Loading EveryPlace content…
Public Google reviewers rate this highly and often mention compassionate and attentive nursing staff. Schedule a visit to confirm the fit.
based on 23 Google reviews
Email Birch Gardens to yourself
Get a one-time email with a link to this profile so it is easy to find and share later.
This sends one email and does not add you to a mailing list.
Public Google reviewers rate Birch Gardens highly. Reviewers highlight: compassionate and attentive nursing staff, warm, family-oriented atmosphere. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Birch Gardens is highly regarded by families for its warm, home-like atmosphere and the compassionate, attentive nature of its nursing and administrative staff. While many reviewers praise the facility's recent improvements in care standards and cleanliness, some past concerns regarding administrative presence and suitability for advanced cognitive impairment have been raised.
Quality Themes
Tap a score for detailsStrengths
Concerns
Rating Trends
Tap a year to see what changed
Distribution · 23 analyzed
This facility actively engages with reviewer feedback.
Personalized based on this facility's data
Key Review Excerpts
“Her mental health issues were finally addressed and properly medicated, she is lovingly cared for by an attentive staff, she is able to enjoy a spacious room and bathroom with her picture posted by the door so she can find her way to the correct room.”
“My Dad has been here for over two years. My wife and I both noticed a dramatic improvement in the quality of care, and the general condition of the facility after Rachel Craig took over.”
“The medical staff monitors my brother’s diabetes and helps him get on with his daily living. Your patience is appreciated and he speaks kindly after you all.”
Source: VA State Licensing Agency
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/23/2025 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES BUILDINGS AND GROUND Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: November 6, 2025, from 11:30 a.m. until 2:15 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: 33 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: 8 Number of interviews conducted with staff: 6 Observations by licensing inspector: Licensing inspector toured facility, including some resident rooms, and interviewed some staff and residents. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Based on direct observation and staff interviews, the facility failed to ensure building was kept free of infestations of insects. Evidence: 1. A complaint received by the regional licensing office on 10/23/2025 alleged that ?gnats through the building were bad?, which included the kitchen area. 2. During a tour of the facility on 11/06/2025, LI observed several gnats in resident 6 and 7?s shared bathroom on the mirror above the sink. 3. Photo evidence taken. 4. Resident 7 stated that gnats were so bad last night at dinner that they were landing in the food. Resident 7 stated the gnats have been in the building approximately a month. Resident 7 had expressed concerns regarding gnats to staff 1 and 3. Resident 7 keeps a fly swatter in room to kill the gnats, and LI observed resident kill two gnats. 5. Staff 4 and 6 acknowledged seeing gnats throughout the building, including the kitchen. 6. Staff 3 acknowledged seeing gnats for about a week, especially around sink in beauty shop. Staff 3 stated, ?one was in my coffee yesterday?. 7. Staff 1 acknowledged the presence of gnats in the building and stated that Terminix was coming that day. Staff 1 later confirmed that Terminix did not service the facility on the day of inspection but came out on 11/21/2025.
Based on direct observation and staff interviews, the facility failed to ensure that the interior of building was maintained in good repair. Evidence: 1. During the facility tour on 11/6/2025 licensing inspector (LI) observed approximately 19 one-inch gaps between the flooring throughout the main hallway leading into the dining room of the facility posing a risk for possible tripping hazards and resident falls. 2. Staff 1 acknowledge the presence of gaps in the floor and that the areas could pose a risk for tripping. Staff 1 acknowledged gaps in floor does not meet the standard of maintaining the building in good repair. Photo evidence taken.
Based on direct observation and staff interview, the facility failed to ensure all furnishings were kept clean and in good repair and not soiled in a manner that presents a health hazard. Evidence: 1. A complaint received by the regional licensing office on 10/23/2025 alleged that ?the rooms of the residents are disgusting- body fluids are stuck in carpets.? 2. During a tour of the facility on 11/06/2025 with staff 1, LI observed a large, circular stain in the middle of the carpet in room of residents 9 and 10. Staff 1 acknowledged that there was area on the carpet that was discolored but said it was due to frequent cleaning. LI asked staff 1 about appearance and smell of carpet and asked about the possibility of replacing. Staff 1 acknowledged that carpet was soiled and not in good repair and needed to be replaced. 3. During a tour of the facility on 11/06/2025 with staff 1, LI observed feces on the bathroom wall and trim next to commode, in an unlined trash can, and on the shower floor. Staff 1 acknowledged that these areas were soiled with feces and stated that resident 11 takes herself to the bathroom and ?that?s what she does?. Staff 1 acknowledged that housekeeping does not clean well. 4. Photo evidence taken.
