Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 The Chesapeake during CMS and state inspections, most recent first.
Nurse staffing information was not posted in a prominent, readily accessible location on a nursing unit. Surveyors did not observe the daily staffing sheet during tours, and an alert resident, a visitor, and five alert and oriented residents all stated they did not know where to find the staffing information. The Administrator later showed a sheet leaning against a wall near a binder at the nursing station; the print was very small and did not clearly identify the census number.
A facility failed to ensure residents knew how to contact the Ombudsman or file a complaint with the state agency. During a resident group interview, none of the residents present knew who the Ombudsman was, how to contact that office, or where to find complaint information. The Administrator, AD, and admissions coordinator stated these rights were addressed on admission, in resident meetings, and in the resident handbook.
Survey Results Book Not Readily Accessible: The facility failed to keep the survey results book readily accessible to residents, family members, and legal representatives. A sign in the main hall directed people to request the book from the main office, and the Administrator stated it had been moved there during construction after initially being available to everyone. The Administrator, DON, and ADON were informed of the finding.
A facility failed to ensure residents knew how to file a grievance or complaint. In a group resident interview, none of the residents present were aware of the grievance process. The Administrator said resident rights and grievance information were addressed on admission, in Resident Council Meetings, and in the Resident Handbook, while the AC said it was covered on admission and at resident meetings.
Respiratory care was not provided according to oxygen orders for three residents. Oxygen tubing and humidification equipment were observed overdue or not dated/labeled, and an LPN found one resident’s O2 flow set at 3.5 L when the order called for 2 L. The DON and ADON acknowledged the weekly tubing changes were missed for at least one resident, and another resident’s oxygen equipment was also found dated beyond the expected change schedule.
A resident group reported that snacks were not regularly offered mid-day or at bedtime, and bedtime snacks were rare unless tied to a planned activity. Surveyors did not observe snacks being offered or provided during the survey period. The DM said snacks were available to all units but was unsure how they were distributed, and the Administrator agreed snacks were not offered consistently.
A resident with intact cognition and diagnoses including UTI, MS, DM2, major depressive disorder, and muscle weakness had an uncovered catheter bag observed during a survey tour. The DON confirmed the bag should have been covered for privacy and dignity.
Resident privacy and confidentiality were not maintained when a progress note in one resident’s chart included the name of another resident while documenting an incident at the admin desk. The note described one resident tipping forward in a W/C while talking with the other resident, and the DON acknowledged that placing another resident’s name in a chart is not acceptable and violates privacy and confidentiality.
A resident admitted with multiple diagnoses, including rhabdomyolysis, a cervical fracture, pulmonary hypertension, depression, heart failure, cognitive communication deficit, and osteoporosis, did not have a baseline care plan completed within the required 48 hours. The resident was cognitively intact per BIMS but dependent on staff for bathing, dressing, and transfers. The DON and ADON both stated baseline care plans should be completed within 24 to 48 hours, and the ADON could not locate the resident’s baseline care plan.
Care plans were not kept current for three residents. One resident with dementia and contracture had a communication plan that did not address her increased use of Italian and did not reflect an elbow extension splint order. Another resident with CHF, COPD, and Alzheimer’s disease had a comfort care order, but the care plan still included lab monitoring, incentive spirometry, and intake/output interventions that did not match current orders or practice. A third resident’s plan did not reflect DNR/hospice status and continued outdated infection and enhanced barrier precaution focuses after those conditions had resolved or were no longer ordered.
Oxygen Flow Rate Not Followed: Staff failed to follow a resident’s physician order for oxygen therapy. A resident with SOB and hypoxia was observed receiving oxygen at 3.5 L via NC even though the order was for 2 L, and an LPN later confirmed the incorrect flow rate before adjusting the machine.
Failure to maintain infection prevention and control practices in the kitchen and linen area. An ADM and another employee were observed in the kitchen without hairnets, including a server from the IL community. In addition, a white blanket and sheet were found on top of a dirty linen bin next to an open clean cart, and the Chef placed the items into the clean cart after stating they were clean. The DON and Administrator were informed, and the facility policy required an infection prevention and control program to maintain a safe, sanitary environment.
