Commonwealth Senior Living at King's Grant House

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

Commonwealth Senior Living at King's Grant House was inspected 15 times between April 23, 2021 and August 22, 2025 by the Virginia Department of Social Services. 13 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 38 violations under 29 distinct standards. 6 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. 12 of these 15 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

Two Year

License expires

07/20/2027

Administrator

Daniel Cassiere

Licensing inspector

Lanesha Allen

Inspector phone

757-715-1499

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

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

August 22, 2025Complaint survey1 violation

Inspection dates

08/22/2025

Areas reviewed

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

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/22/2025 3:00 pm to 3:30pm. 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 7/11/2025 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: 71 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: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations

22VAC40-73-680-D

Description: Based on record review and staff interview, the facility did not ensure that medications shall be administered in accordance with physician’s or other prescriber’s instructions.

Evidence

On 07/11/2025, Licensing received a self-reported incident from staff #2 indicating that on 07/11/2025 at 06:00 AM, staff #1 administered to resident #1 Clonazepam 1mg, Buspirone 10mg, Cartlevo 25-100mg, Multivitamin, Omeprazole 40mg, Baclofen 5mg belonging to resident #2.
As a result, the resident’s responsible party was notified, and resident 1’s physician was notified and Resident #1 was transported to the Emergency Room for assessment. Resident #1 was monitored the resident hourly for the subsequent 72 hours forchange in status.
During the on-site follow-up to the report, LI interviewed staff #2 and staff #3 and then reviewed resident 1’s charting notes from 07/11/2025-07/31/2025, each were consistent with the medication error from the self-reported incident.

Plan of correction

What Has Been Done to Correct? a. Medication Pass Observation completed and documented with current RMA’s. b. In-Service with all RMA’s of, Documenting Medication Pass Policy (MP15) and Medication Handling Policy (MP04). How Will Recurrence Be Prevented? a. Medication Pass Observation will be completed for RMA’s during the training process. b. Medication Pass Observation will be completed as an ongoing audit tool for RMA’s. c. Medication policy review with RMA’s annually. Person Responsible: Resident Care Director and Executive Director Due Date: 10.13.2025

May 19, 2025Inspection3 violations

Inspection dates

05/19/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS

Technical assistance

22VAC40-73-70 22VAC40-73-320

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: 05//2025 11:30 am to 5:30pm. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed:3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch, activity and medication pass were observed by licensing inspector. Tour of the facility interior/ exterior and first aid kits reviewed. Water Temperature checked. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on the record review the facility did not ensure the fall risk rating shall be reviewed and updated after a fall.

Evidence

The record for resident #1 contains a progress note that documents on the following dates the resident experienced a fall: 4/26/2025. The residents record did not contain a fall risk rating after the resident’s fall that occurred on 4/26/2025.
The record for resident #3 contains progress notes that documents on the following dates the resident experienced a fall: 5/1/2025. Resident’s #3 record did not contain documentation of a fall risk rating completed for fall that occurred on 5/1/2025.

Plan of correction

What Has Been Done to Correct? Residents #1fall on 4/26/2025 and #3 fall on 5/1/2025, fall risk rating was completed __X_ Yes _____No How Will Recurrence Be Prevented? Re-educated Executive Director and Resident Care Director on regulation 40-73-325-B to complete a Fall Risk Rating on each resident after each fall Person Responsible: Resident Care Director or designee Due Date: June 2, 2025

22VAC40-73-450-C

Based on the record review the facility did not ensure the comprehensive individualized service plan shall be completed within 30 days after admission.

Evidence

The record for resident #1, admission date of 11/25/24 does not contain a comprehensive individualized service plan.
The record for resident #7, admission date of 3/14/2025 does not contain a comprehensive individualized service plan.

