026)
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 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 (Apr 5, 2026)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 5, 2026)
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 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 5, 2026)
Provide appropriate colostomy, urostomy, or ileostomy 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 (Apr 5, 2026)
Provide enough food/fluids to maintain a resident's health.
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 5, 2026)
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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 5, 2026)
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 5, 2026)
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 (Apr 5, 2026)
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 5, 2026)
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 (Apr 5, 2026)
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 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 5, 2026)
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 (Apr 5, 2026)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 5, 2026)
Provide and implement an infection prevention and control 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 (Apr 5, 2026)
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 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 (Apr 5, 2026)
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 5, 2026)
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 (Apr 5, 2026)
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 (Aug 30, 2024)
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 (Aug 30, 2024)
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 (Aug 30, 2024)
No health-deficiency rows were deterministically linked to this inspection.
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 (Dec 26, 2021)
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 (Dec 26, 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 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 (Dec 26, 2021)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Dec 26, 2021)
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 (Dec 26, 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 (Dec 26, 2021)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 (Dec 26, 2021)
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 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 (Dec 26, 2021)
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 (Dec 26, 2021)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 (Dec 26, 2021)
Provide safe and appropriate respiratory care for a resident when needed.
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 (Dec 26, 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 (Dec 26, 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 (Dec 26, 2021)
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Dec 26, 2021)
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 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 (Dec 26, 2021)
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 (Dec 26, 2021)
Provide and implement an infection prevention and control 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 (Dec 26, 2021)
Keep all essential equipment working 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 (Dec 26, 2021)
Make sure that a working call system is available in each resident's bathroom and bathing area.
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 (Dec 26, 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 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 (Dec 26, 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 (Dec 26, 2021)
No health-deficiency rows were deterministically linked to this inspection.
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 (Apr 6, 2019)
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 (May 13, 2019)
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 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 6, 2019)
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 (Apr 6, 2019)
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 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 6, 2019)
Provide care and assistance to perform activities of daily living for any resident who is unable.
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 6, 2019)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 6, 2019)
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 6, 2019)
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 (Apr 6, 2019)
Ensure each resident’s drug regimen must be free from unnecessary 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 6, 2019)
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 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 13, 2019)
Provide or obtain dental services for 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 (Apr 6, 2019)
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 (Apr 6, 2019)
Provide and implement an infection prevention and control program.
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 13, 2019)
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 (Apr 6, 2019)
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 (Apr 6, 2019)
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 6, 2019)
Penalties & enforcement
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Facility history
6 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
20 deficiencies were recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
An ownership change was recorded. New organization: 3900 LLEWELLYN AVENUE OPCO LLC.
NORFOLK FACILITY OPERATIONS, LLC → 3900 LLEWELLYN AVENUE OPCO LLC
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
21 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
17 deficiencies were recorded. That includes 1 higher-severity deficiency.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 2 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 | 2.973 | 2.336 |
| RN categories | 0.302 | 0.163 |
Contract staff accounted for 0% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.018 lower 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 | 2.56 | 0.274 | 0.664 | 1.622 | 0% | 91 |
| 2025Q3 | 2.701 | 0.284 | 0.76 | 1.657 | 0% | 92 |
| 2025Q4 | 2.893 | 0.281 | 0.831 | 1.782 | 0% | 92 |
| 2026Q1 | 2.789 | 0.262 | 0.886 | 1.641 | 0% | 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.
Trust participation
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.