3 Reports · 1 Summary
Inspection Summary
5 inspections covered, Sep 2021 – Oct 2025.
Inspection Reports Summary
Visit Reason
This report covers 5 inspections of Davis & McDaniel Veterans Care Center from September 10, 2021 to October 7, 2025 by the Virginia Department of Social Services.
Findings
Across that history VDSS cited 16 violations under 15 distinct standards. All 5 inspections ended with violations cited.
Violations (16)
22VAC40-80-120-E-1: Facility failed to post the most recently issued license on premises.
22VAC40-73-680-M: Medications ordered for PRN administration were not available for a resident.
22VAC40-73-470-B: Facility failed to ensure skilled nursing treatments were provided by licensed nurse.
22VAC40-73-210-D: Medication staff did not receive required continuing education.
22VAC40-73-325-B: Fall risk rating was not reviewed and updated after resident falls.
22VAC40-73-640-A: Medication management plan not fully implemented regarding narcotic counts and glucometer labeling.
22VAC40-73-990-C: Facility failed to complete six month practices of emergency plan.
22VAC40-73-450-F: Individualized service plans were not updated to reflect discontinued oxygen and allergies.
22VAC40-73-40-A: Facility failed to comply with regulations and policies; TB assessments signed by unlicensed staff.
22VAC40-73-250-D: Staff TB screenings lacked dates to show when screenings were done.
22VAC40-73-120-A: New staff orientation was incomplete and missing required sections.
22VAC40-73-640-A: Medication management plan lacked required sections on verifying orders and staff qualifications.
22VAC40-73-450-C: Comprehensive individualized service plans failed to address some assessed needs.
22VAC40-73-680-B: Medications were not kept in pharmacy container until administration.
22VAC40-73-290-A: Written work schedule did not indicate who was in charge at given times.
22VAC40-73-650-E: Prescribers did not sign written orders in resident records.
Report Facts
Violations cited: 16
Distinct standards: 15
Inspections on page: 5
Inspections with violations: 5
Complaint visits: 0
Individual Reports
One document per inspection visit.
Inspection Report — Jan 27, 2022
Complaint Investigation
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.
Violations (1)
Failure to administer the physician ordered vitamin Certavite senior for Resident #44.
Report Facts
Residents affected: 1
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 — May 22, 2019
Routine
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.
Violations (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 — Mar 21, 2018
Routine
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.
Violations (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. |
3 CMS Surveys
CMS Survey — Mar 22, 2018
Mar 22, 2018
CMS Survey — May 23, 2019
May 23, 2019
CMS Survey — Jan 27, 2022
Jan 27, 2022
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