Deep Creek Health & Rehabilitation
Deep Creek Health & Rehabilitation in CHESAPEAKE, VA — inspection on September 19, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 09/16/2025 at 10:59 AM, the Business Office Manager (BOM) stated that the Social Service Director (SSD) got notification from the resident's insurance company of services ending.
She stated that the BOM was responsible for maintaining a copy of the notices in a binder once the last covered day was identified, and a copy of the discharge letter was signed by the resident or their representative.
During an interview on 09/17/2025 at 8:27 AM, the Social Services Director (SSD) stated that she was responsible for completing and issuing the ABN and the NOMNC notices to the resident or representatives if the resident was going home, but stated if the resident stayed in the facility, she did not provide them any forms.
The SSD reviewed the NOMNC provided to Resident #45 and confirmed that the form did not contain the type of services which were to end.
She stated that Resident #45 was also issued an ABN but confirmed that the reason Medicare may not pay for services and the estimated cost for the services were not included on the document.
The SSD stated that therapy typically provided her with a document that indicated why the service was ending, but she did not transcribe that information on the forms that were issued to Resident #45.
She stated that regarding the estimated cost, she did not have knowledge of that information and could not include it on the document.
The SSD then stated that all areas of each form should be fully completed for the resident or family to make informed choices.
The SSD stated that she was unsure why Resident #46's Medicare Part A services ended but thought it was ended by the resident's insurance company.
The SSD reviewed the NOMNC provided to Resident #46 and acknowledged Resident #46 was not provided with the ABN document at the same time.
She then stated that the NOMNC issued to Resident #46 should have included what services were to end and Resident #46 should have been provided with an ABN document. SSD then stated that all areas of each form should be fully completed for both Resident #45 and Resident #46 in order for the resident or resident's representative to make an informed choice.
During an interview on 09/19/2025 at 5:01 PM, the Director of Nursing (DON) stated she was unaware there were concerns with the issuing of ABN documents.
She stated her expectation was that they meet state and federal requirements, and the forms were accurate and issued timely.
During an interview on 09/19/2025 at 4:44 PM, Administrator (ADM) #2 stated he was unaware there were any concerns with the issuing of ABN documents. He said he expected the ABNs to be completed, issued, and reviewed with the resident/representative at least 48 hours prior to each resident's discharge from Medicare Part A services. He stated that all appropriate areas should be completed on the form.
495330 09/19/2025
Deep Creek Health & Rehabilitation 1017 George Washington Highway North Chesapeake, VA 23323
During an interview on 09/17/2025 at 10:26 AM, the Director of Nursing (DON) revealed she expected CNA #3 or LPN #5 to provide incontinence care when they answered the call light or to notify CNA #6, the assigned CNA, so that the care could be provided promptly.
The DON stated residents should not be left in soiled briefs, and passing meal trays was not a reason to delay care.
The DON further stated that she expected incontinence care to be provided while other staff assisted with meals.
During an interview on 09/17/2025 at 4:05 PM, the Administrator (ADM) revealed he expected staff to provide the necessary care immediately. He further stated that if the assigned CNA was providing care to another resident, the staff member who answered the call light should get another CNA, or the nurse to provide incontinence care, if a CNA was unavailable.
495330 09/19/2025
Deep Creek Health & Rehabilitation 1017 George Washington Highway North Chesapeake, VA 23323
During an interview on
assessments to be completed on admission, quarterly, and as needed.
During the survey, no concerns
designated smoking area.
495330 09/19/2025
Deep Creek Health & Rehabilitation 1017 George Washington Highway North Chesapeake, VA 23323
During an
4:44 PM, the former Administrator (ADM) #2 stated with the repeated changes in administration,
were not completed. He stated he expected smoking assessments to be completed on admission, quarterly, and with all changes in the residents' condition.
During an interview on 09/19/2025 at 5:01 PM, Director of Nursing (DON) stated she was unaware of concerns that the facility was not completing required smoking assessments.
The DON stated she expected smoking assessments to be completed on admission, quarterly, and as needed.
495330 09/19/2025
Deep Creek Health & Rehabilitation 1017 George Washington Highway North Chesapeake, VA 23323
Findings included:A facility policy titled, Legionella Water Management Program, revised 07/2017, revealed Our facility is committed to the prevention, detection, and control of water-borne contaminates, including Legionella.
The policy also revealed a section titled, Policy Interpretation and Implementation that specified, 1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the water management team. 3.
