Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SOUTHAMPTON REHABILITATION AND HEALTHCARE CENTER
RICHMOND, VA · 195 certified beds · Last Life Safety survey September 3, 2021
CMS Certification Number 495423 · first certified July 2017
Ownership
Operated by MARQUIS HEALTH SERVICES · For profit - Partnership
- Ownership changed December 1, 2022 (change of ownership)from ENVOY OF FOREST HILLS, LLC
Position within VA
17 citations — more than 74% 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
The latest survey found 3 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2024 to April 2025), and past the point by which nine in ten VA facilities have been surveyed. This facility’s last Life Safety survey was September 2021. 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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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
7 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 17 Life Safety citations above. The Physical Environment Index
- F-0584 Honor 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 20, 2017 | 0 |
| October 4, 2018 | 14 |
| September 3, 2021 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2021-09-03 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2021-09-03 |
| K-0300 | Meet other general requirements that are deficient. | 1 | 2018-10-04 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2018-10-04 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2018-10-04 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2018-10-04 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2018-10-04 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2018-10-04 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Construction Deficiencies 2
- Egress Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Construction Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 3, 2021 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 12, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 12, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 12, 2021) |
October 4, 2018 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Waiver has been granted (December 14, 2018) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (February 22, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (February 22, 2019) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Waiver has been granted (December 14, 2018) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (December 14, 2018) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 14, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.