Virginia DSS · Assisted Living Facility

Sunrise at Reston Town Center

📍 1778 Fountain Drive, Reston, VA, 20190

ID 22596Two Year licenseActive
14
Inspections
On record
9
With violations
Visits that cited something
5
Clean visits
Nothing cited
27
Violations cited
Individual findings
24
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Sunrise at Reston Town Center was inspected 14 times between April 28, 2021 and March 31, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 27 violations under 24 distinct standards. 1 inspection was 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 14 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
10/19/2026
Administrator
Kanetha Breaux
Licensing inspector
Jacquelyn Kabiri
Inspector phone
(703) 397-3017
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

14

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

March 31, 2026Inspection0 violations
Inspection dates
03/31/2026
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-80 Complaint Investigation
Comments
Type of inspection: ¿Complaint¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/31/2026, 10:00 a.m. to 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/26/2026 regarding allegations in the area(s) of: Buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Exercise class and lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 12, 2026Inspection6 violations
Inspection dates
03/12/2026, 03/31/2026, 04/14/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 Complaint Investigation
Technical assistance
680-H 870-A
Comments
Type of inspection: ¿Complaint¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/12/2026 from 11:00 a.m. to 2:50 p.m., on 03/31/2026 from 11:00 a.m. to 2:00 p.m., and on 04/14/2026 from 11:00 a.m. to 12:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/03/2026 and 03/12/2026 regarding allegations in the area(s) of: Resident Care and Related Services and Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 76 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: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: Activities and lunch Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); areas 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on record review and interview, the facility failed to ensure the provision of care and delivery of services was resident-centered to the maximum extent possible and included prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The LI requested the pendant response times records for resident 1 to cover January 05, 2026 through March 1, 2026.
  2. Resident 1 (admitted 03/22/2023) pushed the call bell pendant 18 times in the time frame of January 05, 2026 –March 01, 2026.
  3. On 02/22/2026, the call bell log indicates resident 1’s pendant wasn't answered for 35 min and 13 seconds.
  4. On 02/21/2026, the call bell log indicates resident 1’s pendant wasn't answered for 1 hour, 10 min and 0 seconds.
  5. Staff 1 acknowledged the LI’s findings.
Plan of correction
A. With respect to the specific resident/situation cited: Residents did not experience any negative outcomes due to long call bell response. Staff were re-educated as to the importance of a prompt response and how to request assistance if they are occupied with another resident. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns. Neighborhood Coordinator or designee will conduct a weekly audit of call bell response times to determine if any do not qualify as prompt, and address as necessary. C. With respect to what systemic measures have been put into place to address the stated concern: Neighborhood Coordinator or designee will report out with morning meeting, review in IDT and review in next quarterly QAPI meeting. The results of audit will be presented at the next Quality Assurance and Performance Improvement Committee meeting. During and at the conclusion of the QAPI meeting, the committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-460-A
Based on record review and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. A complaint received on 03/03/2026 stating that resident 1 was hospitalized due to shortness of breath and subsequently underwent amputation of the second toe on the right foot.
  2. The Individualized Service Plan (ISP) dated 03/12/2026 for resident 1 included the following directives: a. “Special instructions: I wear an orthopedic shoe due to a wound under the right foot.” b. “Observe and report any complaints of numbness, tingling, or tremors.”
  3. The facility’s Chronic Disease Management Policy for diabetes states that proper management may prevent complications, including: a. Skin complications such as dryness, itching, infections, blisters, and skin breakdown. b. Neuropathy, including peripheral neuropathy causing pain, tingling, or numbness in extremities.
  4. During a review of resident 1’s record and interviews with staff 2, 3, 4, 5, and 6, there was no indication of monitoring of resident 1’s right foot despite Resident 1’s ISP indication of a wound under right foot.
  5. Staff 2, 3, 4, 5, and 6 acknowledged awareness that resident 1 had a chronic diagnosis of diabetes and required routine medication administration.
