Gray Ridge Village LLC
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Reviewer feedback for Gray Ridge Village LLC suggests areas to investigate further. We recommend visiting in person, talking to current residents and their families, and asking specific questions about the concerns identified in reviews.
State Inspection History
State Inspections
Source: VA State Licensing Agency
Jan 30, 2026Complaint
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: 01/30/2026, 9:44am to 10:20am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/07/2026 regarding allegations in the area(s) of: Admission, retention and discharge of residents and resident care and related services. 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: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident care and related services A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on a review of resident records, the facility failed to operate within the terms of its license. EVIDENCE: 1. According to 22VAC40-73-10, "Residential living care" means a level of service provided by an assisted living facility for adults who may have physical or mental impairments and require only minimal assistance with the activities of daily living ( ADL
Jan 6, 2026Routine21Report
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/06/2026, 9:35am to 5:02pm 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on a review of staff records, the facility failed to ensure that prior to being placed in charge, the staff member shall be informed of and receive training on his duties and responsibilities and provided written documentation of such duties and responsibilities. EVIDENCE: 1. The record for staff #1 did not contain documentation of training related to duties and responsibilities prior to being placed in charge. 2. The record for staff #2 did not contain documentation of training related to duties and responsibilities prior to being placed in charge. 3. According to staff #20, both staff #1 and staff #2 have been placed in charge at the facility on occasion.
Based on a review of staff records, the facility failed to ensure all required personal and social data is maintained in each staff record. EVIDENCE: 1. The record for staff #1 did not contain a job description for registered medication aide. 2. The record for staff #2 did not contain a job description for registered medication aide.
Based on a review of staff records, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. The Virginia Tuberculosis (TB) Screening and Risk Assessment Tool contained in the record for staff #3 was not signed by the person who completed the assessment.
Based on a review of resident records, the facility failed to ensure the report of resident physical examination includes all required information. EVIDENCE: 1. The following sections on the report of resident physical examination dated 12/22/2025 for resident #5 were blank: height, weight and therapy.
Based on a review of resident records, the facility failed to ensure that a risk assessment for tuberculosis shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. Resident #1 was admitted to the facility on 07/13/2023. 2. The most recent tuberculosis evaluation maintained in the record for resident #1 was dated 10/11/2024.
Based on a review of resident records, the facility failed to ensure that the uniform assessment instrument ( UAI
Based on a review of resident records, the facility failed to ensure the comprehensive individualized service plan ( ISP
Based on a review of resident records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section. EVIDENCE: 1. Resident #1 was admitted to the facility on 07/13/2023; there was no record of annual resident rights review contained in the record for resident #1. 2. Resident #6 was admitted to the facility on 09/11/2019; there was no record of annual resident rights review contained in the record for resident #6. 3. Resident #7 was admitted to the facility on 08/16/2022; there was no record of annual resident rights review contained in the record for resident #7.
Based on a review of resident records and interviews with staff, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician's or other prescriber's orders. EVIDENCE: 1. The report of resident physical examination for resident #5, dated 12/22/2025, includes an order for a carbohydrate consistent diet. The individualized service plan ( ISP
Based on a tour of the building and interview with staff, the facility failed to ensure that a copy of a diet manual containing acceptable practices and standards for nutrition shall be kept current and readily available to personnel responsible for food preparation. EVIDENCE: 1. A diet manual was not observed in the kitchen at the time of inspection. 2. Staff #19 was not aware of a diet manual in the kitchen or elsewhere in the facility.
Based on a review of available documentation, the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. EVIDENCE: 1. The most recent documentation of dietary oversight occurred on 05/03/2025.
Based on a tour of the building, the facility failed to ensure that when oxygen therapy is provided, "No Smoking-Oxygen in Use" signs shall be posted. EVIDENCE: 1. An oxygen concentrator was observed in resident room #11 and the "No Smoking-Oxygen in Use" sign was not posted. 2. An oxygen concentrator was observed in resident room #5 and the "No Smoking-Oxygen in Use" sign was not posted. 3. An oxygen concentrator was observed in resident room #2A and the "No Smoking-Oxygen in Use" sign was not posted. 4. An oxygen concentrator was observed in resident room #4 and the "No Smoking-Oxygen in Use" sign was not posted. 5. An oxygen concentrator was observed in the room for resident #8 and resident #6 and the "No Smoking-Oxygen in Use" sign was not posted.
Based on a tour of the building, the facility failed to ensure that any operable window (i.e., a window that may be opened) shall be effectively screened. EVIDENCE: 1. In resident room #32, there was a gap of at least one inch observed in the window with the air conditioning unit that was allowing outside air and insects inside. 2. In resident room #25, the window on the right was not screened.
Based on a tour of the building, the facility failed to ensure that hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. EVIDENCE: 1. The water temperature in the restroom off of the sitting room in the manor reached a temperature of 131.6 degrees Fahrenheit. 2. The water temperature in the restroom for resident room #2B reached a temperature of 130.8 degrees Fahrenheit. 3. The water temperature in resident room #5 reached a temperature of 125.6 degrees Fahrenheit. 4. The water temperature in resident room #22 reached a temperature of 132.5 degrees Fahrenheit.
Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. Dark spots were observed on the hallway floor outside of resident room #23. 2. The paint on the wall by the toilet in the restroom between resident rooms #33 and #35 was peeling. 3. Dark spots were observed on the floor in room #35. 4. Dark spots were observed on the floor in resident room #39. 5. In room #38, the floor of the closet was scuffed and stained. 6. Three bags of trash were observed under the sink in the restroom for resident room #36.