Plan of correction

What Has Been Done to Correct? Residents #1 and #7 have a current comprehensive ISP __X_ Yes _____ No How Will Recurrence Be Prevented? Re-educated Executive Director and Resident Care Director on regulation 40-73-450-C. RCD, ED, or designee will verify resident has an ISP within 30 days of admission Person Responsible: Executive Director, Resident Care Director, or designee Due Date: May 30, 2025

22VAC40-73-320-B

Based on the record review the facility did not ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Results of a risk assessment documenting the absence of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
The record for resident #1, admission date of 11/25/2024, contains a risk assessment for TB dated 12/2/2024. The TB assessment occurred after the resident was admitted to the facility.
The record for resident #4, admission date of 3/22/2024, contains a risk assessment for TB dated 3/26/2024. The TB assessment occurred after the resident was admitted to the facility.
The record for resident #5, admission date of 2/10/2025, does not contain a risk assessment for TB prior to the resident being admitted to the facility.

Plan of correction

What Has Been Done to Correct? Residents #1, #4 and #5 risk assessment will be completed by a physician for Tuberculosis _X__ Yes ___ No How Will Recurrence Be Prevented? Re-educated Executive Director and Resident Care Director on regulation 73-320-B. Moving forward, TB risk assessment will be completed by the PCP and reviewed by the ED/RCD prior to admission. Person Responsible: Executive Director or designee Due Date: June 6, 2025

June 11, 2024Inspection3 violations

Inspection dates

06/11/2024

Areas reviewed

Technical assistance

22VAC40-73-580 22VAC40-73-680

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: 06/11/2024 from 8:48 am to 2:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 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: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-720-A

Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan.

Evidence

Resident #1 had a DNR order completed 11/28/2023; however, Resident #1’s ISP (dated 12/21/2023) indicated the resident was a full code.

Plan of correction

Resident was discharged from community. Audit/comparison of all DNRs to Yardi and residents chart to ensure accurate. Re-educated Executive Director, Resident Care Director, Assistant Resident Care Director, and Wellness Secretary on regulation 73-720-A. Completed DNR form will be collected prior to admission if applicable.

22VAC40-73-640-A

Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.

Evidence

The following expired medications were observed in the medication carts at the facility: a bottle of multivitamins expired 11/2022 for Resident #9.

Plan of correction

Expired medication was removed from the medication cart and destroyed. Re-educated Executive Director, Resident Care Director, and all Registered Medication Aides on regulation 73-640-A and Policy MP-20 Expired, Damaged or Contaminated Medications.

22VAC40-90-40-B

Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.

Evidence

Staff #5 was hired on 11/28/2023; however, their criminal history record report was completed 06/11/2024.
There was not a completed criminal history record reports for Staff #6 (hired 06/20/2023) in their record.

Plan of correction

Received and reviewed background checks on Associates #5 and #6. Re-educated Executive Director and Business Office Manager on regulation 90-(BC3)-40-B. An audit of current associate files was performed to ensure compliance with regulations. Moving forward, we will track the new hire background check to ensure it is received and reviewed within 30 days of hire. If not received within 30 days of hire, associate will be removed from the schedule until background check is received.

April 18, 2024Inspection1 violation

Inspection dates

04/18/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 04/18/2024 from 12:15 pm to 1:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two self-reported incidents were received by VDSS Division of Licensing on 04/13/2024 and 04/17/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 65 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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-reports; 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-reports 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-A

Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

On 04/12/2024, Staff #3 pushed Resident #1 down.
Resident #1 has expressed pain since the incident with Staff #3 and noted change in condition.

Plan of correction

Terminated the associate involved in the incident. Re-educated Executive Director, Resident Care Director, and all direct care associates on regulation 73-460-A

January 31, 2024Complaint survey1 violation

Inspection dates

01/31/2024

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: 01/31/2024 from 1:00 pm to 2:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/09/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-450-C

Based on record review, the facility failed to ensure the comprehensive individualized service plan include a description of identified needs and date identified based upon the fall risk rating.

