1 Inspection Summary
Inspection Reports Summary
Covers 16 inspections · Dec 2020 – Apr 2026Visit Reason
This report covers 16 inspections of The Villages of Rosemont from December 14, 2020 to April 7, 2026, including routine, renewal, complaint, and monitoring inspections.
Complaint Details
Five inspections were prompted by complaints. Investigations included allegations related to Resident Care and Related Services, Personnel, and Mixed Population. Some complaint investigations found no violations, while others resulted in violations issued.
Findings
Across that history VDSS cited 45 violations under 37 distinct standards. Five inspections were prompted by a complaint.
Violations (42)
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission for multiple residents.
22VAC40-73-930-B: Signaling device lacked audible signal and continuous staffing to determine origin of call alert.
22VAC40-73-660-A-6: Medication requiring refrigeration was not refrigerated on medication cart.
22VAC40-73-640-A: Failed to implement written medication management plan to prevent use of outdated medications.
22VAC40-73-680-D: Medications not administered per physician's or prescriber's instructions.
22VAC40-73-320-A: Physical exam did not include TB risk assessment within 30 days preceding admission.
22VAC40-73-640-A: Failed to implement medication management plan ensuring accurate counts of controlled substances.
22VAC40-73-460-H: Personal assistance and care not provided as necessary to meet resident needs.
22VAC40-73-450-C: ISP did not include description of identified needs and time frame for expected outcome.
22VAC40-73-450-E: ISP not signed and dated by resident or legal representative.
22VAC40-73-990-C: Failed to document staff participation in resident emergency practice exercises every six months.
22VAC40-73-410-A: Orientation for new residents and legal representatives not provided or documented upon admission.
22VAC40-73-1030-B: Direct care staff did not attend six hours of cognitive impairment training within four months of employment.
22VAC40-73-100-C-2: Fingerstick devices used for more than one person without proper labeling.
22VAC40-73-210-F: Staff annual training lacked four hours on residents' mental impairments.
22VAC40-73-260-A: Direct care staff lacked current first aid certification.
22VAC40-73-650-A: Medications, supplements, or treatments started or changed without valid prescriber order.
22VAC40-73-440-B: UAIs for private pay individuals not approved and signed by administrator or designee.
22VAC40-73-640-A: Failed to prevent use of outdated medications and plan for proper disposal.
22VAC40-73-680-I: MARs lacked diagnosis, condition, or indication for administering drugs or supplements.
22VAC40-73-680-D: Medications not administered consistent with prescriber instructions and standards.
22VAC40-73-680-C: Medications not administered within one hour before or after scheduled dosing times.
22VAC40-73-490-A: Failed to retain licensed health care professional with required experience for on-site oversight.
22VAC40-73-40-B-12: Department representative not afforded reasonable opportunity to inspect records and interview staff.
22VAC40-73-250-C: Personal and social data missing from staff record.
22VAC40-90-30-B: Sworn statement or affirmation not completed for all employment applicants.
22VAC40-73-325-B: Fall risk rating not completed annually, after condition changes, or post-fall.
22VAC40-73-650-C: Physician's oral orders not reviewed and signed within 14 days.
22VAC40-73-325-A: Fall risk rating not completed by time comprehensive ISP is done for qualifying residents.
22VAC40-73-690-G: Failed to act on pharmacy medication review recommendations.
22VAC40-73-950-F: Emergency preparedness plan not reviewed annually or as needed with documentation.
22VAC40-90-30-B: Sworn statement or affirmation not completed for all applicants for employment.
22VAC40-73-640-A: Failed to prevent use of outdated medications and plan for proper disposal.
22VAC40-73-325-B: Fall risk rating not completed annually, after condition changes, or post-fall.
22VAC40-73-450-C: ISP did not include description of resident's identified needs based on UAI.
22VAC40-73-450-F: Failed to review and update resident ISPs at least once every 12 months.
22VAC40-73-610-B: Menus for meals and snacks not posted conspicuously for residents.
22VAC40-73-980-B: First aid kits lacked required items including blanket, triangular bandages, and manual.
22VAC40-73-440-A: Failed to complete resident UAI at least annually.
22VAC40-73-970-A: Fire and emergency evacuation drills not conducted on all shifts quarterly.
22VAC40-73-440-A: Failed to complete UAI when resident condition changed.
22VAC40-73-460-A: Failed to assume general responsibility for resident health, safety, and well-being.
Report Facts
Violations cited: 45
Distinct standards: 37
Inspections on page: 16
Inspections with violations: 11
Complaint visits: 5
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