Virginia DSS · Assisted Living Facility

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE

📍 4916 West Norfolk Road, Portsmouth, VA, 23703

ID 20215One Year licenseActive
16
Inspections
On record
15
With violations
Visits that cited something
1
Clean visits
Nothing cited
43
Violations cited
Individual findings
27
Standards cited
Distinct rules
7
Complaint visits
Prompted by a complaint

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE was inspected 16 times between January 4, 2021 and April 28, 2026 by the Virginia Department of Social Services. 15 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 43 violations under 27 distinct standards. 7 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 16 are still on the state's site; the other 4 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
02/09/2027
Administrator
Luke Peterson
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

16

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

April 28, 2026Inspection2 violations
Inspection dates
04/28/2026
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 04/28/2026 at 9:25 am to 1:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. complaint was received by VDSS Division of Licensing on 03/24/2026 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: An activity was observed and an observation of the facility’s safe secure environment was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-470-F
Based on the record review and staff interview the facility failed to ensure when the 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 shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident's record. The date and time of occurrence, as well as the personnel involved shall be included in the documentation. 1. 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. If a resident refuses medical attention, the resident's physician shall be notified immediately
Evidence
  1. The record for resident #1 contains the following progress note dated 03/24/26, documented by staff #2 (medication aide): Staff observed red/purple bruising on left eye and left side of nose. The resident’s record did not contain documentation of the resident receiving any medical attention from a licensed healthcare professional within 24 hours.
  2. During an interview on 04/28/26 with staff #3 (licensed health care professional), staff #3 stated their initial assessment and attempt to provide medical attention to the resident was on 03/26/26. Staff #3 observed a purplish/red bruise on the resident’s left eye. Staff #3 proceeded to apply a cold pack to the resident’s eye however the resident refused for the cold pack to be applied. Staff #3 stated the resident’s physician was notified of the bruise to the resident’s eye on 04/02/2026.
  3. The record for resident #1 does not contain documentation of staff #3 assessing the resident on 03/26/26, observation of the resident’s eye nor the medical attention staff #3 attempted to provide and the resident’s refusal.
  4. The record for resident #1 contains the following: • A physician communication form dated 04/02/26 notifying the physician of the bruise on the resident’s eye. • A Physician note dated 04/02/26 of the resident’s visit with the physician for observation of the bruise on the eye.
  5. Resident #1’s individualized service plan (ISP) dated 03/20/26 documents the resident has a diagnosis of Alzheimer’s and resides in the facility’s safe secure environment.
  6. Resident #1’s Uniform Assessment Instrument (UAI) dated 03/20/26 documents the resident’s orientation as disoriented, some spheres, all the time
Plan of correction
What Has Been Done to Correct? Inservice took place on 6/1/2026 to retrain staff on policy and expectations. How Will Recurrence Be Prevented? RCD/ARCD/NP will assess and evaluate residents within 24 hours of incidents occurrence. Person Responsible: ARCD / RCD / ED / BOM Due Date: 6/2/26
22VAC40-73-300-B
Based on the 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
  1. During an interview on 04/28/26 with staff #1, staff #1 stated on 03/23/26 at 5am, staff #1 observed resident #1 on the floor of the resident’s bedroom and staff observed the resident lying on the stomach. Staff #1 proceeded to assist the resident off the floor. Staff #1 confirmed staff #1 did not document the incident in the resident’s record nor in the staff-to-staff communication log.
  2. The record for resident #1 nor the facility’s communication log contain documentation of staff #1 observing resident #1 on the floor on 03/23/26.
Plan of correction
What Has Been Done to Correct? Inservice took place on 6/1/2026 to retrain staff on policy and expectations regarding communication. How Will Recurrence Be Prevented? Shift to shift logs will be reviewed daily. Person Responsible: ARCD / RCD / ED / BOM Due Date: 6/2/26
January 21, 2026Inspection3 violations
Inspection dates
01/21/2026
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 REPORT
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: An unannounced renewal inspection took place on 01/21/2026 at 8:15 am to 4:10 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. The call signaling system was monitored. 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. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-560-E
Based on observation and staff interview the facility failed to ensure all resident records shall be kept in a locked area.
Evidence
  1. During a tour of the facility on 01/21/26 the Licensing Inspector (LI) observed resident records located in the lobby. The resident records were not in a locked area.
  2. During an interview on 01/21/26 with staff #4, staff #4 observed the resident records and confirmed the resident records were not in a locked area.
Plan of correction
What Has Been Done to Correct? Closed/thinned files stored in secured storage area. How Will Recurrence Be Prevented? Closed/thinned files will be stored in secured storage area. Person Responsible: ARCD / RCD / ED / BOM Due Date: 3/6/26
22VAC40-73-1090-A
Based on the record review and staff interview the facility failed to ensure prior to a resident’s admission to a safe, secure environment, the resident shall 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
  1. Resident #1’s, (admitted to safe secure environment on 01/15/26) assessment for serious cognitive impairment dated 01/02/26 documents a response of “No” for the question, Is the Individual named above unable to recognize danger or protect his/her own safety and welfare.
  2. During an interview on 01/21/26 with staff #6, staff #6 confirmed resident #1’s assessment for serious cognitive impairment did not document the resident had an inability to recognize danger or protect her own safety prior to the resident’s admission to the safe secure environment on 01/15/26.
Plan of correction
What Has Been Done to Correct? PCP reassessed for serious cognitive deficit and paperwork updated. How Will Recurrence Be Prevented? Prior to admission serious cognitive deficit to be reviewed to ensure accurate information for admission to secure unit. Person Responsible: ARCD / RCD / ED / BOM Due Date: 3/6/26
22VAC40-73-860-G
Based on the observation of the water temperature, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105°F to 120°F.
