Inspection Reports for Bellgrade Estates
2800 Polo Pkwy, Midlothian, VA 23113, United States, VA, 23113
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Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-02-27 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance related to medication errors, specifically that medications were started, changed, or discontinued without a valid order from a physician or prescriber. Violations were issued based on these findings.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2025-02-27 regarding allegations in Resident Care and Related Services. The evidence gathered supported the allegation of non-compliance and violations were issued.
Deficiencies (1)
| Description |
|---|
| Based on resident record documentation no medication shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-13 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued related to failure to report major incidents, inadequate supervision of resident schedules and care, and failure to administer medications according to physician instructions.
Complaint Details
The complaint investigation was substantiated with violations issued. The complaint involved failure to report a major incident involving Resident #1's panic attack and muscle spasms prior to death, failure to send the resident to the hospital, and failure to administer prescribed medication as ordered.
Deficiencies (3)
| Description |
|---|
| The facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| The facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs. |
| The facility failed to ensure that medications were administered according to physician instructions. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the Virginia Department of Social Services regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance related to medication administration. The facility failed to administer multiple medications according to physician orders for Resident #1 during February 2025, resulting in violations being issued.
Complaint Details
The complaint was substantiated as the evidence supported non-compliance with standards related to medication administration. Violations were issued based on the findings.
Deficiencies (1)
| Description |
|---|
| Facility failed to administer medication in accordance with physician's orders, including multiple missed doses of various medications for Resident #1 in February 2025. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Number of missed medication doses: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Licensing Inspector | Inspector conducting the complaint investigation and issuing the violation notice |
Inspection Report
Renewal
Census: 81
Deficiencies: 2
Dec 16, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations. The facility was issued a violation notice and given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure that resident rights and responsibilities were reviewed annually based on staff record reviews. |
| The facility did not ensure that it was free from foul odors, with a foul odor noted in the first-floor hallway containing rooms 100-120. |
Report Facts
Number of residents present: 81
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Renewal
Census: 102
Deficiencies: 13
Jun 21, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found multiple violations related to resident records, staff training, documentation, and building conditions. The facility failed to comply with several regulatory standards, including documentation of resident approvals, staff orientation, training hours, resident assessments, and fire safety inspections.
Deficiencies (13)
| Description |
|---|
| Failed to obtain written approval for a resident to reside in a safe, secure environment in a special care unit. |
| Failed to perform a six month or annual review of the appropriateness of each resident’s continued residence in the special care unit. |
| Failed to verify that staff orientation and training occurred within the first seven working days of employment. |
| Failed to ensure that all direct care staff attend at least 18 hours of training annually. |
| Failed to document prior to or at the time of admission all the information on the personal and social information form. |
| Failed to keep the personal and social information form current. |
| Failed to update the Uniform Assessment Instrument at least annually. |
| Failed to review and update the resident individualized service plan at least once every 12 months. |
| Failed to ensure that the rights of residents in an assisted living facility were reviewed with each resident and staff annually. |
| Failed to ensure that all resident records are current, retained at the facility and kept in a locked area. |
| Did not maintain a current picture or description of each resident for identification purposes. |
| Did not ensure that the building was free from foul odors. |
| Failed to comply with the Virginia Statewide Fire Prevention Code as determined by at least an annual inspection by the appropriate fire official. |
Report Facts
Number of residents present: 102
Number of resident records reviewed: 10
Number of staff records reviewed: 4
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 3
Last fire inspection date: Aug 11, 2022
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-05 regarding allegations in the area of resident care and related services.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. The inspection summary will be posted publicly within five business days of receipt.
Complaint Details
Complaint received on 2024-01-05 regarding resident care and related services; investigation did not substantiate the complaint.
Report Facts
Number of residents present: 102
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2023-10-31 regarding allegations in the area of Resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint received by VDSS Division of Licensing on 2023-10-31 regarding Resident care and related services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 102
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Apr 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 5, 2024, regarding allegations in resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint related inspection triggered by allegations in resident care and related services; the complaint was not substantiated.
Report Facts
Number of residents present: 102
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 96
Deficiencies: 1
Apr 3, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services following a self-report received by VDSS regarding allegations in resident care.
Findings
The investigation supported the self-report of non-compliance related to supervision of resident schedules, care, and activities, including prevention of falls and wandering. Violations were issued based on evidence including incidents of a resident with dementia wandering away from the facility multiple times.
Deficiencies (1)
| Description |
|---|
| Failed to provide supervision of resident schedules, care, and activities including attention to specialized needs such as prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Number of staff records reviewed: 0
Number of resident interviews conducted: 0
Inspection Report
Renewal
Census: 117
Deficiencies: 3
Dec 7, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified non-compliance with several standards related to staff orientation and training, completion of uniform assessment instruments for residents with significant condition changes, and development of preliminary plans of care at admission. Violation notices were issued with opportunities for the licensee to submit plans of correction.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure verification that staff received a copy of current job description and documentation of orientation and training. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there was a significant change in the resident's condition. |
| Facility failed to ensure a preliminary plan of care was developed on or within seven days prior to admission to address the basic needs of the resident. |
Report Facts
Residents present: 117
Resident records reviewed: 10
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 0
Oct 21, 2022
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to assess compliance with applicable standards and laws.
