Hearth Record

Mary Immaculate Hospital

An acute care hospital in Newport News, Virginia 23602

2 Bernardine Drive, Newport News, Virginia 23602. (757) 886-6000.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 2 deficiencies in 1 month of the last 36. Last cited Jul 2026. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Jul 29, 2026: a complaint inspection.

2 deficiencies cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

2 deficiencies in 1 month of the last 36. Last cited Jul 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

2 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Jul 29, 2026: complaint inspection2 deficiencies

  • Medical Staff Bylaws

    The inspectors’ words, 596 words

    “MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 46466 Based on facility document reviews, medical record reviews and interviews, the facility failed to enforce the medical staff bylaws for one (1) of four (4) patient records reviewed. (Patient #1) The findings include: A review of the facility’s “Medical Staff Bylaws”, adopted by the medical staff November 27, 2022, indicated in part: “...All medical care provided at the Hospital shall conform with the following...applicable System/Hospital policies...”. A review of the the facility’s “Safety and/or Sentinel Event and/or Serious Reportable Event Reporting and Management” policy, effective September 8, 2025, indicated in part: “...D. Event reporting: All entities within the organization (patient care and nonpatient care departments, including inpatient, outpatient, ambulatory, home health, hospice, and long-term care) are responsible for reporting patient safety occurrences an potential occurrences. 1. Associates who identify or observe a safety event document the circumstances and facts in the event reporting system...”. On May 12, 2026, Patient #1 (P1) presented to ED with complaint of abdominal pain and underwent a computed tomography (CT) scan. The provider, Staff Member #12 (SM12) interpreted the CT scan and documented the following results: “Findings may represent a gastritis. No evidence of perforation or abscess”. An addendum was added to this report on May 14, 2026, by the same provider and documented “...There are a few tiny bubbles of free air posterior to the stomach which may represent gastric perforation”. A Pulmonology Progress Note documented on May 14, 2026, at 5:00 PM indicated “Addendum. Received call from (physician) who had received a call from the reading radiologist ...as per (physician), patient CT abdomen and pelvis from 5/12/2026 showed few tiny bubbles of free air posterior to the stomach which may represent gastric perforation...Given ambiguity of findings consulted (surgeon). (Surgeon) recommended CT abd pelvis with oral contrast...”. On July 29, 2026, at 10:25 AM, Staff member #3 (SM3) indicated in an interview that typically, when a provider either misread or did not identify visual findings on an X-ray, it would be brought to SM3’s attention and they would review the medical record and determine if a peer to peer review was necessary. In this case, SM3 was not aware of the findings and the addendum made to P1’s CT scan reading and did not know why it was not reported to them. SM3 stated that they get notified of such events either via a submission of a complaint/grievance or by the facility’s safety reporting system. Staff Member #3 indicated that this incident was not submitted in the hospital’s safety reporting system and it should have been. During the survey, SM3 contacted the Medical Director (MD) of Imaging by phone and discussed this case. The MD was not aware of the findings and stated they would review the record upon their return from leave. On July 29, 2026, at 11:10 AM, an interview was conducted with Staff Member #12 (SM12). SM12 stated that they read P1’s second CT scan and noticed the bubbles of air, and reviewed P1’s first CT scan completed on May 12, 2026 again. At that time, SM12 visualized the bubbles on the first CT scan. SM12 generated an addendum to the first documented CT scan results. SM12 explained that they are aware of the facility’s safety reporting system, but was “never told to” document an incident like this in the system. They only corrective action they are familiar with is to create an addendum to the report.”

    Rule A0353. Standard-level. From a complaint.