Evidence

The last plan of care for Resident #1 was updated on 06/05/2023 and identified the resident as a fall risk.
Resident #1’s record documented at least 7 falls in December 2023 and 1 fall in January 2024.
The facility did complete a fall risk rating and analysis following each fall in December 2023 and January 2024 to include fall mitigation/prevention for future falls; however, the interventions listed for fall mitigation/prevention were not added to Resident #1’s individualized service plan.

Plan of correction

Care plans updated with most recent fall risk rating. Re-educated Executive Director, Resident Care Director, and LPNs on regulation 73-450-C.

January 4, 2024Inspection0 violations

Inspection dates

01/04/2024

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: 01/04/2024 from 11:09 am to 11:35 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/27/2023 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 1, 2023Complaint survey0 violations

Inspection dates

08/01/2023

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 8/1/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/22/2023 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Background Checks. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 13, 2023Inspection8 violations

Inspection dates

06/13/2023, 06/14/2023

Areas reviewed

Technical assistance

22VAC40-73-290 22VAC40-73-1140

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: 06/13/2023 from 8:40 am to 3:30 pm and 06/14/2023 from 9:33 am and 11:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-980-H

Based on observation, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water with at least 48 hours of the supply on site.

Evidence

The emergency food and water supply reviewed with Staff #8 included several jugs of water with the expiration date of 7/2022 and 9/2022. The availability of unexpired water in the emergency supply is not enough to serve 62 residents for 48 or 96 hours in the case of an emergency.

Plan of correction

Emergency water supply delivered 6/28/2023. Re-educated Executive Director and Dining Service Director on regulation 73-980-H. Water bottles were dated 6/2023 and calendared for replacement in 2 years

22VAC40-73-720-A

Evidence

Upon review of Resident #3’s record, their ISP (dated 5/17/23) and their personal data sheet indicate the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.
Upon review of Resident #6’s record, their ISP (dated 3/2/23) and their personal data sheet indicate the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.

Plan of correction

Resident #3 and #6 changed to Full Code until DNR is received. Audited remaining resident files to ensure compliance. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-720-A. Completed DNR form will be collected prior to admission if applicable.

22VAC40-73-490-A

Based on interview, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight.

Evidence

Staff #5 was unable to provide a copy of a completed Health Care Oversight.

Plan of correction

HealthCare Oversight completed on 6/28/2023. Re-educated Executive Director, Resident Care Director on regulation 73-490-A.

22VAC40-73-980-C

Based on record review and interview, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.

Evidence

Two first aid kits within the facility were reviewed. The first aid kit on the first floor of the assisted living was last checked on 12/05/2022. The first aid kit on the second floor of the assisted living was last checked on 02/05/2023.
Staff #5 confirmed the first aid kits have not been checked monthly.

Plan of correction

Audit was performed on both First Aid kits. Re-educated Executive Director, Resident Care Director, and Wellness Secretary on regulation 73-980-C. First Aid kit audit will be performed every month and documented.

22VAC40-73-640-A

Evidence

The following expired medications were observed in the medication carts at the facility: Pravastatin 20mg tabs expired 01/31/2023 for Resident #4, Senna Plus 8.6-50mg tabs expired 05/09/2023 and Bisacodyl 5mg tabs expired 05/10/2023 for Resident #7, Stool Softener tabs expired 05/04/2023 for Resident #9, and Amlodipine Besylate 5mg tabs expired 06/06/2023 and Montelukast Sod 10mg tabs expired 05/02/2023 for Resident #10.

Plan of correction

Resident #4, #7, #9 and #10 expired medications were removed from the med cart. Re-educated Executive Director, Resident Care Director, LPN, Wellness Secretary, and RMAs on regulation 73-640-A. Med cart audits will be performed each week.

22VAC40-73-560-E

Based on observation, the facility failed to ensure all resident records be kept in a locked area.

Evidence

During the tour of the facility, the narcotic count book which includes confidential resident information for the first-floor medication cart in the assisted living was unattended and accessible as it was noted on top of the medication cart.

