Bickford of Spotsylvania
Families consistently rate this highly — reviewers highlight warm and attentive staff. Schedule a visit to confirm the fit.
based on 44 Google reviews
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What this means for your family
This facility is excellent for its culture of care and the visible dedication of its frontline staff and activity coordinators. However, you must exercise extreme caution regarding financial transactions; ensure all deposit agreements are documented in writing and follow up aggressively to ensure refunds are processed.
Google Reviews
Google Reviews
44 reviews on Google“Families will find a warm, family-oriented environment with highly praised staff members, particularly the Family Advocate, who are noted for their personalized care and welcoming tours. However, there are serious, recurring allegations regarding the failure to return move-in deposits and poor follow-up communication from management following resident deaths or changes in care.”
Quality Themes
Tap a score for detailsStrengths
- Warm and attentive staff
- Personalized care approach
- Welcoming and professional tours
- Engaging resident activities
Concerns
- Failure to refund deposits (mentioned by 2 reviewers)
- Poor administrative follow-up/communication (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 30 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1We've heard wonderful things about how warm and attentive the staff is here; how do you ensure that personalized care approach stays consistent for every resident?
- 2Could you walk us through some of the specific activities or social events that help keep the residents engaged throughout the week?
- 3How does the administrative team handle communication with families to ensure we are always kept in the loop regarding our loved one's well-being?
- 4What is the specific protocol for handling medical emergencies or urgent care needs during the overnight hours?
- 5Can you explain your process for managing deposits and financial transitions to ensure everything is clear and documented for the family?
- 6Since you are memory care certified, how do the daily routines differ for residents specifically in that program?
Personalized based on this facility's data
Key Review Excerpts
“The staff's focus on detail and commitment to making Bickford of Spotsylvania a great place for all of its residents. The customized care provided for each and every resident there impressed me.”
“My brother stayed at Bickford for 1 1/2 years. He moved as he was unhappy with another place within Fredericksburg. What a difference. Anything I asked about I got a reply immediately or a note telling me who would reply and when (and they did).”
“It has been more than 90 days and the deposit has not been returned. We have reached out numerous times and are told we will get an update, and then most times no one follows up with us.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Dec 11, 2025Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/11/2025 Time In: 12:49 PM Time out: 4:14 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/14/2025 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents engaging in scheduled activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on record review and staff interview, the facility failed to ensure to have staff adequate 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. During the onsite inspection, 12/11/2025, staff 4 provided a disclosure statement that detailed adequate staff and confirmed the staffing schedule to include both assisted living facility and the safe, secure environment: first shift (7 am ? 3 pm) 2 registered medication aides (RMAs) and 3 certified nursing assistants (CNAs) were to be scheduled; second shift (3 pm ? 11 pm) 2 RMAs and 3 CNAs; and third shift (11 pm ? 7 am) 1 RMA and 2 CNAs. 2. The May and October 2025 staffing schedules indicated that RMAs were not scheduled on the first shift: 05/31/2025, 10/12/2025, and 10/18/2025. 3. The November 2025 staffing schedule indicated that one RMA was scheduled on the first shift: 11/09/2025, 11/10/2025, 11/14/2025, and 11/15/2025. 4. The October and November 2025 staffing schedules indicated that RMAs were not scheduled on the second shift: 10/12/2/2025, and 11/13/2025. 5. The May, October, and November 2025 staffing schedules indicated that one RMA was scheduled on the second shift: 05/26/2025, 05/31/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/18/2025, and 11/15/2025. 6. The October 2025 staffing schedule indicated that RMAs were not scheduled on the third shift: 10/12/2025, 10/13/2025, and 10/18/2025. 7. The October 2025 staffing schedule indicated that CNAs were not scheduled on the first and second shift on 10/12/2025. 8. During the onsite inspection, 12/11/2025, staff 4 confirmed that the facility did not have staff 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.
Based on record review and staff interview, the facility failed to maintain a written plan that specified 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. This plan should be directly related to actual resident acuity levels and individualize care needs. Evidence: 1. Upon request the facility did not provide a written plan that specified 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 residents in care. 2. During the onsite inspection, 12/11/2025, staff 4 provided the disclosure statement in lieu of the written plan. Staff 5 confirmed that the written plan was not provided upon request.