Based on direct observation and staff interviews, the facility failed to ensure that building was free from foul, stale, and musty odors. Evidence: 1. A complaint received by the regional licensing office on 10/23/2025 alleged that ?the rooms of the residents are disgusting and smell like urine.? 2. During a tour of the facility on 11/06/2025 with staff 1, LI detected a stale, musty smell in the shared apartment of residents 9 and 10. Staff 1 acknowledged that there was a smell but stated ?it was how resident 9 smelled.? Neither resident was in the room at the time to which staff 1 indicated ?he (resident 9) makes it smell this way.? 3. During a tour of the facility on 11/06/2025 with staff 1, licensing inspector detected a strong smell of feces in the bedroom and bathroom of resident 11. Staff 1 acknowledged that there was a smell of feces in resident 11?s bedroom and bathroom.
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 7/8/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/29/2025 10:00 a.m. - 10:55 a.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: 35 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: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed resident records, incident reports, and facility communication logs. Additional Comments/Discussion: None 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. 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 6/24/2025 regarding allegations in the area(s) of: Building and Grounds Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/25/2025 2:40 p.m. - 3:15 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: 34 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector toured the inside and outside of the facility including the kitchen and resident rooms. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Building and Grounds A violation notice was 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on direct observation, the facility failed to ensure that the interior of the building was maintained in good repair and kept clean. Evidence: 1. During the facility tour on 6/25/2025, two licensing staff observed the main facility kitchen with dark brown liquid and food substance dried and splattered and/or dripped on several of the walls and floors throughout the kitchen. 2. Three cabinet drawers had been removed and left missing in the kitchen as well as two cabinet doors that had been removed. 3. Photo evidence taken.
Based on direct observation the facility failed to ensure all furnishings were kept in good repair and condition. Evidence: 1. During the facility tour on 6/25/2025, two licensing staff observed four (4) out of 12 rocking chairs on the front porch to have broken pegs or a missing arm rest. 2. Photo evidence taken.
Based on direct observation the facility failed to ensure that any operable window (i.e., a window that may be opened) was effectively screened. Evidence: 1. During the facility tour on 6/25/2025, two licensing staff observed nine operable windows in the dining room, one operable window in the activity room, and 1 operable window in the common area lobby to be without a screen. 2. Photo evidence taken.
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/2/2025 from 8:45 a.m. to 3:30 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: 34 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: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, pharmacy review, healthcare oversight, menus, activity calendars and dietician report. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on record review and staff interview the facility failed to 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. Evidence: 1. Upon request the facility did not provide a review of the emergency preparedness plan with residents or staff. 2. During an interview with staff 1, when asked if there was a semi-annual review of the emergency preparedness plan completed with residents and staff, staff 1 stated ?no?.
Based on record review and staff interview, the facility failed to ensure the record of the required fire and emergency evacuation drills were kept in the facility for two years. Evidence: 1. Review of the records of the fire and emergency evacuation did not include a record for July of 2024 or May of 2025. 2. Upon request the facility did not provide a record for the fire drills completed in July of 2024 or May of 2025. 3. During an interview with staff 1, when asked if there was a fire drill completed in July of 2024 or May of 2025, staff 1 stated ?they were done but I can not find the records.?
Based on direct observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the facility tour on 6/2/2025, two licensing staff observed the laundry room door unlocked that contained a spray bottle of unlabeled cleaning solution, a jug of Tide laundry detergent, three spray bottles of Pledge wood oil, two containers of cleaner with bleach, three containers of Lysol toilet bowl cleaner, one spray can of Raid insect spray, one spray bottle of glass cleaner and one gallon jug of bleach. 2. Photo evidence taken.
Based on record review, the facility failed to ensure each direct care staff member who did not have current certification in first aid had received certification in first aid within 60 days of employment. Evidence: 1. Staff 2 hired 11/16/2024 as a direct care aide, did not have a current certification in first aid. 2. Upon request the facility did not provide a certification in first aid for staff 2.
Based on record review and staff interview the facility failed 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. Evidence: 1. The facility written staffing plan stated on page 78, number 6, ?The staffing matrix will be as listed below: ?When Birch Gardens Assisted Living has 32 to 39 residents, they will staff 1 Registered Medication Aide (RMA) and 3 Direct Care Aides (DCA) per shift.? 2. The facility census on the date of the inspection (6/2/2025) was 34. 3. The staff Schedule for 5/26/2025 through 6/2/2025 showed that out of 21 shifts, 12 shifts were not staffed according to the written staffing plan, with seven out of seven-night shifts having only one RMA and one DCA scheduled. 4. During an interview with staff 1, when asked what the facility typically staffed per shift, staff 1 indicated two to three DCA?s and one RMA on first and second shift, and one DCA and one RMA on third shift.
Based on record review and staff interview the facility failed to ensure at least once every six months, all staff on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced. Evidence: 1. Upon request the facility did not provide any exercises in which the procedures for resident emergencies were practiced. 2. During an interview with staff 1, when asked if the procedures for resident emergencies were practiced at least once every six months, staff 1 stated ?no.?
