Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
3 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 3
Deficiencies: 1
Date: Oct 7, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance related to the posting of the most recently issued license on the premises. The facility had not updated the posted license to the current one dated 8/19/2025.
Deficiencies (1)
Facility failed to ensure that the most recently issued license was posted on the premises; the posted license was outdated.
Report Facts
Number of residents present: 3
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
Inspection Report
Monitoring
Census: 4
Deficiencies: 2
Date: Sep 17, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with regulations related to nursing treatments and medication availability. Violations were documented regarding the failure to ensure skilled nursing treatments were provided by licensed personnel and the failure to have ordered PRN medications available for a resident.
Deficiencies (2)
Facility failed to ensure a resident's need for skilled nursing treatments was met by licensed nurse or contractual agreement.
Facility failed to ensure the medications ordered for PRN administration were available for a resident.
Report Facts
Number of residents present: 4
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Deficiencies: 3
Date: Sep 26, 2023
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found non-compliance with several standards including failure to ensure medication staff received required continuing education, failure to update fall risk ratings after resident falls, and failure to implement parts of the medication management plan related to controlled substances counts and infection control procedures.
Deficiencies (3)
Facility failed to ensure medication staff received continuing education as required by the Virginia Board of Nursing.
Facility failed to ensure that a fall risk rating is reviewed and updated after a fall.
Facility failed to implement parts of its medication management plan, specifically regarding accurate counts of controlled substances and infection control procedures related to blood glucose monitoring.
Report Facts
Dates missing narcotic count signatures: 5
Fall incidents for resident 6: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Current Inspector | Named as the licensing inspector conducting the inspection. |
| Holly Copeland | Licensing Inspector | Contact person for questions regarding the inspection. |
| Staff 1 | Named in medication administration continuing education deficiency and medication management plan observations. | |
| Staff 4 | Interviewed regarding medication administration training and fall risk evaluations. |
Inspection Report
Renewal
Census: 13
Deficiencies: 5
Date: Aug 29, 2022
Visit Reason
The inspection was a renewal visit conducted to assess compliance with licensing regulations and facility standards for the assisted living facility.
Findings
The inspection found multiple areas of non-compliance including improper signing of TB assessments by unlicensed staff, incomplete new staff orientation, untimely TB screenings for staff, outdated individualized service plans for residents, and incomplete six-month emergency practice exercises.
Deficiencies (5)
The licensee failed to ensure TB Risk Assessments were signed by a Licensed Nurse rather than a Registered Medication Aide.
The facility failed to have complete new staff orientation covering required topics.
The facility failed to ensure TB screenings for staff were done within required time frames.
The facility failed to update individualized service plans to reflect discontinued oxygen and allergy precautions.
The facility failed to complete six-month practice exercises for resident emergencies covering physical and mental health emergencies.
Report Facts
Number of residents present: 13
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 6
Timeframe for audit frequency: 3
Timeframe for audit frequency: 2
Timeframe for audit frequency: 1
Date of most recent emergency practice exercise: Oct 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the renewal inspection |
| Susan Mallory | Licensing Inspector | Contact person for questions regarding the inspection findings |
| Director of Infection Control | Established TB screening completion and verification process for staff |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Jan 27, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to administer a physician-ordered vitamin to a resident.
Complaint Details
The complaint investigation found that the facility staff failed to administer the ordered vitamin to Resident #44. The issue was substantiated by observation and staff admission.
Findings
The facility staff failed to administer the physician-ordered vitamin Certavite senior to Resident #44 during the medication pass, as observed and confirmed by staff interview and clinical record review.
Deficiencies (1)
Failure to administer the physician ordered vitamin Certavite senior for Resident #44.
Report Facts
Residents affected: 1
Resident census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN (licensed practical nurse) #1 | Staff who failed to administer the medication and admitted the error | |
| Administrator | Made aware of the medication administration issue | |
| Director of Nursing (DON) | Made aware of the medication administration issue | |
| Assistant Administrator | Made aware of the medication administration issue | |
| Assistant Director of Nursing (ADON) | Made aware of the medication administration issue |
Inspection Report
Renewal
Census: 18
Deficiencies: 5
Date: Sep 14, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the Davis & McDaniel Veterans Care Center.
Findings
The inspection identified multiple violations including failure to maintain a written work schedule indicating who is in charge, incomplete individualized service plans, inadequate medication management policies, unsigned or expired medication orders, and improper medication storage practices.
