Havenwood
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State Inspection History
State Inspections
Source: VA State Licensing Agency
Dec 11, 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: 12/11/2025 9:30AM to 12:15PM 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 12/08/2025 regarding allegations in the areas of: resident care and related services & emergency preparedness Number of residents present at the facility at the beginning of the inspection: 15 Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: emergency preparedness 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility. EVIDENCE: During on-site inspection on 12/11/2025, staff person 2 informed the licensing inspector (LI) that resident 1 was seen by Collateral 1 on 12/02/2025 for follow-up regarding the resident?s recent hospitalization; however, the record for resident 1 did not contain documentation of Collateral 1?s visit. Staff person 2 confirmed this is accurate and that she would reach out to Collateral 1?s office to obtain a copy of the visit for the resident?s record.
Based on facility medication management plan review, medication cart audit, resident record review, and staff interview, the facility failed to implement its medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan states that controlled drugs are counted every shift by the LPN or RMA on duty and any discrepancies are reported to the Administrator immediately upon discovery. If after rechecked again by the administrator, there is in fact a discrepancy there will be an internal investigation and DSS as well as local authorities will be notified. (All controlled drugs are kept double locked in the medication cart and only licensed or certified employees have access to the cart). 2. During on-site inspection on 12/11/2025, staff person 1 provided documentation to the licensing inspector (LI) that on 11/30/2025 when staff person 2 was the off-going medication administration staff person and staff person 3 was the on-coming medication administration staff person, staff persons 2 and 3 did not conduct a count of the narcotics in the brown cabinet in the medication closet prior to staff person 3 taking possession of the medication cart keys from staff person 2. In addition, interview with staff person 1 revealed that all medication administration staff are to sign the controlled substance count sheet for the medication cart and the brown closet to verify that the narcotic count is accurate. The November 2025 controlled substance count sheets contain numerous dates/times that medication staff did not sign. Staff person 1 confirmed this is accurate.
Based on resident record review, staff interview and medication cart audit, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 11/28/2025, for Aspirin 81MG chewable tablet take 1 tablet in the morning and 1 tablet before bedtime. 2. The facility?s medication cart contains an 8AM card of Aspirin 81MG that was delivered to the facility from the pharmacy on 11/28/2025 with a total of 19 tablets and an 8PM card of Aspirin 81MG that was delivered to the facility from the pharmacy on 11/28/2025 with a total of 20 tablets. During on-site inspection on 12/11/2025, at approximately 9:43AM the 8AM card of Aspirin 81MG had 8 of 19 tablets left of the medication and on 12/12/2025 at approximately 8:02AM the 8PM card of Aspirin 81MG had 10 of the 20 tablets left of the medication. Staff person 1 confirmed that the resident received Aspirin 81MG on 12/11/2025 at 8:00PM. The resident?s November 2025 medication administration record ( MAR
Based on resident record review and staff interview, the facility failed to ensure the medication administration record ( MAR
Based on staff interview and facility documentation, the facility failed to ensure to have a written plan for resident emergencies that includes procedures for making pertinent medical information and history available to the rescue squad and hospital, including a copy of the current medication administration record ( MAR
Dec 3, 2025RoutineCleanReport
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/03/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/25/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 15 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Oct 28, 2025Routine14Report
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: 10/28/2025 7:52AM to 2:00PM 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure within four months of the starting date of employment, direct care staff shall attend at least six hours of training in working with individuals who have a cognitive impairment. EVIDENCE: 1. Interview with staff person 1 revealed that the facility serves a mix population of residents (residents that may have serious cognitive impairments). 2. Staff person 6 was hired at the facility on 01/16/2025. The record for staff person 6 only contains documentation that the staff person only completed 3 hours of cognitive impairment training within the first 4 months of their employment. Staff person 1 confirmed this is accurate.
