English Meadows Fishersville Campus
Families consistently rate this highly — reviewers highlight compassionate and attentive nursing staff. Schedule a visit to confirm the fit.
based on 42 Google reviews
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What this means for your family
This facility shows signs of improvement under new leadership, with recent reviews praising the modern environment and compassionate staff. However, families must perform due diligence regarding clinical communication and verify the facility's ability to handle specific medical diagnoses, as past issues with physician accessibility and staffing were noted.
Google Reviews
Google Reviews
42 reviews on Google“Families may find comfort in the facility's modern, clean environment and the compassionate care provided by specific leadership and staff members. However, there are significant, serious allegations regarding medical mismanagement, difficulty communicating with physicians, and concerns over financial ethics regarding deposits.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and attentive nursing staff
- Modern, clean, and well-maintained facility
- Strong leadership under the current Executive Director
- Effective memory care for maintaining resident dignity
Concerns
- Difficulty communicating with physicians/clinical staff
- Staffing shortages and lack of teamwork (mentioned by 2 reviewers)
- Issues with financial refunds/deposits
Rating Trends
Tap a year to see what changed
Distribution · 32 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1We've heard wonderful things about the leadership under your current Executive Director; how does that leadership style impact the day-to-day culture for the residents?
- 2With your specialized memory care certification, how do you specifically focus on maintaining the dignity and independence of residents as their needs change?
- 3Could you tell us more about the dining experience and how the menu is planned to ensure residents enjoy their meals?
- 4How does the nursing team coordinate with outside physicians to ensure there are no gaps in medical communication or care updates?
- 5What steps is the facility taking to ensure consistent staffing levels and strong teamwork across all shifts?
- 6What does a typical day of social activities and engagement look like for a resident in the assisted living wing?
Personalized based on this facility's data
Key Review Excerpts
“Terrika Neely and the staff at English Meadows have taken so much stress and strife out of my father's life. My stepmother has late stage alzheimer's disease. The memory care unit helps her to maintain her dignity.”
“The facility is clean, updated, and modern which contributes to a positive atmosphere! And now with Terrika there as the new Executive Director, there have been even more positive changes that can only be attributed to her vision and leadership.”
“I have often had the opportunity to to go to The Retreat at Fishersville as an outside home health employee. I have always found the staff there to be quite friendly, considerate, and compassionate.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Dec 3, 2025RoutineCleanReport
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/28/2025 regarding allegations in the area(s) of: Resident care and related services Protection of adults and reporting Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/3/2025 from 3:56 p.m. until 4:18 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: 48 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: 3 Observations by licensing inspector: Licensing inspector toured the community, specifically memory care, reviewed resident record, including medications and progress notes, and interviewed staff. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Dec 3, 2025RoutineCleanReport
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/20/2025 regarding allegations in the area(s) of: Resident care and related services Protection of adults and reporting Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/3/2025 from 2:45 p.m. until 3:24 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: 48 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: Licensing inspector toured the community, specifically memory care, reviewed resident records, including medications and progress notes, interviewed staff and residents. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Dec 3, 2025RoutineCleanReport
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/28/2025 regarding allegations in the area(s) of: Resident care and related services Protection of adults and reporting Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/3/2025 from 3:25 p.m. until 3:55 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: 48 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: 2 Observations by licensing inspector: Licensing inspector toured the community, specifically memory care, reviewed resident records, including medications and progress notes, interviewed staff and residents. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Oct 17, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/8/2025 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: 10/17/2025 from 10:31 a.m. until 11:42 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: 41 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector reviewed resident record including UAI
