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Every family's needs are unique. We encourage you to visit Bickford of Chesapeake in person, speak with staff and current residents' families, and trust your instincts. The data on this page provides a starting point, but your personal impression matters most.
While many visitors praise the facility's beautiful, modern building and the compassionate nature of certain staff members, there are significant and recurring reports of serious care failures. Families should be aware of frequent complaints regarding extremely slow response times to call bells, failure to follow dietary restrictions, and inconsistent medication management.
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Key Review Excerpts
“The team goes above and beyond to create a warm, family-like atmosphere while ensuring residents feel safe, supported, and valued.”
“All residents wear a fall monitor, but we found they weren’t of much use when our father fell and laid on the floor for 5 hours, and that’s on camera.”
“The building is beautiful, but my family's experience was heartbreaking for our dad. He declined rapidly after moving in and sadly, he was only a resident for six months before he passed away.”
Source: VA State Licensing Agency
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/18/2025 9:10 am to 11:00 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/13/2025 regarding allegations in the area(s) of: Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of morning activity was completed in the assisted living facility. Call bells tested. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Based on a review of documentation and staff interviews, it was determined that the facility did not ensure the resident?s individualized service plan ( ISP
Based on a review of documentation and interviews, it was determined that the facility did not ensure to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: 1. A review of the call bell logs for Resident #1 identified 6 occurrences of the call bell being pushed, with the following response time: 8/2/25 54 minutes and 55 seconds, 8/5/25 1 hour and 22 seconds, 8/7/25 1 hour 13 minutes and 2 seconds, 8/8/25 43 minutes 15 seconds, 8/13/25 1 hour and 2 minutes 6 seconds, 8/21/25 50 minutes 49 seconds. 2. A review of the call bell logs for Resident #2 identified 8 occurrences of the call bell being pushed, with the following response time: 8/1/25 1 hour 51 minutes 30 seconds, 8/5/25 1 hour 4 minutes 39 seconds, 8/7/25 1 hour 21 seconds, 8/9/25 1 hour 31 minutes 18 seconds, 8/19/25 1 hour 58 minutes 35 seconds, 8/24/25 54 minutes 26 seconds, 8/25/251 hour 12 minutes 44 seconds, 8/28/25 1 hour 14 minutes 17 seconds.
Type of inspection: Renewal An unannounced on-site renewal inspection conducted by two Region1 Licensing Inspectors. (Ar. 08:20 a.m./Dep 14:45 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication pass observation (AL/scu), breakfast meal (scu), emergency preparedness, activity (AL) Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes Licensing Inspector at 757- 439-6815 or by email at willie.barnes@dss.virginia.gov
Based on observation and staff interviewed, the facility failed to ensure the first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates did not past their expiration date. Evidence: 1. On 9-3-25, the first aid kit for the facility vehicle checked with staff #5 and first aid kit at the nurse?s station checked with staff #3 and #1 did not include a disposable single-use breathing barriers or shields for use with rescue breathing or CPR. The first aid kits also did not include an assortment of sizes of gauze pads and roller gauze. 2. Staff #1 #3 and #5 acknowledged the first aid kits did not include all required items.
Based on documents reviewed and staff interviewed, the facility failed to ensure a criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. On 9-3-25, the facility did not have a criminal history record report for the following employees: (a) staff CRC
Based on records reviewed and staff interviewed, the facility failed to ensure each direct care staff member who did not have current certifications in first aid shall receive a certification within 60 days of employment. Evidence: 1. On 9-3-25, staff #4?s record did not include documentation of adult first aid. Staff?s date of hire noted as 1-28-25. 2. Staff #1 acknowledged the aforementioned staff?s record did not have documentation of adult first aid training within 60 days of employment.
Based on records reviewed and staff interviewed, the facility failed to ensure it did not obtain and or retain individuals with prohibited conditions or care needs. Evidence: 1. On 9-3-25, resident #1?s August and September 2025 medication administration records ( MAR
Based on record reviewed and staff interviewed, the facility failed to ensure that the facility document that the order of priority specified in 1100-A of the regulation was followed, and the documentation was retained in the resident?s file. Evidence: 1. On 9-3-25, a review of resident #1?s record noted the resident was admitted to the facility and placed on the facility?s safe, secure unit on 5-22-25. The facility did not have documentation of the person in the order of priority granting approval for placement in the facility?s safe, secure environment (sse). 2. Staff #1 and #2 acknowledged the aforementioned resident?s record did not have approval for placement on the sse from someone in the order of priority.