Evidence
  1. The water temperature measured in resident #4’s restroom sink was measured to be 94°F.
  2. Staff #5 confirmed the water temperature measured in resident #4’s restroom sink was measured to be 94°F.
Plan of correction
What Has Been Done to Correct? Water heater temp increased - repair made. How Will Recurrence Be Prevented? Water temperatures will be routinely checked and monitored, with repairs being made and deficiencies documented only when found. Person Responsible: ARCD / RCD / ED / BOM Due Date: 3/6/26
August 14, 2025Complaint survey1 violation
Inspection dates
08/14/2025
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 IMPAIRMENTS
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: An unannounced complaint inspection took place on 08/14/25 from 9:15 am to 4:30 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 08/06/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility’s policy and procedures was completed. 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 of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on the record review, medication administration record review, and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains the following: • A physician note and hospital discharge summary signed and dated by the physician on 11/26/24 that includes instructions to take paroxetine 20 mg daily for major depressive disorder. • a physician visit note dated 12/04/24 that includes instructions to take paroxetine 20mg, 1 tablet by mouth once a day • a physician visit note dated 05/19/25 that includes instructions to take paroxetine 20mg, take 1 tablet by mouth every night at bedtime.
  2. Resident #1’s November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, and July 2025 Medication Administration Records (MARs) did not include paroxetine as a listed medication for medication administration.
  3. During an interview on 08/14/25 with staff #1, staff #1 stated resident #1 was not administered paroxetine during the timeframe of November 2024 through June 2025. Staff #1 stated the medication was to be filled and provided by the resident’s family however the facility did not have documentation of the facility’s attempts to receive the medication from the family nor the facility’s attempts to fill the medications per the instructions as provided in the resident’s physician notes.
Plan of correction
What Has Been Done to Correct? N/A Resident no longer in facility How Will Recurrence Be Prevented? Upon return from hospital or MD visit, and new orders received, order placed in MD communication log for review. Person Responsible:ARCD / RCD / ED / BOM Due Date:10/24/25
August 14, 2025Inspection1 violation
Inspection dates
08/14/2025
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 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: An unannounced monitoring inspection took place on 08/14/25 from 9:15 am to 4:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 07/31/2025 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: 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: A review of the facility’s policy and procedures was completed. Residents were observed in the common areas. 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 of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on the incident report review, resident record, and staff interviews, the facility failed to ensure care provision and service delivery shall be resident-centered to the maximum extent possible and include: Prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #1’s incident report dated 07/31/25 documents the following incident: • On 07/17/25 at 10:34 pm, “while resident was being transferred from shower chair to wheelchair resident became weak unable to stand and was lowered to the floor by staff, who requested immediate assistance to transfer resident back to wheelchair and into bed. Resident did not complain of pain at this time.” • On 07/22/25 at 10:30 am, “x-ray was ordered per physician, resident sent to ER.”
  2. The record for resident #1 contains the following: • A progress note dated 07/18/25 stating the resident is complaining about her right leg and right hip hurting. An x-ray exam was completed on the resident. • x-ray results sent to the facility on 7/18/25 at 22:47/10:47 pm documents “Bones are osteoporotic. A right hip prosthesis is seen. A distal femoral nondisplaced oblique fracture is seen in the supracondylar region. Nondisplaced distal femoral supracondylar fracture.”
  3. During an interview on 08/14/25 with staff #1, staff #1 confirmed resident #1’s x-ray results were sent to staff #1’s fax machine located in staff #1’s locked office however staff #1 was not working at the facility when the x-ray results were sent. Staff#1 did not read the results until 07/21/25 when staff #1 returned to the facility. Staff #1 confirmed the direct care staff was aware of resident #1’s completion of an x ray, but the direct care staff did not have access to the results.
  4. Staff #1 confirmed resident #1’s physician order instructing the facility to send the resident to the emergency department (ED) was sent to the facility on 07/21/25 however staff #1 did not read the physician order until 07/22/25 and the resident was sent to the ED on 07/22/25 around 10:30 am. The resident did not receive treatment until the 4th day after the x ray results were completed.
  5. The record for resident #1 contains hospital notes (page 5) dated 07/22/25 that document the following: • “right distal femur metaphysical comminuted closed fracture. Other fracture of right femur, initial encounter for closed fracture.” • The patient was treated non operatively and was placed in a hinged knee brace locked in 30 degrees of flexion, The leg was wrapped in soft roll and an ace wrap to help protect the skin from the brace. The resident returned to the facility on 07/22/25.
Plan of correction
What Has Been Done to Correct? Plan implemented and retraining completed to ensure communication including faxed results and orders are accessible to staff over weekends and in off hours. How Will Recurrence Be Prevented? Manager on duty as well as lead medication aid will be responsible for checking the RCD office for communications to ensure no resident orders are delayed. Person Responsible: ARCD / RCD / ED / BOM Due Date: 10/24/25
January 14, 2025Inspection4 violations
Inspection dates
01/14/2025
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 LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-610 Menu for Meals and Snacks
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: An unannounced renewal inspection took place on 01/14/2025 from 8:09 a.m. to 5:03 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: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-300-B
Based on the record review 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 resident, including complaints and incidents or injuries related to physical or mental conditions. The information shall be included in the records of the involved residents.
Evidence
  1. The record for resident #1 contains the following progress notes: 11/09/24 “resident did not return from hospital on 7-3 shift.” 11/09/24 “resident is still in the hospital. Daughter called and said he would not be coming back today.” 11/10/24 “resident returned home around 2:45 pm.” The resident’s record did not contain documentation of reason for the resident’s hospital visit to include problems experienced by resident, incidents, or injuries.
