Paul Spring Independent, Assisted Living & Memory Care Community

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Paul Spring Independent, Assisted Living & Memory Care Community was inspected 30 times between December 16, 2020 and January 30, 2026 by the Virginia Department of Social Services. 15 of those visits ended with violations cited and 15 with none. Across that history VDSS cited 34 violations under 24 distinct standards. 8 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 27 of these 30 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

01/14/2027

Administrator

Joyceline Owusu-Dankwaa

Licensing inspector

Nina Wilson

Inspector phone

(703) 635-6074

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

January 30, 2026Complaint survey1 violation

Inspection dates

01/30/2026

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/30/2026 Time in: 9:59 AM Time out: 10:17 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/29/2026 regarding allegations in the area(s) of: Building and Grounds and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 136 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed snow and ice throughout the parking lot and within designated parking spaces. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov

Violations

22VAC40-73-870-G

Based on licensing observation and staff interview, the facility failed to ensure that grounds should be properly maintained to include mowing of grass and removal of snow and ice.

Evidence

During the onsite inspection, 01/30/2026, licensing inspector (LI) observed snow and ice throughout the parking lot and within designated parking spaces. The snow and ice were not thoroughly removed, making it difficult to navigate the lot in a vehicle and/or on foot.
During the onsite inspection, staff 1 stated that collateral contact 1 had been plowing the grounds daily since 01/24/2026 through 01/30/2026; but it was difficult to maneuver through the parking lot due to vehicles remaining parked. Staff 2 confirmed that although collateral contact 1 was plowing the parking lot, there were areas that were covered in snow and

Plan of correction

Immediate Corrective Action On 01/30/2026, the facility contacted the contracted snow removal provider (Collateral Contact 1) and required immediate return to the facility to fully clear all remaining snow and ice from: • Parking lot driving lanes • All designated parking spaces • Walkways and entry points Ice melt/salt was applied to all affected areas to ensure safe vehicle and pedestrian access. All vehicles remaining in the lot were relocated to allow complete plowing and clearing. 2. Measures to Prevent Recurrence To prevent future occurrences: • Residents, families and Staff have been instructed that during snow events, vehicles must be temporarily moved (when possible) to ensure full access for plowing. • The Environmental services director and/or the Administrator or designee will conduct and document a visual inspection of the grounds following each snow removal service. 3. Monitoring Plan • A Snow and Ice Removal Log has been implemented. • The Administrator or designee will: o Inspect the ground after each snowfall. o Document condition of parking lot and walkways. o Verify completion of plowing and salting. • Monitoring of the exterior grounds will occur after every snow event for 90 days and ongoing as needed during winter months. 4. Responsible Party The Facility Administrator is responsible for ensuring compliance with snow and ice removal requirements and ongoing monitoring of ground maintenance. Date to be corrected: 01/30/2026

November 20, 2025Inspection5 violations

Inspection dates

11/20/2025

Areas reviewed

Technical assistance

Licensing inspector reviewed the following standards with the facility: 22VAC40-73-50, 22VAC40-73-250, 22VAC40-73-310, 22VAC40-73-325, and 22VAC40-73-970.

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2025 Time in: 11:03 AM Time out: 5:49 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 136 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents engaged in scheduled activities, dining for lunch and dinner, and entering and exiting the facility for community outings. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

22VAC40-73-930-D

Based on resident record review and staff interview, the facility failed to ensure each resident with an inability to use the signaling device, in addition to any other services, the following should be met: this inability should be included in the resident’s individualized service plan (ISP); the plan should specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other anticipated resident needs; and once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff should make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.

Evidence

Resident 1’s individualized service plan (ISP, dated 01/24/2025) indicated an inability to utilize a call pendant due to cognitive impairment.
Resident 1’s ISP (dated, 09/02/2025) indicated that they will remain on “closed secure unit.” Residents residing on a safe, secure environment have an inability to utilize a call pendant due to cognitive impairment.
Resident 3’s individualized service plan (ISP) did not include an inability to use a signaling device or specify a minimal frequency of daily rounds to be made by direct care staff.
During the onsite inspection, 11/20/2025 staff 7 provided documentation of rounds; however, the rounds were not of rounds being made no less often than every two hours when resident 1 and resident 3 went to bed each evening and until they had arisen each morning due to an inability to utilize a signaling device. 5. Upon request the facility did not provide documentation that rounds were made no less often than every two hours when resident 1 (admit date, 01/24/2025) and resident 3 (admit date, 09/02/2025) went to bed each evening and until they had arisen each morning.

Plan of correction

• Effective immediately, the community will implement a consistent process for documenting resident rounding in PCC, aligned with each resident’s plan of care and ISP requirements. • The DCS will review all residents’ ISPs to identify any similar requirements for scheduled rounds or monitoring, and ensure staff are aware of and trained on those requirements. • Nursing staff have been re-educated on Resident’s ISP requirements and the importance of adhering to individualized care plans including monitoring resident for pendant use or need for rounding. • The Director of Clinical Services and/or designee will audit Resident’s rounding documentation daily for the next 30 days to ensure compliance. • The DCS or designee will conduct weekly audits of rounding logs for all residents with scheduled check-in requirements for 90 days. • Any noncompliance will result in immediate corrective counseling and retraining of staff. Completion Date: Will be fully implemented by 01/31/26. Responsible Party: Director of Clinical Services and/or designee

22VAC40-73-450-H

Based on resident record and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.

Evidence

Resident 1’s (admit date, 01/24/2025) ISP (dated, 01/24/2025) stated, “resident is unable to utilize pendant due to cognitive impairment. Staff will check on resident every two hours and attend to needs.”
Upon request the facility did not provide daily rounds every two hours for resident 1.
During the onsite inspection on 11/20/2025, staff 7 provided documentation of rounds; however, the rounds were not of daily check-ins, every two hours due to resident 1’s inability to utilize the call pendant.