Based on record review and staff interviews, the facility failed to ensure the comprehensive plan of care, developed on day of admission, addressed the basic needs of the resident that adequately protected his health, safety, and welfare and was signed by the resident or his legal representative. Evidence: 1. The regional licensing office received an Adult Protective Services (APS) complaint on 10/9/2025 indicating that resident 1, a resident in a safe, secure environment, had a restraint attached to the bed creating a safety concern for both the resident and staff. 2. During facility tour on 10/17/2025, Licensing Inspector (LI) observed a hospital bed in resident 1?s room with a half bedrail on one side and the other side of the bed flush against the wall. 3. Record for resident 1, admitted 9/27/2025, contained a comprehensive plan of care dated 9/27/2025 that did not include bedrails as an identified need. 4. During an interview with the LI on 10/17/2025, resident 1 stated that rail on the bed was for ?fall protection?. When LI asked resident 1 if rail was used for anything else, such as repositioning in bed, resident 1 stated, ?No, just fall protection.? LI asked resident 1 if he could show how to lower the rail, to which resident responded, ?Maybe another time?. 5. During interview with staff 1 on 10/17/2025, staff 1 stated resident 1?s bed rail was more of a hinderance than a benefit. Staff 1 also stated resident 1 would grab onto the rail during transfers and often would not let go. Staff 1 stated it would be safer for resident 1 if he did not have the rail. 6. During interview with staff 2 on 10/17/2025, staff 2 stated that resident 1 required assistance with transfers from the bed and also required assistance with repositioning in the bed. Staff 2 stated the bed rail was not used by resident 1 for bed repositioning and resident 1?s spouse wanted the bed rail to prevent from resident 1 from falling out of bed. Staff 2 stated that resident 1 will grab onto the rail during transfers and not let go. Staff 2 also stated it would be better for resident 1 if he did not have the rail. Staff 2 stated that the bed rail for resident 1 was more of a safety risk than a benefit. 7. Record for resident 1, admitted 9/27/2025, contained a comprehensive plan of care dated 9/27/2025 that was only signed by staff 4 and did not contain the signature of the resident or his legal representative. 8. During an interview on 10/17/2025 with LI, staff 4 confirmed the comprehensive plan of care for resident 1 did not contain bedrails as an identified need. Both staff 3 and 4 confirmed the presence of a bedrail on resident 1?s bed. Staff 4 explained that the family had wanted the rail to prevent resident 1 from falling from bed.
Based on record review and staff interview, the facility failed to ensure a physician's written order was obtained that specified the condition, circumstances, and duration under which the restraint was to be used. Evidence: 1. The regional licensing office received an Adult Protective Services (APS) complaint on 10/9/2025 indicating that resident 1, a resident in a safe, secure environment, had a restraint attached to the bed creating a safety concern for both the resident and staff. 2. History and Physical for resident 1, dated 9/15/2025, did not contain an order from the physician for use of a bedrail. Subsequent physician?s orders dated 9/29/2025, 9/30/2025, and 10/14/2025 received by the facility for resident 1 did not contain an order for the use of a bedrail. 3. During an interview on 10/17/2025 with LI, both staff 3 and 4 confirmed the presence of a bedrail on resident 1?s bed which met the definition of a physical restraint-equipment adjacent to the resident?s body that the resident cannot remove or move out of the way easily, which restricts freedom of movement. 4. During an interview on 10/17/2025 with the LI, staff 4 confirmed the facility had not obtained a physician?s order which specified the condition, circumstances, and duration under which the restraint (bedrail) was to be used. 5. Photo evident taken.
Oct 17, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/11/2025 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: 10/17/2025 from 9:30 a.m. until 10:30 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: 41 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: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector reviewed resident records, Medication Administration Records, physician orders, and Registered Medication Aid employee file. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection 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-reported incident 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 resident record review and staff interviews, the facility failed to administer medications in accordance with the physician's or other prescriber?s instructions. Evidence: 1. The regional licensing office received a self-reported incident on 10/11/2025 indicating on 10/11/2025 14 9:39 a.m., staff 1, a Registered Medication Aide (RMA) administered resident 1?s morning medications to resident 2. 2. Resident 1?s morning medications which were administered to resident 2 included Aspirin 81 mg, Carb/Levo 25- 100 mg, Escitalopram 20 mg, and Finasteride 5 mg. 3. Progress note for resident 2 on 10/11/2025 at 3:13 p.m. documented resident 1?s morning medications being administered to resident 2. 4. During an interview with LI on 10/17/2025, staff 2 and 3 confirmed that staff 1 did not administer medications to resident 2 in accordance with the physician?s instructions. Therefore, staff 1 was removed as an RMA indefinitely and is working only as a Certified Nurse Assistant (CNA).
