Tall Oaks Assisted Living — Virginia Inspection Report

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

Tall Oaks Assisted Living was inspected 25 times between December 18, 2020 and May 26, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 14 with none. Across that history VDSS cited 28 violations under 24 distinct standards. 9 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. 22 of these 25 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

Three Year

License expires

04/01/2027

Administrator

Mavis Adu

Licensing inspector

Jacquelyn Kabiri

Inspector phone

(703) 397-3017

Approved for

Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

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

May 26, 2026Inspection0 violations

Inspection dates

05/26/2026

Areas reviewed

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: 05/26/2026, 10:20 a.m. to 12:15 a.m. 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 05/18/2026, 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: 114 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 (Observed Resident) Number of interviews conducted with staff: 1 and 3 written statements from staff. Observations by licensing inspector: Lunch 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(s) 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 Jacquelyn Kabiri, Licensing Inspector, at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 26, 2026Inspection0 violations

Inspection dates

05/26/2026

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: 05/26/2026, 9:20 a.m. to 10:20 a.m. 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 05/15/2026, regarding allegations in the area(s) of: Resident Care and Related Services, complaint investigation. Number of residents present at the facility at the beginning of the inspection: 114 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: 2 Observations by licensing inspector: Activities in memory care and transporting of residents to the rose garden. 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(s) 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 Jacquelyn Kabiri, Licensing Inspector, at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 23, 2026Inspection6 violations

Inspection dates

03/23/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (18) Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report

Technical assistance

TA: Staffing Plan updates, 450, 22VAC40-73-325.A,

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: 03/23/2026, 10:00 a.m. to 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: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:4 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch, exercise group, medication passes. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-700-1

Based on a record review and interview, the facility failed to have a valid physician's order that includes the source of the oxygen such as compressed gas or concentrator.

Evidence

Resident 3 had a physician's order dated 01/03/2025 for oxygen 2L through N/C PRN for SOB.
The source of oxygen was not specified.
Staff 1 confirmed the LI’s findings.

Plan of correction

Description of Problem: Based on a record review and interview, the facility failed to have a valid physician's order that includes the source of oxygen such as compressed gas or concentrator. Corrective action for those affected: Numerous: The residents who were identified had their orders reviewed, and new orders were obtained that included the source of the oxygen.” What steps has the facility taken to identify other Residents with the potential to be affected? All residents with oxygen orders were reviewed. New orders were obtained that include the specified oxygen sources. Measures put in Place or systemic changes to prevent Recurrence Nurses have received education to ensure that all oxygen orders are complete, including specification of the oxygen source. How Corrective Actions Will Be Monitored “New orders will be reviewed to ensure that all sources are properly documented and included in each order.” How Corrective Actions Will Be Monitored “The DON or designee will review nursing communication daily. They will identify new residents who have received oxygen orders and will review each order for accuracy, including verification of the prescribed oxygen source.” The date is to be corrected, and the staff member is responsible: 03/23/2026 The staff member responsible: Director of Nursing and Assistant Director of Nursing. ADMINISTRATOR _Mavis Adu_____________ DATE RECEIVED __03/23/2026__________ DATE COMPLETED__03/23/2026___

22VAC40-73-750-E

Based on direct observation and staff interview, the facility failed to ensure that there were sufficient bed and bath linens in good repair so that residents always have clean sheets, pillowcases, and blankets.

Evidence

On 03/23/2026, the Licensing Inspector (LI) observed resident 1’s bedding inside their apartment. The LI noted a white pillowcase with navy blue thin stripes that contained large circular spots of what appeared to be a dried food substance. Additionally, the blue plastic mattress cover was observed to be ripped on the right side closest to the wall, exposing the white mattress underneath.
Staff 1 was present at the time of the observation and confirmed the LI’s findings.
Photo evidence was obtained.

Plan of correction

Description of Problem Based on direct observation and staff interview, the facility failed to ensure that there were sufficient bed and bath linens in good repair so that residents always have clean sheets, pillowcases, and blankets. Corrective action for those affected: Numerous. The resident is currently under hospice care, and the hospice provider is responsible for supplying the mattress for the hospital bed. The hospice company and family has been notified and contacted to arrange for a replacement mattress. Staff have been reeducated on promptly changing any dirty or soil linen as soon as they are observed. What steps has the facility taken to identify other Residents with the potential to be affected? “The facility conducted checks of residents’ mattresses to ensure they are in good condition. Regular procedures are in place to ensure residents have clean linens.” Measures put in Place or systemic changes to prevent Recurrence Weekly x 4 and then monthly there after checks are conducted in residents’ apartments to ensure that linens are clean, and mattresses are maintained in good condition. How Corrective Actions Will Be Monitored Housekeeping Director or designee will be conducting the weekly and monthly checks to ensure they are done. The date is to be corrected, and the staff member is responsible. Areas identified were corrected on 03/23/2026 The staff member responsible: Housekeeping Director. ADMINISTRATOR _Mavis Adu_____________ DATE RECEIVED __03/23/2026__________ DATE COMPLETED__03/23/2026___

22VAC40-73-350-A

Based on staff interview, the facility failed to ensure registration with the Department of State Police to receive notice of the registration or re-registration of any sex offender within the same or a contiguous zip code.

Evidence

In an interview with the LI on 03/23/2026, staff 1 confirmed that the facility was not registered to receive notifications of sex offenders in the area.