Deficiencies (5)
Facility failed to maintain a written work schedule that indicates who is in charge at any given time.
Facility failed to address some assessed needs on comprehensive individualized service plans (ISP).
Facility failed to have some required sections in their written plan for medication management.
Facility failed to have prescribers signed written orders in resident records.
Facility failed to keep medications in the pharmacy container until they were to be administered to the residents.
Report Facts
Inspection dates: 4
Number of souffle cups with medications observed: 12
Number of souffle cups with medications observed: 15
Inspection Report
Routine
Deficiencies: 5
Date: May 22, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, use of restraints, professional standards of care, accident hazards, catheter care, and medication administration at the Virginia Veterans Care Center.
Findings
The facility was found deficient in multiple areas including failure to provide a private space for resident council meetings, improper use of physical restraints, failure to follow professional standards in medication administration, inadequate accident hazard prevention, lack of proper catheter orders, and medication errors related to digoxin administration.
Deficiencies (5)
Failed to provide a private uninterrupted space for resident council meeting.
Failed to ensure one resident was free from physical restraints, including fall mats and bed/chair alarms.
Failed to follow professional standards by not obtaining apical pulse prior to administering digoxin to Resident #16.
Failed to ensure Resident #96 had physician-ordered padded side rails and geri-sleeves in place.
Failed to ensure Resident #55 had physician orders for Foley catheter including catheter and bulb size.
Report Facts
Residents in survey sample: 37
Apical pulse BIMS score: 12
Apical pulse BIMS score: 4
Medication dose: 125
Medication dose: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed administering medication to Resident #16 and interviewed regarding pulse measurement |
| LPN #4 | Licensed Practical Nurse (agency nurse) | Interviewed regarding care for Resident #96 and observed missing geri-sleeves and padding |
| RN #1 | Registered Nurse (Unit Manager) | Interviewed regarding Foley catheter orders for Resident #55 |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 21, 2018
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations regarding resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to complete PASARR screenings for several residents, failure to provide baseline care plans, failure to update and review comprehensive care plans, inadequate supervision and hazard prevention related to bed alarms, failure to offer non-pharmacological pain management interventions, failure to report medication irregularities to the medical director, failure to monitor psychotropic medication use including target behaviors and effectiveness, failure to discard expired medications, and failure to maintain infection control practices.
Deficiencies (10)
Facility staff failed to complete level 1 PASARR screenings for four residents (#28, #65, #76, #117).
Facility staff failed to provide residents and representatives with a summary of the baseline care plan for two residents (#363 and #44).
Facility staff failed to review and revise the person centered comprehensive care plan for Resident #63.
Facility staff failed to ensure bed alarms were properly used and monitored for Residents #45 and #107.
Facility staff failed to offer non-pharmacological interventions for pain management for Residents #63 and #76.
Facility staff failed to report medication irregularities to the medical director for Residents #41, #74, #86, and #117.
Facility staff failed to identify and monitor target behaviors and effectiveness associated with Seroquel use for Resident #156.
Facility staff failed to monitor psychotropic drug use including specific behaviors, nursing interventions, and effectiveness for Resident #46.
Facility staff failed to discard expired medications; a multi-dose vial of Tuberculin Purified Protein Derivative expired on 3/6/18 was found available for use.
Facility staff failed to ensure infection control practices were followed; oxygen tubing for Resident #14's CPAP machine was found lying on the floor.
Report Facts
Residents missing PASARR: 4
Residents missing baseline care plan summary: 2
Residents affected by bed alarm issues: 2
Residents affected by pain management deficiencies: 2
Residents with medication irregularities not reported to medical director: 4
Residents with psychotropic monitoring deficiencies: 2
Expired medication found: 1
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Notified of missing PASARRs and pain management deficiencies; reviewed clinical records. |
| LPN #1 | Licensed Practical Nurse | Notified of bed alarm deficiencies and infection control issue; assisted surveyor. |
| Director of Nursing | Director of Nursing | Reported admissions source; involved in notification of deficiencies and corrective actions. |
| Administrator | Administrator | Informed of multiple deficiencies during summary meetings. |
| QAPI Nurse | Quality Assurance/Performance Improvement Nurse | Informed of medication irregularities and psychotropic monitoring deficiencies. |
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