Based on record review, the facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time. The facility should maintain a copy of the schedule for two years. Evidence: 1. Upon request the facility did not provide the staff schedule for 09/21/2025 and 10/19/2025. 2. During the onsite inspection 12/11/2025, staff 2 confirmed that the staff schedules for 09/21/2025 and 10/19/2025 were ?not found? or provided to licensing inspector (LI).
Based on record review and staff interview, the facility failed to have, keep current, and implement a written plan for medication management. The facility?s medication plan should address procedures for administering medication and should include methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670. Evidence: 1. The licensing department received a self-report on 11/14/2025 stating, ?an unlicensed employee administered medications to residents in an assisted living facility? on 05/31/2025, 09/21/2025, 10/19/2025, and 11/13/2025. 2. The Medication Management Plan stated, ?medication is only to be administered, supervised, or reminders given by qualified Bickford Family Members (BFMs). Qualified BFMs: BFMs who are licensed/certified/credentialed to administer medications and whose medications tasks have been successfully delegated by the nurse. 3. During the onsite inspection, 12/11/2025, staff 4 confirmed that due to insufficient staffing of registered medication technicians an employee who did not meet the qualification requirements for administering medications documented that they administered over two hundred medications to approximately thirty residents over the course of the following days: 05/31/2025, 09/21/2025, 10/19/2025, and 11/13/2025.
Based on record review and staff interview, the facility failed to ensure that when staff administered medications to residents, the following standards applied: each staff person who administered medications should be authorized by 54.1-3408 of the Virginia Drug Control Act. All staff responsible for medication administration should: be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide, except as specified in subdivision 2 of this section. Evidence: 1. The facility submitted a self-report on 11/14/2025, stating that ?an unlicensed employee administered medications to residents." 2. The facility?s Med Pass Details indicated that staff 1 administered over two hundred medications to approximately thirty residents over the course of the following days: 05/31/2025, 09/21/2025, 10/19/2025, and 11/13/2025. 3. Upon request the facility, 12/11/2025 was unable to provide a license by the Commonwealth of Virginia to administer medications or a registration with the Virginia Board of Nursing as a medication aide for staff 1. 4. During the onsite inspection, 12/11/2025, staff 4 confirmed that staff 1 was suspended and was formerly under investigation for administering medications to residents without a license by the Commonwealth of Virginia to administer medications or a registration with the Virginia Board of Nursing as a medication aide.
Dec 11, 2025ComplaintCleanReport
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: 12/11/2025 Time in: 4:15 PM Time out: 5:30 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 11/25/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, Resident Care and Related Services, and Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents engaging in scheduled activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Jul 8, 2025Complaint
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/8/2025 11:15 A.M. ? 1:40 P.M. 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 7/1/2025 regarding allegations in the area(s) of: Building and grounds, and staffing. 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: 0 Number of staff records reviewed:0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, resident rooms, resident bathrooms, and laundry room. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Based on observations and a staff interview, the facility failed to ensure that all furnishings, including furniture, were clean and in good repair. Evidence: 1. The Licensing Inspector (LI) toured the building with Staff 1 on 7/8/2025. During the tour, LI and staff 1 observed that in the memory care area, a fan above the dining room tables had a buildup of dust on its blades, and a chair in the dining area was soiled. 2. Staff 1 confirmed the fan and chair needed cleaned. 3. Photo evidence
Apr 7, 2025Routine
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/7/2025 9:20 a.m. ? 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/3/2025 regarding allegations in the area(s) of: resident care and staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 46 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, secure unit activities and exit door functionality, dining services, and resident room. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Based on resident record review and staff interviews, the facility failed to ensure doors that lead to unprotected areas were monitored or secured through devices that conform to applicable building and fire codes, including constant staff oversight, security bracelets that are part of an alarm system or delayed egress mechanisms. Evidence: 1. Resident 1 was admitted to the secure care unit on 3/31/2025. 2. The Licensing Inspector (LI) received an incident report from the facility advising that resident 1 had eloped from the secure care unit on 4/2/2025 and was returned to the facility by law enforcement. No injuries noted. Facility also noted on the incident report that resident 1?s wander guard would be set to a higher signal and there was a glitch in the system. New wander guards would be ordered. 3. Staff 2 provided a written statement to the facility on 4/4/2025 which indicated resident 1 ?was able to get through the door without the alarm going off due to improperly {sic} working alarm system again this year? 4. On 4/7/2025, staff 1 demonstrated for the LI how the exit doors would alarm for 15 seconds when pushed prior to opening. 5. During lunch preparation, the LI stood in the middle of the dining room amongst staff and residents to listen for the door alarm following activation by staff 1. The LI was able to faintly hear the door alarm. 6. At 12:00 p.m. on 4/7/2025, the LI approached the main door of the secure unit which opened into the dining room of the unit. The LI activated the door alarm and entered the secure unit and observed staff 1 and staff 2 assisting residents with lunch preparations. Neither staff member responded to the door alarm. 7. Staff 1 confirmed to the LI that staff did not respond to the door alarm when activated.