Nurse Staffing Information Not Readily Accessible
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted every day in a prominent place and readily accessible to residents, staff, and visitors on one nursing unit. During the initial tour on 12/2/2025 and again on 12/3/2025, surveyors did not observe the daily nurse staffing information posted on the unit. During a medication pass and pour observation on 12/3/2025, an alert resident stated he did not know how to determine how many staff members were working. At approximately 12:40 p.m. on 12/3/2025, a visitor stated she did not know where the staffing information was located. At approximately 1:00 p.m., five alert and oriented residents told a surveyor they did not know where to find the daily nurse staffing information. Later that day, the Administrator stated the information was posted and walked the surveyor to the nursing station, where a sheet of paper was found leaning against the wall near a binder. The Administrator explained that the form listed the facility name, shift, nursing positions, and census number, but the font was very small and did not clearly identify the census number. During end-of-day debriefing, the Administrator and DON were informed that the information was not readily accessible and that the form was difficult to see where it was placed on the counter.
Resident Rights Information Not Known by Residents
Penalty
Summary
The facility failed to ensure residents were aware of their right to contact the Ombudsman for advocacy and their right to file a complaint with the state certification agency. During a group resident interview on 12/03/25, none of the five residents in attendance (#2, #11, #21, #31, and #43) knew what or who the Ombudsman was or how to contact that office, and none knew they could make a complaint with the state agency or where to find that information. The Administrator and Activities Director stated that Resident Rights were addressed on admission and discussed in Resident Council Meetings and the Resident Handbook. The admissions coordinator stated that informing residents where to find information on contacting the Ombudsman and/or the state agency was a collaborative effort by facility staff and leadership and that this was addressed on admission and at resident meetings.
Survey Results Book Not Readily Accessible
Penalty
Summary
The facility failed to ensure the survey results book was readily accessible to residents, family members, and legal representatives of residents. During a facility tour, a sign on the bulletin board in the main hall leading to the Health Center Unit stated that the survey book was available upon request in the main office. The Administrator later stated that the survey book had initially been available to everyone without needing to request access, but it was moved to the office during construction. During the end-of-day meeting, the Administrator, DON, and ADON were informed of the finding.
Resident Grievance Rights Not Communicated
Penalty
Summary
The facility failed to ensure residents were aware of how to file a grievance or complaint. During a group resident interview on 12/03/25, none of the five residents who attended were aware of the availability of a grievance or complaint process or how to file one. The Administrator stated that Resident Rights, including how to file a grievance or complaint, are addressed on admission and discussed in Resident Council Meetings and in the Resident Handbook. The Admissions Coordinator stated that informing residents about where to find information regarding their rights was a collaborative effort of facility staff and leadership and that it is addressed on admission and at Resident Meetings. The facility's policy titled Resident's Rights was reviewed, and the Administrator, DON, and ADON were informed of the findings at the end of day meeting on 12/04/25, with no further information provided.
Respiratory Care Not Provided per Oxygen Orders
Penalty
Summary
Facility staff failed to provide respiratory care consistent with physician orders and professional standards for three residents receiving oxygen therapy. For one resident, the oxygen nasal cannula and concentrator tubing were observed dated 11/23/2025 even though the order required the tubing to be cleaned and changed weekly, and the MAR showed the tubing had been signed off as changed on 11/16/2025 and 11/23/2025. The humidification bottle attached to the oxygen concentrator was not dated. The ADON stated the tubing is changed weekly on Sunday and acknowledged that this resident’s tubing must have been missed, while the DON stated the tubing should have been changed weekly and that it was not done in this case. For another resident with diagnoses including acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, and heart failure, the oxygen concentrator tubing and humidification bottle were observed dated 11/23/2025. The DON stated these items are changed every Sunday and should have been changed on 11/30/2025. The MAR directed that the oxygen mask, tubing, and humidifier be changed on Sunday and that filters be rinsed nightly when in use. The resident’s MDS showed a BIMS score of 13 out of 15, indicating intact cognitive abilities for daily decision-making. For a third resident receiving oxygen therapy for shortness of breath and hypoxia, the MAR ordered oxygen at 2 liters via nasal cannula every shift and oxygen mask, tubing, and humidifier changes on Sunday. During observation, the resident was receiving 3.5 liters via nasal cannula, and the oxygen tubing was not dated or labeled. The resident stated staff had come earlier to change the tubing and increase the oxygen, and the IP later entered the room saying she was there to change the tubing. On a later observation, the flow rate remained at 3.5 liters until an LPN checked the order, confirmed it was 2.0 liters, and adjusted the oxygen machine.