Plan of correction

Effective immediately, the community will implement a consistent process for documenting resident rounding in PCC, aligned with each resident’s plan of care and ISP requirements. • The Director of Clinical Services and/or designee will audit Resident’s rounding documentation daily for the next 30 days to ensure compliance. • Any noncompliance will result in immediate corrective counseling and retraining of staff. • Nursing staff have been re-educated on Resident’s ISP requirements and the importance of adhering to individualized care plans including monitoring resident for pendant use or need for rounding. Completion Date: Will be fully implemented by 01/31/2026. Responsible Party: Director of Clinical Services and/or designee

22VAC40-73-640-A

Based on resident record review and staff interview, the facility failed to ensure to have, keep current, and implement a written plan for medication management to include procedures for administering medication and a plan for proper disposal of medication.

Evidence

During the onsite inspection on 11/20/2025, licensing inspector requested to review resident 5’s routine and PRN medications with staff 9. During the review, staff 7 provided three medications that were not on resident 5’s physician order sheet: Vitamin D3 (1 bottle and 1 bubble pack), Essential Multivitamin (1 bottle), and Atorvastatin 20 MG (2 medication bottles).
During the onsite inspection on 11/20/2025, staff 7 and staff 9 confirmed that Vitamin D3, Essential Multivitamin, and Atorvastatin 20 MG were not properly disposed of after each medication was discontinued.

Plan of correction

• All discontinued medications (Vitamin D3, Essential Multivitamin, Atorvastatin 20 mg) identified during inspection were immediately removed from the medication storage area and disposed of according to facility policy and pharmacy guidelines. • Resident #5’s physician order sheet was reviewed and reconciled to ensure only current, active medications remain available for administration. • A full audit of all resident medication storage areas was conducted to identify and remove any discontinued or expired medications. This was completed on 11/25/2025. • Staff training was conducted on 11/25/2025 to reinforce proper medication administration and disposal procedures. Attendance records were maintained. • The Director of Clinical Services and/or designee will conduct monthly audits of medication storage areas to ensure compliance with disposal procedures. Completion Date: Will be Completed by 01/31/2026. Responsible Party: Director of Clinical Services and/or designee

22VAC40-73-280-B

Based on record review and staff interview, the facility failed to maintain a written plan that specified the number and type of direct care staff required to meet day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan should be directly related to actual resident acuity levels and individualized care needs.

Evidence

Upon request the facility did not provide a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care.
During the onsite inspection, 11/20/2025, staff 7 provided the disclosure statement. Section 5. General Number, Position Types, and Qualifications of Staff on Each Shift, as a written plan, which did not reflect the actual resident acuity levels and individualized care needs.

Plan of correction

Immediately completed a comprehensive review of current staffing assignments and verified that staffing levels are appropriate based on resident census and acuity levels on 11/26/25 • The Executive Director, Director of Clinical Services, or their designee will work in collaboration with the regional team to promptly develop and implement a formal written staffing plan. This plan will outline the number and type of direct care staff required for each shift, based on the current resident census and acuity levels. • Staff will be trained on the updated staffing plan to ensure awareness and compliance. Completion Date: The written staffing plan will be completed, implemented, and staff trained by January 31, 2026. Ongoing monitoring will continue thereafter.

22VAC40-73-1110-A

Based on resident record review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee should determine whether placement in the special care unit is appropriate. The determination and justification for the decision should be in writing and retained in the resident’s file.

Evidence

Upon request, the facility did not provide a determination and justification for the decision to place resident 1 (admit date, 01/24/2025) and resident 3 (admit date, 06/26/2025) in a safe, secure environment prior to admission.
During the onsite inspection on 11/20/2025, staff 7 confirmed that resident 1 and resident 3’s records did not include determination and justification for the decision to place resident 1 and resident 3 in a safe, secure environment.

Plan of correction

• The Executive Director or designee has completed written determinations and justifications for residents 1 and 3 for their placement in the special care unit. This was completed 11/26/25 • The Executive Director or designee will audit all memory care charts for the next 30 days to ensure compliance. • Training will be conducted on required forms in Memory Care including written determination and justification for Memory Care placement. This will be completed by 01/31/2026

August 14, 2025Complaint survey0 violations

Inspection dates

08/14/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/14/2025 Time in: 10:41 AM Time out: 11:34 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/27/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 143 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for outings, participating in scheduled activities, and interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 14, 2025Inspection0 violations

Inspection dates

08/14/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/14/2025 Time in: 9:50 AM Time out: 10:40 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/23/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 143 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for outings, participating in scheduled activities, and interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 8, 2025Inspection1 violation

Inspection dates

01/08/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/08/2025 Time In: 2:30 PM Time Out: 3:08 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 12/10/2024 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 138 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector (LI) observed residents entering and exiting the community, participating in scheduled facility activities, and dining in the dining room for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self report; area(s) of non-compliance with standard(s) or law were: Admission, Retention and Discharge of Residents and Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

22VAC40-73-470-C

Based on resident and facility record review, the facility retained a resident with a non-healing dermal ulcer III.

Evidence

Resident 1’s (admit date, 09/16/2020) homecare agency notes stated, “sacral stage 3” on 04/19/2024, 04/22/2024, 04/24/2024, 04/29/2024, 05/13/2024, 05/15/2024, and 05/17/2024.
During the onsite inspection on 01/08/2025, the facility was unable to provide documentation indicating resident 1’s sacral wound was determined by an independent physician to be stage 3 healing from 04/19/2024-05/17/2024 while the resident was residing and retained at the facility.