Plan of correction

Narcotic count book was moved to the locked cabinet behind the nurse station. Re-educated Executive Director, Resident Care Director, LPN, Wellness Secretary and RMAs on regulation 73-560-E. Narcotic count book to be stored in locked cabinet behind the nurse station on each floor.

22VAC40-73-320-A

Based on record review, the facility failed to ensure the admitting physical examination include a completed risk assessment documenting the absence of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
The initial TB risk assessment for Resident #3 (dated 5/2/23) and Resident #4 (dated 12/7/22) are not completed as they do not indicate a review of the risks or recommendation on if TB testing is indicated at this time.

Plan of correction

Resident #3 and #4 TB risk assessment was completed by their PCP. Re-educated Executive Director and Resident Care Director on regulation 73-320-A. Moving forward, TB risk assessment will be completed by the PCP and reviewed by the ED/RCD prior to admission.

22VAC40-90-40-B

Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.

Evidence

There were not completed criminal history record reports for Staff #6 (hired 05/02/2023) and Staff #7 (hired 11/07/2022) in their record.

Plan of correction

Associates #6 and #7 removed from the schedule on until background checks are received and reviewed. Re-educated Executive Director and Business Office Manager on regulation 90-(BC3)-40-B. An audit of current associate files was performed to ensure compliance with regulations. Moving forward, new hires will not start until background check is received and reviewed.

May 24, 2023Complaint survey8 violations

Inspection dates

05/24/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical assistance

22VAC40-73-460 22VAC40-73-930

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: 5/24/2023 from 8:30 am to 10:40 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/15/2023 regarding allegations in the area(s) of: Administration and Administrative Services, Resident Care and Related Services, and Buildings and Grounds. Number of resident records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were Administration and Administrative Services and 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-470-F

Based on record review and interview, the facility failed to ensure when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional be secured immediately. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention. A notation shall be made in the resident's record of such notice, including the date, time, caller, and person notified.

Evidence

Resident #1 was sent to the ER on 5/14/2023; however, there is no evidence or indication in the resident’s record that their legal representative was notified.

Plan of correction

Resident #1 POA was notified. Re-educated Executive Director, Resident Care Director, LPN, Registered Medication Aide, and Wellness Secretary on regulation 73-470-F.

22VAC40-73-1100-A

Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.

Evidence

Resident #1 transferred into the safe, secure environment on 4/6/2023; however, Resident #1 did not have documentation of approval for placement in a special care unit in the resident’s record.

Plan of correction

Setting up meeting with resident #1 POA. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-1110-A. An audit will be completed of current resident files to assure that written approval has been received for residents with a serious cognitive impairment currently residing in safe, secure environment. Audit will be completed by 6/15/2023. Moving forward, prior to placement in safe, secure environment due to serious cognitive impairment the ED/designee will assure that there is written approval for placement per regulatory standards.

22VAC40-73-1110-A

Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment.

Evidence

Resident #1 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.

Plan of correction

Setting up meeting with resident #1 POA. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-1110-A. An audit of current resident files will assure that appropriateness for placement in a special care unit was reviewed prior to admission and that appropriateness of placement for continued residence has been completed at 6 months post admission and at least annually thereafter. Audit and updates, as warranted, will be completed by 6/15/2023. Moving forward, following regulatory standards, the ED/designee will review appropriateness of placement in special care unit prior to placement, 6 months post admission, and at least annually thereafter.

22VAC40-73-440-A

Based on record review, the facility failed to ensure the UAI for residents be completed whenever there is a significant change in the resident's condition.

Evidence

Resident #1 transferred into the safe, secure environment on 4/6/2023; however, an UAI was not completed for this significant change. The last UAI for Resident #1 was completed on 9/9/2022.

Plan of correction

Updated resident #1 UAI to reflect change in condition. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-440-A.

22VAC40-73-1090-A

Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been 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.

Evidence

Resident #1 transferred into the safe, secure environment on 4/6/2023; however, the assessment of serious cognitive impairment was not completed until 4/29/2023.

