1 Inspection Summary
Inspection Reports Summary
Covers 23 inspections · Apr 2023 – Apr 2026Visit Reason
This report covers 23 inspections of The Warren facility from April 13, 2023 to April 2, 2026, including routine, complaint, renewal, and monitoring inspections.
Complaint Details
Seventeen inspections were prompted by complaints alleging issues in resident care, staffing, medication administration, and facility policies. Investigations supported some allegations resulting in violations; others were not supported.
Findings
Across that history VDSS cited 71 violations under 50 distinct standards. 14 of 23 visits ended with violations and 9 with none. 17 inspections were prompted by a complaint.
Violations (70)
22VAC40-73-440-B: Facility failed to ensure UAI was completed and signed by qualified assessor and administrator or designee.
22VAC40-73-450-A: Facility failed to develop preliminary plan of care on or within seven days prior to admission.
22VAC40-73-100-C-3: Facility failed to ensure readily accessible necessary personal protective equipment including soap and gloves.
22VAC40-73-320-A: Facility failed to obtain physical exam by independent physician within 30 days preceding admission.
22VAC40-73-70-A: Facility failed to report major incident within 24 hours that threatened resident safety.
22VAC40-73-40-A: Facility failed to ensure compliance with its own policies and procedures regarding bed bugs.
22VAC40-73-460-A: Facility failed to assume general responsibility for health, safety, and well-being of residents.
22VAC40-73-410-A: Facility failed to provide orientation upon admission including emergency procedures and call system use.
22VAC40-73-860-I: Facility failed to store cleaning supplies and hazardous materials in a locked area.
22VAC40-73-260-A: Facility failed to ensure direct care staff maintained current first aid certification.
22VAC40-73-720-A: Facility failed to ensure DNR orders were carried out only with valid physician order and included in service plan.
63.2-1720-A: Facility failed to obtain original criminal history record report within 30 days of employment.
22VAC40-73-310-D: Facility failed to provide written assurance of appropriate license to resident at admission.
22VAC40-73-680-C: Facility failed to administer medications within one hour before or after scheduled dosing time.
22VAC40-73-680-D: Facility failed to administer medications in accordance with physician’s instructions.
22VAC40-73-450-C: Facility failed to identify resident needs on Individualized Service Plan.
22VAC40-73-280-A: Facility failed to have sufficient staff to meet residents’ physical, mental, and psychosocial needs.
22VAC40-73-450-A: Facility failed to develop preliminary plan of care to address resident basic needs.
22VAC40-73-260-B: Facility failed to ensure at least one staff had current CPR certification on each shift.
22VAC40-73-250-C: Facility failed to maintain personal and social data in staff records.
22VAC40-73-1030-B: Facility failed to ensure direct care staff attended six hours training on cognitive impairments within four months of hire.
22VAC40-73-350-B: Facility failed to ascertain and document if potential resident was a registered sex offender prior to admission.
63.2-1606-A: Facility failed to immediately report suspicions of abuse, neglect, or exploitation of an aged or incapacitated adult.
22VAC40-73-560-H: Facility failed to retain complete resident record for at least two years following discharge.
22VAC40-73-330-B: Facility failed to conduct mental health screening when resident displayed concerning behaviors.
22VAC40-73-460-E: Facility failed to document changes in resident condition and corresponding actions taken.
22VAC40-73-300-B: Facility failed to maintain written communication between direct care staff on significant happenings and incidents.
22VAC40-73-310-B: Facility failed to ensure resident needs could be met prior to admission by reviewing required documents and conducting interview.
63.2-1808-A-15: Facility failed to ensure physical or mechanical restraints were used only with appropriate safeguards and orders.
22VAC40-73-680-C: Facility failed to administer medications within required timeframe as ordered by physician.
22VAC40-73-680-D: Facility failed to administer medications in accordance with physician’s or prescriber’s instructions.
22VAC40-73-640-A: Facility failed to adhere to medication management plan for controlled drug counts.