Findings
The inspection found no violations of applicable standards or laws during the visit.
Inspection Report
Monitoring
Deficiencies: 7
Oct 21, 2022
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at Bellgrade Estates Senior Living.
Findings
The inspection identified multiple violations including failure to document order of priority for resident placement, incomplete allergy reaction documentation, incomplete individualized service plans (ISP), improper medication storage, inaccurate activity schedule documentation, and incomplete fire and emergency evacuation drawings.
Deficiencies (7)
| Description |
|---|
| Failed to document that the order of priority for resident placement was followed and retained in the resident's file. |
| Failed to ensure the resident's physical examination documented a description of the person's reaction to any known allergies. |
| Failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the UAI. |
| Failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative. |
| Failed to ensure the written schedule of activities documented a substitution of activity change on the schedule. |
| Failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. |
| Failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, or telephones. |
Report Facts
Number of pills observed outside container: 10
Retraining hours for staff: 8
Retraining hours split: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Licensing Inspector | Current inspector conducting the monitoring inspection. |
| Alexandra Poulter | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs. |
Inspection Report
Renewal
Census: 121
Deficiencies: 14
May 18, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for Bellgrade Estates Senior Living.
Findings
The inspection identified multiple violations including failure to report major incidents within 24 hours, incomplete staff orientation and health records, inadequate fall risk assessments, incomplete individualized service plans, medication administration errors, unsafe hot water temperatures, building maintenance issues, and deficiencies in staff background checks.
Deficiencies (14)
| Description |
|---|
| Facility failed to report a major incident involving Resident #4 to the regional licensing office within 24 hours. |
| Facility failed to maintain personal and social data on staff including documentation of staff orientation. |
| Facility failed to maintain health information including initial tuberculosis exam in staff records. |
| Facility failed to review and update fall risk ratings after resident falls. |
| Facility failed to develop a preliminary plan of care on or within seven days prior to admission. |
| Comprehensive individualized service plan did not include identified needs based on admission physical exam. |
| Individualized service plans were not signed and dated by residents or legal representatives. |
| Licensed health care professional failed to provide adequate health care oversight and documentation. |
| Medications were not kept in pharmacy issued containers with proper labels until administration. |
| Medications were administered not in accordance with physician's orders; crushing instructions not followed. |
| Hot water temperatures at resident room taps exceeded the required range of 105°F to 120°F. |
| Interior of the building was not maintained in good repair and cleanliness; carpet stains and tears observed. |
| Staff made materially false statements on sworn statements or affirmations. |
| Criminal history record reports were not obtained timely or were missing for staff members. |
Report Facts
Residents present: 121
Resident records reviewed: 10
Staff records reviewed: 3
Resident interviews: 5
Staff interviews: 3
Hot water temperatures (°F): 146.7
Hot water temperatures (°F): 140.4
Hot water temperatures (°F): 138.6
Hot water temperatures (°F): 139.7
Hot water temperatures (°F): 127.5
Hot water temperatures (°F): 133.3
Hot water temperatures (°F): 148.2
Days late for criminal history report: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged missing orientation and background check information; provided fall risk ratings; involved in healthcare oversight | |
| Staff #3 | Observed administering medications improperly; had false sworn statement; late criminal history report | |
| Staff #4 | Missing orientation documentation and tuberculosis exam in staff record | |
| DON | Director of Nursing | Responsible for ensuring incident reports sent within 24 hours and ISP documentation |
| ED | Executive Director | Oversees fall reports and admission record reviews |
| Business office Manager | Sent for training on hiring and process completion; involved in background checks | |
| ADON | Assistant Director of Nursing | Trained on ISP documentation and signing |
Inspection Report
Monitoring
Deficiencies: 3
Feb 2, 2022
Visit Reason
A focused monitoring inspection was conducted to follow up on previously cited violations regarding concerns in resident care and related services, including medication administration and infection control.
Findings
The facility failed to ensure proper implementation of infection control measures consistent with CDC guidelines, including improper mask usage by staff. Additionally, deficiencies were found in medication record keeping, including missing physician orders and incomplete documentation of medication administration for residents.
Deficiencies (3)
| Description |
|---|
| Failure to implement infection control program consistent with CDC guidelines, including staff not properly wearing masks. |
| Resident records lacked physician's signed written orders or dated notation of oral orders for medications. |
| Failure to administer medications according to physician's instructions and document administration or omission on Medication Administration Records (MAR) for multiple medications and dates. |
Report Facts
Medication administration omissions: 15
Inspection date: Feb 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Inspector | Named as current inspector conducting the inspection |
| Staff #4 | Confirmed failures in medication order documentation and medication administration documentation | |
| Administrator | Present onsite during inspection | |
| Director of Nursing | Present onsite during inspection and involved in plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 2, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-reported incident regarding allegations in resident care and related services, specifically concerning Resident #1 wandering from the facility.