Based on a tour of the building, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. EVIDENCE: 1. The baseboards were missing on approximately half of ?A? hall. 2. In resident room #25, the electrical outlet on the wall behind the bed nearest the door was broken. 3. In the restroom for resident room #35, there was a large crack in the shower wall below the shower head that was covered with a dark colored putty. 4. Dead bugs were observed in the first, second and fourth overhead light fixtures nearest the exit on ?A? hall. 5. In the restroom for resident room #39, the caulk around the toilet was soiled/stained and was separated from the base of the toilet. 6. In room #38, there were no baseboards along two of the walls or the closet space. 7. The baseboard was missing on the wall behind the toilet in resident room #32. 8. In resident room #26, broken slats were observed on the window shade above the air conditioner. 9. In resident room #26, the vinyl chair near the bed by the door was worn with the finishing coming off on the seat, the arms and the back. 10. The chairs in the hall/sitting area were worn with the finish coming off. 11. In resident room #2A, broken slats were observed on the window shade on the patio door. 12. In resident room #4, broken slats were observed on the window shade on the patio door.
Based on a tour of the building, the facility failed to ensure a temperature of at least 72?F shall be maintained in all areas used by residents during hours when residents are normally awake. EVIDENCE: 1. In resident room #31, the wall thermometer had a reading of 68 degrees Fahrenheit at 10:08am on the date of inspection. 2. In resident room #26, the wall thermometer had a reading of 68 degrees Fahrenheit at 10:29am on the date of inspection.
Based on a tour of the building, the facility failed to ensure that fluorescent lights shall be replaced if they flicker or make noise. EVIDENCE: 1. The lights in the two overhead fixtures at the end of ?A? hall were flickering at the time of inspection.
Based on a tour of the building, the facility failed to ensure there shall be ventilation to the outside in order to eliminate foul odors. EVIDENCE: 1. In resident room #36, the vent fan in the bathroom was inoperable. 2. The vent fan in the shower room off the dining room in the main building was not in place/inoperable. 3. The vent fan in the bathroom off the second dining room was inoperable. 4. The vent fan in the bathroom for resident room #14 was inoperable. 5. The vent fan in the bathroom for resident room #11 was inoperable. 6. The vent fan in the bathroom off the dining room in The Manor was inoperable.
Based on a review of available documentation, the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. EVIDENCE: 1. There was no documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced within the past six months.
Based on a review of resident records, the facility failed to operate within the terms of its license. EVIDENCE: 1. According to 22VAC40-73-10, "Residential living care" means a level of service provided by an assisted living facility for adults who may have physical or mental impairments and require only minimal assistance with the activities of daily living ( ADL
Nov 18, 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: 11/18/2025, 1:06pm to 1:31pm and 12/23/2025, 1:51pm to 2:00pm 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 11/10/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 85 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: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Nov 17, 2025Complaint
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: 11/17/2025 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 09/09/2025 regarding allegations in the area(s) of: Admission, retention and discharge of residents, resident care and related services, resident accommodations and related provisions. Number of residents present at the facility at the beginning of the inspection: 85 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: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: 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: Admission, retention and discharge of residents. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on collateral information and interview with staff, the facility failed to provide to one resident or the resident's legal representative, a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and shall show the balance due or any credits for overpayment. EVIDENCE: 1. According to a written statement by collateral #1 and collateral #2, monthly accounting information was never received regarding resident #1. 2. According to interview with staff #1, financial information was provided to collateral #1 upon request, but not on an ongoing monthly basis.
Oct 29, 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: 10/29/2025, 10:57am to 11:17am 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 09/16/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: n/a Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Oct 29, 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: 10/29/2025, 11:18am to 11:33am and 11/25/2025, 2:44pm to 3:02pm 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 09/17/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 81 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: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on a review of resident records and interview with staff, the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order and that orders shall be organized chronologically in the resident's record. EVIDENCE: 1. A medication list dated 09/08/2025 observed in the record for resident #1, and the September 2025 medication administration record ( MAR
Based on resident records and interview with staff, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. Based on the physician?s order signed on 08/20/2024 and the September 2025 medication administration record ( MAR
Based on a review of resident records, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions. EVIDENCE: 1. Based on the physician?s order signed on 08/20/2024 and the September 2025 MAR
Oct 29, 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: 10/29/2025, 11:34am to 12:05pm 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 09/17/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 81 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: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on review of resident records and interview with staff, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. According to an incident report dated 09-13-2025, staff #1 ?accidentally gave her (resident #1) medication along with another resident?s.? 2. Staff #1 reported during an interview that a medication card for resident #2 was attached to the medication card for resident #1, and the medications were mistakenly given to resident #1 along with her other scheduled medications. 3. According to the September 2025 medication administration record ( MAR
Oct 29, 2025Complaint
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: 10/29/2025, 12:06pm to 12:44pm 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 09/29/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 81 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: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Based on a review of resident records and interview with staff, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. EVIDENCE: 1. The physician?s order dated 07/11/2025 states resident #1 is prescribed the following medication: Insulin lispro (Humalog) 100 unit/ML injection cartridge, Inject 7 units three times daily before meals plus sliding scale of 2 units for every 50mg/dl > 150mg/dl MDD 40 units 2. The physician?s orders for resident #1 signed 09/30/2025 contain the order as written above and the following parameters for the sliding scale: 0-199 Give 7 units, 200-249 Give 9 units, 250-299 Give 11 units, 300-349 Give 13 units, 350-399 Give 15 units, 400-449 Give 17 units, 450-499 Give 19 units, 499+ Give 21 units. 3. Based on the medication administration record ( MAR
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