Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Deep Creek Health & Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain or implement an effective water management program as required by its infection prevention and control policy. Key staff, including the Maintenance Director and DON, were unclear about their responsibilities, and there was no documentation or monitoring for Legionella or other waterborne pathogens. The program had been discontinued after removal of water features, leaving all residents potentially affected.
The facility did not maintain an effective pest control program, resulting in ongoing pest activity such as ants, roaches, flies, gnats, and spiders in resident rooms, communal areas, and the kitchen. Lapses in contracted pest control services due to non-payment led to the Maintenance Director using over-the-counter products, which were insufficient to address persistent pest issues. Staff and residents reported continued pest problems, and surveyors directly observed pests in multiple facility locations.
The facility did not secure smoking materials or complete required smoking safety assessments for three residents who smoked, allowing residents to keep cigarettes and lighters in their possession and failing to document quarterly evaluations as required by policy. Staff interviews confirmed that independent smokers maintained control of their smoking supplies, and administrative changes led to lapses in assessment and monitoring.
Facility administration did not enforce or revise its smoking policy, resulting in residents being allowed to keep smoking materials and smoke independently without required safety assessments. Staff and leadership were unaware of missed quarterly evaluations, and policy requirements were not followed due to changes in administration.
The facility did not provide two residents with complete and accurate Advance Beneficiary Notices and Notices of Medicare Non-Coverage when ending Medicare Part A skilled services. Forms were missing required details such as the specific services ending, reasons for non-coverage, and estimated costs, and in one case, the ABN was not provided at all. Staff interviews confirmed a lack of awareness and incomplete documentation, preventing residents or their representatives from making informed decisions.
A resident who required staff assistance for ADLs and had intact cognition was left in a soiled brief for over three hours after requesting incontinence care. Multiple staff members responded to the resident's call light but failed to provide care or notify the assigned CNA, resulting in a significant delay before the resident's needs were met.
Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to develop and implement an effective water management program as part of its infection prevention and control program, specifically to prevent the growth of opportunistic waterborne pathogens such as Legionella. The facility's policy required an interdisciplinary water management team, a detailed diagram of the water system, identification of risk areas and situations, and documentation of control measures. However, interviews revealed that the Maintenance Director was not performing or documenting water testing for Legionella, did not have a diagram or list of at-risk areas, and was unfamiliar with the facility's plumbing. The Director of Nursing believed the water management plan was overseen by administration, while the current Administrator stated the program was discontinued after the removal of a water fountain. The previous interim Administrator confirmed that the facility previously had a water management program, which was not maintained after certain water features were removed. At the time of the survey, the facility census was 89 residents, all of whom were potentially affected by the lack of an effective water management program. There was no evidence of ongoing monitoring or documentation to identify or control sources of waterborne bacteria, and key staff members were unclear about their roles and responsibilities regarding the water management program. The absence of a current, implemented program and lack of staff knowledge and documentation directly led to the deficiency cited by surveyors.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which specified the need for an ongoing program to keep the building free of insects and rodents. Despite having a commercial pest control service agreement in place, the facility experienced lapses in service due to non-payment, resulting in the termination of the contract after February 2025. Facility invoices confirmed that pest control services were not provided for several months, and interviews with staff revealed that the lapse was related to payment issues and administrative transitions. During this period, the Maintenance Director attempted to address pest activity using over-the-counter products, but was aware that these efforts were insufficient, especially in rooms with recurrent pest problems. Observations and documentation indicated ongoing pest activity throughout the facility, including ants, roaches, flies, gnats, and spiders in resident rooms, communal areas, the kitchen, and bathrooms. The facility's maintenance log recorded multiple instances of pest sightings over a span of nearly two years, with increased frequency and persistence in certain rooms. During the survey, pests were directly observed by surveyors in various locations, and all residents attending a Resident Council meeting reported ongoing pest issues in their rooms. Staff interviews corroborated that pest activity was a known and recurring problem, and that the facility's response was limited to internal efforts by the Maintenance Director in the absence of professional pest control services. Key staff, including the Administrator, DON, and Maintenance Director, described a process for reporting and addressing pest activity, but acknowledged the lack of a current pest control contract and the challenges in managing pest issues effectively. The former Interim Administrator was unaware of the contract termination and believed payment had resolved the issue, but did not verify the resumption of services. The Certified Dietary Manager also reported periodic pest activity in the kitchen, with staff resorting to makeshift methods to control flies. The combination of service lapses, insufficient internal measures, and ongoing pest activity across multiple areas of the facility led to the deficiency in maintaining an effective pest control program.