Plan of correction

In respect to the specific resident/situation cited: Resident was out of the community at the time of the inspection and has since been absent from the community. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Conduct mandatory wound documentation training for all nursing staff focusing on identification, classification, and documentation procedures. Meeting with partnered Home Health providers to review prohibited conditions in ALF including wounds and communication expectations with staff. Require supervisory sign-off on all wound care documentation done by third party vendors to add an additional layer of oversight. With respect to what systemic measures have been put into place to address the stated concern: Establish a clear communication channel for wound care concerns, including mandatory escalation of missed documentation incidents to the Administrator. Weekly chart audits for wound care cases over the next 90 days. Monthly meetings between facility and third-party vendors to ensure adherence to updated documentation policies. Quarterly review of wound care documentation protocols to maintain ongoing compliance.

January 8, 2025Complaint survey1 violation

Inspection dates

01/08/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/08/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/30/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 138 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector (LI) observed residents dining for lunch, interacting with peers and staff, entering and exiting the community for outings, and participating in scheduled activities within the facility. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

22VAC40-73-460-H

Based on resident record review, the facility failed to ensure that personal care was provided so that the needs of the resident were met, including care with the activities of daily living: toileting.

Evidence

Resident 1’s (admit date, 03/11/2022) individualized service plan (ISP) stated, “assist resident with incontinence in bathroom, change Depends and incontinent pads and provide peri-care. Check resident for incontinence every 2-3 hours.”
Resident 1’s peri-care was documented as completed every 4 hours twice on 12/02/2024, twice on 12/10/2024, twice on 12/11/2024, once on 12/14/2024, once on 12/22/2024, and once on 12/31/2024.
Resident 1’s peri-care was documented as completed every 5 hours once on 12/03/2024, once on 12/09/2024, and once on 12/15/2024.
Resident 1’s peri-care was documented as completed every 6 hours twice on 12/01/2024, once on 12/03/2024, once on 12/06/2024, once on 12/08/2024, once on 12/10/2024, once on 12/12/2024, once on 12/13/2024, once on 12/16/2024, once on 12/19/2024, once on 12/20/2024, once on 12/23/2024, once on 12/27/2024, and once on 12/30/2024.
Resident 1’s peri-care was documented as completed every 7 hours once on 12/07/2024, once on 12/04/2024, once on 12/07/2024, once on 12/18/2024, once on 12/21/2024, once on 12/22/2024, and once on 12/25/2024.
Resident 1’s peri-care was documented as completed every 8 hours once on 12/07/2024, once on 12/11/2024, and once on 12/26/2024.
Resident 1’s peri-care was not routinely documented as completed during overnight hours, ranging from 6 – 10 hours in the month of December 2024.
On 01/08/2025, LI interviewed staff 1 who confirmed that resident 1’s peri-care was not routinely documented.

Plan of correction

In respect to the specific resident/situation cited: Provided an Inservice on 1/10/25 to team members on delivering and documenting care in alignment with each resident’s individualized service plan to ensure consistency, quality, and person-centered care. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Implementation of a Rounding Schedule: Established clear rounding intervals tailored to each resident’s care plan as appropriate. Verified documentation was completed and reviewed for adherence. With respect to what systemic measures have been put into place to address the stated concern: Enhanced Staff Training: Conducted mandatory training on proper rounding protocols and individualized incontinent care per care plans. Reinforced the importance of timely and compassionate care in preventing skin breakdown and ensuring dignity. Real-Time Monitoring & Accountability Measures: Introduced electronic tracking systems for incontinent care and rounding completion. Assigned supervisors to conduct random audits and spot checks.

January 8, 2025Inspection4 violations

Inspection dates

01/08/2025, 01/09/2025

Areas reviewed

Technical assistance

LI provided guidance on the following standards: 22VAC40-73-970-E and 22VAC40-73-870-G.

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/08/2025 Time In: 3:08 PM Time Out: 5:53 PM 01/09/2025 Time In: 10:19 AM Time Out: 6:27 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 138 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector (LI) observed residents entering and exiting the community for outings, participating in scheduled activities, interacting with staff and peers, participating in physical therapy, exercising in the gym, dining for breakfast, lunch, and dinner, and interacting with family and other visitors. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

22VAC40-73-240-C

Based on volunteer record review, the facility failed to ensure that the facility maintained documentation on volunteers.

Evidence

Volunteer 7’s records were not provided upon request.
On 12/18/2024, LI interviewed staff 8 who confirmed that the volunteer records were not provided.

Plan of correction

In respect to the specific resident/situation cited: All Volunteer documentation received and in Compliance as of May 8, 2025. With respect to what systemic measures have been put into place to address the stated concern: Require all volunteers to complete standardized intake forms that include consent for background checks and background checks must be received by facility before volunteers begin working with residents. Conduct periodic internal audits to assess compliance.

22VAC40-73-990-C

Based on facility record review and staff interview, the facility failed to ensure that once every six months, all staff on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced.

Evidence

A resident emergency drill was conducted on the first shift, 01/01/2024. The emergency drill was signed by seven staff members. There were 78 staff members who clocked in to work on 01/01/2024.
A resident emergency drill was conducted on the first, second, and third shift, 07/10/2024. The first shift emergency drill was signed by 24 staff members. The second shift emergency drill was signed by 27 staff members. The third shift was signed by eight staff members. There were 93 staff members who clocked in to work on 07/10/2024.
On 01/08/2025, licensing inspector (LI) interviewed Staff 9 confirmed that staff did not participate.