  • Supervision Of Contract Staff

    The inspectors’ words, 685 words

    “SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46466 Based on facility document reviews, medical record reviews and interviews, the facility failed to document pain assessments per facility policy for four (4) of four (4) patient records reviewed. (Patient #1, 2, 3 and 4) The finding include: A review of the facility’s policy “Pain Management”, effective 5/26/2026, indicated in part: “...Applies to all patient care areas, including but not limited to the Emergency Department...”A. Pain Assessments: 1. Shall be conducted: a) During any emergency department visit...e) Upon patients’s initial complaint of pain...g) Before or at the time administration of “as needed” (prn) medications for pain...4. shall include at least a pain score, pain location, and pain descriptors...B. Pain Goal: 1. Document patient’s pain goal...with initial assessment of pain...C. Pain Management...4. Pharmacological Management...The patient’s pain score will be assessed and documented prior to the administration of any as needed (PRN) pain medication...D. Pain Reassessments: 1. Reassessment of pain using the same pain scale should occur after the intervention as clinically indicated...2. Pain reassessments should be completed based on the type of intervention (pharmacological and/or non-pharmacological) and no later than 4 hours post intervention and should include pain score or patient response to intervention...G. Documentation: Pain documentation using a standardized scale and including functional descriptors when indicated: 1. Initial and ongoing assessments...4. Flowsheets, 5. MAR (medication administration record). Medical record reviews conducted on July 28, 2026, revealed the following: Patient #1’s (P1) medical record revealed that P1 arrived at the Emergency Department (ED) on May 12, 2026 at 8:10 PM. Triage was started at 8:16 PM, and no pain assessment, pain goals or pain descriptors were documented in the medical record (MR). Per MR review, P1 received pain medication at 9:34 PM and no pain assessment, pain goals or pain descriptors were documented. The MR didn’t contain any documentation of a pain reassessment after 9:34 PM. At 10:05 PM, P1 was administered pain medication and MR didn’t reveal any documentation of a pain assessment, pain goals or pain descriptors while in ED. P1 was admitted and transferred to the floor on May 13, 2026 at 12:00 AM. P2’s medical record revealed that the patient arrived to the ED on May 12, 2026, at 10:29 PM with complaints of chest and back pain. P2’s MR didn’t evidence of pain assessment, pain goals or pain descriptors documentation during this ED stay. P3’s medical record revealed that the patient arrived to the ED on May 13, 2026 at 5:52 AM. P3’s MR evidenced documentation of pain assessment with a pain score, but no pain goal was documented. P4’s medical record revealed that the patient arrived to the ED on May 13, 2026 at 1:16 PM. The patient received pain medication at 2:46 PM for a reported pain score of 10/10. Per MR review, P4’s pain was not reassessed until the patient was admitted and transferred to the floor at 10:15 PM. On July 28, 2026, at 2:20 PM, Staff Member #8 (SM8) explained in an interview that patients are assessed for pain and pain goals during triage and should be documented in the patient’s chart. SM8 indicated that after a patient receives pain medication, the patient is to be reassessed for pain within 60 to 90 minutes or per facility policy. On July 29, 2026, at 9:30 AM, Staff Member #10 (SM10) revealed in an interview that pain assessments should be conducted on initial triage at the Emergency Department (ED) with the pain score, pain goal and location of pain documented in the patient’s chart. SM10 indicated that pain reassessments should be completed within four (4) hours after pain medication administration and documented in the patient’s medical record.”

    Rule A0398. Standard-level. From a complaint.

The one inspection in the last three years
Inspections on record
DateVisitWhat the record says
Jul 29, 2026Complaint inspection2 deficiencies cited

How do patients fare?

  • CMS’s overall for it is 4 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 6; safety of care, 1 better and 0 worse of 4; readmission, 1 better and 1 worse of 8.
  • Patients rate it 3 of 5 in CMS’s patient survey (525 surveys completed, Oct 1, 2024 to Sep 30, 2025): 64% rated it 9 or 10 out of 10, and 65% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.4%, heart failure 14.3%, pneumonia 17.9%, COPD 11.8%, stroke 9.5%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 15.2%, heart failure 22.9%, pneumonia 17.5%, COPD 19.6%, hip or knee replacement 5.5%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 174 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
  • 74% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 1 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 54 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 53 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Jul 1, 1966.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
  • 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
  • 83% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Bon Secours Hampton Roads Health System Inc. owns 100% directly since Jan 1, 2020.
  • 18 owners or officers are people: Ann M Kirk (corporate director); Kevin Clark (corporate director); Angela Reddix (corporate director); Patricia Davis-Hagens (corporate director); David A Cannady (corporate director); Brian Yanofchick (corporate director); John Starcher (runs it (operational or managerial control)); Dawn Glynn (corporate director); Corey Mccray (corporate director); Raymond L Mccue (corporate director); Teresa Beale (corporate director); Jonathan L Haynes (corporate officer); Jonathan L Haynes (corporate director); Jonathan L Haynes (managing employee (on the payroll)); John E Snellings (corporate director); Cynthia C Romero (corporate director); Kimberly M Ralston (managing employee (on the payroll)); Joy L Jefferson (corporate director).
  • CMS’s Provider of Services file records 1 change of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
Bon Secours Mercy Health Inc.Owns 5% or more through other companies100%Sep 1, 2018
Bon Secours Hampton Roads Health System Inc.Owns 5% or more directly100%Jan 1, 2020

How does it compare nearby?

  • Of the 2 hospitals CMS lists in Newport News City, 2 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 3 of 5.
  • CMS rates this one 4 of 5.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

1 compared
PlaceOverall star rating
Riverside Regional Medical Center3

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

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