Plan of correction

Description of Problem: Based on staff interview, the facility failed to ensure registration with the Department of State Police to receive notice of the registration or re-registration of any sex off ender within the same or a contiguous zip code. Corrective action for those affected: Numerous: The sex offender registry search for the facility’s ZIP code was updated using the current Executive Director’s email. How Corrective Actions Will Be Monitored: It will be monitored by the Executive Director. The date is to be corrected, and the staff member is responsible: 03/23/2026 Staff member responsible: Executive Director. ADMINISTRATOR _Mavis Adu_____________ DATE RECEIVED __03/23/2026__________ DATE COMPLETED__03/23/2026___

22VAC40-73-450-A

Based on record review and interview, the facility failed to ensure that each resident’s individual service plan (ISP) was developed on or within seven days prior to admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects their health, safety, and welfare.

Evidence

Record review revealed that resident 4 (admitted on 02/24/2026) did not have an Individualized Service Plan (ISP) present in the resident’s record.
During the inspection, staff 1 was unable to locate or provide an ISP for resident 4 upon request.

Plan of correction

Description of Problem: Record review revealed that resident 4 (admitted on 02/24/2026) did not have an Individualized Service Plan (ISP) present in the resident's record. Corrective action for those affected: Numerous: Care plans were completed on 03/23/2026. What steps has the facility taken to identify other Residents with the potential to be affected? The facility conducted a review of all resident move-ins over the past six months to ensure that care plans were completed per regulatory standards. Measures put in Place or systemic changes to prevent Recurrence Facility will implement a pre–move-in checklist to ensure Individualized Service Plans (ISPs) are initiated based on the UAI assessment at least seven (7) days prior to the resident’s move-in date. A post–move-in review will be conducted within seventy-two (72) hours of admission to ensure the initial ISP has been completed. How Corrective Actions Will Be Monitored: This will be monitored before moving in and 72 hours after moving in. The date is to be corrected: 04/30/2026 Staff members are responsible: Executive Director, Director of Nursing or Designee ADMINISTRATOR _Mavis Adu_____________ DATE RECEIVED __03/23/2026__________ DATE COMPLETED__04/30/2026___

22VAC40-73-450-E

Based on record review and interview, the facility failed to ensure that each resident’s individualized service plan (ISP) contained a signature and date of the resident or their legal representative.

Evidence

The ISP (dated 05/04/25) for resident 2 did not contain a resident or POA signature.
Staff 1 acknowledged the LI’s findings.

Plan of correction

Description of Problem: Based on record review and interview, the facility failed to ensure that each resident's individualized service plan (ISP) contained a signature and date of the resident or their legal representative. Corrective action for those affected: Numerous: The resident’s family has been contacted several times to attend a care plan meeting; however, they have been unable to do so. The care plan has been emailed to the Power of Attorney (POA) for review. They have been asked to contact us with any questions, sign the document, and return it at their earliest convenience. What steps has the facility taken to identify other Residents with the potential to be affected? The facility is currently reviewing all residents’ care plans to ensure that care plan meetings are conducted with family members to obtain required signatures, or directly with residents who can participate. Measures put in Place or systemic changes to prevent Recurrence Facility will offer families who are unable to attend in person the option to participate in care plan meetings via Teams or to have the care plans emailed to them for review and signature of acknowledgment... How Corrective Actions Will Be Monitored Corrective action will be monitored monthly to ensure that all care plans completed within the month have a scheduled care plan meeting with the resident’s or their POA. If families are unable to attend in person, a virtual meeting via Teams or a phone call will be offered, and the care plan will be emailed for their review and signature. Acceptance will be documented on the ISP and in the file until final signature is obtained. The date is to be corrected: 04/30/2026 Staff member is responsible: Director of Nursing, Executive Director or designee ADMINISTRATOR _Mavis Adu_____________ DATE RECEIVED __03/23/2026__________ DATE COMPLETED__04/30/2026___

22VAC40-73-490-D

Based on record review and interview with staff, the facility failed to ensure the healthcare oversight included the specific residents for whom the oversight was provided must be identified.

Evidence

Healthcare oversight documents dated 03/01/2026-09/30/2026 did not identify the residents reviewed for either oversight period.
Staff 1 confirmed during the interview that the residents reviewed were not identified with the healthcare oversights from either period.

Plan of correction

Description of Problem Based on record review and interview with staff, the facility failed to ensure the healthcare oversight included the specific residents for whom the oversight was provided must be identified. Corrective action for those affected: Numerous. Healthcare oversight stated that all residents were accounted for. A list of all residents was printed and attached to the healthcare oversight report. What steps has the facility taken to identify other Residents with the potential to be affected? A list of all 110 residents was printed and attached to the healthcare oversight report immediately upon discovery. Measures put in Place or systemic changes to prevent Recurrence Moving forward, specific residents’ names and room numbers will be included in the healthcare oversight report. How Corrective Actions Will Be Monitored The executive Director or designee will review each healthcare oversight report to determine it outline names and room numbers of Residents reviewed. The date is to be corrected,03/23/2026 The staff member responsible: Executive Director or Designee ADMINISTRATOR _Mavis Adu_____________ DATE RECEIVED __03/23/2026__________ DATE COMPLETED__03/23/2026___

March 23, 2026Inspection0 violations

Inspection dates

03/23/2026

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: 03/23/2026, 5:00 p.m. to 6:40 p.m. 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 02/19/2026 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: 113 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: 1, Facility files viewed, and medication cart audit. Observations by licensing inspector: Exercise group 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(s) 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 29, 2025Inspection1 violation

Inspection dates

10/29/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/29/2025, 10:00 a.m. to 12:00 p.m. 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 10/09/2025 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: 114 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: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-300-B

Based on document review, resident record review, and staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.