Plan of correction

In respect to the specific resident/situation cited: Emergency Preparedness Drill has been conducted in accordance with the regulatory requirements as of 1/22/25. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Inservice team member on the importance of participating in emergency drills. With respect to what systemic measures have been put into place to address the stated concern: Implement a mandatory sign-in sheet for drills to document participation. Integrate the attendance records with the clock-in system to ensure all employees on duty are accounted for. Assign supervisors to verify attendance and follow up with absent employees immediately. Continue to conduct unannounced drills in accordance with the community's Emergency Preparedness Plan. Uphold staff Accountability on Mandatory Trainings per policy.

22VAC40-73-460-H

Based on resident record review, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident were met.

Evidence

Resident 2’s (admit date, 10/15/2022) individualized service plan (ISP) stated, check every 2-3 hours in apartment when awake to offer any assistance. Ensure resident’s apartment is free of fall and trip hazards when checking residents. Resident 1’s December 2024 ISP documentation did not reflect that fall prevention every 2-3 hours.
Resident 2’s fall prevention was documented every 4 hours, once on 12/18/2024, once on 12/21/2024, once on 12/24/2024, twice on 12/25/2024, once on 12/30/2024, once on 01/04/2025, twice on 01/05/2025, once on 01/09/2025, and twice on 01/10/2025.
Resident 2’s fall prevention was documented every 5 hours, once on 12/09/2024,12/13/2024, 01/06/2025, 01/08/2025; and twice on 01/07/2025.
Resident 2’s fall prevention was documented every 6 hours, once on 12/10/2024, 12/12/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/20/2024, 12/23/2024, 12/26/2024, and 12/27/2024.
Resident 2’s fall prevention was documented every 7 hours, once on 12/11/2024, 12/17/2024, 12/19/2024, 12/25/2024, 01/01/2025, 01/03/2025, 01/04/2025, and 01/08/2025.
Resident 2’s fall prevention was documented every 8 hours once on 12/30/2024.

Plan of correction

In respect to the specific resident/situation cited: Provided an Inservice on 1/10/25 to team members on delivering and documenting care in alignment with each resident’s individualized service plan to ensure consistency, quality, and person-centered care. In respect to how the facility will identify residents/situations with the potential for the identified concerns: An audit completed to identify residents with increased rounding needs. Implementation of a Rounding Schedule: Established clear rounding intervals tailored to each resident’s care plan as appropriate. Verified documentation is completed and reviewed for adherence. With respect to what systemic measures have been put into place to address the stated concern: Enhanced Staff Training: Conduct mandatory training on proper rounding protocols relating to fall prevention per care plans. Reinforced the importance of timely rounding in preventing falls Real-Time Monitoring & Accountability Measures: Audit electronic tracking systems for falls prevention and rounding completion. Assigned supervisors to conduct random audits and spot checks.

22VAC40-73-990-B

Based on facility record review, the facility failed to ensure the procedures in the plan for resident emergencies were reviewed by the facility every six months with all staff. Documentation of the review was signed and dated by each staff person.

Evidence

The resident emergencies were reviewed on 04/06/2024.The resident emergency review was signed by eight staff members. There were 79 staff members who clocked in to work on 04/06/2024.
The resident emergencies were reviewed on 11/18/2024; the shift was not documented. The resident emergency review was signed and dated by eight staff members. There were also eight staff members who signed but did not date the emergency review. There were 88 staff members who clocked in to work on 11/18/2024.
The resident emergencies were reviewed on 11/18/2024; the shift was not documented. The resident emergency review was signed and dated by ten staff members. There were 94 staff members who clocked in to work on 11/19/2024.

Plan of correction

In respect to the specific resident/situation cited: Emergency Preparedness Review has been conducted in accordance with the regulatory requirements as of 1/22/25. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Inservice team member on the importance of participating in emergency Review. With respect to what systemic measures have been put into place to address the stated concern: Implement a mandatory sign-in sheet for drills to document participation. Integrate the attendance records with the clock-in system to ensure all employees on duty are accounted for. Assign supervisors to verify attendance and follow up with absent employees immediately. Continue to conduct unannounced drills in accordance with the community's Emergency Preparedness Plan. Uphold staff Accountability on Mandatory Trainings per policy.

January 8, 2025Inspection0 violations

Inspection dates

01/08/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/08/2025 Time In: 12:52 PM Time Out: 1:50 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report incident was received by VDSS Division of Licensing on 11/29/2024 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 138 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector (LI) observed the physical plant of the facility. LI observed residents entering and exiting the facility for community outings. LI observed visitors and residents engaging in Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 19, 2024Inspection0 violations

Inspection dates

08/19/2024

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2024 Time In: 10:28 AM Time Out: 2:42 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/05/2024 regarding allegations in the areas of: Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 149 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed residents interacting with one another, engaging in family visits, and community outings. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 5, 2024Inspection0 violations

Inspection dates

02/05/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced focused monitoring inspection was conducted on 2/5/24. Two resident records were observed and interviews were conducted. No violations were cited during the inspection. An exit meeting was held. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at m.massenberg@dss.virginia.gov or (703) 431-4247. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 9, 2024Complaint survey0 violations

Inspection dates

01/09/2024

Areas reviewed

22VAC40-73 BUILDINGS AND GROUNDS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/9/2024 (3:10 PM - 4:50 PM) A complaint was received by VDSS Division of Licensing on 12/4/23 regarding an allegation in the area(s) of: Building and Grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted: Six Observations by licensing inspector: Building and grounds An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 28, 2023Inspection2 violations

Inspection dates

12/28/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/28/23 (8:00 AM - 5:15 PM) Number of residents present at the facility at the beginning of the inspection: 149 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 10 Number of interviews conducted with residents: Three Number of interviews conducted with staff: Three Observations by licensing inspector: Meals, medication administration, activities The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction:(i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

22VAC40-73-680-M

Based on record review and observation, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility.

