Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
THALIA GARDENS REHABILITATION AND NURSING
VIRGINIA BEACH, VA · 138 certified beds · Last Life Safety survey June 9, 2022
CMS Certification Number 495241 · first certified June 1991
Ownership
Operated by EASTERN HEALTHCARE GROUP · For profit - Corporation
- Ownership changed March 1, 2022 (change of ownership)from ACCORDIUS HEALTH AT RIVER POINTE LLC
Position within VA
25 citations — more than 91% 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 8 citations; the earlier surveys in the window averaged 8.5. 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 (January 2025 to January 2026), and past the point by which nine in ten VA facilities have been surveyed. This facility’s last Life Safety survey was June 2022. 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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3 inspection-and-testing tags have 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.
Emergency preparedness
4 of the 25 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)
14 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 25 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-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 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.
- F-0908 Keep all essential equipment working safely.
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 | 25 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 4, 2018 | 8 |
| August 29, 2019 | 9 |
| June 9, 2022 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2019-08-29 |
| 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 | 2022-06-09 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2019-08-29 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2022-06-09 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2019-08-29 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2019-08-29 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2022-06-09 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2018-05-04 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Smoke Deficiencies 6
- Emergency Preparedness Deficiencies 4
- Miscellaneous Deficiencies 3
- Other 6
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Smoke Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 9, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (July 24, 2022) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (July 24, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 24, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 24, 2022) |
| 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 23, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 23, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 23, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 23, 2022) |
August 29, 2019 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 7, 2019) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 7, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 7, 2019) |
May 4, 2018 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 7, 2018) |
| 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 (June 7, 2018) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 7, 2018) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 7, 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 (June 7, 2018) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 7, 2018) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 7, 2018) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 7, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.