Plan of correction
What Has Been Done to Correct? N/A How Will Recurrence Be Prevented? Moving forward daily audits will be conducted for all facility progress notes. Staff education on documentation ongoing Person Responsible: ARCD / RCD / ED Due Date: 2/3/25
22VAC40-73-290-B
Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. Upon arrival at the facility on 01/14/2025 at 8:09 am, the Licensing Inspector (LI) observed a posting of the Manager on Duty listed as staff #5 and the Shift Supervisor listed as staff #7. Staff #4 and staff #6 was not on site at the facility upon the LI arrival.
Plan of correction
What Has Been Done to Correct? Accurate onsite PIC position in view of residents and public How Will Recurrence Be Prevented? PIC posting to be reviewed and changed in accordance with staffing daily Person Responsible: ARCD / RCD / ED / BOM Due Date: 2/3/25
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized plan (ISP) shall be completed with 30 days after admission and shall include the following: Description of needs and date identified based upon the Uniform Assessment Instrument (UAI)
Evidence
  1. Resident’s #3 UAI dated 7/26/24 documents the resident needs mechanical help for walking and mobility. The resident’s ISP dated 7/23/24 does not include the mechanical help needed for walking and mobility.
  2. Resident’s #4 UAI dated 10/26/24 documents the resident needs mechanical help for transferring. The resident’s ISP dated 10/26/24 does not include the mechanical help needed for transferring.
Plan of correction
What Has Been Done to Correct? Resident ISP updated How Will Recurrence Be Prevented? Moving forward all equipment used for mobility will be updated on the ISP/UAI Person Responsible: ARCD / RCD / ED Due Date: 2/3/25
22VAC40-90-40-C
Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes.
Evidence
  1. Staff #4, date of hire 10/01/24, criminal record report contains two convictions for barrier crimes (18.2-57).
Plan of correction
What Has Been Done to Correct? Staff member terminated. How Will Recurrence Be Prevented? Additional screening of background checks to be provided. Person Responsible: ARCD / RCD / ED / BOM Due Date: 2/3/25
October 22, 2024Complaint survey3 violations
Inspection dates
10/22/2024
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 ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 10/22/24 from 9:14 am to 1:47 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 09/30/24 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility’s policy and procedures was completed. 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 of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. The record for resident #2 contains an Individualized Service Plan (ISP) dated 7/12/24 that documents the following: resident has a diagnosis of “dementia” and residents in the “memory care unit.” “resident requires occasional reminding with how to use the emergency response system.” “status checks, 2 per shift.”
  2. The facility’s round logs did not include documentation status checks, 2 per shift, and 2-hour rounds from the time the resident went to bed each evening until arisen in the morning were completed for resident #1 on the following dates: (a) 8/8/24, 8/9/42, 8/13/24, 8/15/24, 8/17/24, and 8/30/24 during the 7am to 3pm shift. (b) 8/3/24, 8/4/24, 8/6/24, 8/14/24, 8/17/24, 8/18/24, 8/26/24, and 8/27/24 during the 3pm to 11pm shift. (c) 8/24/24 and 8/29/24 during the 12pm to 7am shift.
Plan of correction
What Has Been Done to Correct? N/A How Will Recurrence Be Prevented? Daily and weekly audits of two hour round sheets to be completed by ARCD/RCD/RMA. Staff documentation education ongoing. Person Responsible: ARCD / RCD / ED Due Date: 11/8/2024
22VAC40-73-440-A
Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission.
Evidence
  1. The record for resident #2, admission date of 5/31/24, did not contain a UAI completed prior to admission. The UAI in the record is dated 6/03/24.
Plan of correction
What Has Been Done to Correct? N/A How Will Recurrence Be Prevented? Moving forward UAI’s will be completed at time of admission. Staff training implemented regarding UAI’s. Person Responsible: ARCD / RCD / ED Due Date: 11/8/2024
22VAC40-73-200-C
Based on the staff record review the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment.
Evidence
  1. The record for staff #1, hire date 5/07/24, did not contain documentation of staff #1 meeting one of the direct care staff qualifications.
  2. The record for staff #1 contains a new hire form that documents staff #1’s job title as a personal care assistant (PCA). Staff #5 was unable to provide documentation staff #1 completed a personal care aide training program approved by the Virginia Department of Medical Assistance Services.
Plan of correction
What Has Been Done to Correct? Staff member terminated. How Will Recurrence Be Prevented? Hiring team has been retrained to ensure that all new hires licenses/certificates meet all state requirements Person Responsible: ARCD / RCD / ED / BOM Due Date: 11/8/2024
July 25, 2024Complaint survey3 violations
Inspection dates
07/25/2024
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 ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 07/25/24 from 9:33 am to 12:45 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 07/01/2024 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility’s policy and procedures was completed. 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 allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on the record review the facility failed to implement a written plan for medication management to include: Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan includes the following: “shift counts are performed at the end of each shift or when the person responsible for medication changes.”
  2. The facility’s “Narcotic Shift Count” form did not include staff signatures for both the off going and oncoming shifts for the following dates and shifts: 06/04/24, 3-11 Shift. 06/04/24, 11-7 shift. 06/07/24, 11-3 shift. 06/20/24, 3-11 shift. 06/22/24, 7-3 shift. 06/23/24, 7-3 shift. 07/14/24, 3-11 shift. 07/17/24, 7-3 shift.
Plan of correction
What Has Been Done to Correct? Ongoing education and intermittent oversight of narcotic count by leadership. How Will Recurrence Be Prevented? Ongoing education and intermittent oversight of narcotic count by leadership. Educate all med-admin staff on CSL Policies VA12.113 and VA12.129, moving forward corrective action will be taken for all non-compliance. Person Responsible: ARCD / RCD / ED
22VAC40-73-680-I
Based on the record review the facility failed to ensure the Medication Administration Record (MAR) shall include: For as needed (PRN) medications: symptoms for which medications was given, exact dosage given, and effectiveness.