  6. Staff 1 acknowledged that resident 1 had a chronic condition and confirmed the toe amputation occurred on 03/05/2026.
Plan of correction
A. With respect to the specific resident/situation cited: Resident was found to have wound underneath second toe, resulting in amputation. Upon return to community, staff were tasked with daily checks specific to this resident until reassessment was completed. Resident was reassessed for care needs B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director or designee conducted an audit of residents with diabetes to determine that there is a plan in place for all diabetic residents, including those who do not receive ADL assistance and address as needed. C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director or designee will audit clinical and progress notes for residents to determine that alerts are addressed as expected. The results of audit will be discussed at weekly IDT meeting for the next 3 months, then presented at the next quarterly Quality Assurance and Performance Improvement Committee meeting. During and at the conclusion of the QAPI meeting, the committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-450-F
Based on record review and interview, the facility failed to ensure the individualized service plan be updated and include a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. Resident 1 admitted to the facility on 03/22/2023.
  2. Resident 1’s Individualized Service Plan (ISP), dated 03/13/2026, states under “Special Conditions,” “I wear orthopedic shoe [sic] due to wound under right foot.” and “I am diabetic.”
  3. The ISP for Resident 1 (dated 03/13/2026) does not specify who will provide the services related to the special instructions listed on the ISP. The ISP for Resident 1 also lacked specifics regarding the frequency and duration of services, as well as who was responsible for the care and observation of the Resident 1’s foot wound and diabetes.
  4. Staff 1 acknowledged the ISP reviewed as most current for Resident 1 and the special instructions listed.
Plan of correction
A. With respect to the specific resident/situation cited: The resident was found to have wound underneath second toe, resulting in amputation. Resident Care Director updated ISP and special instructions including what services are being provided and who will be providing the services. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director or designee conducted an audit of residents with diabetes to determine that ISP and any special instructions are accurate and the most up to date including what services are being provided and by whom they are being provided. C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director or designee will conduct an audit of resident ISP’s including special instructions to determine that all have the most up to date information. The results of audit will be discussed monthly at a weekly IDT meeting for the next 3 months, then presented at the next quarterly Quality Assurance and Performance Improvement Committee meeting. During and at the conclusion of the QAPI meeting, the committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at quarterly Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-490-D
Based on record review and staff interview, the facility failed to ensure the specific residents for whom the health care oversight was provided must be identified.
Evidence
  1. During onsite inspection on 03/12/2026, the health care oversights dated 07/2025 through 11/2025 did not include the specific residents for whom the oversight was provided. Additionally, the oversight did not list specific dates, only the month and the year. The form shows “Second half of 2025” and the months 03/2025-11/2025.
  2. Staff 1 acknowledged that the names of the residents reviewed were not listed in the health care oversight.
Plan of correction
A. With respect to the specific resident/situation cited: Health Care Oversight was completed, but information is not documented all in one easy to review format. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Will revamp healthcare oversight process including individual resident reviews, dietician and pharmacy audits in a way that is easier to review in its entirety. C. With respect to what systemic measures have been put into place to address the stated concern: In compliance with regulations, the revamped Health Care Oversight (HCO) will continue to be conducted/documented semi-annually. After revamping semi-annual HCO, the Executive Director and/or designee will file sign document and review document at the Quarterly QAPI meeting. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-640-A
Based on a review of the facility's medication management plan and staff interviews, the facility failed to follow their medication management plan.
Evidence
  1. The Licensing Inspector (LI) responded to a complaint regarding resident 1’s medication being discovered in a medication cup, stacked inside six empty medication cups, in the kitchen cabinet of resident 1’s apartment.
  2. During interviews throughout the onsite inspection, staff 6 and staff 7 stated that they administered medications to resident 1 and reported that the resident preferred to take medications with or after breakfast. Staff indicated that, rather than waiting for the resident to take the medication, they would at times leave the medication in a clear medication cup for the resident to take later.