Based on record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. Resident 3 (admitted 11/11/2024) had a sex offender search completed 12/4/2024. 2. During an interview with staff 1, when asked If the sex offender search was completed prior to admission staff 1 stated ?no it wasn?t?.
Based on direct observation the facility failed to ensure that the interior and exterior of all buildings were maintained in good repair. Evidence: 1. During the facility tour on 6/2/2025 two licensing staff observed approximately 19 one-inch gaps between the flooring throughout the main hallway leading into the dining room of the facility posing a risk for possible tripping hazards and resident falls. 2. Photo evidence taken.
Based on record review and staff interview the facility failed to ensure whenever physical restraints were used that the facility assisted the resident with the restraint as often as necessary, but no less than 10 minutes every hour, for hydration, safety, comfort, range of motion, exercise, elimination, and other needs. Evidence: 1. During the facility tour on 6/2/2025 two licensing staff observed a half rail in the upright position on an unoccupied bed in resident 2?s apartment. 2. During an interview with staff 1, when asked if resident 2 could remove or lower the rails independently when in use, staff 1 stated ?no [they] couldn?t.? 3. When asked if there was documentation of the assistance with hydration, safety, comfort, range of motion, exercise, elimination, and other needs, no less than every 10 minutes every hour, staff 1 stated ?no.?
Based on direct observation the facility failed to implement a procedure for posting the name of the current on-site person in charge. Evidence: 1. During the facility tour on 6/2/2025, two licensing staff observed a white board in the resident hallway dated 6/1/2025 with ?RMA? and ?aides? written on it but no names listed. 2. Photo evidence taken.
Based on record review the facility failed to ensure that the comprehensive Individualized Service Plan ( ISP
Based on record review and staff interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Record review of all new hires since the last inspection on 2/16/2024 showed that five of 20 employee criminal history record reports were not completed on or prior to the 30th day of employment. 2. Upon request the facility could not provide a criminal history record report for five of 20 records reviewed. 3. During an interview with staff 1, when asked if there were criminal history record reports obtained for the five staff, staff 1 stated ?I sent them off but never got them back?.
Based on direct observation and staff interview the facility failed to ensure that over the-counter medications were labeled with the resident's name, or in a pharmacy-issued container, until administered. Evidence: 1. During observation of medication administration, the licensing inspector observed a bottle of Tylenol inside of the original packaging that was missing the top of the package and was not labeled with the resident?s name. 2. During an interview with staff 6, when asked if the medication was labeled with the resident?s name, staff 6 stated ?it was labeled on the top, but someone tore it off.? 3. Photo evidence taken.
Based on direct observation, record review, and staff interview, the facility failed to ensure if a restraint was used, that it was imposed in accordance with a physician's written order that specified the condition, circumstances, and duration under which the restraint was to be used. Evidence: 1. During the facility tour on 6/2/2025 two licensing staff observed a half rail in the upright position on an unoccupied bed in resident 2?s apartment. 2. Record review for resident 2 (admitted 5/2/2023) included a physical exam and report dated 5/1/2023, with a diagnosis of Vascular Dementia listed and a Uniform Assessment Instrument ( UAI
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 5/14/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/14/2025 11:30 a.m - 2:15 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: 34 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents during meals, in their rooms and in common areas. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
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: 2/28/2025 10:40am-11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 1/29/2025 regarding allegations in the areas of: Personnel, resident care and related services, and protection of adults and reporting. 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. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed staff and resident interactions, resident rooms, bathrooms, and common areas. Residents were observed during activities and in common areas. Additional Comments/Discussion: None 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. 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@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: 12/12/2024 2:59pm-5:00pm 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 12/10/2024 regarding allegations in the area(s) of: Resident care and related services, staffing, and reporting. Number of residents present at the facility at the beginning of the inspection: 34 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: 4 Observations by licensing inspector: The licensing inspector observed residents in common areas and during meals, staff and resident interactions, and staff schedules. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Based on record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. Evidence: 1. A complaint was received by the regional licensing office on 12/10/2024 alleging resident 1 had eloped from the facility and fallen and obtained an injury and there was no contact made by the facility with family, the physician, or adult protective services. 2. An incident report was received by the regional licensing office from the facility reporting the same incident as the complaint. 3. During an interview with staff 1, Staff 1 confirmed that resident 1 wandered out of the facility and was brough back to the facility by an unknown person who found him outside. 4. When asked if resident 1 had previous wandering behavior, staff 1 stated ?yes?.
Based on record review and staff interview, 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 or wandering from the premises. Evidence: 1. During the record review on 12/12/2024, there was no documentation of the notification of the next of kin or adult protective services of the incident. 2. During an interview with staff 5, staff 5 confirmed that they were the supervisor on duty on the date of the incident, and that the next of kin nor APS was notified of the incident.