22VAC40-73-680-I: Facility failed to ensure MAR included initials of direct care staff administering medication.
22VAC40-73-260-A: Facility failed to ensure direct care staff maintained current first aid certification.
22VAC40-73-700-2: Facility failed to post 'No Smoking-Oxygen in Use' sign where oxygen tanks were present.
22VAC40-73-450-E: Facility failed to ensure ISPs were signed and dated by resident or legal representative.
22VAC40-73-560-F: Facility failed to ensure all records were treated confidentially.
22VAC40-73-450-F: Facility failed to ensure ISPs were reviewed and updated as needed for significant resident condition changes.
22VAC40-73-1040-A: Facility failed to ensure behavioral observations or evidence were reflected in resident record before restricting movement.
22VAC40-73-860-I: Facility failed to store cleaning supplies and hazardous materials in locked area.
22VAC40-73-290-B: Facility failed to post name of current person in charge conspicuously.
22VAC40-73-560-F: Facility failed to ensure records were treated confidentially.
22VAC40-73-1070-B: Facility failed to keep harmful objects inaccessible to residents with serious cognitive impairment except under staff supervision.
22VAC40-73-640-A: Facility failed to adhere to medication management plan for controlled drug counts.
22VAC40-73-680-C: Facility failed to administer medications within required timeframe as ordered by physician.
22VAC40-73-680-D: Facility failed to administer medications in accordance with physician’s or prescriber’s instructions.
22VAC40-73-450-D: Facility failed to document coordinated plan of care on ISP between facility and Hospice agency.
22VAC40-73-440-A: Facility failed to ensure residents were assessed using UAI at least annually for eight residents.
22VAC40-73-280-A: Facility failed to have sufficient staff to meet residents’ physical, mental, and psychosocial needs on evening and overnight shifts.
22VAC40-73-450-A: Facility failed to complete comprehensive ISPs within 30 days after admission for two residents.
22VAC40-73-450-F: Facility failed to update ISPs once every 12 months for nine residents.
22VAC40-73-260-A: Facility failed to ensure direct care staff received first aid certification within 60 days of employment.
22VAC40-73-250-C: Facility failed to maintain sworn disclosure statement in staff record.
22VAC40-73-260-A: Facility failed to ensure direct care staff maintained current first aid certification.
22VAC40-90-40-B: Facility failed to obtain criminal history record report on or prior to 30th day of employment.
22VAC40-73-260-C: Facility failed to post listing of staff with current first aid or CPR certification.
22VAC40-73-560-F: Facility failed to ensure records were treated confidentially.
22VAC40-73-50-A: Facility failed to disclose on resident statement about on-site emergency electrical power source.
22VAC40-73-620-A: Facility failed to have dietician oversight every six months of special diets.
22VAC40-73-680-C: Facility failed to administer medications within one hour before or after scheduled dosing time.
22VAC40-73-450-C: Facility failed to identify resident needs on ISP.
22VAC40-73-680-D: Facility failed to administer medications in accordance with physician’s instructions.
22VAC40-73-70-C: Facility failed to submit written report of incidents within seven days from date of incident.
22VAC40-73-310-D: Facility failed to provide written assurance of appropriate license to resident at admission.
22VAC40-73-330-A: Facility failed to conduct mental health screening prior to admission when indicated.
22VAC40-73-340-A: Facility failed to obtain psychosocial and behavioral information from primary sources prior to admission.
22VAC40-73-320-A: Facility failed to obtain physical exam by independent physician within 30 days preceding admission.
22VAC40-73-70-C: Facility failed to submit written report of incidents within seven days from date of incident.
22VAC40-73-310-B: Facility failed to ensure resident needs could be met prior to admission by reviewing required documents and conducting interview.
63.2-1808-A-15: Facility failed to ensure physical or mechanical restraints were used only with appropriate safeguards and orders.
Report Facts
Violations cited: 71
Distinct standards: 50
Inspections on page: 23
Inspections with violations: 14
Complaint visits: 17
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