  3. A review of the facility’s medication management plan under general guidelines states: “Residents should be observed taking the medication followed by the offering of water or other fluids,” and “Medications should not be left for a resident to consume at a later time.”
  4. Staff 1 confirmed that staff 6 and staff 7 left medications for resident 1 and did not remain in the room to observe the resident taking the medication.
  5. On 03/20/2026, staff 1 submitted a final self-report identifying a medication error involving resident 1’s insulin. The report indicated that the physician’s orders were transcribed incorrectly into the Medication Administration Record (MAR), as the parameters for evening insulin administration were not included.
  6. A review of resident 1’s February 2026 MAR showed an order for Insulin Lispro (1 unit dial) subcutaneous solution pen injector 100 unit/mL, to inject 10 units three times daily related to Type 2 Diabetes, with instructions to administer per a sliding scale. However, the MAR did not include the sliding scale parameters and documented administration at 7:30 a.m., 11:30 a.m., and 4:30 p.m.
  7. A review of the facility’s medication management plan under error reporting states: “Right Medication (Includes transcription of medication orders.)”
  8. Staff 1 confirmed the medication transcription error of resident 1’s insulin during the inspection.
Plan of correction
A. With respect to the specific resident/situation cited: Resident was not known to experience a negative outcome due to a cup of morning medications not administered and proper procedure in accordance with the communities Medication Management Program. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director or designee conducted unannounced med pass observations to verify that MCM’s are following all required tasks during medication administration in accordance with Virginia Board or Nursing and Sunrise Medication Management Plan C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director or designee conducted refresher trainings with all Medication Care Managers. The documentation of training courses will be placed in MCM’s personnel files. Completions will be presented to the next quarterly Quality Assurance and Performance Improvement Committee meeting. During and at the conclusion of the QAPI meeting, the committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-680-B
Based on document review and staff interview, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 03/12/2026, the Licensing Inspector (LI) received a complaint regarding prescription pills found in an unlabeled clear plastic medication cup, stacked inside six empty medication cups, located in Resident 1’s kitchen cabinet.
  2. During interviews with staff 6 and staff 7, staff 6 and staff 7 confirmed that resident 1’s medication was taken from the prescription containers, placed into a plastic medication cup, and at times left for the resident to self-administer.
  3. Resident 1 (admitted 03/22/2023) had a Uniform Assessment Instrument (UAI), dated 03/13/2026, which indicated the resident required medication administration and monitoring by licensed nursing staff (LPN) and medication technicians. The assessment did not support self-administration of medications.
  4. A review of resident 1’s Individualized Service Plan (ISP), dated 03/13/2026, indicated that resident 1 had “moderately impaired memory/cognition”.
  5. Staff 1 confirmed that the pills were found unlabeled in a clear medication cup, stored within six additional empty medication cups in resident 1’s apartment.
Plan of correction
A. With respect to the specific resident/situation cited: Resident was not known to experience a negative outcome due to a cup of morning medications not administered according to proper procedure. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director or designee conducted unannounced med pass observations to verify that MCM’s are administering medications per regulations. C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director or designee conducted refresher trainings and assigned additional virtual trainings specific to passing medication for all Medication Care Managers. The documentation for training courses will be placed in MCM’s personnel files. Completions will be presented at the next quarterly Quality Assurance and Performance Improvement Committee meeting. During and at the conclusion of the QAPI meeting, the committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
September 26, 2025Inspection2 violations
Inspection dates
09/26/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: ¿Monitoring¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/26/2025, 10:30 a.m. to 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/17/2025, regarding allegations in the area(s) of: Direct Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on a video review and staff interview, the facility failed to ensure that staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities.
