Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- VirginiaLowest tier among peers285 rated homes · average 3.0★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs VA avg
- StaffingCan add or remove a star1★−1.5 vs VA avg
- Quality measuresCan add or remove a star2★−1.9 vs VA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 21% of peersVA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersVA avg2.5★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 2% of peersVA avg3.9★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.34hrsAbove only 35% of peersVA avg3.82Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.32hrsAbove only 10% of peersVA avg0.69Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better54%Above only 35% of peersVA avg48%RN turnover67%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$31,445Above only 13% of peersVA avg$16,279Fines · denials2 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthNov 2018 – Jul 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jul 15, 2024Cycle 1worst F · no actual harm
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected Aug 30, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationD · isolatedCorrected Aug 30, 2024
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Aug 30, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Aug 30, 2024
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Aug 30, 2024
- F584Honor 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.Resident RightsE · patternCorrected Aug 30, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Aug 30, 2024
- F680Ensure the activities program is directed by a qualified professional.Quality of Life and CareF · widespreadCorrected Aug 30, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Aug 30, 2024
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Aug 30, 2024
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationE · patternCorrected Aug 30, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected Aug 30, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 30, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Aug 30, 2024
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationD · isolatedCorrected Aug 30, 2024
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationD · isolatedCorrected Aug 30, 2024
- F946Provide training in compliance and ethics.AdministrationD · isolatedCorrected Aug 30, 2024
Jul 20, 2023Cycle 3worst F · no actual harm
- F585Honor 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.Resident RightsD · isolatedCorrected Aug 31, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 31, 2023
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Aug 31, 2023
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 31, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 31, 2023
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 31, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Aug 31, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Aug 31, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Aug 31, 2023
Jun 1, 2023Cycle 3worst G · actual harm$12,093, $19,352
- F585Honor 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.Resident RightsD · isolatedCorrected Aug 31, 2023
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jul 12, 2023
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jul 12, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 12, 2023
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jul 12, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Aug 31, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 31, 2023
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 31, 2023
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Jul 12, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 31, 2023
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Jul 12, 2023
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Aug 31, 2023
- F776Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.AdministrationD · isolatedCorrected Jul 12, 2023
- F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Jul 12, 2023
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Aug 31, 2023
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jul 12, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Aug 31, 2023
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Jul 12, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Aug 31, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 12, 2023
Apr 14, 2023Cycle 3worst E · no actual harm
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected May 18, 2023
- F885Report COVID19 data to residents and families.Infection ControlC · widespreadCorrected May 18, 2023
- F886Perform COVID19 testing on residents and staff.Infection ControlE · patternCorrected May 18, 2023
- F887Educate 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.Infection ControlE · patternCorrected May 18, 2023
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected May 18, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 18, 2023
Jan 20, 2022Cycle 2worst E · no actual harm
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 4, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 4, 2022
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Mar 4, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Mar 4, 2022
Nov 29, 2018Cycle 3worst D · no actual harm
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Jan 11, 2019
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected Dec 12, 2018
- F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Dec 13, 2018
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.34hrs
- Registered nursesRN hours only0.32hrs
- Licensed practical nursesLPN hours0.83hrs
- Nurse aidesCNA hours2.20hrs
- Weekend nursingAll staff on Saturdays and Sundays2.89hrs
- Virginia average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better54%Above only 35% of peersVA avg 48%
- RN turnoverRegistered nurses only67%Not ranked by CMS
- Administrators who leftIn the past year—
- Occupancy60 certified beds · ~52 residents a day86%Above only 30% of peersVA avg 87%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $31,445In fines
- 2Fines
- 0Payment denials
- $16,279VA avg in fines
Actions on record
- Jun 1, 2023Civil money penalty$12,093
- Jun 1, 2023Civil money penalty$19,352
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- Creative Care Resources LLC
- West Coast Commonwealth LLC
- Traditions Senior Management INC
- Roy Bridges
- Kimberly Justiniano
- Joseph Hopkins
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 495328 · 1150 MARSH STREET, TAPPAHANNOCK, VA, 22560.
- Percentiles compare this facility with every rated nursing home in Virginia and Essex County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