Evidence
  1. Resident’s #3 “Controlled Drug Record” documents the resident was given one tablet of Tramadol as a PRN on the dates of 04/09/24 and 04/13/24. Resident’s #3 MAR for April 2024 does not include documentation the resident was given Tramadol as a PRN on the dates of 04/09/24 and 04/13/24 and does not include symptoms for which the Tramadol was given and the effectiveness for the dates of 04/09/24 and 04/13/24.
Plan of correction
What Has Been Done to Correct? Ongoing education How Will Recurrence Be Prevented? Educate all med-admin staff on CSL Policies VA12.102, VA12.113 and VA12.129, moving forward corrective action will be taken for all non-compliance. Person Responsible: ARCD / RCD / ED
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admissions.
Evidence
  1. The record for resident #3, admission date 12/07/23, contains a preliminary plan of care dated 12/07/23. Resident’s #3 ISP is dated as completed on 02/10/24. The resident’s record does not contain an ISP completed 30 days after the resident’s admission date of 12/07/23.
Plan of correction
What Has Been Done to Correct? Residents ISP unable to be completed due to resident having moved out. How Will Recurrence Be Prevented? Audit of ISP’s will be completed for all residents to ensure inactive ISP is current. ARCD/RCD will review Yardi daily for compliance. Person Responsible: ARCD / RCD / ED
February 8, 2024Inspection6 violations
Inspection dates
02/08/2024
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 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 LICENSE22VAC40-80 THE LICENSING PROCESS
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: An unannounced monitoring inspection took place on 02/08/24 from 8:05 a.m. to 6:21 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: 69 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: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized care plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. The record for resident #2, admission date 12/31/22, contains a preliminary plan of care dated 12/31/22, and an ISP completed 03/14/23 and 08/23/23. Resident’s #2 record does not contain an ISP completed within 30 days after the resident’s admission date.
  2. The record for resident #3, admission date 12/15/23, contains a preliminary plan of care dated 12/14/23. The record for resident #3 does not contain an ISP completed within 30 days after the resident’s admission date.
  3. Staff #6 confirmed the records for residents #2 and #3 does not contain an ISP completed within 30 days after the resident’s admission.
Plan of correction
What Has Been Done to Correct? The ISP record for resident #2 and resident #3 has been updated accordingly to reflect all services being rendered How Will Recurrence Be Prevented? The community will ensure that all ISP’s are completed upon admission and annually as well as when changes occur to reflect the residents needs. Person Responsible: Resident Care Director or designee
22VAC40-73-940-A
Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. The facility’s record contains an annual fire inspection completed on 02/14/22. Staff # 6 acknowledged the facility’s record of the last fire inspection completed is dated 02/14/22 and the facility has no record of an annual fire inspection being completed for 2023.
Plan of correction
What Has Been Done to Correct? Appropriate fire official contacted by maintenance director How Will Recurrence Be Prevented? Annual fire inspection to be completed as to comply with the Virginia Statewide Fire Prevention Code. Person Responsible: Maintenance Director or designee
22VAC40-73-680-D
Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a physician order dated 10/11/23 documenting the following instructions: “Take blood pressure Q AM if systolic is less than 110 administer Midodrine 2.5mg.” Resident’s #1 record and the Jan. 2024 Medication administration record (MAR) does not include documentation the resident was administered Midodrine when the resident’s systolic was documented on the MAR as being less than 110 on the following dates: 01/02/24 through 01/10/24, and 01/15/24 through 01/25/24.
Plan of correction
What Has Been Done to Correct? The record for resident #1 was reviewed facility ensured that medication is administered in accordance with physicians orders. How Will Recurrence Be Prevented? RMAs will be receive a training on following MD orders. RMAs will receive a training on proper data input of blood pressure readings on MAR. Person Responsible: Resident Care Director or Designee
22VAC40-73-450-F
Based on the record review the facility failed to ensure ISPs shall be reviewed and updated at least once every 12 months and as needed for a significant change in the resident’s condition.
Evidence
  1. The record for resident #2 contains a hospice care evaluation and a hospice care plan with an effective date of 11/29/23. Resident’s #2 progress notes documents resident is currently receiving hospice care services. Resident’s #2 most recent ISP in the record is dated 08/23/23. The record for resident #2 does not contain an ISP completed when the resident began receiving hospice care services effective 11/29/23.
Plan of correction
What Has Been Done to Correct? ISP record for resident #2 was reviewed and updated accordingly How Will Recurrence Be Prevented? The community will address needs of residents during the weekly meeting and update the ISP to reflect those needs and or changes. Person Responsible: Resident Care Director or designee
22VAC40-73-430-H-1
Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal guardian and designated contact person a dated statement signed by the licensee or administrator that contains the following statement: the actions taken by the facility to assist the resident in discharge and relocation process; the date of the actual discharge from the facility and the resident’s destination.
Evidence
  1. Resident’s #7, discharge statement dated 09/20/23 did not include the following documentation: actions taken by the facility to assist the resident in discharge and relocation process and the resident’s destination.
Plan of correction
What Has Been Done to Correct? Dated statement for resident #7 has been updated. How Will Recurrence Be Prevented? With all future discharges the facility will ensure that the resident or legal guardian and designated contact person are provided a dated statement signed by the licensee or administrator that contains the following statement: the actions taken by the facility to assist the resident in discharge and relocation process the date of the actual discharge from the facility and the residents destination. Person Responsible: Administrator or designee
22VAC40-73-440-A
Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. The record for resident #2 contains a hospice care evaluation and a hospice care plan with an effective date of 11/29/23. Resident’s #2 progress notes documents resident is currently receiving hospice care services. Resident’s #2 most recent UAI in the record is dated 08/23/23. The record for resident #2 does not contain a UAI completed when the resident began receiving hospice care services effective 11/29/23.