Evidence

On 10/09/2025, the Licensing Inspector (LI) received an incident report via email stating that resident 1 was observed with one stage 3 wound and two stage 2 wounds on the buttocks. The LI reviewed resident 1’s progress notes for the period 10/01/2025 through 10/07/2025. A. There were no entries documenting the condition of resident 1’s wounds during that time. B. On 10/08/2025, staff 3 documented in the progress notes that resident 1 was observed with bed sores on the buttocks. C.On 10/10/2025, resident 1 was admitted to the hospital for treatment of other medical conditions and received care for bed sores. D.During an interview, staff 1 confirmed that communication was not updated to inform all shifts of resident 1’s bed sores.

Plan of correction

Description of Problem Based on document review, resident record review, and staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Corrective action for those affected: Numerous. Staff were re-educated on the importance of reporting and documenting all observed skin changes in the Resident’s Plan of Care (POC) program to ensure timely follow-up and appropriate interventions. What steps has the facility taken to identify other Residents with the potential to be affected? Facility nurses have completed head-to-toe assessments on residents identified as being at risk for skin breakdown and have implemented appropriate interventions as needed. Measures put in Place or systemic changes to prevent Recurrence Nurses have been re-educated to perform weekly skin assessments on residents at risk for skin breakdown. Direct care staff are to report any changes in residents’ skin condition to the nurse supervisor verbally and document the findings in the Plan of Care (POC) How Corrective Actions Will Be Monitored The Director of Nursing or Designee. The Director of Nursing or designee will conduct weekly monitoring of all newly documented skin issues in PCC to ensure that appropriate interventions have been implemented, and all relevant parties have been notified

October 29, 2025Inspection0 violations

Inspection dates

10/29/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/29/2025, 12:00 p.m. to 1:00 p.m. 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 10/10/2025 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: 114 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: 2 Observations by licensing inspector: Lunch Additional Comments/Discussion: None 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 4, 2025Complaint survey2 violations

Inspection dates

09/04/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION

Technical assistance

Discussed the AC and the upcoming new chiller installation.

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: 09/04/2025, 1:00 p.m. to 3:15 p.m. The Acknowledgement of Inspection form was signed and lef t at the facility for each date of the inspection. Three complaints were received by VDSS Division of Licensing on 08/26/2025, 08/28/2025, and 09/02/2025, regarding allegations in the area(s) of : Direct Care and Related Services, Building and Grounds, Emergency Preparedness and, Complaint Investigation. Number of residents present at the f acility at the beginning of the inspection: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the f acility. Number of resident records reviewed: 0 Number of staf f records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staf f : 1 Observations by licensing inspector: None Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection f indings. The evidence gathered during the investigation supported the allegation(s) 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 f acility 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 f ive (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 of f ice 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 f acility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-880-C

Based on observation and interview, the facility failed to provide in all buildings an air conditioning system for all areas used by residents, including residents' bedrooms and common areas. Temperatures in all areas used by residents shall not exceed 80°F.

Evidence

On 09/04/2025, from approximately 1:30 p.m. to 3:00 p.m.,the licensing inspector (LI), accompanied by Staff 1, conducted a temperature survey using an automatic handheld thermometer throughout the facility, floor by floor, including random resident rooms and common areas. The following areas read the following temperature readings: a. Fifth Floor:
Odd numbered rooms hallway near exit door: 80.2°F
Even numbered rooms hallway: 80.6°F b. Fourth Floor:
Nurse’s station (open area): 82°F 2.Elevator area: 82°F
Resident 1’s apartment: 82.3°F
Resident 2’s apartment 82.0 °F c. Third Floor:
Odd side hallway apartment: 86.4°F
Dining room Area: 86.5°F d. Second Floor: 1.Nurse’s station (open area): 86.7°F 2.Odd side hallway apartment: 86.4°F e. Rose Garden Floor (secured area): 1.Hallway leading to locked doors: 86°F 2.Living room common area and dining room combo (wall thermostat reading): 76°F 3.Sunroom: 85.8°F
Staff 1 acknowledged the temperatures in the identified areas utilized by residents exceed 80°F.
Pictures taken as evidence.

Plan of correction

The facility has provided portable AC units and standing fans for Residents upon request. Additionally, two portable AC units have been placed—one on each floor, including the kitchen. Multiple notifications have been sent to Residents and their families regarding the status of the new chiller installation. Residents have also been offered extra fluids for hydration and are being closely monitored for any signs or symptoms of dehydration. Residents are monitored throughout the day and offered portable AC units or standing fans as needed. Random room temperature checks are conducted, and if adjustments are necessary, AC units or fans are provided with the Resident’s consent. New chillers are currently being installed to help prevent the recurrence of this issue. The Executive Director will be responsible for oversight.

22VAC40-73-880-D

Based on observation and staff interview, the facility failed to develop and implement a plan to protect residents from heat-related and cold-related illnesses in the event of loss of air-conditioning or heat due to emergency situations or malfunctioning or broken equipment.