Based on record review, the facility failed to ensure the uniform assessment instrument ( UAI
Based on record review and staff interview, the facility failed to ensure a preliminary individualized service plan ( ISP
Based on record review and staff interviews, the facility failed to develop a comprehensive ISP
Based on resident record review and staff interviews the facility failed to provide supervision of resident care, including attention to specialized needs, such as prevention of wandering from the premises. Evidence: 1. On 4/7/2025, the Licensing Inspector (LI) reviewed resident 1?s admitting history and physical dated 3/28/2025 which identified resident 1 as having wandering and exit seeking behaviors and required placement in a secure unit to reduce risk of elopement. 2. Resident 1?s Individual Service Plan ( ISP
Based on record review and staff interviews, the facility failed to document rounds that were made for residents with a documented service need. Evidence: 1. During review of the ISP
Based on record review and staff interview, the facility failed to conduct exercises for resident emergencies, at least every six months, which included procedures for a missing resident. Evidence: 1. LI requested to see the last two resident emergency exercises. Staff 4 provided a resident emergency exercise conducted on 4/3/2025. 2. LI requested a resident emergency exercise conducted six months prior to 4/3/2025. Staff 4 confirmed a resident emergency exercise had not been completed prior to 4/3/2025.
Apr 7, 2025Other
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/7/2025 1:45 p.m. ? 4:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/23/2025 regarding allegations in the area(s) of: resident care and staffing. Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, resident room, dining services Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at jeffrey.marnien@dss.virginia.gov
Based on email communication and interviews, the facility failed to ensure the assisted living facility operated under the supervision of an acting administrator no more than two times during any two-year period unless authorized to do so by the department. Evidence: 1. During a previous inspection on 9/20/2024, the Licensing Inspector (LI) determined that staff 5 was the acting administrator for the facility. 2. LI received an email from staff 7 on 10/17/2024 which stated staff 6 would assume the role as acting administrator for the facility beginning 10/17/2024. Staff 6 was acting through 11/20/2024. 3. LI received an email from staff 7 on 2/10/2025 which stated staff 3 would now be the acting administrator effective 2/10/2025. 4. LI emailed staff 7 on 2/10/2025, seeking confirmation of compliance with Standard 150-B, Part Six: allowable duration of an acting administrator, and Part Nine: a limit of no more than two acting administrators within a two-year period. No response was received. 3. Staff 7 did not request to assign a third acting administrator within a two-year period of time.
Jan 16, 2025Routine11Report
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/16/2025 9:00 a.m. ? 4:35 p.m., 1/17/2025 9:00 a.m. ? 7:15 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: 54 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: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Building and grounds, activities, meal pass, medication pass. Additional Comments/Discussion: This is a renewal inspection. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Based on record review and staff interview the facility failed to follow their own policies and procedures. Evidence: 1. During document review on 1/16/2025, LI observed the medication reviews were completed on 2/29/2024, 5/31/2024, and 11/30/2024. 2. During interview with staff 1 on 1/16/2025, LI asked if the medication reviews were Completed quarterly or every six months? Staff 1 stated they were completed quarterly. LI requested the facility policy stating medication reviews would be completed quarterly. 3. Staff 1 provided Pharmacy Coordination Policy which stated, ?A quarterly medication audit is completed at the Branch by an independent pharmacist.? 4. LI requested documentation of an August 2024 medication review to complete the quarterly medication review sequence. Staff 1 confirmed the August 2024 medication review could not be located and documentation was not available from the independent pharmacist.
Based on staff record reviews and staff interview the facility failed to ensure the staff orientation and required training occurred within the first seven working days of employment for 4 out of 4 staff records reviewed. Evidence: 1. LI reviewed staff 2, (date of hire (DOH) 9/12/2024), staff 4 (DOH 8/5/2024), staff 5 (DOH 3/25/2024), and staff 6 (DOH 9/19/2024) employee records on 1/17/2025. 2. Each orientation record contained a company document stating it must be completed within 10 days of hire. The company orientation document did not include orientation criteria in this subsection. 3. Staff 1 reviewed the orientation document and the standards with the LI. Staff 1 confirmed the company orientation form did not meet criteria within this subsection.