Plan of correction
What Has Been Done to Correct? UAI record for resident #2 was reviewed and updated accordingly How Will Recurrence Be Prevented? The community will address needs of residents during the weekly meeting and update the UAI to reflect those needs and or changes. Person Responsible: Resident Care Director or Designee
September 25, 2023Inspection0 violations
Inspection dates
09/25/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 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: An unannounced monitoring inspection took place on 09/25/2023 from 9:16 am to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on 08/17/2023 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: 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: A review of the staffing schedule, and daily shift communication log was completed. An observation of the safe secure environment was completed. Additional Comments/Discussion: None The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 27, 2023Complaint survey1 violation
Inspection dates
06/27/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 06/27/2023 from 9:06 am to 1:50 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 06/21/2023 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: 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: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A review of the staffing schedule, and daily shift communication log was completed. An observation of resident activities was completed. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-H
Based on the record review 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, including assistance or care with bathing, at least twice a week but more often if needed or desired.
Evidence
  1. The record for resident #1 contains an Individualized Services Plan (ISP) dated 04/16/23 documenting the resident requires assistance with bathing and identifies Direct Care Staff as the persons to provide the assistance. The resident’s record, skin assessment sheets, and shift to shift communication log included documentation the resident received assistance with bathing once a week on 05/11/2023, during the week of 05/07/23 through 05/14/2023, and once a week on 05/29/2023 during the week of 05/28/2023 through 06/04/2023.
  2. The record for resident #2 contains an ISP dated 06/13/22 documenting the resident requires assistance with bathing and identifies Direct Care Staff as the persons to provide the assistance. The resident’s record, skin assessment sheets, and shift to shift communication log did not include documentation assistance with bathing occurred twice a week during the timeframe of 05/13/2023 through 05/23/2023.
Plan of correction
Community will be compliant with residents ISP. Documentation will reflect compliance of ISP. Staff education will be implemented on an ongoing basis on documentation and documenting by exception. RCD or designee will review progress notes and end of shift reports regularly.
December 5, 2022Inspection5 violations
Inspection dates
12/05/2022, 12/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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
Technical assistance
ISP documentation to identify type of assistive devices needed for the resident.
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: An unannounced renewal inspection took place on 12/05/22 from 8:38 a.m. to 4:35 p.m. and 12/06/22 from 8:45 a.m. to 4:30 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: 59 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: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and call bell system was monitored. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-1090-A
Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall 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
  1. The record of resident #5 includes an assessment of serious cognitive impairment dated 11/23/22 which includes a response of “No” for the question “is the individual unable to recognize danger or protect his/her own safety and welfare.”
  2. The record of resident #5 includes an approval for placement in special care unit dated 11/22/22.
  3. Staff #6 and staff #7 acknowledged the assessment of serious cognitive impairment dated 11/23/22 in the record for resident #5 included a response for “No” for the question “is the individual unable to recognize danger or protect his/her own safety and welfare.”
Plan of correction
What Has Been Done to Correct? The assessment of serious cognitive impairment was sent to the physician to be updated. How Will Recurrence Be Prevented? The Resident Care Director or designee will review the assessment of serious cognitive impairment and ensure that it is filled out correctly by the physician prior to admission. All resident charts will be reviewed for accuracy. Person Responsible: Resident Care Director or designee
22VAC40-73-450-C
Based on record review the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based upon the uniform assessment instrument (UAI).
Evidence
  1. The record of resident # 6 UAI dated 09/26/22 documented a mechanical and human help need for transferring. The need for mechanical and human help for transferring was not included on the ISP dated 11/01/22.
  2. Staff # 6 acknowledged the ISP in the record for resident #6 dated 11/01/22 did not include the need for transferring as identified on the UAI dated 09/26/22.
Plan of correction
What Has Been Done to Correct? The ISP record for resident #6 was reviewed and updated accordingly to reflect current need. How Will Recurrence Be Prevented? The RCD will review the resident records to ensure that the ISP reflects the needs identified on the UAI as updates occur. All resident charts will be reviewed for accuracy. Person Responsible: Resident Care Director or designee
22VAC40-73-860-G
Based on observation the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105°F to 120°F.
Evidence
  1. During the onsite inspection, the water temperature in room # 130 was measured 127 degrees F. The water temperature in Room # 131 was measured to 129 degrees F.
  2. Staff # 10 acknowledged the water temperatures in Room 130 and Room 131 to exceed the required degrees.
Plan of correction
What Has Been Done to Correct? The maintenance director adjusted the water heater immediately to get the desired temperature. How Will Recurrence Be Prevented? The maintenance director will continue to do weekly water temperature checks in random resident rooms and will continue to document them in the designated binder. The maintenance director will place mixing valves on the water source for units 130 and 131 to ensure that the water is able to stay at the desired temperature. Person Responsible: Maintenance Director or designee
22VAC40-73-410-A
Based on the onsite record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident’s record.
Evidence
  1. The record of resident # 1 did not include documentation of an orientation upon his admission date of 03/25/22.
  2. Staff #6 and staff #7 acknowledged documentation on an orientation was not included in the record for resident #1.
Plan of correction
What Has Been Done to Correct? The resident acknowledged that he had received orientation on day of admission. The acknowledgement was place in his record. How Will Recurrence Be Prevented? The administrator will follow the audit guide for each new resident to ensure that every resident has documentation of having received orientation. Person Responsible: Administrator or designee
22VAC40-73-560-E
Based on record review the facility failed to ensure all resident records shall be kept current and retained at the facility.
Evidence
  1. The record of resident #1 includes an ISP dated 6/13/22 which identifies “DNR: CPR will be withheld in the event of cardiac/respiratory arrest per Durable Do Not Resuscitate.” The record did not include a DNR order.
  2. Resident #1 record included a personal and social data information which documents a response of “n/a” for the section “information on advance directives, DNR orders or organ donation if applicable.”