Plan of correction

Re-educated Executive Director and Resident Care Director on regulation 73-1090-A. An audit will be completed of current resident’s residing in safe, secure environment to assure an assessment for serious cognitive impairment has been completed as per regulatory standards. This audit will be completed by 6/15/2023. Moving forward, prior to admission or within 7 days of admission, if emergency placement needed, to safe, secure environment the ED/designee will assure an assessment for serious cognitive has been completed by the physician.

22VAC40-73-70-A

Based on record review and discussion, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

On 5/14/2023, Resident #1 was sent to the hospital for an abscess and returned later that same day. The After Visit Summary indicates Resident #1 reported allegations of abuse.
Through interviews with Staff #1 and Staff #2, it confirmed Resident #1 reported allegations of abuse while at the hospital.
There was no documentation of this allegation in Resident #1’s record nor was the allegation of abuse reported to the regional licensing office.

Plan of correction

Re-educated Executive Director and Resident Care Director on regulation 73-70-A. Moving forward, within 24 hours of major incidents that has negatively affected or that threatens the life, health, safety or welfare of any resident, the ED/designee will notify the regional licensing office as per regulatory standards.

22VAC40-73-450-F

Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident’s condition.

Evidence

Resident #1 transferred into the safe, secure environment on 4/6/2023; however, Resident #1’s ISP was not reviewed or updated to reflect this significant change. The last ISP for Resident #1 was completed on 11/20/2022. The ISP completed 11/20/2022 also does not reflect the resident receiving home health services (effective 5/19/23) and the rounding frequency made by direct care staff to monitor for emergencies and other unanticipated resident needs.

Plan of correction

Resident #1 ISP updated to reflect Home Health Services and rounding every 2-hours by staff. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-450-F.

22VAC40-73-450-E

Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), and by the resident or their legal representative.

Evidence

Resident #1’s ISP dated 11/20/2022 is not signed and dated by the licensee, administrator, or their designee, (i.e., the person who has developed the plan), nor by the resident or their legal representative.

Plan of correction

Setting up ISP review meeting with resident #1 POA. Re-educated Executive Director, Resident Care Director, LPN, and Wellness Secretary on regulation 73-450-E. An audit will be completed of current residents’ ISPs to assure that appropriate signatures have been obtained, per regulatory standards. This audit will be completed by 6/30/2023. Signatures that may be required will be obtained.

October 21, 2022Inspection2 violations

Inspection dates

10/21/2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 10/21/2022 from 9:11 am to 10:42 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/07/2022 regarding allegations in the area(s) of: Resident Care and Related Services. 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: 1 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-240-G

Based on record review, the facility to ensure all volunteers be under the supervision of a designated staff person when residents are present.

Evidence

During an activity on 10/06/2022, Staff #3 confirmed Volunteer #1 was alone with residents for brief amount of time.

Plan of correction

Reeducate Program Director and Activity Staff on Regulation 240-G – all volunteers shall be under the supervision of designated staff member when residents are present. Reeducated all associates on Regulation 240-G. Supervision of all volunteers.

22VAC40-73-460-D

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

Evidence

On 10/06/2022, Resident #1 and Resident #2 attended an assisted living activity outside of the safe, secure environment. During the activity, Resident #1 and Resident #2 went to the restroom unattended by staff. Residents did not return to the activity and wandered to a nearby elevator. Residents took the elevator to the ground floor and exited the facility. Approximately ten minutes after leaving the activity, a spouse of another resident reported Resident #1 and Resident #2 were outside the facility. Resident #1 and Resident #2 were then redirected back into the community without incident.
The UAI for Resident #1 and Resident #2 (both dated 07/08/2022) indicates the residents are an elopement risk and require supervision with mobility.
Staff #3 confirmed the aforementioned incident to include the lack of supervision of resident activities.