Evidence

PRN Aleve, ordered 3/24/22 for Resident #7, was not present during the medication cart inspection. Facility staff confirmed that Resident #7's PRN Aleve was not present, at the time of the medication cart inspection. PRN Acetaminophen, ordered 2/20/19 for Resident #9, was expired at the time of the medication cart inspection. Resident #9's Acetaminophen package expired on 11/30/23. Resident #9's PRN Afrin sinus solution, ordered 5/10/21, was not present during the medication cart inspection. Facility staff confirmed that no additional PRN Acetaminophen was present for Resident #9, and that the resident's Afrin sinus solution was not present at the time of the medication cart inspection. PRN Clindamycin, ordered 10/25/22 for Resident #11, was expired at the time of the medication cart inspection. The medication package indicated that the medication expired in July 2023. Facility staff confirmed that no additional Clindamycin was present for Resident #11, at the time of the medication cart inspection.

Plan of correction

PRN medications were immediately ordered and available the same day. All PRN medications will be reviewed on a weekly basis to ensure availability.

22VAC40-73-680-D

Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Resident #9's December MAR (medication administration record) was reviewed during the inspection. The MAR indicates that Resident #9's Metoprolol Succinate ER should be held when the resident's SBP (systolic blood pressure) is less than 120. The MAR states that Resident #9 was administered Metoprolol on 12/1/23 when the resident's blood pressure was 111/59. The MAR also states that Resident #9 was administered Mtetoprolol on 12/9/23, when the resident's blood pressure was 113/63.

Plan of correction

Clinical Services will conduct mandatory re-training for nurses and Registered Medication Aides regarding medication administration/medication management plan. Two clinical team members will verify parameters for all blood pressures prior to medication administration. Clinical administration will conduct routine, unannounced medication administration audits for monitoring and observation.

November 21, 2023Inspection0 violations

Inspection dates

11/21/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced monitoring inspection was conducted to follow-up on facility reported incidents. Interview conducted, resident records observed, and one staff record was observed. No violations were cited during the inspection. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 21, 2023Complaint survey0 violations

Inspection dates

11/21/2023

Areas reviewed

22VAC40-73 BUILDINGS AND GROUNDS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/21/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/25/23 regarding an allegation in the area(s) of: Building and Grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted: 3 Observations by licensing inspector: Facility documentation An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 11, 2023Inspection1 violation

Inspection dates

09/11/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced monitoring inspection was conducted on 9/11/23 in response to facility-reported incidents. Building and grounds were inspected and records were reviewed. Violation was discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

22VAC40-73-460-D

Based on documentation, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

Resident #1 was admitted to the facility's memory care unit on 8/21/23. Resident #1's record includes an assessment of serious cognitive impairment, that states that Resident #1 has a serious cognitive impairment with an inability to recognize danger or protect her own safety and welfare. Facility documentation states that on 8/23/23, Resident #1 was able to leave the memory care unit, after asking a staff member to let her out of the unit. Resident #1 reported that she was there to visit someone, and the staff member opened an exit door. Another staff member reportedly observed Resident #1 outside, and returned her to the memory care unit.

Plan of correction

Staff member received immediate corrective action. Refresher in-service provided for all staff on Inspiritas elopement. An elopement book will be created to identify memory care residents who are at risk of leaving the unit. Assistant Director or Clinical services will conduct Inspiritas daily huddle with the team to prevent further instances.

August 4, 2023Inspection0 violations

Inspection dates

08/04/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/4/23 (1:10 PM - 2:45 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Incident reports were received by the licensing office on 8/2/23 and 8/4/23 regarding allegations in the area of: Resident Care and Related Services. Number of participant records reviewed: 5 Number of staff records reviewed: 2 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 3 An exit meeting was conducted to review the findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 13, 2023Inspection1 violation

Inspection dates

07/13/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced monitoring inspection was conducted on 7/13/23. Medication administration, resident records, and facility documentation was observed. Interview was conducted. The violation was discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on documentation and observation, the facility failed to ensure that medications are administered in accordance with the physician’s instructions.

Evidence

Medication administration was observed for Resident #1, during the inspection. Resident #1's medications were placed in a pill cup and the medication packages were returned to the medication cart. The licensing inspector inquired about Resident #1’s Calcium Citrate-Vitamin D. Resident #1’s MAR called for the resident to receive two tablets of Calcium Citrate-Vitamin D during the medication administration, but only one tablet was placed in the pill cup for administration. Resident #2’s July MAR was reviewed during the inspection. On 7/5/23, Resident #2’s Amlodipine was documented as not given because his vitals were outside of parameters for administration. Resident #2’s Amlodipine order did not contain parameters for the medication’s administration.

Plan of correction

Resident #1’s medication orders were reviewed and verified by the Director of Clinical Services. A refresher in-service was completed on 7/13/23 to review medication administration policy and 5 Rights of Medication. Resident #2’s Amlodipine order was clarified with physician by DCS and an in-service on medications and parameters was completed on 7/13/23. The Director of Clinical Services will complete order reviews periodically to compare medication administration record with physician orders. With respect to what systemic measures have been put into place to address the stated concern. The Director of Clinical Services will conduct random and routine 1:1 medication observation with each team member for monitoring and observation to verify continued compliance with medication management.

May 19, 2023Inspection0 violations

Inspection dates

05/19/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced focused monitoring inspection was conducted on 5/19/23 to follow-up on facility reported incidents. Resident records were observed and an interview was conducted. No violations were cited during the inspection. An exit meeting was held. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at m.massenberg@dss.virginia.gov or (703) 431-4247. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 21, 2023Complaint survey2 violations

Inspection dates

02/21/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced complaint inspection was conducted on 2/21/23 in response to a complaint received by the licensing office on 2/10/23 regarding Resident Care and Related Services, and Administration and Administrative Services. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

22VAC40-73-680-I

Based on documentation, the facility failed to ensure that the medication administration record (MAR) includes all of the required information.