  3. Staff # 6 and staff #7 acknowledged a copy of the DNR order was not in the record for resident # 1.
Plan of correction
What Has Been Done to Correct? The ISP record for resident #1 was changed to reflect current DNR status. How Will Recurrence Be Prevented? The RCD will review the resident records to ensure that the ISP reflects current code status. All resident charts will be reviewed for accuracy. Person Responsible: Resident Care Director or designee
January 31, 2022Inspection8 violations
Inspection dates
01/31/2022; 02/04/2022
Areas reviewed
Part I- General ProvisionsPart II- Administration and Administrative ServicesPart III- PersonnelPart IV- Staffing and SupervisionPart V- Admission, Retention and Discharge of ResidentsPart VI- Resident Care and Resident ServicesPart VII- Resident Accommodations and Related ProvisionsPart VIII- Buildings and GroundsPart IX- Emergency PreparednessPart X- Additional Requirements for facilities that care for adults with serious cognitive impairmentsBackground Checks for Assisted Living FacilitiesThe Sworn Statement or AffirmationThe Criminal History Record ReportProtection of adults and reporting
Technical assistance
Technical assistance: physician's order need to specify area for cream to be applied; powder cream should specify the amount of powder to be administered; bedroom spacing when more than one resident reside in room; healthcare oversight audit should be conducted by someone not completing UAI/ISPs; equipment need by resident should be available (example- nebulizer)
Comments
An unannounced renewal inspection was conducted on 1-31-22 (ar 08:00/ dep 18:00). Facility census was 44. Medication pass observed, tour of facility, breakfast meal observed, activity observed; emergency preparedness reviewed, staff and resident records reviewed, first aid kit reviewed, resident council minutes reviewed. Violations and technical assistance provided throughout the day during the inspection. An exit conducted with administrator and staff on 1-31-22. A final exit conducted with administrator via telephone on 2-4-22.The acknowledgement form was completed and sent to the administrator. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today ,2-9-22. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible.
Violations
22VAC40-73-680-M
Based on record review, observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for this specific resident, and properly stored at the facility.
Evidence
  1. On 1-31-22 during medication pass observation with staff #6, resident #4’s Loperamide was not available.
  2. A check of the medication cart on the safe, secure unit (Sweet Memories) with staff # 3 and #7, resident #5’s Tylenol was not available.
  3. On 1-31-22 and 2-4-22, staff #1 acknowledged resident’s PRN medications should be available in the facility.
Plan of correction
The medication for resident #4 and #5 was ordered prior to it not being available per medication management plan, the medication arrived to the community 1-31-22. The community contacted the pharmacy and reminded them that if they cannot provide medication refills timely that they needed to follow the plan and use the backup pharmacy to ensure that medications are on hand regardless of the inclement weather. The staff will reorder medications per the policy. The pharmacy will receive a call if a medication ordered does not come in timely so that it can be sent through the backup pharmacy. A medication cart audit will continued to be done to ensure that all medications are available. Resident Care Director or designee 2-9-22 and on-going
22VAC40-73-470-A
Based on record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met for one of five sampled records.
Evidence
  1. Resident #3’s record included a signed physician’s order dated 7-21-21 for physical therapy, occupational therapy and speech therapy. The resident’s record did not document occupational therapy and speech therapy services evaluated and/or completed. The ISP dated 11-16-21 did not document services beginning and/or ending date.
  2. On 1-31-22 and 2-3-22, the physician’s order for speech and occupational therapy evaluation and treatment not being completed was addressed with staff #1 and #2.
Plan of correction
The record for resident #3 was reviewed. The resident was opened to hospice services on 2-3-22 and the MD wrote new orders to include physical therapy but not speech or occupational therapy. Since the physician changed the orders the speech and occupational therapy was not completed. The doctors most current orders will always be followed. The community will ask for a discontinued order if needed. Resident Care Director or designee 2-9-22 and on-going
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care need for four of five sampled resident’s record
Evidence
  1. Resident 1’s January 2022 medication administration record (mar) documented resident prescribed Seroquel. Resident’s record did not include a treatment plan for psychotropic medication.
  2. Resident #2’s January 2022 MAR documented resident prescribed Escitalopram and Lorazepam. Resident’s record did not include a signed treatment plan for psychotropic medication.
  3. Resident #3’s January 2022 Mar documented resident prescribed Alprazolam, Mirtazapine and Venlafaxine. Resident’s record did not include a signed treatment plan for psychotropic medication.
  4. Resident #4’s January 2022 Mar documented resident prescribed Risperidone. Resident’s record did not include a psychotropic treatment plan.
  5. On 1-31-22 and 2-3-22 during exit meeting, staff #1 and 2 acknowledged psychotropic treatment plans were not available for residents #1, #2, #3 and #4.
Plan of correction
Resident #1,2,3,and 4’s psychotropic treatment plans were put in place. The Resident Care director or designee will ensure that the physician puts a treatment plan in place for each psychotropic medication ordered. A monthly audit will be conducted by the Resident Care Director or Designee for all psychotropic medications to ensure that there are plans in place and current according to physician orders. Resident Care Director or designee 2-11-22 and on-going
22VAC40-73-450-D
Based on record review, the facility failed to ensure when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP) for one of five sampled records.
Evidence
  1. Resident #2’s record documented hospice services dated 11-5-21. The services documented in the contracted agreement noted skilled nursing, social worker, chaplain and a caregiver/aide. The ISP dated 11-5-21 and 1-17-22 did not include when, what and where these services were to be provided.
  2. On 1-31-22 and 2-3-22 during the exit meeting staff #1 and #2 acknowledged the ISP did not include the specific hospice services being provided for resident #2.
Plan of correction
The ISP record for resident #2 was reviewed and updated accordingly to reflect all services being rendered. The community will address needs of residents during the weekly meeting and updated the ISP to reflect those needs and or changes. Resident Care Director or designee 2-11-22 and on-going
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F).