Findings
The investigation found multiple violations including failure to document significant incidents in shift communications, inadequate preliminary care planning addressing cognitive impairment, insufficient supervision of resident activities including wandering, and failure to document notable changes in resident condition.
Complaint Details
The visit was complaint-related based on a self-reported incident of Resident #1 wandering off the property on 11-01-2021. The investigation substantiated non-compliance with standards.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a method of written communication was utilized to keep direct care staff informed of significant resident incidents including mental conditions. |
| Facility failed to ensure a preliminary plan of care addressed the basic needs of the resident protecting health, safety, and welfare. |
| Facility failed to provide supervision of resident activities including wandering from the premises. |
| Facility failed to ensure documentation of any notable change in a resident's condition including altered behavior and corresponding actions taken. |
Report Facts
Inspection Dates: 4
Resident wandering distance: 0.5
Resident wandering duration: 30
Resident admission date: Oct 21, 2021
Resident admission to Safe, Secure Environment: Nov 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Inspector | Named as current inspector conducting the investigation |
| Staff #1 | Confirmed incident of Resident #1 wandering and provided details about the event | |
| Staff #2 | Signed Nurse's Notes documenting resident behavior on 11-01-2021 |
Inspection Report
Monitoring
Deficiencies: 0
Nov 10, 2021
Visit Reason
A non-mandated monitoring inspection was initiated to conduct an investigation through documentation review and on-site observation.
Findings
The evidence gathered during the investigation did not support non-compliance with standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 10, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding resident care and related services at Bellgrade Estates Senior Living.
Findings
The investigation found multiple violations including failure to ensure individualized service plans matched resident needs, incomplete physician orders lacking diagnosis or indications for medications, and inadequate medication administration records not documenting medication administration or omissions as required.
Complaint Details
The complaint was substantiated with evidence supporting non-compliance with standards or law in resident care and medication administration.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based on the Uniform Assessment Instrument (UAI). |
| Facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. |
| Facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with standards of practice outlined in the registered medication aide curriculum. |
| Facility failed to ensure the medication administration record (MAR) included the diagnosis, condition, or specific indications for administering the drug. |
Report Facts
Medication administration omissions: 11
Medications not administered: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Inspector | Current inspector conducting the complaint investigation. |
| Staff #1 | Staff member interviewed who confirmed discrepancies in documentation and medication administration. | |
| DON | Director of Nursing | Designated to ensure audits and corrections related to medication administration and documentation. |
| ADON | Assistant Director of Nursing | Involved in ensuring UAIs and ISPs match and are correct for resident care needs. |
Inspection Report
Monitoring
Deficiencies: 1
Oct 8, 2021
Visit Reason
A non-mandated monitoring inspection was initiated to investigate compliance with personnel standards, specifically regarding the facility administrator's full-time presence as the on-site agent of the licensee.
Findings
The investigation found non-compliance with the requirement that the administrator serve full-time on-site. The facility had an interim administrator working less than full-time hours, which violated licensing standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the administrator served full-time as the on-site agent of the licensee. |
Report Facts
Dates of administrator employment: Staff #1 worked full-time at a different community starting 2020-05-10 and as Executive Director at this facility from 2021-07-10 to 2021-10-03
Administrator work hours: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Watkins | Inspector | Named as current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 12, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding resident care, related services, and resident rights. The investigation was conducted from August 12 to August 20, 2021, including on-site observation and record review.
Findings
The investigation found non-compliance with mandated reporting of suspected abuse, failure to ensure physician orders included diagnosis or indications for medications, and failure to treat residents with courtesy, respect, and dignity. Violations were issued based on these findings.
Complaint Details
The complaint alleged staff disrespect and verbal abuse toward residents, improper medication administration, and failure to report suspected abuse. The complaint was substantiated based on interviews and record reviews.
Deficiencies (3)
| Description |
|---|
| Staff failed to report suspected abuse, neglect, or exploitation of residents as mandated by Virginia Code § 63.2-1606. |
| Facility failed to ensure physician orders identified diagnosis, condition, or specific indications for administering each drug. |
| Facility failed to ensure residents were treated with courtesy, respect, and consideration as persons of worth, sensitivity, and dignity. |
Report Facts
Inspection dates: 5
Medications without diagnosis or indications: 10
Inspection Report
Monitoring
Census: 101
Deficiencies: 0
Jun 24, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards.
Findings
The inspection found no violations with applicable standards or law. Documentation including resident records, nurse's notes, MARs, UAIs, ISPs, faxes, emails, and physician's orders were reviewed and found complete.
Inspection Report
Renewal
Census: 101
Deficiencies: 0
Jun 23, 2021
Visit Reason
A renewal inspection was initiated on June 23, 2021 and concluded on June 25, 2021 to assess compliance with applicable standards and laws for Bellgrade Estates Senior Living.
Findings
The inspection determined no violations with applicable standards or law. No violations were issued.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
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