Plan of correction

Reeducated all associates and educate all volunteers on Regulation 460-D Personal Care and General Supervision of all residents. Reeducate all staff on Regulation 460-D, General Supervision of residents. Memory Care residents will be accompanied by a staff member to the restroom while off the secure unit.

June 29, 2022Inspection5 violations

Inspection dates

06/29/2022, 07/07/2022

Areas reviewed

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: 6/29/2022 from 8:28 am to 3:40 pm and 7/7/2022 from 9:44 am to 12:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-90-40-H

Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes.

Evidence

Staff #6 was hired on 12-07-2021 and working the floor 06-29-2022. A criminal history record report for Staff #6 was completed on 12-08-2021. The criminal history record report indicates Staff #6 was convicted of a misdemeanor barrier crime on 08-02-2021.

Plan of correction

Removed staff #6 from the schedule until criminal background check is clear. Reeducate Executive Director and Business Office Manager on regulation 40-H. Audit current staff background checks to ensure compliance. Business Office Manager or designee will verify criminal background checks prior to hire.

22VAC40-73-720-A

Evidence

Upon review of Resident #6’s record, there are inconsistencies in regards to the resident’s code status. The Durable DNR order in the resident’s record is dated 9/13/21.The ISP (dated 6/23/22) for Resident #6 indicates the resident’s code status is a Full Code.
Upon review of Resident #7’s record, the ISP (dated 5/20/22) indicates the code status of the resident as a DNR. The resident does not have a signed DNR order or Durable DNR in their record.

Plan of correction

Verified and obtained DNR or Full Code for residents #6 and #7. Resident Care Director or designee to obtain either DNR or Full Code for each new admission upon admission. Audit current residents code to ensure compliance.

22VAC40-73-310-H

Based on record review, the facility admitted and retained individuals with prohibited conditions or care needs.

Evidence

Resident #3 admitted to the facility on 09-21-2021. The physical examination and report for Resident #3 (dated on 9/08/21) indicates the resident requires continuous licensed nursing care.

Plan of correction

PCP to reassess resident #3 for appropriateness to retain resident. Re educate Executive Director, Resident Care Director, and Sales Director on Regulation 310-H. Audit current resident H&P to ensure compliance. Resident Care Director or designee will verify Health & Physical Report to ensure compliance prior to admission to community.

22VAC40-73-325-A

Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. The facility also failed to ensure that a fall risk rating was completed after a fall.

Evidence

Upon review of the resident’s record, Resident #7 (admitted 5/20/22) meets the criteria for assisted living care and has falls documented in progress notes on 5/28/22 and 6/18/22; however, there was no documentation of a fall risk rating being completed in the resident’s record.

Plan of correction

Fall Risk Rating completed for resident #7. Reeducate Resident Care Director on regulation 325-A. Resident Care Director or designee to complete a Fall Risk Rating on each resident after each fall.

22VAC40-73-440-A

Based on record review, the facility failed to ensure the UAI for residents be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

Resident #2 admitted to the facility on 02-11-2022; however, the UAI in their record was dated 03-23-2022 and not signed for approval by the administrator or designee.
Resident #4 admitted to the facility on 11-01-2021; however, the UAI in their record was dated 11-18-2021.

Plan of correction

Reeducate Resident Care Director on regulation 440-A. Resident Care Director or designee to ensure UAI is completed and signed at admission for each resident. Audit all admission UAI’s to ensure compliance.

March 29, 2022Inspection2 violations

Inspection dates

03/29/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated self-report inspection was initiated on 03-29-2022 and concluded on 04-05-2022. A self-reported incident was received by the department regarding an allegation of neglect. Records were observed and staff were interviewed onsite on 03-29-2022. Any violations related or not to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations

22VAC40-73-460-B

Based on record review and interview, the facility failed to ensure care provision and service delivery be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.

Evidence

Upon record review, the resident called for assistance and Staff #3 refused to provide care to Resident #1. Before other staff could respond, Resident #1 fell in apartment.

