The Vardell Report.Deep Creek Health & Rehabilitation

Across 4 inspections from April 2019 to September 2025, state surveyors documented 44 findings at Deep Creek Health & Rehabilitation; 44 have a recorded correction; CMS lists no enforcement action in the window.

Inspections

4

2019–2025, standard and complaint

Findings

44

Deficiencies cited by state inspectors

Corrected

44

Of 44 findings, with a recorded correction date

Penalties

0

No fines or payment denials in the window

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Sep 192025

   Standard health inspection

   9 findings

   The same visit included a complaint investigation.

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Oct 27, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Oct 27, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Oct 27, 2025
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Oct 27, 2025
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Oct 27, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Oct 27, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Oct 27, 2025
   • F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level ENo actual harm, potential for moreCorrected Oct 27, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 27, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Nov 162023

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 8, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jul 222021

   Standard health inspection

   17 findings

   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Sep 5, 2021
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level ENo actual harm, potential for moreCorrected Sep 5, 2021
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level ENo actual harm, potential for moreCorrected Sep 5, 2021
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected Sep 5, 2021
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 21, 2021
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Sep 5, 2021
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Sep 5, 2021

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Apr 162019

   Standard health inspection

   17 findings

   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level ENo actual harm, potential for moreCorrected May 31, 2019
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level ENo actual harm, potential for moreCorrected May 31, 2019
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level ENo actual harm, potential for moreCorrected May 31, 2019
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel ENo actual harm, potential for moreCorrected May 31, 2019
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected May 31, 2019
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level ENo actual harm, potential for moreCorrected May 31, 2019
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 31, 2019
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level BPotential for minimal harmCorrected May 31, 2019

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Citation F582, Cited in Three Inspections

   Inspectors cited F582 in April 2019, July 2021 and September 2025. The agency describes it this way: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F582 across all 4 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in July 2021, November 2023 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F689 across all 4 inspections, oldest to newest
3. 3

   Citation F622, Cited in Two Inspections

   Inspectors cited F622 in April 2019 and July 2021. The agency describes it this way: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F622 across all 4 inspections, oldest to newest
4. 4

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in April 2019 and July 2021. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F623 across all 4 inspections, oldest to newest
5. 5

   Citation F625, Cited in Two Inspections

   Inspectors cited F625 in April 2019 and July 2021. The agency describes it this way: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F625 across all 4 inspections, oldest to newest
6. 6

   Citation F640, Cited in Two Inspections

   Inspectors cited F640 in April 2019 and July 2021. The agency describes it this way: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F640 across all 4 inspections, oldest to newest
7. 7

   Pre-Admission Screening, Cited in Two Inspections

   Inspectors cited F645 in April 2019 and September 2025. This citation covers the required screening for mental illness or intellectual disability before admission (PASARR). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F645 across all 4 inspections, oldest to newest
8. 8

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in April 2019 and July 2021. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F657 across all 4 inspections, oldest to newest
9. 9

   Pressure Injury Care, Cited in Two Inspections

   Inspectors cited F686 in April 2019 and July 2021. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212325F686 across all 4 inspections, oldest to newest
10. 10

    Citation F727, Cited in Two Inspections

    Inspectors cited F727 in April 2019 and July 2021. The agency describes it this way: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212325F727 across all 4 inspections, oldest to newest
11. 11

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in April 2019 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212325F880 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What changed after F582 was cited, and how do you check it now?

   Citation F582: cited in three inspections, most seriously at level D.

2. 02

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in three inspections, most seriously at level E.

3. 03

   What changed after F622 was cited, and how do you check it now?

   Citation F622: cited in two inspections, most seriously at level E.

4. 04

   When do you transfer or discharge a resident, and how much notice do families get?

   Notice Before Transfer or Discharge: cited in two inspections, most seriously at level E.

5. 05

   What changed after F625 was cited, and how do you check it now?

   Citation F625: cited in two inspections, most seriously at level E.

6. 06

   What changed after F640 was cited, and how do you check it now?

   Citation F640: cited in two inspections, most seriously at level E.

7. 07

   Was the required pre-admission screening done for every resident, and how is it tracked?

   Pre-Admission Screening: cited in two inspections, most seriously at level E.

8. 08

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in two inspections, most seriously at level D.

9. 09

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in two inspections, most seriously at level D.

10. 10

    What changed after F727 was cited, and how do you check it now?

    Citation F727: cited in two inspections, most seriously at level E.

11. 11

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level F.

12. 12

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

13. 13

    Has the home been fined or had payments denied before this record begins?

    CMS lists no fines or payment denials in this window. The record starts April 16, 2019; anything earlier is not in it.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Virginia state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Apr 16, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Jul 22, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Nov 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Sep 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 495330

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.