Parham Health Care: Medication Delays, Neglect - VA
Federal inspectors found Resident #123 alert and cognitively intact during their August complaint investigation. She scored a perfect 15 out of 15 on mental status testing. She could make her own medical decisions.
But she couldn't get her medications on time.
The woman's carbidopa/levodopa, a critical Parkinson's medication, arrived hours behind schedule throughout the spring. On March 25, the 1 p.m. dose came at 2:31 p.m. On May 25, her 5 p.m. dose didn't arrive until 7:42 p.m.
The worst delay happened that same May evening. Eleven medications ordered for 9 p.m. — including pain medication oxycodone, sleep aid doxepin, and muscle relaxant tizanidine — sat undelivered until 8:15 the next morning.
"There just were not enough staff to take care of residents," she told inspectors during their August 29 visit. "This situation happened to her often."
The medication delays were just part of her daily neglect.
Inspectors found the woman lying in the same soiled bed from 10 a.m. until 1:40 p.m. Her entire room smelled of urine, feces, and body odor. Her socks, meant to be white, had dried brown stains. Records showed she was completely dependent on staff for all personal care.
The facility's own documents claimed she received a bath every morning. But inspectors never saw her out of bed during daytime hours throughout their entire survey.
Her care plan promised medications would be administered according to doctor's orders. The facility's medication policy said the same thing. But the timestamps on her medication administration records told a different story across three months of delays.
In April, eight medications ordered for 9 a.m. didn't arrive until 11 a.m. Eye drops, vitamins, blood pressure medication, diabetes drugs — all delayed by two hours on April 25.
The woman had been admitted to Parham with multiple serious conditions requiring precise medication timing: Parkinson's disease, muscle atrophy, type 2 diabetes, hypertension, and anemia. Parkinson's medications particularly require consistent scheduling to maintain symptom control.
During the August 29 inspection, she remained alert and oriented to person, place, time, and situation despite the medication chaos. She understood exactly what was happening to her.
Inspectors confronted facility administrators about the delays during an end-of-day meeting on August 29. The administrator, director of nursing, and corporate clinical support consultant were all present.
Five days later, on September 3, the director of nursing told surveyors they had implemented changes. Resident #123 was now receiving needed care every two hours and getting medications on time.
"They further stated they had nothing further to provide," the inspection report concluded.
The facility had 28 residents in the survey sample. Only one case of medication delays was documented, but that single case revealed months of systematic failures for a vulnerable woman who depended entirely on staff for survival.
Her perfect cognitive scores meant she was fully aware of every delayed dose, every hour spent lying in soiled bedding, every promise broken by the people responsible for her care.
The violation carried a "minimal harm" classification, affecting "few" residents according to federal ratings. But for Resident #123, the harm was daily and relentless — medication delays that could worsen her Parkinson's symptoms, combined with basic hygiene neglect that left her lying in waste for hours.
Federal inspectors completed their survey on September 3, 2025. The facility must submit a plan of correction, but Resident #123 had already endured months of delayed medications and inadequate care before anyone intervened.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Parham Health Care & Rehab Center in RICHMOND, VA was cited for neglect violations during a health inspection on September 3, 2025.
Federal inspectors found Resident #123 alert and cognitively intact during their August complaint investigation.
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.