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Deficiency Category | Inspection Date: 4/17/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 7/14/22 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 2/27/20 Complaint Reporting Period: 3/1/22 - 2/28/23 |
---|---|---|---|
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: | 4/17/24Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | No complaint inspections |
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25 | 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 safe, appropriate dialysis care/services for a resident who requires such services. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Some |
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | 4/17/24 | 7/31/24 | 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. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/17/24 | 7/31/24 | 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 and implement an infection prevention and control program. | 4/17/24 | 7/31/24 | 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) |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 4/17/24 | 7/31/24 | 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) |
---|---|---|---|---|
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. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 4/17/24 | 7/31/24 | 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. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 4/17/24 | 7/31/24 | 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 each resident’s drug regimen must be free from unnecessary drugs. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
No Environmental 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) |
---|---|---|---|---|
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | 4/17/24 | 7/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Date of last standard health inspection: | 7/14/22Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 6/14/23Read the full report (PDF) |
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | 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: |
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 safe, appropriate dialysis care/services for a resident who requires such services. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 6/14/23 | 7/11/23 | 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) |
---|---|---|---|---|
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 7/14/22 | 8/22/22 | 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) |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/14/23 | 7/11/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident receives an accurate assessment. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 7/14/22 | 8/22/22 | 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) |
---|---|---|---|---|
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. | 7/14/22 | 8/22/22 | 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. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
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. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor 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. | 7/14/22 | 8/22/22 | 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 a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 7/14/22 | 8/22/22 | 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: | 2/27/20Read the full report (PDF) |
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | 7/14/22Read the full report (PDF) |
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 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) |
---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 2/27/20 | 3/16/20 | 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 enough food/fluids to maintain a resident's health. | 2/27/20 | 3/16/20 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 2/27/20 | 3/16/20 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 2/27/20 | 3/16/20 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 2/27/20 | 3/16/20 | 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 and implement an infection prevention and control program. | 2/27/20 | 3/16/20 | 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) |
---|---|---|---|---|
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 2/27/20 | 3/16/20 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 2/27/20 | 3/16/20 | 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) |
---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 2/27/20 | 3/16/20 | 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) |
---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 2/27/20 | 3/16/20 | 2 - Minimal harm or potential for actual harm | Some |
Dispose of garbage and refuse properly. | 2/27/20 | 3/16/20 | 1 - Potential for minimal harm | Many |
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. |
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 safe, appropriate dialysis care/services for a resident who requires such services. | 7/14/22 | 8/22/22 | 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. | 7/14/22 | 8/22/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 6/14/23 | 7/11/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/14/23 | 7/11/23 | 2 - Minimal harm or potential for actual harm | Some |
This nursing home has not had any infection control inspections in the past 3 years. |