Based on an observation during a tour of the facility, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision. EVIDENCE: Interview with staff person 1 revealed the facility is a mixed population. During on-site inspection on 10/28/2025 at approximately 9:00AM, the licensing inspector (LI) observed an opened bottle of Remedy Clinical Antifungal Power and a bottle of Remedy Specialized Protect Zinc Oxide Paste Skin Protectant in resident 2?s bathroom in which there were no staff present. Interviews with staff persons 1 and 2 confirmed these items are from hospice and should not be left in the resident?s bathroom.
Based on staff record review and staff interview, the facility failed to ensure direct care staff shall meet one of the requirements in this subsection and if the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. EVIDENCE: The record for staff person 6 contains a certificate of completion for completing a personal care/companion care training program in June 2021 from Collateral 1; however, there is no documentation in the staff person?s record regarding the curriculum or any information to provide evidence that the course meets one of the requirements of 22VAC40-73-200-C. 1. through 7. Interview with staff person 1 confirmed this is accurate.
Based on staff record review, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment. EVIDENCE: The record for staff person 5, date of hire 08/12/2024, contains documentation that staff person 5 completed Basic Life Support (CPR and AED) on 08/24/2024; however, Basic Life Support does not contain first aid training.
Based on resident record review, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician and the report of such examination shall be on file at the assisted living facility and shall contain a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H and a statement that specifies whether the individual is or is not capable of self-administering medication. EVIDENCE: The record for resident 1 contains a report of resident physical examination, dated 06/13/2025, does not contain documentation whether the resident is or is not capable of self-administering medication. Also, the document contains documentation that the resident requires continuous licensed nursing care which is a prohibited condition.
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall. EVIDENCE: 1. The uniform assessment instrument ( UAI
Based on resident record review and staff interview, the facility failed to ensure upon admission a new resident was provided an orientation including emergency response procedures, mealtimes, and use of the call system, acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident?s record. EVIDENCE: Resident 1 was admitted to the facility on 06/16/2025. The record for resident 1 does not contain documentation that the resident, or the resident?s legal representative, received orientation. Interview with staff person 1 confirmed this is accurate.
Based on resident record review and staff interview, the facility failed to ensure for private pay individuals that the uniform assessment instrument ( UAI
Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility. EVIDENCE: The record for resident 1 contains the following resident care notes by facility staff; dated 07/08/2025 and 07/23/2025 that the resident was out with a family member to a medical appointment; dated 07/21/2025 that resident went to the emergency room, and dated 10/04/2025 that the resident was admitted to the hospital on 10/04/2025 and returned to the facility on 10/06/2025; however, the record for resident 1 does not contain any documentation regarding the medication appointments, emergency room visit and hospitalization. Interview with staff person 2 confirmed this is accurate.
Based on medication cart audit, facility plan review and staff interview, the facility failed to implement its medication management plan in regard to methods to prevent the use of outdated, damaged, or contaminated medications. EVIDENCE: 1. The facility?s medication management plan indicates that the LPN checks all medications twice weekly for any outdated, damaged or contaminated medications. Interview with staff person 1 revealed to the licensing inspector (LI) that insulin pens are to be dated by the medication administration staff due to the insulin expiring within a certain time frame once they are opened and in use. 2. During a medication cart audit, the LI and staff person 1 observed that the insulin pens for residents 4, 5, and 6 did not contain a date of when the insulin pens were opened.
Based on resident record review and staff interviews, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. EVIDENCE: 1. Resident 1 was admitted to the facility on 06/16/2025. During on-site inspection, it was brought to the attention of the licensing inspector (LI) that resident 1?s family member is coming to the facility daily to apply Mupirocon 2% ointment and a clean bandage to an area on the top of the resident?s head from a previous biopsy that was performed. Interview with staff person 2 revealed that the resident?s family has been coming to do this daily since the resident was admitted to the facility and that it was being done two times a day by family but recently changed to the family doing this one time a day. 2. The record for resident 1 does not have a physician?s order for the aforementioned treatment to be provided to the resident. Interview with staff person 1 confirmed this is accurate.