Sep 18, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 9/13/2025 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: 9/18/2025 11:50 a.m. ? 1:20 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: 38 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector reviewed staff communication, nurses notes, incident reports, and video footage. 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on record review the facility failed to ensure the services provided by hospice were included in the individualized service plan ( ISP
Based on observation, staff, resident, and collateral contact interviews, the facility failed to ensure residents were free from mental, emotional, and physical abuse and was free from threats or other demeaning acts against them. Evidence: 1. The regional licensing office received a complaint on 9/13/2025 alleging that staff 3 had mentally and physically abused resident 1. 2. During the investigation on 9/18/2025 video footage was provided by the facility that showed staff 3 pushing resident 1 in their wheelchair to a table when resident 1 slid out of their chair to the floor. Staff 3 was then observed moving the wheelchair out of reach, leaving resident 1 on the floor of the common area for greater than 20 minutes. 3. During an interview with resident 1, when asked if they were afraid of staff 3, resident 1 stated ?yes?. 4. The Adult Protective Services disposition stated ?A review of the facts shows there was a preponderance of evidence to substantiate the allegations of mental abuse, physical abuse, and neglect.?
Aug 8, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 7/25/2025 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: 8/8/2025 9:30 a.m. ? 12:15 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: 38 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: 3 Observations by licensing inspector: The licensing inspector reviewed physician orders, medication administration records, controlled drug count sheets, and the staffing schedule. 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on record review, staff and collateral interview, the facility failed to administer medications in accordance with physician or other prescriber's orders. Evidence: 1.A complaint was received by the regional licensing office on 7/25/2025 indicating that Morphine was not administered as ordered during the weekend of 6/14/2025. 2. During record review for resident 1, it was determined that the resident had a physician?s order dated 6/9/2025 for as needed morphine .5 ml every one hour as needed. 3.Resident 1 had a change in Morphine orders on 6/13/2025 to add Morphine .25 ml every four hours scheduled and change the as needed Morphine to .25 ml every one hour as needed. 4. Resident 1 had another change in Morphine orders on 6/14/2025 to change the scheduled morphine to 1 ml every four hours and to keep the as needed morphine of .25 ml as needed every one hour as needed. 5. The controlled drug record for resident 1?s one prefilled syringe of 0.25 ml every four hours scheduled,indicated that on 6/15/2025 resident 1 was administered one prefilled syringe of 0.25 ml at 1:15 a.m., 5:00 a.m., 9:03 a.m., 10:17 a.m., 12:40 p.m., 1:59 p.m., and 10:00 p.m. when the resident should have been receiving 1 ml every four hours as ordered on 6/14/2025. 6. A separate form for resident 1 labeled ?Narcotics Inventory Count Sheet? dated 6/9/2025 indicated Morphine, take .5 ml to 1 ml every one hour as needed by mouth or under tongue one every hour, indicated that on 6/14/2025 the following doses were given, .5 ml at 1:27 a.m., .5 ml at 5:10 a.m., .5 ml at 2:16 p.m., .5 ml at 6:24 p.m., and .5 ml at 7:57 p.m. when the resident should have been receiving .25 ml every one hour as needed as ordered on 6/13/2025. 7. During an interview with a pharmacy representative at pharmacy 1, the order for the morphine change orders on 6/13/2025 to change the as needed Morphine from .5 ml to .25 ml every one hour as needed was never entered or administered and the order for the morphine change on 6/14/2025 to change the scheduled dosage from .25 scheduled to 1 ml was not entered in or administered until 3 days after the order was written on 6/16/2025. 8. During an interview with staff 3, when asked what the facility policy or process was when a medication is changed on a weekend staff 3 stated ?the order is sent to the pharmacy and if the pharmacy is closed then the order would need to be manually entered by facility staff.? When asked who is able to enter orders at the facility, staff 3 stated ?only [staff 4]?.
Aug 8, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 8/8/2025 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: 8/8/2025 12:15 p.m. ? 12:45 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: 38 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: 1 Observations by licensing inspector: The licensing inspector reviewed medication administration records and the medication management plan. 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 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 have adequate knowledge, skills, and abilities 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. Evidence: 1. A complaint was received on 8/8/2025 indicating resident 1 was unable to receive their scheduled medication because there was not a nurse on site to administer the injection. 2. Review of resident 1?s August medication administration record ( MAR
Based on record review and staff interview the facility failed to administer medications in accordance with physician or other prescriber?s order. Evidence: 1. A complaint was received on 8/8/2025 indicating resident 1 was unable to receive their scheduled medication because there was not a nurse on site to administer the injection. 2. Resident 1 had an order for Mounjaro 7.5 mg/0.5 ml solution, to inject 0.5 ml (7.5 mg) subcutaneous once a week. 3. Review of resident 1?s August medication administration record ( MAR
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