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Deficiency Category | Inspection Date: 4/15/22 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 11/29/18 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 9/21/17 Complaint Reporting Period: 4/1/22 - 3/31/23 |
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Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
Quality of Life and Care Deficiencies | |||
Infection Control Deficiencies | |||
Resident Assessment and Care Planning Deficiencies | |||
Nursing and Physician Services Deficiencies | |||
Resident Rights Deficiencies | |||
Nutrition and Dietary Deficiencies | |||
Pharmacy Service Deficiencies | |||
Environmental Deficiencies | |||
Administration Deficiencies |
Date of last standard health inspection: | 4/15/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | No complaint inspections |
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Virginia: | |
Average number of Health Deficiencies in the United States: |
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide enough food/fluids to maintain a resident's health. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 4/15/22 | 5/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Many |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure staff are vaccinated for COVID-19 | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Plan the resident's discharge to meet the resident's goals and needs. | 4/15/22 | 5/27/22 | 3 - Actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Some |
No Pharmacy Service Deficiencies were found during this inspection period. |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 11/29/18Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | No complaint inspections |
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Virginia: | |
Average number of Health Deficiencies in the United States: |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
No Infection Control Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
PASARR screening for Mental disorders or Intellectual Disabilities | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
No Nursing and Physician Services Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
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. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that residents are free from significant medication errors. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Ensure 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. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 11/29/18 | 1/7/19 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental Deficiencies were found during this inspection period. |
No Administration Deficiencies were found during this inspection period. |
Date of last standard health inspection: | 9/21/17Read the full report (PDF) |
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 4/15/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
Total number of Health Deficiencies for this nursing home: | |
Average number of Health Deficiencies in Virginia: | |
Average number of Health Deficiencies in the United States: |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Provide necessary care and services to maintain or improve the highest well being of each resident . | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Some |
Develop policies and procedures for influenza and pneumococcal immunizations. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
No Infection Control Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Allow residents the right to participate in the planning or revision of care and treatment. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Review or revise the resident's care plan after any major change in physical or mental health. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
No Nutrition and Dietary Deficiencies were found during this inspection period. |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that residents are safe from serious medication errors. | 9/21/17 | 11/3/17 | 3 - Actual harm | Few |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Some |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | 9/21/17 | 11/3/17 | 3 - Actual harm | Few |
Have a program that investigates, controls and keeps infection from spreading. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Train all employees on what to do in an emergency, and carry out unannounced staff drills. | 9/21/17 | 11/3/17 | 2 - Minimal harm or potential for actual harm | Few |
Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/15/22 | 5/27/22 | 2 - Minimal harm or potential for actual harm | Some |
This nursing home has not had any infection control inspections in the past 3 years. |