Potomac Place

Documentation was discussed with the provider.

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: 4/24/26 (9:00 AM - 5:30 PM), 5/13/26 (3:20 PM - 5:50 PM), 5/18/26 (2:30 PM - 3:10 PM) 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 3/4/26 regarding allegations in the area(s) of: Administration and Administrative Services; Personnel; Resident Care and Related Services; Article 3: Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: One Number of staff records reviewed: One Number of interviews conducted with residents: None Number of interviews conducted with staff: Four Observations by licensing inspector: Meal, Activity 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 allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was 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. 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.virqinia.gov

Documentation was discussed with the provider.

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: 4/24/26 (9:00AM – 5:30 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of staff records reviewed: Three Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, Medication Administration, Activity 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. 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 Marshall Massenberg, Licensing Inspector at (804} 543-5188 or by email at marshall.x.massenber dss.virginia.gov.

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/20/2025 5:00pm - 5:10pm 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 2/11/2025 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: 81 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: Facility policies on discharging residents, resident records and care giver notes. Additional Comments/Discussion: n/a An exit meeting will be 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/19/2025 8:45 a.m. – 3:11 p.m., 2/20/2025 8:50 a.m. – 5:00 p.m. 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: 62 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: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, dining services, observed medication pass to residents, and activities provided. 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/14/2024 12:10pm – 3:10pm 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 10/29/2024 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Observed lunch meal pass and staff assisting residents during meal in the memory care unit. Additional Comments/Discussion: Completed tour of the building and discussed operations with the Administrator. An exit meeting will be 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: No

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/14/2024 9:30am – 12:10pm 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 11/13/2024 regarding allegations in the area(s) of: Administration. Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities conduced in the memory care unit. Additional Comments/Discussion: Completed tour of the building and discussed operations with the Administrator. An exit meeting will be 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: No

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: April 24, 2024, 8am-2pm 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: 95 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: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector observed medication administration passes. Additional Comments/Discussion: The Licensing Inspector reviewed the following at the time of inspection: menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician reports and healthcare oversight. 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 Laura Lunceford, Licensing Inspector at (540) 219-9264 or by email at laura.lunceford@dss.virginia.gov

Date of Inspection: March 23 and 24, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 85 Number of records reviewed and interviews conducted- 18 records (both staff and residents), 13 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meal times and activities. The Licensing Inspector reviewed the following during the inspection: menus, activity calendars, pharmacy review, dietician report, healthcare oversight, resident council documentation and resident rights reviews. Date of Inspection: March 23 and 24, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 85 Number of records reviewed and interviews conducted- 17 records (both staff and residents), 12 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meal times and activities. The Licensing Inspector reviewed the following during the inspection: dietician report, auxiliary grant records, menus, healthcare oversight, pharmacy review, resident rights reviews, and activity calendars.

Date of Inspection: May 9, 2022 Type of Inspection: Monitoring inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 82 Number of records reviewed and interviews conducted- 6 resident records and 5 staff records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The residents were observed during activities and snack times as well as physical therapy. Staff were observed during a medication pass. The Licensing Inspector reviewed the following during the inspection: activity calendars, menus, resident council minutes, fire drills and health care oversight.

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 March 19, 2021 and concluded on March 23, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 66. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities, staff schedules, healthcare oversight, fire drills, and the dieticians report submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.