Inconsistent Snack Service
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests because staff failed to offer and provide snacks at bedtime. During the survey from 12/02/2025 through 12/04/2025, there were no observations of snacks being offered or provided to residents. In a resident group interview on 12/03/2025, five residents stated they did not receive snacks mid-day or at bedtime regularly, said it was rare to receive bedtime snacks, and reported that snacks were usually given only in connection with a planned activity. The Dietary Manager stated snacks were available to all units and residents but was unsure about distribution. The Administrator later stated snacks were available but agreed they were not offered consistently.
Uncovered Catheter Bag Observed
Penalty
Summary
The facility failed to cover the catheter bag for Resident #48, who was admitted on 8/29/23 and had diagnoses including urinary tract infection, multiple sclerosis, type 2 diabetes mellitus without complications, major depressive disorder, and muscle weakness. The quarterly MDS with an ARD of 10/10/25 coded the resident as completing the BIMS with a score of 15 out of 15, indicating intact cognitive abilities for daily decision making. During an observation tour on 12/2/25 at 3:30 PM, surveyors observed that the resident’s catheter bag was not covered with a privacy bag. A second observation tour with the DON at 3:35 PM confirmed the catheter bag was uncovered, and the DON stated there should be a cover over the resident’s catheter bag for privacy and dignity.
Resident Name Included in Another Resident’s Medical Record
Penalty
Summary
The facility failed to ensure privacy and confidentiality of a resident’s medical record when a progress note in one resident’s chart contained the name of another resident. During a clinical record review, a note in Resident #18’s electronic medical record dated 11/29/2025 was found to include Resident #49’s name while describing an incident at the admin desk in which Resident #18 was seated talking with Resident #49 and tipped forward in her wheelchair before staff caught her from falling to the floor. Resident #49 was admitted with diagnoses including dementia with anxiety, osteoporosis, hypertension, malignant neoplasm of the breast, cardiomegaly, and hypertensive chronic kidney disease, and her most recent MDS coded a BIMS score of 7, indicating severe cognitive impairment. Resident #18 was admitted with diagnoses including rhabdomyolysis, displaced fracture of the first cervical vertebra, pulmonary hypertension, history of pneumonia, depression, heart failure, cognitive communication deficit, and osteoporosis, and her most recent MDS coded a BIMS score of 15, indicating intact cognitive abilities. The DON reviewed the note and stated that naming another resident in a resident’s medical record was not acceptable and was a violation of privacy and confidentiality.
Missing Baseline Care Plan After Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan within 48 hours of admission for Resident #18. During a clinical record review on 12/3/25, it was found that the resident did not have a baseline care plan, and the first care plan was not created until 11/10/25, seven days after admission. The resident was admitted with diagnoses including rhabdomyolysis, displaced fracture of the first cervical vertebra, pulmonary hypertension, history of pneumonia, depression, heart failure, cognitive communication deficit, and osteoporosis. Her most recent MDS, with an ARD of 11/7/25, coded her BIMS as 15 out of 15, indicating intact cognition. The record also showed that Section GG 0170 coded the resident as dependent on staff for bathing and dressing and for sit-to-stand, and requiring partial to maximum assistance with sit-to-lying and chair/bed-to-chair transfer. The DON stated that every resident is to have a baseline care plan written within 24 to 48 hours after admission, and the ADON stated that she was responsible for ensuring baseline care plans were completed within that timeframe and for writing and updating care plans. When asked to locate the baseline care plan for Resident #18, the ADON was unable to find one and stated, "I must have missed that one."