The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 5.
The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: 1) receiving; 2) cold water distribution; 3) heating; 4) hot water distribution; and 5) waste; c.
The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) Storage tanks; 2) Water heaters; 3) Filters; 4) Aerators; 5) Showerheads and hoses; 6) Misters, atomizers, air washers, and humidifiers; 7) Hot tubs; 8) Fountains; and 9) Medical devices such as CPAP machines, hydrotherapy equipment, etc. d.
The identification of situations that can lead to Legionella growth, such as 1) Construction; 2) Water main breaks; 3) Changes in municipal water quality; 4) The presence of biofilm scale or sediment; 5) Water temperature fluctuations; 6) Water pressure changes; 7) Water stagnation and 8) Inadequate disinfection. G. A diagram of where control measures are applied, and j.
Documentation of the program.
During an interview on 09/19/2025 at 2:52 PM, the Maintenance Director stated the facility had a water management plan prior to his employment as the Maintenance Director approximately two years prior and no current testing was being performed to monitor areas for potential sources of Legionella.
The Maintenance Director stated he performed checks of the water temperatures and monitored the ice machine, but he did not document that.
The Maintenance Director also acknowledged he did not have a diagram or list of any areas that could be potentially at risk of being a source of waterborne bacteria and stated, This is an old building, and I don't have a clue about the plumbing.
During an interview on 09/19/2025 at 4:53 PM, the Director of Nursing (DON) stated she felt that the water management plan was overseen by administration.
She stated she expected the facility to develop and implement a water management plan as part of the infection control program.
During an interview on 09/19/2025 at 1:57 PM, Administrator (ADM) #1 stated they no longer had a water management program after the previous administrator shut that down when the facility turned off the water fountain in the front of the building.
During an interview on 09/19/2025 at 4:36 PM, the previous interim Administrator (ADM) #2 stated the facility should have an implemented water management program. He stated the facility previously had one in place until they removed all the fountains that should have extended through the entire inside and outside of the facility and included anywhere water could become stagnant in order to prevent the spread of waterborne bacteria.
495330 09/19/2025
Deep Creek Health & Rehabilitation 1017 George Washington Highway North Chesapeake, VA 23323
During an interview on 09/17/202 at 2:53 PM, the Director of Nursing (DON) stated she expected staff to record in the maintenance logbooks at each nursing station any pest activity observed or to report pest activity directly to the Maintenance Director.
The DON stated that she expected the Maintenance Director to review the maintenance logbooks daily, address any concerns, and report on the follow-up during the morning meetings.
The DON stated that if the Maintenance Director could not resolve the pest activity, then he should coordinate with management and contact the pest control vendor for the pest activity to be addressed.
The DON stated that she was aware of the facility's current pest activity, described as “gnats,” from discussions during the facility's morning meetings.
The DON said she expected the facility to provide and maintain a pest control program that minimized pest activity.
During an interview on 09/17/2025 at 3:16 PM, the former Interim Administrator (ADM #2) stated that he was the Administrator for the facility from July 2025 until Friday, 09/12/2025, and that he was aware of residents who had voiced concerns in August 2025 regarding flies in the facility. He stated the flies were coming from the door to the smoking patio. He stated that residents propped the smoking patio door open, which allowed pests to enter the facility. He stated staff were educated to monitor the door to the smoking patio to ensure the doors were closed and not held open for extended periods of time. He stated he was not aware that the pest control contract was terminated. He stated the facility received an email from the pest control provider for the account to be paid in full, and payment was made. He said after he observed pest activity in the facility in the last month, he spoke to the Maintenance Director about pest services and was told that pest services from the vendor were on hold due to lack of payment. ADM #2 stated he contacted the corporate payable clerk and verified that the facility's bill was paid, so he expected the pest control vendor to resume services, but he did not contact the pest control vendor to verify the status of current services for the facility.
- During a tour of the kitchen on 09/17/2025 at 11:15 AM, a fly was observed flying around in the
kitchen.
During an interview on 09/17/2025 at 11:15 AM, the Certified Dietary Manager (CDM) stated that there were flies in the kitchen periodically.
The CDM stated the occasional observations of pests in the kitchen were no comparison to the seriousness of pests observed in the rest of the building. He stated that to minimize the flies in the kitchen, staff were to ensure the double entry doors that led to the exterior of the building near the back parking area were kept closed and staff used rolled up parchment paper to swat the flies.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.