Evidence

During the facility inspection conducted on 09/04/2025, between 1:00 p.m. and 3:00 p.m., the LI observed window air-conditioning units being used by the facility in the common areas on the lobby level and on floors 2, 3, 4, and 5.
Staff 1 and the LI toured the facility’s hallways and common areas, as well as resident 1’s and resident 2’s apartments. LI took the air temperatures, and it exceeded 80°F, with oscillating fans in use.
During an interview with LI, staff 1 confirmed that the facility experienced a loss of air conditioning due to malfunctioning or broken equipment. Staff 1 was unable to provide a documented plan outlining the facility’s procedures for protecting residents from heat-related illnesses in the event of such a failure.

Plan of correction

An emergency preparedness plan has been developed and successfully implemented to ensure the safety and well-being of all residents and staff. An emergency preparedness plan has been developed and successfully implemented to ensure the safety and well-being of all residents and staff. The Executive Director will be responsible for oversight.

August 19, 2025Inspection0 violations

Inspection dates

08/19/2025

Areas reviewed

22VAC40-73 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: 08/19/2025, 2:40 p.m. to 4:40 p.m. 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 08/05/2025 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 110 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: None. Additional Comments/Discussion: None. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 19, 2025Inspection0 violations

Inspection dates

08/19/2025

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

Discussed the AC/HVAC in the facility and its repair, not in working order.

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: 08/19/2025, 1:40 p.m. to 2:40 p.m. 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 08/09/2025 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 110 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: Memory care residents doing craft activities. Additional Comments/Discussion: None. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 2, 2025Complaint survey0 violations

Inspection dates

07/02/2025

Areas reviewed

22VAC40-73 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: 07/02/2025, 10:30 a.m. to 1:00 p.m. 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 06/26/2025, 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: 113 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: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: Interviewed collateral contacts 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 Jacquelyn Kabiri, licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 25, 2025Inspection1 violation

Inspection dates

06/25/2025

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: 06/25/2025, 1:00 p.m. to 4:16 p.m. 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 05/15/2025 regarding allegations in the area(s) of: Resident care and related services and personnel. Number of residents present at the facility at the beginning of the inspection: 113 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: 3 Observations by licensing inspector: None. Additional Comments/Discussion: Interviewed a collateral contact. 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: 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-40-A

Based on resident record review and staff interviews, the facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department and the facility’s own policies and procedures.

Evidence

On 05/15/2025, the facility submitted a self-report to the licensing inspector (LI), regarding an alleged incident of abuse involving resident 1 and staff 3. On 05/19/2025, the facility completed its internal investigation and determined that the allegations of abuse were not substantiated.
During an onsite inspection on 05/25/2025, the LI reviewed records and conducted interviews related to the self-reported incident on 05/15/2025. According to the facility’s policy titled “Right to Dignity from Abuse Neglect and Exploitation”, the procedure section, item 5, states: “In accordance with company policy, the Administrator will suspend the accused employee, without pay, pending outcome of investigation, rom contact with residents or otherwise see that residents are protected during the investigation.” 3.The work schedule for staff 3 showed that they worked on 05/17/2025 and 05/18/2025, despite the alleged incident of abuse on 05/15/2025.
During the interviews conducted on 5/25/2025, both staff 1 and staff 3 both confirmed that staff 3 was not suspended pending the outcome of the investigation, as indicated in their policy.

Plan of correction

Description of Problem Based on the Resident record review and staff interviews, the facility failed to ensure compliance with all regulations for licensed assisted living facilities and the terms of the license issued by the department and the facility’s policies and procedures. Corrective action for those affected: Numerous. • The staff member involved was immediately removed from the schedule on the day the concern was reported. The individual had no further interaction with the resident until the resident’s family provided consent for continued involvement from investigation findings What steps has the facility taken to identify other Residents with the potential to be affected? The facility will follow company policies and procedures, suspending team members for alleged violations until the investigation has been conducted and they have been determined not to be guilty, before bringing them back to work. Measures put in Place or systemic changes to prevent Recurrence Company policies will be reviewed and followed in all matters related to resident care and complaints. How Corrective Actions Will Be Monitored The Executive Director will be responsible for oversight. The date is to be corrected, and the staff member is responsible. Areas identified were corrected on 06/25/2025 Staff members Responsible will be the Executive Director or Designee.

April 30, 2025Inspection2 violations

Inspection dates

04/30/2025

Areas reviewed

22VAC40-73 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 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report

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: 04/30/2025, 9:30 a.m. to 4:40 p.m. Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8, Number of staff records reviewed: 3, plus 8 new employees partial review Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch Additional Comments/Discussion: None 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. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-870-A

Based on direct observation the facility failed to ensure the interior of the building be maintained in good repair and kept clean.

Evidence

On 4/30/2025, the following observations were made on the memory care unit around 11:00 a.m.: a. Two blue chairs were observed, to be worn with a dingy film on the surface with torn leather areas on the back and armrest. b. The green carpet in the memory care living room area was noted to have stains and or spotting.
The following are additional observations made within the facility on 04/30/2025: a. A ceiling tile was observed hanging down, exposing the interior of the ceiling in the nursing office located on the third floor. b. Resident 2’s apartment was observed to have broken mini blinds on the window, a hole in the drywall next to the bed, and black scuff marks on the lower part of the apartment door. c. The hallway ceiling on the second floor had approximately 15 small brown spots on the ceiling. d. The lobby wall outside of the conference room, has two sections with torn wallpaper. e. At 11:12 a.m., what appeared to be scrambled eggs, along with a fork and knife, was observed on the floor beneath a kitchen table in the dining room.
Photo evidence taken.