Based on resident record review, the facility failed to ensure the written Do Not Resuscitate (DNR) Order is included on a resident?s individualized service plan ( ISP
Based on observation during a tour of the facility, the facility failed to ensure the findings of the most recent inspection of the facility was posted. EVIDENCE: The most recent inspection conducted at the facility was on 08/07/2025 and 09/16/2025 and the final inspection notice has been provided to the facility; however, during on-site inspection the inspection that was posted in the facility was dated 09/30/2024.
Based on staff record review and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: The record for staff person 3, date of hire 08/19/2025, and the record for staff person 4, date of hire, 08/14/2025, did not contain the results of a criminal history record report. Interview with staff person 1 confirmed this is accurate.
Aug 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: 08/07/2025 1:30PM to 2:45PM and 09/16/2025 8:35AM to 10:10AM 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 07/21/2025 and 08/12/2025 regarding allegations in the area of: resident care and related services 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. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on resident record review, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record ( MAR
Based on resident record review and staff interview, the facility failed to ensure that the use of PRN
Jun 17, 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: 06/17/2025 9:45AM to 11:00AM 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: 15 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order for Lispro Insulin inject three times daily with meals per sliding scale: if blood sugar (BS) is 80-150 give 2 units of insulin; if BS is 151-200 give 3 units of insulin; if BS is 201-250 give 4 units of insulin; if BS is 251-300 give 5 units of insulin; if BS is 301-350 give 6 units of insulin; if BS is 351-400 give 7 units of insulin; if greater than 400 give 8 units of insulin. The physician?s order also states for medication staff to notify the resident?s medical doctor if the resident?s BS is less than 70 or greater than 450. 2. The resident?s May and June 2025 medication administration records ( MAR
Jun 17, 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: 06/17/2025 9:45AM to 11:00AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/29/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 14 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: medication cart An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Apr 10, 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: 04/10/2025 8:45AM to 11:15AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 1 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 01/21/2025, for Lispro Insulin (Humalog Insulin) inject insulin 3 times daily with meals per sliding scale: blood sugar (BS) 80-150 = 2 units; BS 151-200 = 3 units; BS 201-250 = 4 units; BS 251-300 = 5 units; BS 301-350 = 6 units; BS 351-400 = 7 units, BS great than 400 = 8 units and notify medical doctor if BS if less than 70 or greater than 450. The February, March and April 2025 medication administration records ( MAR
Dec 4, 2024Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/04/2024 8:35AM to 11:52AM 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: 16 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: 5 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on facility plan review, resident record review and staff interview, the facility failed to ensure to implement its medication management plan in regard to methods for verifying that medication orders have been accurately transcribed to medication administration records ( MAR
Based on resident record review, staff interview and observation, the facility failed to ensure staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the uniform assessment instrument ( UAI
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 10/25/2024, for the following Novlog sliding scale insulin order: less than 70, correct for hypoglycemia ? Notify MD (medical doctor); 70-100 ? 4 units; 101-150 ? 5 units; 151-200 ? 6 units; 201-250 ? 7 units; 251-300 ? 8 units; 301-350 ? 9 units; 351-400 ? 10 units; 401-450 ? 11 units; 451-500 ? 12 units; 501-550 ? 13 units call MD; 551-600 ? 14 units call MD; and over 600 15 units call MD. 2. Resident care notes for resident 1, dated 10/25/2024 at 1:00PM, contains documentation that resident?s current Novolog scale was discontinued. The record for the resident contains the following signed physician?s order, dated 10/25/2024, to discontinue the current Novolog order for the resident and use the following Novolog sliding scale insulin order: inject insulin sub-q 3 times daily before meals per sliding scale ? less than 70, correct for hypoglycemia and notify MD; 70-100 ? 0 units; 101-150 ? 4 units; 151-200 ? 5 units; 201-250 ? 6 units; 251-300 ? 7 units; 301-350 ? 8 units; 351-400 ? 10 units; 401-450 ? 12 units; 451-500 ? 14 units; greater than 500 ? 16 units and if blood sugar is greater than 500, give sliding scale insulin and recheck in 1 hour, notify MD if still greater than 500. The October 2024 medication administration record ( MAR
Based on resident record review, the facility failed to ensure medication administration records ( MAR
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