Based on observation and staff interview the facility failed to post a list of staff who were first aid and CPR certified in the facility so that the information was readily available to all staff at all times and kept up to date. Evidence: 1. During tour of the facility on 1/16/2025, LI requested to view the posted list of staff who were first aid and CPR certified. 2. Staff 1 confirmed the list had not been kept current and posted in the facility and the information was not readily available to all staff at all times.
During document review and staff interview the facility failed to ensure the resident written agreement included a provision that the resident had been informed of the facility policy on weapons on the premises and that the resident has been informed residents could establish and maintain a resident council. Evidence: 1. During interview with staff 3 on 1/17/2025, LI requested if the resident agreement included information that residents would be informed of the facility policy on weapons along with formation of a resident council. 2. Staff 3 reviewed resident agreement and confirmed the facility policy on weapons and formation of resident council was not included in the resident agreement.
Based on record review and staff interview the facility failed to ensure the medication review included a certification by the licensed health care professional that the requirements of subdivision E1 through E11 of this standard were met. Evidence: 1. During document review on 1/16/2025, LI observed a medication review, dated 2/29/2024, which did not include certification by the consulting pharmacist that requirements of subdivision E1 through E11 of this standard were met. 2. Staff 1 reviewed the medication review and confirmed the certification was not included on the form.
Based on staff interviews, the facility failed to develop and implement an orientation and semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual?s respective responsibilities. The review must be documented by signing and dating. Evidence: 1. During an interview with staff 1 and staff 2 on 1/16/2025, LI requested the orientation and semi- annual review of the emergency preparedness and response plan. A Disaster Preparedness and Tornado Training course was provided. 2. Staff 1 and staff 2 confirmed the semiannual review were not completed; documentation was not available and could not be provided.
Based on record review and staff interviews the facility failed to ensure the written plan for fire and emergency evacuation which is to be followed in the event of a fire or other emergency was approved by the appropriate fire official. Evidence: 1. During interview with staff 1 and staff 2 on 1/17/2025, LI asked if the emergency evacuation plan had been approved by the appropriate fire official. 2. Staff 1 and staff 2 confirmed the plan had not been approved by the appropriate fire official.
Based on observation and staff interview the facility failed to ensure the emergency evacuation drawing included the location of a telephone to use in an emergency. Evidence: 1. Licensing Inspector (LI), during a tour of the facility on 1/16/2025, observed the fire and emergency evacuation drawing did not include the identification and location of telephone. 2. During an interview with LI on January 16, 2025, staff 1 confirmed that the fire and emergency drawing did not include the location of telephones. 3. Photo evidence taken and labelled P1.
Based on record review and staff interviews the facility failed to ensure fire drills were completed for each shift in a quarter and were not conducted in the same month. Evidence: 1. During document review, LI observed fire drills were not completed for May 2024, June 2024, July 2024, and August 2024. 2. Drills were also completed on the first shift 9/23/2024 at 10:40 a.m. and 10/18/2024 at 10:50 a.m.
Based on staff interviews the facility failed to ensure resident emergencies were reviewed by the facility, at least every six months, with all staff and documented with the date and staff signature. Evidence: 1. LI requested the review of resident emergencies with all staff every six months including staff signatures and date. 2. Staff 1 and staff 2 confirmed the reviews were not completed every six months; documentation was not completed and could not be provided.
Based on staff interviews the facility failed to ensure every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced and documented. Evidence: 1. LI requested to review documentation of resident emergency exercises every six months. 2. Staff 1 and staff 2 confirmed the resident emergency exercises were not completed; documentation was not available and could not be provided.
Dec 5, 2024Complaint
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/5/2024 9:30am ? 1:30pm. 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 11/8/2024 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication room, medication cart, lunch meal being served. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Based on record review and staff interviews, the facility failed to implement their written plan for medication management. Evidence: 1. Licensing Inspector (LI) requested the most recent physician order sheet (POS) and Medication Administration Record ( MAR
Dec 5, 2024ComplaintCleanReport
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/5/2024 from 1:30 p.m. to 2:00 p.m. 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 11/19/2024 regarding allegations in the area(s) of: resident records Number of residents present at the facility at the beginning of the inspection: 53 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: 2 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: No
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