Parham Health Care & Rehab: Safety Violation - Richmond, VA
That was what federal inspectors found on August 28, 2025, when they walked into a shared room at the facility on a complaint inspection. The bed belonging to Resident 128 had no footboard attached. When inspectors asked Resident 109, the man sharing that room, about it, he said the footboard belonged to his roommate. Resident 128 could not recall how long the footboard had been missing.
That detail, small as it sounds, sits at the center of what inspectors documented: a piece of standard bed safety equipment was absent, the residents living with that absence had no clear answer for how long it had been that way, and the facility's own leadership, when confronted with the finding the following afternoon, offered nothing.
Resident 109 came to Parham carrying a complicated medical history. His diagnoses included HIV, hypertension, anxiety, a traumatic subdural hemorrhage without loss of consciousness, Type 2 diabetes managed with long-term insulin use, alcohol abuse, psychosis, major depressive disorder, a prior cerebral infarction, vascular dementia, a neurocognitive disorder with Lewy bodies, and obstructive pulmonary disorder. His most recent formal cognitive assessment, a quarterly Minimum Data Set evaluation completed with a reference date of July 7, 2025, placed him at a score of 11 out of 15 on the Brief Interview for Mental Status. That score indicates moderate cognitive impairment in daily decision making.
He was the one who told inspectors the footboard belonged to his roommate.
Resident 128 could not say how long it had been missing.
The inspection was a complaint visit, meaning someone had raised a concern serious enough to trigger a federal review. The specific nature of the original complaint is not detailed in the inspection findings, but the bed equipment finding was what inspectors documented and cited.
On August 29, 2025, at 12:28 in the afternoon, inspectors sat down with the facility's Administrator, its Director of Nursing, a Regional Director of Clinical Services, and a Divisional Regional Director of Clinical Services. That is four people in positions of authority over the care delivered inside Parham's walls. Inspectors reviewed the footboard finding with all four of them during what the report describes as an end of day debriefing.
No further information was provided.
That phrase, four words in the inspection report, is doing a great deal of work. It means that after inspectors explained what they had found, after they described the missing footboard and the residents who could not account for its absence, the facility's administrator and three clinical directors had nothing to add. No explanation for when the footboard was removed. No documentation showing it had been flagged and addressed. No corrective action described. Nothing.
Bed footboards are not decorative. On a facility bed, particularly one occupied by a resident with the kind of neurological and physical complexity that Resident 128 or Resident 109 might carry, the footboard serves as a physical boundary, a point of reference, and in some configurations a component of positioning and fall prevention. A shared room in a nursing facility is not a space where missing equipment goes unnoticed by accident. Someone removed it, or it came off, and at some point that became the normal state of the bed.
The inspection finding was classified under a harm level described as minimal harm, including but not limited to potential for actual harm. That classification reflects the federal framework inspectors use to categorize what they find, and it is worth understanding what it means in practice. Minimal harm with potential for actual harm is not a finding that something terrible already happened. It is a finding that the conditions exist for something terrible to happen. The distinction matters because nursing facilities sometimes point to the lower harm classification as evidence that a finding is minor. The classification does not mean the risk is minor. It means inspectors documented a hazard before a resident was hurt.
Resident 109, who has moderate cognitive impairment, who lives with vascular dementia and a neurocognitive disorder with Lewy bodies alongside a history of subdural hemorrhage, was sharing a room with a bed that lacked its footboard. He noticed. He told inspectors about it. He identified it as his roommate's equipment. A man with a documented BIMS score of 11, with psychosis and major depressive disorder among his diagnoses, was the one who flagged the missing safety equipment to the people conducting a federal complaint inspection.
The four administrators in the debriefing room had nothing to say about it.
Parham Health Care & Rehab Center is a long-term care and rehabilitation facility in Richmond. The inspection report filed following the August 2025 complaint visit runs eight pages. The footboard finding appears on the final page, and it is the finding that was reviewed with facility leadership at the close of the inspection's active phase.
What the inspection record does not contain is any indication that the footboard was replaced before inspectors left, or that the facility identified how long the equipment had been absent, or that anyone interviewed staff about when and why it was removed. The record contains the finding, the resident interviews, and four words describing what facility leadership contributed to the conversation about it.
No further information was provided.
Resident 109 had been admitted to Parham with a diagnosis list that reads like a catalog of compounding vulnerabilities. HIV. Hypertension. Anxiety. A bleed inside the skull that did not cause loss of consciousness but that left its mark on a brain already contending with vascular dementia and Lewy body disease. Insulin-dependent diabetes. A history of alcohol abuse. Psychosis. Major depression. A prior stroke. Obstructive pulmonary disorder. He scored in the moderate impairment range on his cognitive assessment but was alert enough, present enough, to tell inspectors that the equipment they were looking at belonged to his roommate.
His roommate, Resident 128, could not remember how long the footboard had been gone.
Between the two of them, they were the only ones in that room who could speak to what was missing and how long it had been that way. The facility's leadership, gathered in a conference room the next afternoon with inspectors sitting across from them, could not or would not add anything to what two residents with significant cognitive and medical impairments had already said.
The inspection was completed on September 3, 2025.
What happens in room D after that, whether Resident 128's bed has a footboard now, whether anyone documented what was missing and for how long, whether the man with the subdural hemorrhage and the Lewy body dementia is sleeping six feet from a properly equipped bed tonight, is not something the inspection report addresses.
The report ends where it ends. The residents remain.
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: 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 26, 2026 · Our methodology
Parham Health Care & Rehab Center in RICHMOND, VA was cited for violations during a health inspection on September 3, 2025.
That was what federal inspectors found on August 28, 2025, when they walked into a shared room at the facility on a complaint inspection.
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.