Based on record review and staff interview, the facility failed to ensure individualized service plans ( ISP
Based on record review and staff interview, the facility failed to ensure for each resident with an inability to use the signaling device, the inability is included in the resident's individualized service plan. Evidence: 1. During an interview with staff 2, when asked if resident 1 was able to use the call bell staff 2 stated ?I?ve never known him to use the call bell?. 2. During an interview with staff 6, when asked if resident 1 was able to use the call bell, staff 6 stated ?no, I wouldn?t say so?. 3. The 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: 11/21/2024 12:26pm ? 2:42pm 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 11/21/2024 regarding allegations in the area(s) of: Building and grounds, resident care and related services, and medication administration. Number of residents present at the facility at the beginning of the inspection: 32 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector reviewed resident and staff records including the medication administration record. Residents were observed during mealtime and in common areas. Additional Comments/Discussion: None 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: 670, 680-D, 870-A 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Based on direct observation the facility failed to ensure resident records are stored in a locked area. Evidence: 1. During the building and grounds tour the medication room door was observed propped open containing a bookshelf housing the resident records. 2. Photo evidence taken.
Based on direct observation the facility failed to ensure the interior of the building be maintained in good repair and kept clean. Evidence: 1. A complaint was received by the regional licensing office alleging mold growing on the walls of the facility. 2. During the building and grounds tour on 11/21/2024 a green and black substance was observed on the interior walls of the closet of apartment 18 as well as several areas of baseboard rotting and separating from the walls. 3. Photo evidence taken.
Based on record review and staff interview the facility failed to administer medications in accordance with the physician's or other prescriber?s instructions. Evidence: 1. A complaint was received by the regional licensing office on 11/21/2024 alleging that medications are not being administered as ordered by the physician. 2. Resident 1 had a physician?s order dated 10/22/2024 that states Reduce Novolog to 3 units TID (hold if bs <100. 3. The October Medication Administration Record ( MAR
Based on record review and staff interview the facility failed to ensure the listing of all staff who have current certification in first aid or CPR is kept up to date. Evidence: 1. Staff 1 provided a list of all staff who are current in first aid and CPR which included staff 2 on the list. 2. The facility did not provide the certification of first aid and CPR for staff 2. 3. When asked if the list was current, staff 1 stated ?I guess not because [staff 2] doesn?t have it?
Based on record review and staff interview, the facility failed to ensure each staff member receive certification in first aid within 60 days of employment. Evidence: 1. The facility did not provide a first aid certification for staff 2 (hired 7/1/2024). 2. During an interview on 11/21/2024, when asked if staff 2 had a first aid certification, staff 1 stated ?I don?t see it?.
Based on direct observation the facility failed to ensure hazardous materials are stored in a locked area. Evidence: 1. During the building and grounds tour the following were observed, a.The medication room door was observed propped open containing a jug of drug disposal on the treatment cart. b. The timeclock room door was left fully open containing a container of Clorox disinfecting wipes on the counter. c. The laundry room door was left cracked open containing a container of Clorox wipes, a spray bottle of resolve, and an unlocked closet containing multiple spray bottles of cleaning solution, and three containers of bleach. 2. Photo evidence taken.
Based on record review and staff interview, the facility failed to ensure staff administering medication are registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. A complaint was received by regional licensing office on 11/21/2024 alleging an unlicensed individual was administering medications. 2. The record for Staff 2, hired 07/01/2024, had a letter from the Department of Health Professions to act as a provisional medication aide dated 6/12/2024. 3. The provisional 120-day period for staff 2 ended 10/10/2024. 4. Staff 2 was scheduled as the RMA on duty and administered medications on 25 dates including October 11,13,15,16,17,18,20,22,23,24,25,27,29,30, 2024 and November 1,3,4,10,12,13,14,15,17,18 and 20, 2024. 5. During an interview on 11/21/2024, staff 1 confirmed that staff 2 had ended the provisional eligibility period and was scheduled as the RMA on duty on the dates listed. Staff 1 stated ?staff 2 passed the RMA exam on November 1, 2024, but is not showing registered with the Board of Nursing.?
Contact this facility directly and verify the details that matter most to your family.
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
English Meadows Fishersville Campus
< 1 miAssisted Living · Fishersville, VA
Birch Ridge (augusta Co)
< 1 miAssisted Living · Staunton, VA
Augusta Nursing & Rehab Center
1.2 miNursing Home · Fishersville, VA
Augusta Medical Ctr Skilled CA
1.2 miNursing Home · Fishersville, VA
Regency at Augusta
1.5 miAssisted Living · Fishersville, VA
Shenandoah Nursing Home
1.6 miNursing Home · Fishersville, VA