Plan of correction

Resident Care Director or designee to re-in-service all Direct Care Staff on regulation 460-B and CSL Care 01- Basic Care Policy. All Care Staff will be instructed on the importance of reporting directly to a supervisor, their inability to provide care for a Resident within a time frame that does not affect the expectations for such care to be delivered. This instruction will also be provided to all future New Care Staff hires.

22VAC40-73-460-H

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

Evidence

Resident #1’s preliminary ISP completed on 2/14/22 indicates the resident was to have a shower twice a week and PRN. An updated ISP for Resident #1 completed on 3/11/22 indicates the resident requires hands on assistance with participation by the resident to complete the task. The timing on the updated ISP states the following: “(1 time(s) per day, every 1 week(s) on Sunday, Thursday . )”
Staff #2 acknowledged the resident’s shower days were Sunday and Thursday. Staff #2 provided documentation for the following days where the resident was offered assistance with a shower: 2/27/22, 3/3/22, 3/7/22, 3/10/22, 3/11/22, 3/12/22, and 3/17/22. The documentation indicates on 3 occasions the shower offered was refused with the resident having received 4 showers.
Staff #1 and Staff #2 were not able to provide documentation indicating if bathing was completed between 2/14/22 and 2/27/22.

Plan of correction

Resident Care Director or designee to re-in-service all Direct Care Staff on regulation 460-H and CSL Care 02 - Personal Care Policy. Shower refusals will be documented on the shift-to-shift log and reviewed daily by Resident Care Director or designee.

August 6, 2021Complaint survey1 violation

Inspection dates

Aug. 6, 2021 , Aug. 9, 2021 , Aug. 19, 2021 and Aug. 23, 2021

Areas reviewed

Resident Care and Related Services

Comments

A non-mandated complaint inspection was initiated on 08-05-2021 and concluded on 08-23-2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.

Violations

22VAC40-73-70-A

Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

“Progress Notes” documented: A. On 07-24-2021, resident #2 “fell to the ground unresponsive” called 911 to report unexpected death.? B. On 07-28-2021, resident #3 “was observed sitting on bathroom floor”? The resident was sent to the emergency room and was admitted to the hospital. Resident #3 was admitted to the hospital due to “slip and fall and kidney stones.” C. The regional licensing office did not receive incident reports from the facility within 24 hours regarding the aforementioned incidents.
Staff #2 acknowledged the aforementioned incidents were not reported to regional licensing office within the required timeframe.

Plan of correction

Resident Care Director re-in-serviced on AL regulation 40-73-(2)-70-A Incident Reporting. Each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

June 30, 2021Inspection2 violations

Inspection dates

June 30, 2021 , July 1, 2021 and July 2, 2021

Comments

A renewal inspection was initiated on 06-30-2021 and concluded on 07-02-2021.The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 48. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, fire drills, fire and health inspection reports, dietary and healthcare oversights, and menus submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 07-02-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-1090-A

Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed in writing 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.

Evidence

Resident #1 was admitted to the facility on 03-04-2020. The resident’s Individualized Service Plan dated 02-27-2021 documented the resident will reside in the Sweet Memories secure unit [special care unit] with a date identified as of 07- 02-2020.
Resident #1’s “Assessment of Serious Cognitive Impairment” form was signed and dated by the Nurse Practitioner (NP) on 07-08-2020. The NP answered “no” to the question, "Does the individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.“ The form also documented ”Pt was moved to memory unit on 07-02-2020 due to symptom exacerbation??
Staff #1 acknowledged resident #1 was placed on the safe, secure environment prior to the resident being assessed by a physician in writing, and that the resident was not assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.

Plan of correction

What Has Been Done to Correct“ Community NP was notified of error on ”Assessment of Cognitive Impairment Form?. Form will be updated during NP’s next visit to King’s Grant Community. How Will Recurrence Be Prevented? Community will conduct a chart audit within the first week of a room change to make sure all documentation pertaining to the room change is updated by all parties. Person Responsible: RCD/ARCD Due Date: 9/27/2021

22VAC40-73-450-F

Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes.