Based on document reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Based on observation and staff interviewed, the facility failed to ensure the findings of the most recent inspection were posted. Evidence: 1. On 9-3-25, the findings of the most recent inspection for the facility were a Complaint Inspection dated 7-2-2024. 2. Staff acknowledged the most recent inspection was not posted.
Based on observation, documents reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN
Based on documents reviewed and staff interviewed, the facility failed to ensure the updated/ reviewed, individualized service plan ( ISP
Based on observation and staff interviewed, the facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 9-3-25, the menu for meals and snacks for the current week was not posted or available on the safe, secure unit. 2. Staff #4 acknowledged the current menu for the week was not posted or available on the facility?s safe, secure unit.
Based on observation, documents reviewed and staff interviewed, the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific hours, times, such as before, after, or with meals. Evidence: 1. On 9-3-25, during the medication pass observation with staff #3, resident #2?s Levothyroxine was administered at 9:35 a.m. The September 2025 medication administration record (Mar) noted medication time for 7:00 a.m. The physician?s order signed and dated 7-22-25 noted medication time of 7:00 a.m. Resident #2?s Atorvastatin, Donepezil, and Eliquis were administered at 9:35 a.m. The resident?s MAR
Based on record reviewed and staff interviewed, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment (sse), direct care staff shall attend at least 10 hours of training in cognitive impairment. Evidence: 1. On 9-3-25, a review of staff #4?s training record, staff had 1.5 hours of cognitive impairment training. Staff?s date of hire noted as 1-28-25. 2. Staff #1 acknowledged the aforementioned staff did not have 10 hours of cognitive training within 4 months of employment.
Based on the document reviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person, whether the certification is in first aid or CPR and both must be kept up to date. Evidence: 1. On 9-3-25, the first aid and CPR listing posted in the administrative section did not include the names of current staff certified in first aid and/or CPR. 2. Staff #1 and #2 acknowledged the FA/CPR posting was not kept up to date as required.
Based on documents reviewed and staff interviewed, the facility failed to ensure the private pay uniform assessment instrument ( UAI
Based on observation and staff interviewed, the facility failed to ensure the current license was posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. On 9-3-25, the license posted on the wall left of the sign-in desk was dated ?November 13, 2023, through November 12, 2024. 2. Staff #1 and #2 acknowledged the current license for the facility was not posted as required.
Based on documents reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/14/2025 from 10:45 am to 11:50 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/06/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2025 from 12:10 pm to 4:15 pm, 03/03/2025 from 9:45 am to 12:10 pm, and 03/12/2025 from 1:15 pm to 2:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Four complaints were received by VDSS Division of Licensing on 02/19/2025, 02/25/2025, 02/27/2025, and 03/07/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure a fall risk rating is completed at least annually and after a fall. Evidence: 1. The most current fall risk rating in the record of Resident #1 was completed on 10/17/2023. 2. The most current fall risk rating in the record of Resident #6 was completed on 11/30/2023. Nursing notes also indicate Resident #6 fell on 11/12/2024, 12/3/2024, 12/10/2024, 1/19/2025, and 2/17/2025.
Based on record review and interview, the facility failed to ensure care provision and service delivery be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. During the onsite inspection on 02/26/2025, the average call bell response time for the past two weeks were reviewed for 5 residents. The average time for staff to respond to Resident #1?s call bell was approximately 37 minutes (5 calls) per documentation. The average time for staff to respond to Resident #2?s call bell was approximately 28 minutes (71 calls) per documentation. The average time for staff to respond to Resident #3?s call bell was approximately 32 minutes (24 calls) per documentation. 2. The facility?s Pull Cord Response Time policy and procedure indicates staff should respond to pull cord alerts within 9-12 minutes.