Care plans not updated to reflect current resident status and orders
Penalty
Summary
The facility failed to ensure that comprehensive care plans were timely developed, reviewed, and revised for 3 residents, and the care plans did not reflect current resident conditions or orders. For Resident #14, who had diagnoses including intracerebral hemorrhage, vascular dementia, contracture, and other chronic conditions, the care plan for communication did not address that she had begun speaking more in Italian as her cognition declined. Her care plan also did not reflect the physician order for a left elbow extension splint for contracture management, even though she was observed wearing the splint on multiple days and therapy staff confirmed OT was working with her on left upper extremity function. For Resident #2, who had diagnoses including heart failure, COPD, atrial fibrillation, diabetes with CKD, and Alzheimer's disease, the care plan was not updated after a comfort care order was written directing no weights, labs, IVs, x-rays unless fracture was suspected, and no hospital transfer. The care plan still included multiple laboratory monitoring focuses that did not reflect the no-labs order, continued an intervention to encourage incentive spirometry even after the order to discontinue it, and included a CHF intervention to monitor intake and output without evidence that intake and output monitoring was being done. For Resident #18, who had diagnoses including rhabdomyolysis, cervical fracture, pulmonary hypertension, heart failure, cognitive communication deficit, and osteoporosis, the care plan was not updated to reflect DNR status and hospice admission. The care plan still listed full code status after a DNR order and hospice admission, and it continued to include infection-related focuses for a UTI and pneumonia after the infection control log showed pneumonia had resolved and there was no evidence of a UTI. The care plan also continued enhanced barrier precautions for skin abrasions despite no current order and no evidence of signage or PPE at the door during observations. The DON and ADON acknowledged that the care plans for these residents had not been updated to reflect their current condition.
Oxygen Flow Rate Not Followed
Penalty
Summary
Facility staff failed to follow the physician’s orders for oxygen administration for one resident. Resident #42 was admitted on 10/09/25 and most recently readmitted on [DATE]; the resident’s diagnoses included a displaced intertrochanteric fracture of the left femur. The admission MDS with ARD 10/14/25 coded the resident as having intact cognitive abilities for daily decision making, with a BIMS score of 14 out of 15. The MAR showed an order for oxygen at 2 liters via nasal cannula every shift beginning 11/08/2025, and the care plan dated 11/11/25 identified oxygen therapy for shortness of breath and hypoxia with an intervention for oxygen settings at 2 liters via nasal cannula as needed. During observation on 12/02/2025, the resident was seen sitting in a wheelchair receiving oxygen at 3.5 liters via nasal cannula, and the resident stated staff had increased the oxygen and that she felt comfortable. On 12/04/2025, the resident again had oxygen set at 3.5 liters instead of the ordered 2.0 liters. An LPN visually confirmed the flow rate was 3.5 liters, checked the orders, and then verified the order was for 2.0 liters via nasal cannula before adjusting the oxygen machine. The facility policy stated oxygen therapy requires a provider order specifying the source, delivery system, flow rate, and whether it is continuous or as needed.
Failure to Maintain Infection Prevention and Control Practices in Kitchen and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program designed to provide a sanitary environment and help prevent the development and transmission of communicable diseases and infections among residents. During an initial tour of the main kitchen, the Assistant Administrator of Culinary Services was observed in the kitchen without a hairnet, and another employee in a blue uniform top was observed walking through the kitchen without a hairnet. The Director of Culinary Services identified the female employee as a server from the Independent Living community and stated that everyone should wear hairnets, but also said she did not work in the health care center and he did not know her name. While exiting the kitchen area, a white bed blanket and a white sheet were observed on top of a dirty linen bin next to an open basket cart. The Chef stated the items were clean and were supposed to be in the clean basket, then took the blanket and sheet from the top of the dirty linen bin and tossed them into the clean open cart. The Director of Culinary Services stated the laundry staff must have put the blanket and sheet there and acknowledged that this did not maintain a clean/dirty concept, adding that these linens were used to wipe up spills on floors and such. The facility's infection prevention and control policy stated the facility had established and was maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
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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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Nursing homes near Newport News
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newport News Nursing & Rehab | 3.2 mi | ★★★★★ | 2 | 0 |
| Newport Post Acute | 3.2 mi | ★★★★★ | 0 | 0 |
| Langley Post Acute | 3.4 mi | ★★★★★ | 0 | 0 |
| Hampton Health & Rehab Center, Llc | 3.5 mi | ★★★★★ | 0 | 0 |
| Bayside Of Poquoson Health And Rehab | 3.6 mi | ★★★★★ | 0 | 0 |
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