Evidence

Resident #1’s current Uniform Assessment Instrument (UAI) dated 03-18-2021 documented the need for supervision with mobility, and mechanical assistance with stairclimbing; however, the current ISP dated 02-27-2021 was not updated to reflect a description of services explaining how staff would supervise the resident with mobility; nor did the ISP document the type of mechanical device needed for stairclimbing.
During a tour of the facility with staff #1 on 07-02-2021, a concentrator and portable oxygen tanks were observed by resident #2’s bed. Resident #2’s oral order dated 03-23-2021 documented, ?02 @ 2L/NC PRN [as needed] for dyspnea; however, the current ISP dated 03-13-2021 was not updated to reflect the resident’s need for oxygen. Staff #2 also confirmed the resident is on PRN oxygen confirmed the resident is on PRN oxygen.
Resident #3’s current UAI dated 05-26-2021 documented the need for supervision with walking and mobility; supervision and mechanical assistance with stairclimbing; and physical and mechanical assistance with stairclimbing; however, the current ISP dated 05-26-2021 was not updated to reflect a description of services explaining how staff would supervise the resident with mobility, transferring, and walking; nor did the ISP document the type of mechanical device needed for stairclimbing and mobility.
Staff #1 acknowledged resident #1, resident #2, and resident #3’s ISPs were not updated to reflect the residents? aforementioned needs.

Plan of correction

What Has Been Done to Correct? ISP for Resident #1 has been updated to reflect mechanical assistance needed stair climbing and explained how staff would assist. ISP for Resident #2 has been updated to reflect the resident’s need for PRN oxygen use. ISP for Resident #3 has been updated to reflect mechanical assistance needed stair climbing ISP also updated to reflect a description of service of how staff would assist resident with mobility, transferring, and walking. How Will Recurrence Be Prevented“ Community has implemented bi-weekly ”At-risk/ISP? meeting to conduct audits on residents ISP/UAI documentation and physician orders. Person Responsible: RCD/ARCD/ED Due Date: 8/25/21 initial meeting will be conducted. On-going meetings will be conducted bi-weekly going forward.

April 23, 2021Complaint survey1 violation

Inspection dates

April 23, 2021 and April 26, 2021

Areas reviewed

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint investigation was initiated on 04-23-2021 and concluded on 04-26-2021. A complaint was received by the department regarding allegations in the areas of Personal Care Services and General Supervision of Care and Restorative, Habilitative, and Rehabilitative Services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations

22VAC40-73-325-C

Based on record review and interview, the facility failed to document an analysis of the circumstances of the fall and interventions initiated to prevent or reduce risk of subsequent falls for residents who meet the criteria for assisted living care.

Evidence

Resident #1's Uniform Assessment Instrument (UAI) dated 12-14-2020, resident #2’s UAI dated 02-11-2021, and resident #4’s UAI dated 03-12-2021 documented the residents? meet criteria for assisted living level of care.
Staff “Progress Notes” indicated the following falls: A. 02-10-2021, resident #1 was observed on the bathroom floor, with evidence of head injury and skin tear to right shoulder; B. 02-28-2021, resident #2 fell in room and c/o [complained of] pain; and C. 04-06-2021, resident #3 was found on the floor; and on 04-16-2021 resident was found on the floor with injury on forehead.
Staff #1 stated ?On the documentation for analysis and interventions you requested for each of the 3 residents [residents #1, #2, and #3 listed above, we do not have.?
Staff #1 and staff #2 acknowledged the facility did not document an analysis of the circumstances of the falls or interventions for residents? #1, #2, or #3.

Plan of correction

What Has Been Done to Correct? Updated Fall Analysis report and implemented Interventions as indicated for residents 1, 2, and 3 How Will Recurrence Be Prevented? Utilize Fall Analysis report post fall for all residents Person Responsible: Resident Care Director, Assistant Resident Care Director or designee