Evidence
  1. On 09/17/2025, a self-report was submitted via email to the licensing inspector of an alleged incident of potential disrespect occurred on 06/05/2025 at approximately 8:30 p.m. between staff 2, staff 3, staff 4, and staff 5 to resident 1.
  2. On 09/25/2025, the LI viewed a 7.29 minute video of the incident on 06/05/2025. The video showed staff 2, staff 3, staff 4, and staff 5 disrespecting resident 1’s rights and disregarding resident 1’s wishes for care.
  3. Based on an interview with LI on 09/26/2025, staff 1 acknowledged the findings of disrespectful behavior.
  4. Video evidence is available.
Plan of correction
Resident #1 Experienced no additional negative outcome due to team members not being considerate and respectful of the rights, dignity, and sensitivities of the resident during care services provided on 6/5/2025 The Executive Director (ED) immediately sent team members on administrative leave, pending investigation of self-report. The Assisted Living Coordinator (ALC) or designee will observe team members at random, weekly for thirty days, then bi-weekly for sixty days when providing care to witness that team members are considerate, and respectful of resident rights, dignity and sensitivities. These observations will be documented and kept in team members’ files. The Executive Director (ED) or designee will conduct an in-depth review with team members at town hall and subsequent meetings. The Executive Director (ED) or designee will verify review, and observations have been completed and documentation placed in team members’ files. The results will be presented to the next Quality Assurance and Performance Improvement Committee. During and at the end of the QAPI meeting, the QAPI committee will re-evaluate and initiate necessary action or extend the review period The Executive Director or designee is responsible for the implementation and ongoing compliance of all components of this plan of correction and address/resolve any variance that may occur. The Executive Director or designee will verify that this Plan of Correction is reviewed and discussed at the Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-40-B
Based on video review and staff interview, the facility failed to follow their own policies and procedures.
Evidence
  1. Staff 1 submitted an incident report on 09/17/2025 regarding Resident 1, who was admitted on 06/06/2023.
  2. The Licensing Inspector (LI) reviewed a 7-minute and 29-second video recording of a fall that occurred on 06/05/2025. The video shows resident 1 lying on the floor in their bedroom after falling. Staff members 2, 3, 4, and 5 physically lifted the resident from the floor onto the bed. During this, the resident can be heard loudly stating that they do not want to be moved from the floor to the bed.
  3. Once resident 1 was positioned on the bed by staff 2, 3, 4, and 5, resident 1 was heard yelling in pain. Staff 4 and 5 then left the room, while staff 2 and 3 continued to adjust, change, and dress the resident as they lay on their side.
  4. The facility policy states that when responding to medical emergencies, a team member will: a. Remain with the resident experiencing the emergency until the emergency medical team arrives. b. Alert the Licensed Nurse or Manager on Duty of the nature of the emergency. c. Provide the resident’s name and current location. d. If the Licensed Nurse or team member is unable to call 911, direct another team member to do so.
  5. Resident 1 was sent to the hospital by ambulance after a 911 call on 06/06/2025. Resident 1 was diagnosed with a left hip fracture.
  6. During an interview with the LI, staff 1 acknowledged that staff did not follow facility policy.
Plan of correction
Team members will follow Sunrise policies and procedures regarding resident participation/decision making regarding care and services and responding to medical emergencies. The Executive Director re-educated the team members on following Sunrise Policies and Procedures specific to resident participation/decisions regarding care and services and responding to medical emergencies. The Resident Care Director (RCD) or designee will randomly follow up with team members post care and/or medical emergencies offering real-time feedback to team members confirming they are responding in accordance with our policies and procedures. These observations will be documented in the team members’ files. The Resident Care Director (RCD) or designee will verify weekly that observation has been completed. The results of the observations will be presented to the Quality Assurance and Performance Improvement Committee quarterly for six months. During and at the end of the six months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for the implementation and ongoing compliance of all components of this plan of correction and address/resolve any variance that may occur. The Executive Director or designee will verify that this Plan of Correction is reviewed and discussed at the Quality Assurance/Improvement Meetings and action initiated when/if necessary.