Plan of correction

Immediate Corrections (Completed by 05/01/2025):Torn chairs were removed from the premises.The stains and spots on the remaining chairs were thoroughly cleaned.The hanging ceiling tile was secured and repaired.Broken blinds were replaced with new ones.Spots on the hallway ceiling were cleaned. Torn and worn wallpaper identified and repaired and replaced as needed.The carpets throughout the facility were cleaned.The dining area floor was cleaned immediately after the residents completed their breakfast service on 4/30. A comprehensive assessment of the building's interior environment was completed to identify all areas needing repair or cleaning. All identified deficiencies have now been corrected.A routine monitoring schedule has been implemented: Daily walkthroughs by Maintenance Director, ED or designee. Weekly Reviews to assess recurring or emerging environmental issues. Monthly Facility Inspections coordinated between the Maintenance Director and Executive Director. All findings from walkthroughs and inspections will be reviewed with the Maintenance Director and Executive Director to ensure timely resolution.The Executive Director will be responsible for oversight of ongoing compliance. Areas identified were completed on 4/30/2025 and 05/01/2025. Staff member Responsible: Maintenance Director, Executive Director or Designee.

22VAC40-73-450-E

Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the licensee, administrator, or their designee (i.e., the person who has developed the plan).

Evidence

1. Resident 1’s ISP, dated 08/16/2024, was not signed by staff licensee, administrator, or his designee, to indicate who completed the ISP.
Staff 1 confirmed the licensee, administrator, or his designee, (i.e., the person who has developed the plan) did not sign and date resident 1's ISP.

Plan of correction

The plan was signed by the person who completed it while the state inspector was present on 04/30/2025. Other residents' ISPs have been reviewed to ensure they are signed by the person completing them. ED will review ISP and check to ensure that whoever completes them signs upon completion. Corrective action will be monitored when the Executive does the final review of the ISPs and when the Executive Director does random chart reviews.

March 19, 2025Complaint survey2 violations

Inspection dates

03/19/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: 03/19/2025, 09:30 a.m. to 1:30 p.m. 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 03/17/2025, regarding allegations in the area(s) of: Staffing 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: 03/19/2025, 09:30 a.m. to 1:30 p.m. 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 03/17/2025, regarding allegations in the area(s) of: Staffing and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 116 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: none Additional Comments/Discussion: none 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. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov

Violations

22VAC40-73-450-E

Based on resident record review and interview, the facility failed to ensure the Individual Service Plan (ISP) is signed and dated by the resident or their legal representative.

Evidence

Staff 1 confirmed resident 1’s ISP (dated 12/29/2024) was updated on 2/17/2025; however, it was not signed by the resident or their legal representative.

Plan of correction

Description of Problem Based on the resident record and interview, the facility failed to ensure the individual service plan is signed and dated by the Resident or their legal representative. Corrective action for those affected: Numerous. The identified resident's ISP was immediately reviewed, and the email attempt to schedule the care plan meeting was documented on the Resident’s ISP What steps has the facility taken to identify other Residents with the potential to be affected? All current resident ISPs have been audited for signatures and dates by the residents or their legal representative, and/or attempts noted on the ISP. Measures put in Place or systemic changes to prevent Recurrence A quarterly review of the care plan will ensure meetings have been held, the responsible parties have signed off, and any failed attempts are documented in the residents’ care plan. How Corrective Actions Will Be Monitored The Executive Director will be responsible for oversight. The date is to be corrected, and the staff member is responsible. Areas identified were corrected on 03/19/2025 Staff members Responsible will be the Director of Nursing or designee.

22VAC40-73-270-1

Based on staff record review and staff interview, the facility failed to ensure that training prior and annually for staff in assisted living facilities that accept, or have in care, residents who are or who may have aggressive behavior included demonstration in self-protection and in the prevention and de-escalation of aggressive behavior.

Evidence

Resident 1’s record indicates the resident has a history of aggressive behavior.
Staff 1 acknowledged staff 3, 4, 5, 6, 7 and 8 provide care to resident 1.
During the onsite inspection on 03/19/2025, Staff 1 was unable to provide documentation verifying that staff 3,4,5,6,7 and 8 had received training in managing residents with aggressive behaviors.

Plan of correction

Corrective action for those affected: Numerous A full audit of all employee training records was conducted to identify any additional gaps in compliance. What steps has the facility taken to identify other Residents with the potential to be affected? N/A Measures put in Place or systemic changes to prevent Recurrence. Going forward, Relias training on managing aggressive behavior will be assigned to all employees, including new hires, upon hire, and annually. How Corrective Actions Will Be Monitored The Administrator, or designee, will audit 100% of new hire training records monthly for the next 6 months. Annual training compliance will be reviewed quarterly by the BOM and reported to the Executive Director. Noncompliance will be addressed promptly with retraining and documentation.

March 19, 2025Inspection0 violations

Inspection dates

03/19/2025

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: 03/19/2025, 1:30 p.m. to 3:00 p.m. 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 03/14/2025 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: 112 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: none Additional Comments/Discussion: none 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 19, 2025Inspection0 violations

Inspection dates

03/19/2025

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: 03/19/2025, 3:00 p.m. to 4:30 p.m. 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 03/13/2025 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: 112 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: none Additional Comments/Discussion: none 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn Kabiri@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 27, 2024Complaint survey0 violations

Inspection dates

12/27/2024

Areas reviewed

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: 12/27/2024, 11:00AM-2:00PM 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 10/28/2024 regarding allegations in the area(s) of: Medication and timeliness specific to a condition. Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: None Additional Comments/Discussion: None 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov Violation Notice Issued: ¿No¿

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 7, 2024Inspection0 violations

Inspection dates

03/07/2024

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

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: 3/7/24 (8:10 AM - 6:00 PM) Number of residents present at the facility at the beginning of the inspection: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meals, medication administration, activities An exit meeting was held. 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 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 13, 2023Complaint survey0 violations

Inspection dates

12/13/2023

Areas reviewed

22VAC40-73 BUILDING 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: 12/13/2023 (2:30 PM - 3:10 PM). A complaint was received by the licensing office on 10/12/23, regarding Building and Grounds. A facility walkthrough was conducted and interviews were completed. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. 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.