Evidence

Resident #2’s February MAR was observed, during the inspection. Resident #2’s MAR did not include information about the administration of her Novolog on 2/5/23 (6:30 AM administration).

Plan of correction

Facility will ensure all MARs include all required information. Nursing Administration to monitor MARs weekly in conjunction with QA meetings to ensure compliance. Wellness director will conduct monthly audits for 90 days.

22VAC40-73-680-D

Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

The morning medication administration was observed, for Resident #1, during the inspection. Resident #1's medication administration record (MAR) called for her to receive 100mcg of Vitamin B12 and 25mcg of Vitamin D daily. Resident #1 was given 1000mcg of Vitamin B12 and 50mcg of Vitamin D, during the observed medication administration. Novolog administration was observed for Resident #2, during the inspection. Resident #2 was going to be administered 28 units of Novolog, before being stopped by the resident's family member. Resident #2's MAR called for her to receive Novolog on a sliding scale. Resident #2's blood sugar was recorded to be 196. The sliding scale indicated that she is supposed to receive 16 units of Novolog, when her blood sugar is between 151 and 200. A review of Resident #2's MAR, states that the resident's Novolog was not administered on 2/2/23 at 6:30 AM (BS: 144) or 2/4/23 at 6:30 AM (BS: 134). The MAR stated that no coverage was required for those administration times on 2/2/23 and 2/4/23. Resident #3's February MAR was reviewed, during the inspection. Resident #3's MAR states that she was administered Metoprolol on 2/11/23 (BP: 108/72) and 2/14/23 (BP: 101/73). Resident #3's MAR states that her Metoprolol should be held for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60.

Plan of correction

Facility obtained updated order for resident medication. All Registered Medication Aides will complete Registered Medication Continuing Education Course. Clinical administration will conduct routine, unannounced medication administration audits for monitoring and observation.

January 31, 2023Inspection0 violations

Inspection dates

01/31/2023, 02/21/2023, 03/07/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Unannounced monitoring inspections were conducted on 1/31/23, 2/21/23, and 3/7/23; in response to facility reported incidents. Resident records, staff records, and interviews were conducted. No violations were cited as a result of the monitoring inspections. Thank you for your cooperation and if you have any questions, please contact me at m.massenberg@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 29, 2022Inspection4 violations

Inspection dates

12/29/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

An unannounced renewal inspection was conducted on 12/29/22 (8:30 AM - 5:50 PM). At the time of entrance, 153 residents were in care. Meals, medication administration and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Additional interviews were conducted after the on-site visit. Violations were discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations

22VAC40-73-860-I

Based on observation and record review, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area.

Evidence

Multi-surface cleaner was observed in the cabinet of Resident #5 of the memory care unit. The cleaner was unlocked and unattended. Resident #5’s record contains an Assessment of Serious Cognitive Impairment, dated 7/16/19, that states that the resident has a serious cognitive impairment and that he is unable to recognize danger or protect his own safety and welfare.

Plan of correction

Facility will ensure all hazardous materials including cleaning supplies are stored in a locked area on the memory care unit. Administration will conduct routine, unannounced room inspections for monitoring and compliance.

22VAC40-73-680-D

Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

The morning medication administration, for Resident #2, was observed during the inspection. Resident #2’s Lisinopril was not administered during the morning medication administration. Resident #2’s Medication Administration Record (MAR) stated that the medication was not given, as the vitals were outside the parameters for administration. Resident #2’s Lisinopril order, dated 9/16/21, does not include any parameters for administration. The MAR stated that Resident #2’s Lisinopril was also held due to vitals being outside of parameters for administration on: 12/5, 12/6, 12/7, 12/10, 12/11, 12/24. The morning medication administration, for Resident #6, was observed during the inspection. Resident #6’s medications were crushed and provided to her, while she was eating breakfast. Included among Resident #6’s medications was Ferrous Sulfate. The medication packaging, for Resident #6’s Ferrous Sulfate, states that the medication should not be crushed and that it should be taken on an empty stomach.

Plan of correction

Clinical Services will conduct mandatory training for nurses and Registered Medication Aides regarding medication administration/medication management plan. Clinical administration will conduct routine, unannounced medication administration audits for monitoring and observation.

22VAC40-73-550-C

Based on documentation and interview, the facility failed to ensure that each resident is free of physical restraints, except in the following situations and with appropriate safeguards: 1. As necessary for the facility to respond to unmanageable behavior in an emergency situation, which threatens the immediate safety of the resident or others. 2. As medically necessary, as authorized in writing by a physician, to provide physical support to a weakened resident.

Evidence

Staff #7 reported that he was called to assist Staff #6 in the process of providing care for Resident #9, due to the resident’s aggression. Staff #7 reported that he held Resident #9’s wrists, so that Staff #6 could change the resident’s clothing. While trying to provide assistance, Staff #7 reported that he was scratched by Resident #9. After being scratched, Staff #7 reported that he held the residents hands and rocked them back and forth, until Staff #6 could complete the care task. Neither Staff #6, nor Staff #7, reported that the situation was an emergency. Staff #7 reported that he did not have any training for aggressive residents and resident restraints. No facility documentation was provided, during the inspection, to indicate that Staff #7 received training regarding aggressive residents or resident restraints. No restraint orders were observed in the record for Resident #9.

Plan of correction

In-person aggressive behavior training in-service will be provided to staff. Audit to be conducted to ensure 100% online Relias compliance.

22VAC40-73-660-B

Based on observation and record review, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents, whose UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents.

