Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Deep Creek Health & Rehabilitation

CHESAPEAKE, VA · 120 certified beds · Last Life Safety survey September 19, 2025

CMS Certification Number 495330 · first certified August 1998

Ownership

Operated by ARK POST ACUTE NETWORK · For profit - Limited Liability company

Ownership changed April 1, 2018 (change of ownership)to GREENBRIER REGIONAL MEDICAL CENTER from CHESAPEAKE REHABILITATION AND CARE CENTER, LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within VA

43 citations — more than 99% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 10 citations; the earlier surveys in the window averaged 16.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens April 2028 — about 19 months from now. This facility’s last Life Safety survey was September 2025. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Emergency preparedness

28 of the 43 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 43 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

How that compares

Citations on file over three years

Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	43
Median facility in VA	10
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
April 16, 2019	26
July 22, 2021	7
September 19, 2025	10

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
E-0034	Provide a means of sharing information on occupancy/needs.	2	2025-09-19
E-0039	Conduct testing and exercise requirements.	2	2025-09-19
E-0037	Establish staff and initial training requirements.	2	2021-07-22
E-0036	Establish emergency prep training and testing.	2	2021-07-22
K-0100	Meet other general requirements.	2	2025-09-19
E-0035	Provide family notifications of emergency plan.	2	2025-09-19
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	2	2025-09-19
E-0030	List the names and contact information of those in the facility.	1	2019-04-16

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 28
Smoke Deficiencies 6
Egress Deficiencies 3
Gas, Vacuum, and Electrical Systems Deficiencies 3
Other 3

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	28
Smoke Deficiencies	6
Egress Deficiencies	3
Gas, Vacuum, and Electrical Systems Deficiencies	3
Construction Deficiencies	2
Miscellaneous Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 19, 2025 — 10 citations

Citations issued on September 19, 2025
Tag	What the surveyor checks	Status
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (October 27, 2025)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (October 27, 2025)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (October 27, 2025)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (November 19, 2025)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (November 19, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (November 19, 2025)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (November 19, 2025)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (November 19, 2025)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (November 19, 2025)
K-0932	Meet other general requirements.	Deficient, Provider has date of correction (January 19, 2026)

July 22, 2021 — 7 citations

Citations issued on July 22, 2021
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (September 5, 2021)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (September 5, 2021)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (September 5, 2021)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (August 24, 2021)
K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	Deficient, Provider has date of correction (August 24, 2021)
K-0400	Meet fire sprinkler requirement for tall buildings.	Deficient, Provider has date of correction (August 24, 2021)
K-0915	Have proper power supply for life support equipment.	Deficient, Provider has date of correction (August 24, 2021)

April 16, 2019 — 26 citations

Citations issued on April 16, 2019
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (May 31, 2019)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (May 31, 2019)
E-0009	Include a process for Emergency Preparedness collaboration.	Deficient, Provider has date of correction (May 31, 2019)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (May 31, 2019)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (May 31, 2019)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (May 31, 2019)
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (May 31, 2019)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (May 31, 2019)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (May 31, 2019)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (May 31, 2019)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (May 31, 2019)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (May 31, 2019)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (May 31, 2019)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (May 31, 2019)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (May 31, 2019)
E-0033	Establish methods for sharing information.	Deficient, Provider has date of correction (May 31, 2019)
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (May 31, 2019)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (May 31, 2019)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (May 31, 2019)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (May 31, 2019)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (May 31, 2019)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (May 31, 2019)
K-0100	Meet other general requirements.	Waiver has been granted (December 7, 2020)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (August 1, 2019)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 1, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 1, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.