August 3, 2023Complaint survey1 violation

Inspection dates

08/03/2023, 08/15/2023, 08/16/2023

Areas reviewed

22VAC40-73 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: 8/3/23 (5:45pm – 6:10pm), 8/15/23 (4:50pm – 6:50pm), 8/16/23 (1:00pm – 4:30pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the licensing office on 6/28/23; regarding Staffing and Supervision, and Resident Care and Related Services. Resident meals, resident records, building and grounds, and facility documentation were observed. An exit meeting was held. The evidence gathered during the investigation supported some, but not all of the allegations; the area of non-compliance was: 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. 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

22VAC40-73-480-E

Based on documentation, the facility failed to ensure that rehabilitative services and other pertinent information is documented in the resident record.

Evidence

Resident #1 and Resident #2 were ordered to receive skilled services for wounds. No documentation was included in the resident record, at the time of the inspection, to document the wound care services that Residents #1 (ordered 6/11/23) and #2 (ordered 6/30/23) received. Facility documentation included weekly skin / wound reports, but the reports do not indicate that the wound treatment was provided by a rehabilitative professional, the service provider’s initial service date, or (if any) aftercare instructions provided to staff.

Plan of correction

The Director of Nursing has reached out to the rehabilitative professional preferred provider and informed them that they must document in the resident's record the initial service date, and aftercare instructions to be provided by Tall Oaks staff. As mentioned in the description of violation, the community has a weekly skin/wound report that has progress information, updates, initials from the person providing services, and date of the services. This document is required by Tall Oaks and the management company as a part of the Quality Assurance reports submitted on a monthly basis.

March 15, 2023Inspection4 violations

Inspection dates

03/15/2023

Areas reviewed

Technical assistance

Documentation was discussed with the provider.

Comments

An unannounced renewal inspection was conducted on 3/15/23 (8:30 AM – 6:00 PM). At the time of entrance, 96 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. 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

22VAC40-73-720-A

Based on record review, the facility failed to ensure that DNR orders are included in the individual service plan.

Evidence

Resident #5's ISP, dated 6/18/22, did not include the resident’s DNR order (signed 6/20/22). Resident #5's ISP states that the resident is Full Code.

Plan of correction

Resident (#5) moved in with full code status. The ISP was completed the day the resident moved in. A change in code status was completed 6-20-23, as indicated in the description of violation. Moving forward the Director of Nursing, Assistant Director of Nursing, or designee, will ensure that all ISP’s are updated when there is a change in condition, level of care, or change in code status.

22VAC40-73-1110-B

Based on record review, the facility failed to ensure that a review of continued appropriateness, is completed six months after a resident is placed in the safe, secure environment.

Evidence

The record for Resident #3, admitted 8/2/22, was reviewed during the inspection. Resident #3's record contained a review of continued appropriateness, dated 12/1/22. Resident #3's record did not contain a review of continued appropriateness, six months after the resident was placed in the safe, secure environment.

Plan of correction

Resident moved into Assisted Living and transitioned to Memory Care on 8-2-22, as indicated in the description from the inspector. A review of the Continued Appropriateness form was completed. The resident had a change in condition and warranted an updated review, which was completed on 12-2-22, four months after admission. Moving forward the Director of Nursing, Assistant Director of Nursing, or designee will ensure that the review of the continued appropriateness form is completed 6 months after admission, then annually after.

22VAC40-90-40-B

Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police, within 30 days of hiring an employee.

Evidence

The criminal history record reports, of new staff members, were reviewed during the inspection. Staff #6 was hired 11/8/22. The criminal history record report, for Staff #6, was completed on 3/15/23. The criminal history record report was not obtained within 30 days of Staff #6's hire date.

Plan of correction

From the time of the previous inspection there were 17 new employee hires, and all but this employee received a criminal history background check. As soon as the Executive Director noticed, he conducted the criminal background check and self-reported to the inspector. Moving forward a criminal history background check will be completed within 30 days of hire by the Executive Director, Business Office Manager, or designee.

22VAC40-73-320-A

Based on record review, the facility failed to ensure that the physical examination report includes all of the required information.

Evidence

Resident #3's physical examination, dated 8/1/22, did not include the resident's reaction to a known allergen (Zithromax). Resident #5's physical examination, dated 5/20/22, did not include the resident's reaction to a known allergen (Shellfish). Resident #6’s physical examination, completed April 2022, did not include documentation about the resident’s allergies and reactions, as that section of the form was left blank. Physician’s orders indicated that Resident #6 is allergic to ACE inhibitors.

Plan of correction

The Director of Admissions, Director of Nursing, Assistant Director of Nursing, or designee will ensure that the Health & Physical forms are completed to include, but not limited to, any known allergies.

July 8, 2022Complaint survey1 violation

Inspection dates

07/08/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

Documentation was discussed with the provider.