Evidence

Calmoseptine was observed in the bathroom of Resident #5 of the memory care unit. Resident #5’s record contained an order, dated 2/13/20, for Calmoseptine. Resident #5’s UAI, dated 8/26/22, states that the resident needs assistance for medication administration. Gold Bond medicated powder was observed in the bathroom of Resident #9 of the memory care unit. Resident #9’s UAI, dated 10/21/22, states that the resident needs assistance for medication administration.

Plan of correction

All medications will be safely secured, stored, and administered by licensed clinical staff. The Inspiritas Director of Clinical Services and Engagement will conduct routine, unannounced room inspections for monitoring and compliance.

July 19, 2022Inspection1 violation

Inspection dates

07/19/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced monitoring inspection was conducted on 7/19/22 in response to facility reported incidents. Resident records and one resident room was observed. Violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations

22VAC40-73-660-B

Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAI has indicated that the resident is capable of self-administering medication.

Evidence

Facility documentation indicated that Resident #1 ingested Biofreeze from a medication cup on 6/15/22. A health care service provider reportedly left the medication cup in the resident's bathroom. Resident #1's room was observed during the inspection. Aspercreme and Nystatin medication bottles were observed to be unlocked in Resident #1's bathroom. Resident #1's UAI, dated 4/12/22, states that the resident needs assistance for medication administration.

Plan of correction

All medications will be safely secured, stored, and administered by licensed clinical staff. The Director of Clinical Services and Engagement will conduct routine, unannounced room inspections for monitoring and compliance.

April 19, 2022Inspection4 violations

Inspection dates

04/19/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

An unannounced monitoring inspection was conducted on 4/19/22. At the time of entrance, 151 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov. Violations:

Violations

22VAC40-73-660-B

Based on observation and record review, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAI has indicated that the resident is capable of self-administering medication.

Evidence

Preparation H cream and ear wax removal medication was observed to be unlocked and unattended, in the room of Resident #4. Resident #4's UAI, dated 12/14/20, states that the resident needs assistance for medication administration. Similisan Dry Eye relief was observed to be unlocked and unattended, in the room of Resident #11. Resident #11's UAI, dated 4/4/22, states that the resident needs assistance for medication administration.

Plan of correction

22VAC40-73-710-B

Based on observation and documentation, the facility failed to ensure that physical restraints are used as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others.

Evidence

Bed rails were observed on the beds of Residents #3 and #5, of the special care unit. Resident #3 has an order, dated 2/24/22, for side rails for turning and repositioning. When asked to demonstrate the usage of the side rail, Resident #3 refused to demonstrate his ability to independently use the side rails for turning and repositioning. Resident #5 has an order, dated 2/22/22, for side rails for turning and repositioning. When asked to demonstrate the usage of the side rail, Resident #5 did not respond to the request to independently use the side rails for turning and repositioning. Resident #5's record contains a physical examination form, dated 7/10/20, that states that he is unable to recognize danger or protect his own safety and welfare.

Plan of correction

Proper orders and required documentation obtained for residents who utilize siderails for turning and repositioning.

22VAC40-73-860-I

Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area.

Evidence

Liquid laundry detergent was observed to be unlocked and unattended in the room of Resident #5, of the memory care unit.

Plan of correction

Facility will ensure all hazardous cleaning supplies and other hazardous materials are stored in a locked area. The Director of Clinical Services and Engagement and Environmental Services Director will conduct routine, unannounced room inspections for monitoring and compliance.

22VAC40-73-1090-A

Based on record review, the facility failed to ensure that each resident is assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, prior to his/her admission to the safe, secure environment.

Evidence

The record for Resident #1, of the memory care unit, was reviewed during the inspection. Resident #1's physical examination Form, dated 3/19/21, states that the resident does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.

Plan of correction

Facility will adhere to pre-admission checklist to ensure that all proper paperwork is obtained prior to the admission of a resident into the facility's safe, secure, environment. Director of Clinical Services will complete admission paperwork audit prior to resident's physical move into the facility to ensure all documents are signed and completed accordingly.

March 2, 2022Complaint survey1 violation

Inspection dates

03/02/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced complaint inspection was conducted on 3/2/22, in response to a complaint that was received by the licensing office on 12/17/21 regarding Resident Care and Related Services. Medication administration, medication orders, and medication administration records were observed during the inspection. The complaint was deemed valid, as a preponderance of evidence supported the allegation. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations

22VAC40-73-680-D

Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Medication administration and medication administration records (MARs) were observed during the inspection. Resident #1's record contained an order for Amlodipine Besylate, dated 12/14/21, that calls for the medication to be held if the resident's systolic blood pressure (SBP) is less than 130. Resident #1's February MAR states that the medication was administered when the resident's SBP was below 130 on the following dates: 2/1/22 (SBP= 114), 2/3/22 (SBP= 122), 2/7/22 (SBP= 119), 2/9/22 (SBP= 121), 2/11/22 (SBP= 113), 2/20/22 (SBP= 109), 2/22/22 (SBP= 121), 2/25/22 (SBP= 119), 2/26/22 (SBP= 112), 2/28/22 (SBP= 121).

Plan of correction

Clinical services will conduct mandatory training for all nurses and med techs regarding best practices for medication administration. The Director of Clinical Services and Assistant Director of Clinical Services will conduct routine, unannounced medication administration audits for monitoring and observation.