Based on record review, the facility failed to complete a resident?s UAI
Based on record review and interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. The information shall be included in the records of the involved residents. Evidence: 1. Staff #1 confirmed police interviewed Resident #1 and Resident #7 following an alleged interaction between the two in November 2024. 2. There was no documentation of a reported/alleged incident in November 2024 nor of the police interview/visit in Resident #1?s record.
Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. Evidence: 1. The task sheet documentation for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 does not indicate the resident received or attempted to receive bathing at least twice a week in February 2025.
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. February 2025 MAR
Based on record review, the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls should a resident who meets the criteria for assisted living care fall. Evidence: 1. Resident #6 meets the criteria for assisted living care; however, there is not documentation of an analysis of the circumstances and interventions that were initiated to prevent or reduce risk of subsequent falls following their documented falls on 11/12/2024, 12/3/2024, 12/10/2024, 1/19/2025, and 2/17/2025.
Based on record review and interview, the facility failed to review and update individualized service plans at least once every 12 months. Evidence: 1. The most current ISP
Based on record review, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional be secured immediately and notify the resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate as soon as possible but no later than 24 hours from a suspected accident or injury. Evidence: 1. Nursing notes indicate Resident #1 complained of right hand ?being bruised and swollen? on 02/01/2025. 2. Resident #1?s record shows there were orders for x-ray of right hand due to pain obtained on 02/03/2025 with results negative of fracture on 02/04/2025. 3. Resident #1?s record does not indicate Resident #1?s next of kin, legal representative, or designed contact person was notified of the situation and action taken. 4. Nursing notes indicate Resident #6 fell on 02/17/2025 with the resident unable to stand. An order for an x-ray of Resident #6?s hips were obtained, completed, and confirmed a right hip fracture on 02/19/2025. 5. Resident #6?s record does not indicate there were any notifications to Resident #6?s physician, next of kin, legal representative, or designated contact person within 24 hours from the situation.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2025 from 12:10 pm to 4:15 pm and 03/03/2025 from 9:45 am to 12:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/13/2025 regarding allegations in the area(s) of: Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review and interview, the facility failed to maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. Evidence: 1. The facility was unable to provide a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care.
Based on record review, the facility failed to adequately staff in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. Evidence: 1. The staff schedule indicates there was only 1 direct care staff from 6:00 am-10:00 am on 02/08/2025 to care for approximately 40 residents residing in assisted living. 2. The February 2025 MAR
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2025 from 12:10 pm to 4:15 pm and 03/03/2025 from 9:45 am to 12:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/14/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #1?s record included orders dated 01/15/2025 to ?elevate legs when sitting down or supine? and ?must have access to water/hydration at all times;? however, Resident #1?s ISP
Based on record review and interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber be provided according to their instructions and documented. Evidence: 1. Resident #1?s record included an order dated 02/06/2025 for labs to be completed. 2. Resident #1?s record did not include results or any follow-up actions on the 02/06/2025 lab order. 3. The facility was unable to provide information regarding obtaining labs per the 02/06/2025 order for Resident #1 during the onsite visit on 02/26/2025 and 03/03/2025.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2025 from 12:10 pm to 4:15 pm and 03/03/2025 from 9:45 am to 12:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/12/2024 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Resident Accommodations and Related Provisions. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling, whether or not it results in injury. Evidence: 1.Resident #1 had an assisted fall per their record on 01/09/2025; however, there was no documentation Resident #1?s designated contact person was notified of the fall.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/03/2025 from 11:45 am to 2:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/15/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the (complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. The MAR
Based on record review, the facility failed to ensure a fall risk rating is completed after a fall. Evidence: 1. Resident #1 fell per nursing notes on 11/25/2024, 8/20/2024, and 7/11/2024; however, the last fall risk rating for Resident #1 was completed on 6/22/2024.
Based on record review, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber be provided according to their instructions and documented. Evidence: 1. The MAR
Based on record review and interview, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Nursing notes for Resident #1 indicate Resident #1 has refused to walk following a fall on 11/25/24. 2. Nursing notes and interviews with staff also indicate the resident is two-person assist with care. 2. The ISP
Based on record review, the facility failed to ensure the MAR
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