September 15, 2025Inspection3 violations
Inspection dates
09/15/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
870.A Carpet condition
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: 09/15/2025, 10:30 a.m. to 3:30 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: 67 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-680-G
Based on observations made during the medication cart audit, the facility failed to ensure that over-the-counter medications remain in their original containers and are labeled with the resident’s name, or in a pharmacy-issued container, until administered.
Evidence
  1. On 09/15/2025, at approximately 11:38 a.m., the licensing inspector (LI) conducted a medication cart audit and observed that the cart contained one 2 oz bottle of Benevolent Supplements 3 mg liquid melatonin with no name or other identifiable information on the container.
  2. Staff 3 confirmed the findings of the medication cart audit.
  3. Photo evidence obtained.
Plan of correction
Resident did not experience any negative outcome due to medication not labeled with name/room #. Medication was labeled with resident name/room # and is in alliance with physician’s order as well as community’s Medication Management Program. The Sr. Resident Care Director re-educated Med Care Managers on the requirements for labeling medication brought in by family in accordance with the community’s Medication Management Program. The Resident Care Director (RCD) or designee audited medication carts, verify medications are properly labeled in alignment with our Med Management Program. SRCD or designee will conduct refresher training with medication care managers and nurses regarding the process of labeling medication brought in by family as well as auditing medication to ensure it matches the physician’s order and is in alignment with our Medication Management Program. The Resident Care Director (RCD) or designee will verify cart audits are being completed weekly for two months to include confirming all medications are labeled and in alliance with physician’s orders and our Medication Management Program. The results of the audit will be presented at the weekly Inter Disciplinary Team meeting. During and at the end of these meeting, the IDT team will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for the implementation and ongoing compliance of all components of this plan of correction and address/resolve any variance that may occur. The Executive Director or designee will verify that this Plan of Correction is reviewed and discussed at the Inter Disciplinary Team meetings and action initiated when/if necessary.
22VAC40-73-640-A
Based on observation of the facility’s medication cart and document review, the facility failed to implement their medication management plan.
Evidence
  1. The facility’s medication management plan states, “Prescription and over-the-counter medications shall be stored as follows: "All medications shall be kept in their original, properly labeled containers.” 2.The medication cart had an over-the-counter medication with no label to indicate whose medication it was.
Plan of correction
Resident did not experience any negative outcome due to medication not labeled with name/room #. Medication was labeled with resident name/room # and is in alliance with physician’s order as well as communities Medication Management Program. The Sr. Resident Care Director re-educated Med Care Managers on the requirements for labeling medication brought in by family in accordance with the community’s Medication Management program. The Resident Care Director (RCD) or designee audited medication carts, verify medications are properly labeled in alignment with our Med Management Program. SRCD or designee will conduct refresher training with medication care managers and nurses regarding the process of labeling medication brought in by family as well as auditing medication to ensure it matches physician’s order and is in alignment with our Medication Management Program. The Resident Care Director (RCD) or designee will verify cart audits are being completed weekly for three months to include confirming all medications are labeled and in alliance with physician’s orders and our Medication Management Program. The results of the audit will be presented at the weekly Inter Disciplinary Team meeting. During and at the end of these meetings, the IDT team will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for the implementation and ongoing compliance of all components of this plan of correction and address/resolve any variance that may occur. The Executive Director or designee will verify that this Plan of Correction is reviewed and discussed at the Inter Disciplinary Team meetings and action initiated when/if necessary.
22VAC40-73-550-G
Based on resident record review, the facility failed to ensure that the Rights and Responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated.
Evidence
  1. The record for resident 1 contained a Resident Rights and Responsibilities dated 06/11/2022.
  2. Staff 1 was unable to provide documentation during the on-site inspection that included the annual Review of Resident Rights and Responsibilities.