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: 7/8/22 (9:05 AM – 12:35 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 5/16/22 regarding allegations in the area of Resident Care and Related Services. The evidence gathered during the investigation supported some, but not all of the allegations. Areas of non-compliance: medication administration. No violations were cited in the area of: care planning. Any violations 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-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

Morning medication administration, for Resident #1, was observed during the inspection. Several of Resident #1’s medications were placed in a pill sleeve and the medication packages were returned to the medication cart. Before the medications could be crushed, the licensing inspector asked about Resident #1’s Metoprolol Succinate. The Metoprolol Succinate bottle states that it should not be crushed or chewed. Resident #1’s chart includes an order, dated 6/29/22, that states that the facility may crush chewable medications.

Plan of correction

The charge nurses, ADON, and DON will ensure that all medications and treatments are administered or preformed per the physicians’ orders or instructions. These are and will continue to be audited on a monthly basis and compared to the Physician order sheets. In this situation, the medication in referenced, the physician’s order indicated that the medication could be crushed, but upon inspection there was a small label on the medication container indicating that “Do Not Crush”. ADON & DON have reached out to the pharmacy to ensure that the EMR system indicates medications that are not to be crushed to alert the Med Tech’s and/or LPN’s.

March 10, 2022Inspection5 violations

Inspection dates

03/10/2022

Areas reviewed

Technical assistance

Documentation was discussed with the provider.

Comments

An unannounced renewal inspection was conducted on 3/10/22. At the time of entrance, 91 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, please contact me via e-mail at M.Massenberg@dss.virginia.gov.

Violations

22VAC40-73-260-A

Based on record review, the facility failed to ensure that direct care staff members maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment.

Evidence

The record for Staff #4, hired 12/30/21, was reviewed during the inspection. The record for Staff #4 contained a nurse aide certification. No documentation was provided, during the inspection, to indicate that Staff #4 received first aid certification within 60 days of being hired.

Plan of correction

The community will ensure that all employees are trained in 1st Aid within 60 days of hire. This particular employee was hired 64 days, was registered to attend the training held on 3/10/22, completed the training, and certification was in hand on 3/10/22. Due to COVID-19 in person trainings that are approved by DSS have been challenging.

22VAC40-73-680-D

Based on observation and 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 for Resident #11 was observed during the inspection. Resident #11's Carbidopa-Levodopa was administered during breakfast. Resident #11's Carbidopa-Levodopa order, dated 1/13/21, called for the medication to be administered 30 minutes before meals.

Plan of correction

The charge nurses, ADON, and DON will ensure that all medications and treatments are administered or performed per the physicians' orders or instructions. These are and will continue to be audited on a monthly basis and compared to the Physician order sheets. In this particular situation, the medication in referenced, the ADON and DON consulted with the resident's attending physician as well as the hospice provider and the order was updated during the inspection. The clarification that was discussed resulted in the order changing to indicate that the medication could be given at any time during the meals, before, or after the meals.

22VAC40-73-450-F

Based on record review and interview, the facility failed to ensure that individualized service plans (ISPs) are reviewed and updated at least once every 12 months.

Evidence

Resident #3's record was reviewed during the inspection. Resident #3's record contained an ISP, dated 1/22/21. Resident #3's ISP was more than a year old, on the date of the inspection. Facility staff reported that the ISP may have been updated and was located in a different area of the facility. The updated ISP was not in the resident's chart and no additional documentation was provided, during the inspection, to verify that Resident #3's ISP was updated annually.

Plan of correction

The DON, ADON, and ED will ensure that all of the Resident ISP's are updated at least annually and ensure that the updated documentation is filed in the resident's chart. This particular resident's care plan was updated and mailed out to the POA prior to the 12 month update requirement, however the POA did not return prior to the date of the inspection. There is documentation (via email) indicating that the DON and POA were in communication prior but due to COVID-19 the family had not returned or scheduled a review.

22VAC40-73-660-B

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

Evidence

Several pill bottles and packages were observed in the room of Resident #5. Resident #5's UAI, dated 10/2/21, states that the resident needs his medication administered/monitored by a lay person.

Plan of correction

The community's nurses and/or med techs will continue to monitor resident rooms for any over the counter medications, including but not limited to, supplements, and ensure proper storage and administration is provided. The charge nurses, ADON, and DON consistently monitor and oversee the residents to ensure that the medications are administered as prescribed, however there are instances where the residents and/or their family members purchase supplements and over the counter medications without the facility's knowledge. Upon discovery of these supplements they were immediately removed, the primary care physician was consulted, and appropriate actions were taken.

22VAC40-73-440-A

Based on record review and interview, the facility failed to ensure that the uniform assessment instrument (UAI) is completed at least annually.

Evidence

The record for Resident #1 was reviewed during the inspection. Residents #1's UAI was dated 2/26/21. Resident #1's UAI was more than a year old, on the date of the inspection. Facility staff reported that the UAI may have been updated and was located in a different area of the facility. The updated UAI was not in the resident's chart and no additional documentation was provided, during the inspection, to verify that Resident #1's UAI was updated annually. The record for Resident #3 was reviewed during the inspection. Resident #3's UAI was dated 1/22/21. Resident #3's UAI was more than a year old, on the date of the inspection. Facility staff reported that the UAI may have been updated and was located in a different area of the facility. The updated UAI was not in the resident's chart and no additional documentation was provided, during the inspection, to verify that Resident #3's UAI was updated annually.

Plan of correction

The DON and ADON will ensure that all UAI's are updated and completed at least annually and as there is a change in condition. There will continue to be monthly audits to ensure all UAI's are current. In this particular incident the updated UAI was completed, however it was not in the resident's medical chart at the time of the survey.