Evidence
  1. On 1-31-22 during a tour of the facility with staff #1, #3 and #4, the water temperature in room #130 on the safe, secure unit (Sweet Memories) was 124 degrees F.
  2. On 1-31-22 and 2-4-22, staff #1 acknowledged the water temperature was beyond the required degrees.
Plan of correction
The maintenance director adjusted the water heater immediately to get the desired temperature. The maintenance director will continue to do weekly water temperature checks in random resident rooms and will continue to document them in the designated binder. Maintenance director 2-9-22 and on-going
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs for four of five records reviewed.
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 1-7-22 documented resident needed assistance with bowel, (less than weekly) and bladder (greater than weekly). The individualized service plan (ISP) dated 1-17-22 did not document who, when and what services would be provided. Resident’s ISP documented resident to not receive cardiopulmonary resuscitation (CPR). The record did not contain documentation of a DNR document signed by a prescriber.
  2. Resident #2’s UAI dated 12-31-21 documented abusive/aggressive/disruptive behavior. The ISP documented services to be provided as “may require special tolerance or staff training”. Resident’s Preliminary ISP dated 11-5-21 and comprehensive ISP dated 1-7-22 did not include resident’s physical therapy services. Physical therapy evaluation documented 11-17-21 and discontinued 12-21-21.
  3. Resident #3’s ISP dated 11-26-21 did not document resident’s physical therapy services documented on 8-25-21, 9-10-21 and 9-17-21; physician’s order dated 7-21-21.
  4. Resident #4’s ISP dated 11-2-21 did not include resident’s physical therapy services 7-8-21 and discontinued 9-14-21 and services documented with another agency 12-3-21, 12-6-21 and 12-13-21. When inquired if physical therapy services are currently being provided or discontinued, staff #2 did not know. Record documented occupational therapy evaluation on 8-11-21 and services discontinued 9-1-21. Skilled nursing services for incision to right knee services and discontinued 7-14-21 was not documented on resident’s ISP.
  5. On 1-31-22 and 2-3-22 during exit meeting, staff #1 and #2 acknowledged residents #1, #2, #3 and #4’s ISP did not include all accessed needs.
Plan of correction
The ISP record for resident #1, 2, 3, and 4 were reviewed and updated accordingly. The community will address needs of residents during the weekly meeting and will updated ISP to reflect those needs and or changes. Resident Care Director or designee 2-22-22 and on-going
22VAC40-73-640-A
Based on record review, observation and staff interviewed, the facility failed to comply with its medication management plan to ensure resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. On 1-31-22 during the medication pass observation with staff #5, resident #1’s Gabapentin was not available for the 9:00 a.m. administration. Resident #3’s Diclofenac cream was not available for the 9:00 a.m. administration.
  2. On 1-31-22, resident #5’s hospice medication, Bisacodyl suppositories and Acetaminophen dated 11-14-20 were in the refrigerator on the safe, secure unit. According to staff #3, resident #5’s hospice services were discontinued November 2021. Staff #3 acknowledged the medication should not be in the refrigerator.
  3. On 1-31-22 and 2-4-22 during the exit meeting, staff #1 and #2 acknowledged resident’s medication should be present and available at time of administration.
Plan of correction
The medication for resident #1 and #3 was ordered prior to it not being available per medication management plan, the medication arrived to the community 1-31-22. The community contacted the pharmacy and reminded them that if they cannot provide medication refills timely that they needed to follow the plan and use the backup pharmacy to ensure that medications are on hand regardless of the inclement weather. The staff will reorder medications per the policy. The pharmacy will receive a call if a medication ordered does not come in timely so that it can be sent through the backup pharmacy. A medication cart audit will continued to be done to ensure that all medications are available. Resident Care Director or designee 2-9-22 and on-going
22VAC40-73-700-2
Based on record review, observation and staff interview, the facility failed to ensure when oxygen therapy is provided, the facility shall ensure it post “NO Smoking –Oxygen In Use” signs in the room of a building where oxygen is in use.
Evidence
  1. On 1-31-22 during medication pass with staff #5, upon entering resident #2’s room, an oxygen tank was present and plugged into the wall outlet. There was no Oxygen sign present in the room and no sign was posted outside the resident’s room. Resident #2’s record included a physician’s order for oxygen dated 1-26-22.
  2. On 1-31-22 and 2-4-22 during the exit meeting, staff #1 and #2 acknowledged the oxygen sign should have been posted.
Plan of correction
The staff immediately placed an oxygen on use sign on the outside of the door to resident #2. The community will ensure that when oxygen is delivered for a resident it will be checked in with the resident care director or designee before placing it into the room of the resident. The resident care director or designee will provide an oxygen in use sign to each resident that has oxygen and it will be placed on the outside of the door visible to others. 2-11-22 and on-going
June 22, 2021Complaint survey1 violation
Inspection dates
June 22, 2021 and June 23, 2021
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 6/22/21 and concluded on 6/23/21. A complain was received by the department regarding allegations in the area of discharge of residents. 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 allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-430-J
Based on record review and discussion, the facility failed to ensure within 60 days of the date of discharge, the resident or his legal representative be given a final statement of account, and return any property, or things of value held in trust or custody of the facility.
Evidence
  1. Resident #1 passed away on 3/9/21 and his personal items were removed from his apartment on 3/12/21.
  2. The Discharge notification provided by the facility was dated 3/15/21 but did not indicate that the resident or his legal representative was notified or received the discharge notification.
  3. Resident #1’s legal representative did not receive any of the personal property until 6/3/21.
  4. Staff #1 acknowledged that the facility did not give the discharge notification or return Resident #1’s personal belongings within 60 days of the date of discharge.
Plan of correction
Not published by VDSS.
