Deficiency Records for Virginia Highlands Care and Rehab LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Virginia Highlands Care and Rehab LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-07 | 2023-12-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-07 | 2023-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-25 | 2023-11-23 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-25 | 2023-11-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-25 | 2023-11-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-18 | 2023-02-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-18 | 2023-02-10 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-01-18 | 2023-02-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-10 | 2022-12-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-10 | 2022-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-10 | 2022-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-10 | 2022-12-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2022-12-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-10 | 2022-12-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-10 | 2022-12-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-11-10 | 2022-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-08 | N |
| Keep all essential equipment working safely. | Health | 2022-11-10 | 2022-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2022-12-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-14 | 2022-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-14 | 2022-12-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-20 | 2022-08-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-20 | 2022-08-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-07-20 | 2022-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-20 | 2022-08-19 | Y |
| Report COVID19 data to residents and families. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-08-19 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-05-04 | 2022-07-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-04 | 2022-07-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-04 | 2022-07-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-04 | 2022-07-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-04 | 2022-07-20 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-01-10 | 2022-02-09 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-10 | 2022-02-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-10 | 2022-02-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-10 | 2022-02-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-10 | 2022-02-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-10 | 2022-02-09 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-10 | 2022-02-09 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-08 | 2021-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-08 | 2021-10-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-08 | 2021-10-07 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-09-08 | 2021-10-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-08 | 2021-10-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-08 | 2021-10-07 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-09-08 | 2021-10-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-08 | 2021-10-07 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-03 | 2021-05-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-11 | 2019-10-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-11 | 2019-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-11 | 2019-10-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-11 | 2019-10-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-11 | 2019-10-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-11 | 2019-10-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-09-11 | 2019-10-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-24 | Not Fixed | Y |
