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Families should approach this facility with extreme caution due to severe allegations regarding hygiene, facility maintenance, and staff professionalism. While some long-term residents' families have praised the loving environment and staff, recent and historical reviews frequently cite issues with odors, cleanliness, and poor communication.
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Distribution · 13 analyzed
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Key Review Excerpts
“Great home , my mom was their for 12yrs ,the best care every. She loved the place & loved the staff. Food was good & love was what you got.”
“The management and staff where very nice and the people are loved and taken care of!”
“I had a brother stay there and it’s the nastiest place I’ve ever seen, Had bed bugs, ceiling caved in and smells so bad. The staff is very rude and puts you on hold when you call and never comes back.”
Source: VA State Licensing Agency
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: 12/31/2025 1:00 pm to 2:15 pm. A self report was received by VDSS Division of Licensing on 6/9/2025 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: 45 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:1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The Licensing Inspector toured buildings and Grounds during visit. Individual interview and staff interview occurred during visit. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Based on the record review the facility did not ensure the fall risk rating be reviewed and updated at least annually. Evidence: 1. The record for resident #1, admission date 5/26/17 contained a fall risk rating dated 3/20/24. 2. The record for resident #2, admission date 4/27/09 contained a fall risk rating dated 11/22/22. 3. Staff #1 confirmed the record for resident #1 did not contain documentation of a fall risk rating completed after the fall that occurred on 11/29/2025.
Based on the record review the facility did not ensure that the rights and responsibilities of residents with the resident or legal representative annually. Evidence: 1. Resident #1 and Resident #2 records did not contain an annual Resident Right review on file. 2. Staff #1 reviewed the records for Resident #1 and Resident #2, and confirmed the record did not contain the annual Resident?s Rights.
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: 7/18/2025 11:45 am to 12:30pm. A complaint was received by VDSS Division of Licensing on 6/9/2025 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: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed:0 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The Licensing Inspector toured buildings and Grounds during visit. Individual interviews with 2 residents occurred during visit. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Based on the record review the facility did not ensure the ISP
Based on the record review the facility did not ensure the ISP
Based on the record review the facility did not ensure the UAI
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: 04/24/2025 11:00 am to 4:00pm. Number of residents present at the facility at the beginning of the inspection: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch, activity and medication pass were observed by licensing inspector. Tour of the facility interior/ exterior and first aid kits reviewed. Water Temperature checked. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Based on the record review the facility did not ensure to ensure a risk assessment for tuberculosis (TB) 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. The record for resident #3, admission date of 5/26/2017, contains a risk assessment for TB dated 11/14/2023. The resident?s record does not contain an annual risk assessment for TB completed after 11/14/2023. 2. Staff #1 confirmed the record for resident #1 did not contain an annual risk assessment for TB completed after the date of 11/14/2023.
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: An unannounced renewal inspection took place on 05/09/2024 at 09:21 am until 01:15 pm. 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: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast, lunch and an activity were observed. A medication pass observation was completed for six residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the staff record review the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) 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 record for staff # 4, contains a risk assessment for TB dated 1/10/23. The staff record did not contain an annual risk assessment for TB completed after 1/10/23. 2. Staff # 5 confirmed the record for staff #4 did not contain an annual risk assessment for TB completed after 1/10/23.
Based on observation it was determined that 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. During the onsite inspection the water temperature in two of the shared bathrooms was measured to 88 degrees F. 2. Staff # 5 verified the temperature in two of the shared bathrooms was measured to 88 degrees F.
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/02/23 from 08:35 am to 3:55pm. 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: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, an activity were observed. A medication pass observation was completed for six residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review the facility failed to ensure actions taken in response to the recommendations noted in subdivision 3 of this subsection (oversite of special diets) shall be documented in the resident?s record. Evidence: 1. Resident #3?s dietary note dated 01/14/23 documents ?the resident needs a specialized Gerd diet.? The resident?s physician order dated 01/04/23 documents a diagnosis of Gerd. The resident?s record does not contain documentation of the actions taken in response to the resident needs of a specialized Gerd diet. 2. Staff #5 acknowledged the resident?s record did not contain documentation of actions takes in response to the dietary note dated 01/14/23.
Based on the record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #2, contains a progress note dated 10/03/22 that documents ?resident was sent out 911, appeared to have a seizure.? A progress note dated 10/04/22 documents ?resident is being admitted for testing and monitoring, and on 11/10/22, resident returned from the hospital.? 2. Staff # 5 acknowledged an incident report was not submitted to the regional licensing office to report the hospital admission for resident #2.
Based on observation the facility failed to ensure all showers shall be kept clean and in good repair and condition. Evidence: 1. During observation with Staff # 5 and staff #6 a shower located in the shared bathroom was observed to have a wet washcloth laying on the bottom/floor tile of the shower. The bottom/floor tile of the shower was observed to be cracking and separating from the wall of the shower. The grab bar located in the shower was observed to be rusted around the area connected to the wall.
Based on the record review the facility failed to ensure the ISP
Based on observation the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. During a tour of the facility with staff #6, the water temperature in a shared bathroom was measured 122.5 degrees F.
An unannounced on-site renewal inspection was conducted on 5-2-22 (ar 07:30 a.m./dep 5:30 p.m). The facility census was 50. A tour of the facility was conducted, medication pass observation conducted, resident interviews and records reviewed/staff records and interviews conducted, emergency supplies reviewed and lunch meal observed. A preliminary exit meeting was conducted with the Administrator and documents requested on 5-2-22 and rec 5-3-22. An exit was conducted on 5-16-22 with the administrator, document requested received on 5-17-22. The Acknowledgement of Inspection form was sent via email to the Administrator on 5-3-22 and 5-17-22. 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 (Willie Barnes), Licensing Inspector at (757)439-6815 or by email at willie.barnes@dss.virginia.gov
Based on record review, observation and staff interviewed, the facility failed to follow its medication management policy to ensure that a resident?s medication was ordered, filled or refilled for the resident in a timely manner to avoid missed dosage. Evidence: 1. On 5-2-22 during medication pass with staff #2, resident #5?s 11:00 AM Seroquel was not available to administer to the resident. 2. Staff #2 acknowledged the aforementioned resident?s medication was not available in the facility to administer at the dosing scheduled time.
