Parham Health Care: Medication Delays, Hygiene Failures - VA
The woman, identified in federal inspection records only as Resident 123, was a patient at Parham Health Care & Rehab Center on East Parham Road when inspectors visited in late August and early September 2025. She had a perfect score on a cognitive screening test, was her own legal decision-maker, and knew exactly what was happening to her.
"There just were not enough staff to take care of residents," she told inspectors during an interview on August 29. She said the late medications and inadequate care happened to her often.
Her medication records confirmed it. In March, April, and May 2025, staff administered her drugs late, repeatedly, across three months of documented timestamps.
On March 25, her carbidopa/levodopa, a critical Parkinson's medication that controls tremors and movement, was ordered for 1:00 p.m. Staff gave it at 2:31 p.m.
April 25 was worse. Eight medications, including her carbidopa/levodopa, a diabetes drug, a blood pressure medication, a pain reliever, and a multivitamin, were all ordered for 9:00 a.m. Staff administered them at 11:00 a.m., two hours late.
May 25 was the worst documented. Her 5:00 p.m. carbidopa/levodopa arrived at 7:42 p.m. Then eleven medications ordered for 9:00 p.m., including oxycodone, gabapentin, mirtazapine, doxepin, and a second dose of carbidopa/levodopa, were not given until the following morning at 8:15 a.m. Eleven hours late.
For a Parkinson's patient, the timing of carbidopa/levodopa is not a scheduling preference. The drug manages the disease's neurological symptoms, and delays can cause muscle rigidity and loss of motor control. The inspection report does not document what symptoms, if any, she experienced during those gaps.
The care records told a parallel story. The facility's own documentation said she received a bath every morning. Inspectors found her soiled in bed at 10:00 a.m. on August 29 and observed her still soiled and in the same position at 1:40 p.m. She was never seen out of bed during daytime hours across the entire inspection period. She was listed as totally dependent on staff for her daily care.
The room smelled of urine, feces, and body odor. Her socks, meant to be white, had dried brown stains.
She told inspectors she knew she was receiving her medications late. She knew what the schedule was supposed to be. She said it anyway, clearly, to people with clipboards, because she had a perfect cognitive score and no one else was going to say it for her.
At an end-of-day meeting on August 29, facility administrators, including the administrator and the director of nursing, were told what inspectors had found. A corporate clinical support consultant was also present.
By September 3, the last day of the survey, the director of nursing told inspectors that Resident 123 was now receiving care checks every two hours and that her medications were being given on time. The director said they had nothing further to provide.
The inspection covered 28 residents. Surveyors identified the medication delay problem in one of them.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lowest tier of severity in the federal rating system. The finding fell under the regulatory category requiring facilities to ensure residents receive medications with the services of a licensed pharmacist, meaning the problem was logged as a pharmacy services failure rather than a direct care failure.
Parham Health Care & Rehab Center is a for-profit facility. The inspection was complaint-driven, meaning someone reported a concern before surveyors arrived.
The woman who scored a perfect 15 out of 15 on her mental status exam, who knew the name of the medication and the time it was supposed to arrive, spent months waiting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parham Health Care & Rehab Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Parham Health Care & Rehab Center in RICHMOND, VA was cited for violations during a health inspection on September 3, 2025.
She had a perfect score on a cognitive screening test, was her own legal decision-maker, and knew exactly what was happening to her.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.