May 14, 2021Complaint survey0 violations

Areas reviewed

22VAC40-90 The Criminal History Record Report

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 15, 2021Inspection0 violations

Areas reviewed

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 3/15/2021 and concluded on 3/17/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 85. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records, five staff records, medication administration records, local fire and health inspections, and other documentation 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.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 18, 2020Complaint survey3 violations

Inspection dates

Dec. 18, 2020

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity

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 complaint inspection was initiated on 12/18/20 and concluded on 2/12/21. A complaint was received by the department regarding allegations in the areas of: Personnel, Staffing and Supervision, Resident Care and Related Services, and Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. 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 evidence gathered during the investigation supported the allegations 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. 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

22VAC40-73-1090-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

Resident #1’s record was observed during the inspection. The resident record includes documentation about Resident #1's placement in the memory care unit on 6/29/20. The resident’s record contained a Physician Assessment of Serious Cognitive Impairment for Admission to Memory Care. The form includes an area to document the resident’s serious cognitive impairment status as well as the resident’s ability to recognize danger and protect his/her safety and welfare, but the areas were left blank. The form documented Resident #1’s name and says “see attached.” The attachment included an initial evaluation conducted by a geriatric psychiatrist, dated 6/22/20. The evaluation lists Resident #1 as having a diagnosis of dementia and that the resident presents as moderately impaired. The evaluation does not state that Resident #1 has 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. Additional documentation from the psychiatrist was included, but the visits were conducted after the resident had been placed in the memory care unit.

Plan of correction

All documents will be reviewed by the ED, DON, or designee before the resident is placed in the secured neighborhood to ensure proper forms are accurately completed by the MD. Upon further review, the Assistant Executive Director and Director of Nursing were able to locate the appropriate form from the discharge file that was previously in storage on site. The Serious Cognitive Impairment form listed was received from the primary care physician on 6-29-20 at 5:46pm, which was prior to the resident’s placement in the secured neighborhood.

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 #1’s August and September medication administration records (MARs) were observed during the inspection. Resident #1’s Memantine was discontinued on 8/9/20. The MAR stated that Memantine was administered to Resident #1 on 8/10/20. Resident #1’s record contained a PRN order for Ativan 0.5mg, dated 8/17/20, that called for the resident to receive the medication every 8 hours as needed. The MAR states that the medication was given when less than eight hours elapsed between administrations on: 8/26/20 (9:17 AM and 4:38 PM), 8/27/20 (9:29 AM and 1:08 PM), 8/28/20 (12:36 PM and 7:15 PM), and 8/31/20 (11:20 AM and 1:27 PM). Resident #1’s record contained an order for Ativan 0.5mg, dated 8/24/20, that called for the resident to receive the medication two times per day. The MAR states that the scheduled medication did not begin until 9/1/20.

Plan of correction

All readmission medications will be checked by the Charge Nurse on duty at the community and a call to pharmacy to reconcile and update the profile each time for accuracy will be completed at the time of readmission. Director of Nursing to address, train, and provide in-service sessions for the RMA’s and LPN’s on the process of accessing the EMR portal to address updates on any changes to resident medications, treatment orders, or profile information. The contracted pharmacy partner associated with this community will provide on-site training on the EMR portal and provide access to the community employees that have access to this platform. Resident #1 was discharged from Reston Hospital Center at 11:27pm back to the community. Upon readmission the updated orders from the discharging physician were faxed to the pharmacy as well as the resident’s primary care physician. Pharmacy administrative employees updated the profile that included a medication that was discontinued after the medication was administered as previously ordered at 9am. The profile was updated at 10am. Director of Nursing provided mandated in-service training sessions to the RMA’s and LPN’s to ensure appropriate corrective actions taken with the focus being on medication administration as prescribed by the attending physicians. The community will continue training and medication administration observation will be conducted by the Director of Nursing, Nursing Department Coordinator, Assistant Executive Director, and Executive Director on a monthly basis. RMA involved in early administration of PRN meds will be trained specially every month for the next 6 months. Director of Nursing has contacted all attending physicians to ensure that they all have a direct line to the contracted pharmacy partner when calling in any medications that need a hard prescription on record. A copy of this will also be provided to the community for the resident’s medical record. The medication listed, Ativan, is a controlled substance and cannot be filled without a prescription. The phone order was called into the pharmacy; however, the pharmacy would not fill the order until the prescribing physician had signed the order. To prevent future delay in dispensing narcotics, all physicians will call prescriptions directly to the pharmacy.

22VAC40-73-680-K

Based on record review, the facility failed to obtain a detailed medication order from the resident’s physician, for medication aides to administer PRN Medication. The order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.

Evidence

Resident #1’s record contained a PRN order for Ativan 0.5mg, dated 8/17/20. The order did not include the symptoms that indicate the use of the medication or directions as to what to do if symptoms persist. The MAR states that Resident #1’s PRN Ativan was first administered by a medication aide on 8/19/20.

Plan of correction

All nursing staff responsible for distribution of medications will be in serviced to ensure that all medication order received have a diagnosis. Follow up with MD within 24 hours of administering PRN medication must be included in the order. Director of Nursing and Nursing Department Coordinator will ensure orders for PRN medications shall include symptoms that indicate the use of the medication, exact dose, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist. Director of Nursing will continue to provide in-service trainings for RMA’s to ensure they are looking at the above-named items and document accordingly.