October 12, 2021Complaint survey5 violations

Inspection dates

10/12/2021

Areas reviewed

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS

Comments

A non-mandated complaint inspection was initiated on 10/12/21 and concluded on 12/20/21. A complaint was received by the department regarding allegations in the areas of: Admission, Retention, and Discharge of Residents; Resident Care and Related Services; and Building and Grounds. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted on-site observations at the facility on 10/12/21, 11/15/21, and 12/13/21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations

22VAC40-73-680-D

Evidence

Resident #2’s Metoprolol Tartrate, ordered 4/24/21, was to be held when the resident’s Systolic Blood Pressure (SBP) is less than 110 or when her heart rate (HR) is less than 60. Resident #2’s Metoprolol Tartrate was given on 6/16/21 (6 PM administration) when the resident’s SBP was 109. The medication was also given on 7/12/21 (9 AM administration) when the resident’s heart rate was 58.

Plan of correction

Clinical Services will conduct mandatory training for all nurses and med techs regarding best practices for medication administration. The Director of Clinical Services and Assistant Director of Clinical Services will conduct routine, unannounced medication administration audits for monitoring and observation.

22VAC40-73-460-H

Based on record review, the facility failed to ensure personal assistance and care are provided to each resident as necessary so that the needs of the resident are met.

Evidence

Evidence: Resident #2’s UAI, dated 5/1/21, states that she needs mechanical and physical assistance for bathing. The bath log indicated that Resident #2 was not bathed from 6/2/21 – 6/18/21. The log indicates that there were six resident refusals during that time period. No information was included in the resident record to explore the reasons for the continued refusals or if the resident needed additional supports to have the bath completed. Resident #3’s UAI, dated 5/21/21, states that she needs mechanical and physical assistance for bathing. The bath log indicated that Resident #3 was not bathed in June or August, and that she only had one bath in July. The log indicates that Resident #3 refused bathing assistance 12 times in June, seven times in July, and eight times in August. No information was included in the resident record to explore the reasons for the continued refusals or if the resident needed additional supports to have the bath completed.

Plan of correction

Facility will document bathing refusal in resident EHR. Continued refusals will be communicated to physician and responsible party to identify additional support needed. Staff in-service to be conducted with CNAs to report to Charge Nurse for documentation. Nurse will document refusals and offer alternatives

22VAC40-73-460-B

Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.

Evidence

Call bell reports (June 2021 – August 2021) were reviewed during the inspection. There were 24 instances when staff members took longer than 30 minutes to respond to Resident #2’s call bell. There was one instance when staff members took longer than 30 minutes to respond to Resident #3’s call bell.

Plan of correction

Facility will monitor call response times on a weekly basis to ensure a prompt response to resident needs. Clinical Services Director will conduct weekly review of call response times in the community. Outliers will be assessed with appropriate interventions as necessary.

22VAC40-73-560-E

Based on record review, the facility failed to ensure that the resident record is kept current.

Evidence

Resident #1’s record contained a hospital discharge document, dated 7/19/21. The document stated that the resident needed a diet consistent with carbohydrate and heart healthy, and that the resident needed all meals to be supervised. The discharge document also states that home nursing is required for skilled assessment including cardiopulmonary assessment and dietary education for disease management and dietary instruction. Resident #1’s UAI, dated 5/13/21, states that the resident eats meals without assistance. Resident #1’s physical exam, dated 3/24/21, states that the resident eats a regular diet. No documentation was found in the resident record to update Resident #1’s need for a new diet, meal supervision, or that the required home nursing was received by Resident #1.

Plan of correction

Clinical Services Director will review all hospital readmissions prior to return to community for appropriateness and new orders. Clinical Services Director will reassess resident upon return to community for any clinical changes.

22VAC40-73-580-F

Based on record review, the facility failed to ensure that residents are weighed at least monthly.

Evidence

Weight records (June 2021 – August 2021) were reviewed during the inspection. Resident #1’s record did not contain weight documentation for the months of June and July. Resident #3’s record did not contain weight documentation for the months of June, July, or August.

Plan of correction

Facility will conduct an audit of residents at risk for weight loss to be conducted by Clinical Services Director or designee by 1/28/22. Residents identified through audit will be weighed monthly. Significant weight loss and routine weights will be reviewed by Dietician quarterly. Any and all recommendations will be followed as ordered.

October 12, 2021Inspection0 violations

Inspection dates

10/12/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated self-report inspection was initiated on 10/12/21 and concluded on 10/18/21. A self-reported incident was received by the department regarding an allegation in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted on-site observations at the facility on 10/12/21 and 10/18/21. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 3, 2021Inspection0 violations

Inspection dates

08/03/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated self-report inspection was initiated on 8/3/21 and concluded on 9/21/21. Self-reported incidents were received by the department regarding allegations in the area of: Resident Care and Related Services. The licensing inspector emailed the administrator's designee a list of documentation required to complete the investigation. The licensing inspector conducted on-site observations at the facility on 8/3/21 and 8/23/21. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 24, 2021Inspection0 violations

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated self-report inspection was initiated on 5/24/21 and concluded on 6/23/21. A self-reported incident was received by the department regarding an allegation in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 6/21/21. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 5, 2021Inspection0 violations

Inspection dates

Feb. 5, 2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 2/5/21 and concluded on 2/25/21. A self-reported incident was received by the department regarding allegations in the area of Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector requested a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 16, 2020Inspection1 violation

Inspection dates

Dec. 16, 2020

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 12/16/20 and concluded on 12/18/20. The wellness director was contacted by telephone to initiate the inspection. The administrator reported that the census was 134. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records and five staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations

22VAC40-73-320-A

Based on record review, the facility failed to ensure that each resident's physical examination includes all of the required information.

Evidence

The physical examination for Resident #3, dated 6/15/20, was observed during the inspection. The physical examination form listed Resident #3's allergies, but not her allergic reactions.

Plan of correction

Moving forward the Executive Director or Wellness Director will ensure that all History & Physical forms have the Plan of Correction: Moving forward, the Executive Director or Wellness Director will ensure that all History & Physical forms have the resident's allergic reactions documented.