Failure to Secure Smoking Materials and Complete Required Smoking Safety Assessments
Penalty
Summary
The facility failed to secure smoking materials and conduct required smoking safety assessments for residents who smoke, as outlined in its own smoking policy. The policy required that residents be evaluated for smoking safety on admission, quarterly, and upon significant change, and that smoking materials be secured by staff rather than kept in residents' possession. However, one resident with a history of multiple sclerosis and muscle weakness was allowed to keep cigarettes and a lighter in their room and on their person, despite documentation that the resident was a daily smoker and had previously been found smoking in bed. Staff interviews confirmed that independent smokers were permitted to maintain control of their smoking materials, contrary to the facility's policy. Another resident with a diagnosis of nicotine dependence was identified as a smoker in the care plan, but there was no evidence that a smoking safety evaluation had ever been completed for this resident. Staff interviews revealed that this resident also kept their smoking supplies with them, and the lack of assessment was attributed to administrative changes and oversight. The Director of Nursing and former interim administrator both stated that smoking assessments were expected to be completed on admission, quarterly, and as needed, but acknowledged that these were not consistently performed. A third resident with nicotine dependence and respiratory conditions had a history of moderately impaired cognition and was documented as unable to safely handle smoking materials. While a smoking safety evaluation was completed on admission and again over a year later, there was no documentation of quarterly assessments as required. The failure to conduct regular assessments and secure smoking materials as per policy was attributed to changes in administration and a shift in practice to honor resident independence, resulting in lapses in monitoring and documentation.
Failure to Enforce and Update Smoking Policy and Assessments
Penalty
Summary
Facility administration failed to enforce or appropriately revise its smoking policy, resulting in inconsistent adherence to safety protocols for residents who smoke. The facility's policy required quarterly smoking safety assessments and prohibited residents from keeping smoking materials in their possession, allowing only disposable safety lighters. However, interviews with staff and residents revealed that the previous administration directed staff to relax these requirements without formally updating the policy. As a result, residents who were considered independent smokers were permitted to keep their own smoking materials and smoke at their discretion, contrary to the written policy. The Director of Nursing and current administration were unaware that required smoking assessments were not being completed. Record reviews showed that one resident began smoking after admission and kept cigarettes and a lighter in their room and on their person, with no updated smoking safety evaluation documented. Another resident's record indicated tobacco use, but quarterly smoking safety evaluations were not completed as required. A third resident's record contained no evidence of any smoking safety assessment, despite the resident being identified as an independent smoker. Staff interviews confirmed that the lack of assessments and policy adherence was due to changes in administration and a lack of awareness among current leadership.
Failure to Provide Complete Advance Beneficiary Notices and Medicare Non-Coverage Information
Penalty
Summary
The facility failed to provide complete and accurate Advance Beneficiary Notices (ABNs) and Notices of Medicare Non-Coverage (NOMNC) to two residents who were ending their Medicare Part A skilled services. For one resident with a history of stroke, chronic respiratory failure, moderate cognitive impairment, and communication difficulties, the facility issued an ABN and NOMNC that were incomplete. The forms did not specify which Medicare Part A services were ending, the reason for non-coverage, or an estimated cost for continued services, despite the resident's cognitive and communication challenges. The Social Services Director (SSD) confirmed that information from therapy regarding the reason for service termination was not transcribed onto the forms, and she lacked knowledge of the estimated costs to include. For another resident with severe cognitive impairment and communication problems following a stroke, the facility did not provide the required ABN at the time of Medicare Part A service termination. The NOMNC issued was signed by staff on behalf of the resident but did not specify which services were ending. The SSD acknowledged that the ABN was not provided and that the NOMNC lacked necessary details. She also stated that she was unsure why the resident's Medicare services ended and that all areas of the forms should have been completed for informed decision-making. Interviews with facility staff, including the Business Office Manager, SSD, Director of Nursing, and Administrator, revealed a lack of awareness and understanding regarding the proper completion and issuance of ABN and NOMNC forms. Staff confirmed that forms were not fully completed and that required information was missing, preventing residents or their representatives from making informed choices about their care and financial responsibilities.
Failure to Provide Timely Incontinence Care Due to Staff Communication Breakdown
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was dependent on staff for assistance with activities of daily living (ADLs). The resident, who had intact cognition and required substantial to moderate assistance for toileting and personal hygiene, reported turning on their call light at approximately 7:00 AM to request incontinence care. When a CNA responded, the resident was told that breakfast trays were about to be distributed and that the assigned CNA would be notified. However, the assigned CNA was not informed of the resident's need for care at that time. Subsequently, the resident received breakfast and, after waiting for an unspecified period, activated the call light again. This time, an LPN responded and was told by the resident that incontinence care was still needed. The LPN relayed to the resident that the assigned CNA would be there soon, but did not directly communicate the resident's request to the CNA. Interviews with staff revealed that the assigned CNA was unaware of the resident's need for incontinence care until much later and did not provide care until approximately 10:15 AM, over three hours after the initial request. Facility policy required prompt assistance with ADLs, including elimination needs, and staff interviews confirmed that the expectation was for care to be provided immediately or for another staff member to assist if the assigned CNA was unavailable. The delay in care resulted from a breakdown in communication among staff members, with multiple staff failing to notify the assigned CNA or provide care themselves, leaving the resident in a soiled brief for an extended period.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chesapeake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Portside Health & Rehab Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Portsmouth | 3.3 mi | ★★★★★ | 16 | 0 |
| Portsmouth Health And Rehab | 4.4 mi | ★★★★★ | 7 | 1 |
| Chesapeake Health And Rehabilitation Center | 5.7 mi | ★★★★★ | 3 | 0 |
| Harbor's Edge | 5.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.