February 2, 2021Complaint survey1 violation
Inspection dates
Feb. 2, 2021 , Feb. 2, 2021 , Feb. 3, 2021 , Feb. 4, 2021 and Feb. 17, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
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 2/1/21 and concluded on 2/17/21. A complaint was received by the department regarding allegations in the areas of medical care/nursing services and missed appointments. 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 allegation however, non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-C
Based on record review and discussion, the facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs and date identified, and a written description of what services will be provided to address identified needs based upon the Uniform Assessment Instrument (UAI).
Evidence
  1. Resident #3’s UAI dated 9/24/2020 documented orientation as, ?disoriented, some spheres, some of time, spheres affected situation“. The resident’s ISP dated 9/24/2020 documented ”Neurocognitive? in the Description of Services to be Provided.
  2. The ISP also documented the description of need as “Additional Services”. Documented in the Description of Services to be Provided is, “due to incontinence”, resident requires occasional/monthly nursing services ordering of supplies, scheduling of appointments, and other services??
  3. Laundry was identified as a need however; the ISP did not identify specifics of what, when, where or by whom.
  4. Date identified for resident’s needs for bowel incontinence, bladder incontinence, wheeling, and money management was not documented on the ISP.
  5. Staff #5 acknowledged the resident’s ISP did not document aforementioned information.
Plan of correction
RCD and ED will make corrections to Orientation removing person,place, and time. RCD and ED will make correction to ISP specifically listing additional services and provide detail of services and provide detail of services to be provided. RCD and ED will make corrections to ISP specifically who is providing laundry services, when they are providing laundry services, where the services will take place. RCD and ED will make corrections to ISP that will indicate date needs were identified for incontinence, wheeling and money management. RCD and ED will review ISP to ensure corrections were made to ISP.
January 21, 2021Complaint survey2 violations
Inspection dates
Jan. 21, 2021 , Jan. 22, 2021 , Jan. 25, 2021 , Jan. 26, 2021 and Jan. 27, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 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 1/21/21 and concluded on 1/27/21. A complaint was received by the department regarding allegations in the area of notification of family member after an incident. 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 allegation 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
22VAC40-73-450-C
Based on record review and discussion, the facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the Uniform Assessment Instrument (UAI).
Evidence
  1. Resident #1 UAI dated 8/14/2020 documented incontinence with bowel and bladder. The resident’s ISP dated 8/14/2020 did not document the need.
  2. Staff #4 acknowledged Resident #1’s ISP dated 8/14/2020 did not document incontinence with bowel and bladder.
Plan of correction
RCD made correction to ISP to reflect incontinence of bowel and bladder. RCD & ED will review ISP to ensure correct level of care in regards to incontinence level is indicated.
22VAC40-73-450-F
Based on record review and discussion, the facility failed to update the Individualized Service Plan as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #3 was admitted on 2/8/18 with a regular diet. Physician’s order dated 11/24/2020 documented a new order for “no added salt diet”.
  2. Resident #3’s ISP dated 8/14/2020 did not reflect the change in the diet.
Plan of correction
RCD made correction to ISP to reflect "no added salt diet". RCD & ED will review ISPs to ensure correct diets and changes in diet are reflected.
January 4, 2021Inspection2 violations
Inspection dates
Jan. 4, 2021 , Jan. 5, 2021 and Jan. 6, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 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 renewal inspection was initiated on 1/4/2021 and concluded on 1/6/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 57. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, Health Care Oversight, Fire Inspection, Health Department Inspection, Fire and Emergency drills, and Dietitian Oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-320-A
Based on record review and discussion, the facility failed to ensure the physical examination report documented the descriptions of the person’s reactions to known allergies.
Evidence
  1. Resident #2’s physical examination report dated 12/9/2020 did not document a description of reactions to known allergies: latex, natural rubber, and Penicillin.
  2. Staff #5 acknowledged Resident #2’s physical examination report dated 12/9/2020 did not include the aforementioned information.
Plan of correction
RCD is auditing all H&Ps for reactions to identified allergies. Addendum has been added to all current residents indicating allergies and reactions to those allergies. RCD & ED will review all physical examination reports upon admission to ensure that reactions to all allergies are listed and indicated on H&P.
22VAC40-73-450-C
Based on record review and discussion, the facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the physical examination and/or Uniform Assessment Instrument (UAI).
Evidence
  1. Resident #1’s physical examination report dated 8/31/2020 documented a “regular diet-no salt” diet. Additionally, the resident’s record did not include documentation indicating that the resident’s diet was changed to remove ?no added salt?. sa t?. a. Resident #1’s ISP dated 10/8/2020 did not include the “regular diet-no salt” diet that was documented on the physical examination report. b. Staff #5 acknowledged Resident #1’s ISP dated 10/8/2020 did not include the “regular diet-no salt” diet. Additionally, Staff #5 did not provide a physician’s order that changed the resident’s diet. c. Resident #1’s UAI dated 8/31/2020 documented the resident needs mechanical help and human help supervision with bathing; however, Resident #1’s ISP dated 10/8/2020 did not document the mechanical help needed for bathing. d. Staff #5 acknowledged Resident #1’s ISP dated 10/8/2020 did not document the mechanical help needed for bathing.
  2. Resident #3’s physical examination report dated 8/12/2020 documented a “regular diet-easy to chew” diet. Additionally, the resident’s record did not include documentation indicating that the resident’s diet was changed to remove “easy to chew”. a. Resident #3’s ISP dated 9/17/2020 did not include the “regular diet-easy to chew” diet that was documented on the physical examination report. b. Staff #5 acknowledged Resident #3’s ISP dated 9/17/2020 did not include the “regular diet-easy to chew” diet. Additionally, Staff #5 did not provide a physician’s order that changed the resident’s diet.
Plan of correction
RCD made correction to ISP to reflect "no added salt" diet order. RCD made correction to ISP to reflect correct functional status regarding bathing assistance. RCS added "easy to chew" to IPS as indicated on admission orders. ED &RCD will review ISPs to ensure correct diet and functional status is documented on ISP.