Based on observation and staff interviewed, the facility failed to ensure the fire and emergency evacuation drawing posted included all of the requirements of the regulations. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the fire and emergency evacuation drawing did not include the primary and secondary route and the location of telephones in the building. 2. Staff #1 acknowledged the evacuation posting did not include all required information.
Based on staff interviewed, the facility failed to ensure a written method of communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence: 1. On 5-2-22, during the medication pass with staff #2, staff was asked to check the communication log to determine if resident #5?s medication was ordered or refill called in to the pharmacy as there was no medication for the 5-2-22 scheduled 11:00 am dosage. Staff stated the communication among staff was shared verbally and there was a board with information noted but was changed daily. 2. Staff was asked if the information was documented in the resident?s record if not in the communication log book. Staff was not sure if information was documented in the residents? record so that other staff members with the need to know was informed. 3. Staff #1 and #2 acknowledged the facility did not have a communication log of written communication.
Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with 22VAC40-73-260- A and B of the regulation, was posted in the facility so that the information was readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date. Evidence: 1. On 5-2-22 following the medication administration pass, staff #2 was asked where the first aid and CPR listing was posted. 2. After searching the medication room and nursing station, staff #2 acknowledged the first aid and CPR listing was not posted in the facility.
Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 5-2-22 during a tour of the facility with staff #5, the water temperature for the bathroom located across from room B-27 on the women?s hallway was 90 degrees F (10:31 a.m.). The shower across from room #15 and next to room #15 was 97.3 degrees (10:35 a.m.). 2. Staff #5 acknowledged the water temperature did not meet regulation requirement.
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Based on observation and staff interviewed, the facility failed to ensure the rights and responsibilities of residents was printed in at least 14-point type and posted conspicuously in a public place all the facility. Evidence: 1. On 5-2-22 during a tour of the facility staff #1 was asked where the residents? rights were posted. Staff stated at the front of the facility. The residents? rights and responsibility could not be located on the morning of 5-2-22. 2. Staff #1 acknowledged the residents? rights and responsibilities was not posted on the day the inspector?s tour of the facility.
Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social data document was kept current for residents. Evidence: 1. On 5-2-22, resident #3?s physical examination dated 3-20-21 documented resident allergic to Lipitor and Aspirin. 2. Resident #5?s physical examination dated 9-8-21 documented resident allergic to Sulfa drugs, Opiates, Bactrim and Gabapentin. 3. Staff #1 acknowledged the aforementioned residents? allergies not listed on social data form.
Based on observation and staff interviewed, the facility failed to ensure the current license was posted in a place conspicuous to the residents and the public. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the facility?s license was not posted. 2. Staff #1 acknowledged the license was not posted.
Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the restroom located across from room #12, the ceiling was observed to be covered with gray colored substance. The hallway near the dining area was observed to have stacks of tiles and a machine of some with wheels located near the bookshelf with the clock and temperature reading. The air duct on the same hallway was missing a covering, exposing a brown colored substance and hanging electrical wiring. The call bells in the bathroom was not available and/or not operational on the hallway with the dining room and included men and women (shared bedrooms). 2. Staff #1 acknowledged the building condition. Staff #6 acknowledged the call bells not working in the bathrooms on the day of the inspection.
Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, was kept clean and in good repair and condition. Evidence: 1. On 5-2-22 during a tour of the facility with staff #1, the tile in the bathroom on the male hallway was cracked. The water lines underneath the bathroom sinks are rusted and covered with a grey colored substance. The covering over the plumbing wire along the walls and near the sinks are cracking and peeling away 2. The ladies bathroom across from room #12, wall above face sink needs painting. The vents in the ceiling in the unisex restroom across from room #10, the ceiling vents covered with a grey colored substance, also the electrical tubing in the hallway in front of the bathroom door covered with grey colored substance. The walls in bathrooms on the male and female hallways in need of cleaning and or painting. 3. Staff #1 acknowledged areas of the facility needed cleaning and/or repairing.
Based on observation and staff interviewed, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center was posted by each telephone. Evidence: 1. On 5-2-22 staff #2 was asked where the emergency numbers were posted as the inspector did not see the posting. Staff #2 looked in the medication room and also the nursing station and the listing was not found. 2. Staff #1 and #2 acknowledged the emergency telephone numbers required were not posted on the day of the inspection.
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on April 13, 2021 and concluded on April 19, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 48. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, health and fire inspections, fire and emergency drills, dietary oversight, activities calendar, staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Based on record review and discussion, the facility failed to ensure the oversight of special diets included identification of the residents for whom the oversight was provided. Evidence: 1. The dietary oversight dated 01-31-2021 did not document the identification of the residents for whom the oversight was provided. 2. Staff #1 confirmed there are residents with special diets in the facility, and that the oversight did not contain the residents who were identified.
Based on record review and discussion, the facility failed to ensure a valid physician's order with the delivery device was available when oxygen therapy is provided. Evidence: 1. Resident #1?s record contained a physician?s order dated 03-16-2021 that documented, ?Home O2 [oxygen] 2 Liters at night Dx: COPD. 2. Staff #1 confirmed during interview that the delivery device such as nasal cannula, reservoir nasal cannulas, or masks was not documented in Resident #1?s oxygen order.
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