Virginia Gay Nursing & Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Virginia Gay Nursing & Rehab, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jul 16, 2026

  Based on facility record review, interview, the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year (FY) Quarter 2, 2026, and the Centers for Medicare & Medicaid Services Electronic Staffing Data Submission PBJ Long-Term Care Facility Policy Manual (CMS PBJ Manual) the facility failed to submit accurate staffing data to CMS for 1 of 1 quarter reviewed. The facility reported a census of 31 residents. Findings include:The facility PBJ Staffing Data Report dated FY Quarter 2 2026 (January 1 - March 31) documented the facility triggered for a one star staff rating, no RN (Registered Nurse) hours, and failure to have licensed nursing coverage for 24 hours per day. RN hours were flagged on 2/11/2026, 2/12/2026, 2/17/2026, and 2/18/2026. […]

• No harm, potential for more than minimal, widespreadF868Jul 16, 2026

  Based on facility records, interviews, and the facility Quality Assurance Performance Improvement (QAPI) Plan the facility failed to ensure all required staff or a designee attended quarterly QAPI meetings and that the Infection Preventionist provided relevant infection control information to the committee. The facility reported a census of 31 residents. Findings include:A document titled N & R (Nursing and Rehabilitation) QAPI Meeting dated 8/11/2025 documented the Medical Director and the Interim Administrator were absent from the meeting. The list of attendees did not include designees for these roles. A document titled Nursing and Rehabilitation QAPI Meeting Minutes dated 2/19/2026 documented the Director of Nursing/Infection Preventionist (DON/IP) attended the meeting. […]

• No harm, potential for more than minimal, patternF812Aug 1, 2024

  Based on observation, policy review, and staff interview, the facility failed to maintain appropriate food holding temperatures at or above 135 degrees Fahrenheit. The facility identified a census of 35 residents. Findings include: Resident #9 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. During the initial pool interview 7/29/24 at 1:07 PM Resident #9 reported she dines in her room and many times the food is cold. Observation on 7/30/24 at 10:40 AM revealed the pre-meal temperatures as follows: a. Potatoes - 184 degrees b. Ground barbecue pork 211 degrees. […]

• No harm, potential for more than minimal, isolatedF552Jul 16, 2026

  Based on clinical record review, policy review, and staff interviews, the facility failed to obtain consent and provide information about the risks and benefits of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 3 of 5 residents reviewed for psychotropic medications (Residents #1, #3, #7). The facility reported a census of 31 residents.Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 6/10/26, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated severe cognitive impairment. The MDS assessment listed a diagnosis of non-Alzheimer's dementia for the resident. The MDS indicated that Resident #1 took an antipsychotic medication. […]

• No harm, potential for more than minimal, isolatedF628Jul 16, 2026

  Based on clinical record review, staff interview, and facility record review, the facility failed to notify the State Ombudsman office of resident hospital transfers for 1 of 1 resident reviewed for transfers (Resident #9). The facility reported a census of 31 residents.Findings include:The clinical record for Resident #9, admitted on [DATE], documented diagnoses that included unspecified atrial fibrillation, cardiomyopathy, and chronic congestive heart failure.A Social Service Structured Progress Note dated 4/30/26 documented Resident #9 had a hospital stay on 4/18/26 due to cellulitis requiring intravenous (IV) medications.A Health Status Note dated 4/19/26 at 12:50 PM documented Resident #9 returned to the facility following a discharge from the hospital at 12:35 PM after receiving… […]