Plan of correction
The annual Resident Rights and Responsibilities for Resident #1 was emailed to the responsible party by the Executive Director. The signed copy will be placed in the residents’ chart. The Executive Director re-educated the Reminiscence Coordinator on the requirements for the annual Resident Rights and Responsibilities for residents living in the community. The Reminiscence Coordinator (RC) or designee audited residents’ medical charts in the Reminiscence neighborhood to verify a review the annual Resident Rights and Responsibilities was completed for current residents in the Reminiscence neighborhood is complete and filed in the medical record. The Reminiscence Coordinator (RC) or designee will verify the Resident Rights and Responsibilities is signed and placed in the medical chart for residents in the Reminiscence neighborhood during the care plan meeting with resident and responsible party. The results of the audit for the presence of the annual Resident Rights and Responsibilities will be reviewed at our weekly Inter Disciplinary Team Meeting (IDT) for the next 6 weeks. During and at the end of this time period, the IDT team will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for the implementation and ongoing compliance of all components of this plan of correction and address/resolve any variance that may occur. The Executive Director or designee will verify that this Plan of Correction is reviewed and discussed at the Inter Disciplinary Team meetings and action initiated when/if necessary.
September 15, 2025Inspection0 violations
Inspection dates
09/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/15/2025, 9:30 a.m to 10:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/18/2025 regarding allegations in the area(s) of: Direct Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 19, 2024Inspection7 violations
Inspection dates
09/19/2024, 09/20/2024, 09/23/2024
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 SERVICES22V AC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACULTIES TAHT CARE FOR Adults WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/19/2024 11 :00am-2:40pm, 09/20/2024 9:40-3:15pm, 09/23/2024 8:45am-2:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Violations
22VAC40-73-570-B
Based on Li's inspection and facility tour, the facility failed to ensure that all buildings shall be well-ventilated and free from foul, stale, and musty odors. 1. At 12:34 pm, LI detected a strong smell of urine around the bed area in Resident 3's room. 2. LI detected a strong smell of urine in Resident 7's room.
Plan of correction
A. With respect to the specific resident/situation cited: Residents did not experience any negative outcomes from the room not being free from strong smell of urine. Residents’ bedding was changed, and carpet shampooed. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Neighborhood Coordinator or Designee will conduct audit of resident rooms and commons areas to monitor for foul smells. Housekeeping and/or direct care staff will rectify any findings. C.With respect to what systemic measures have been put into place to address the stated concern: Re-education provided to team members on reporting foul smells to housekeeping staff so appropriate measures can be taken. Neighborhood Coordinator or Designee will conduct weekly room rounds for 1 month and monthly for 3 months to assess for foul smells in resident’s room. D. With respect to how the plan of correction will be monitored: The results of room rounds will be presented to the Quality Assurance and Performance Improvement Committee quarterly for 3 quarters starting on December 17th, 2024. During and at the conclusion of 3 quarters, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-1180-A
Based on observation and staff interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. During the inspection on 09/20/2024, 12:05 pm, of resident 5's secure memory room, the bathroom was open, and two blue shaving razors were observed.
  2. One blue razor was observed in an open medicine cabinet.
  3. A second blue shaving razor was observed on the bathroom floor.
  4. During an interview with Staff 2, it was determined that the razors belonged to resident 4, the spouse of resident 5, in a shared bathroom.
  5. Photos taken as evidence.
Plan of correction
A. With respect to the specific resident/situation cited: Resident did not experience any negative outcomes from disposable safety razors being present and scattered but not secured in suite bathroom. Razors were immediately removed. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director (RCD) or designee conducted an audit of all resident’s rooms to confirm hazardous items are secured. Re- education was provided to all staff regarding environmental precautions regulation in assisted living facilities. C. With respect to what systemic measures have been put into place to address the stated concern: Neighborhood Coordinator or designee will conduct weekly room rounds for 1 month and then monthly for 3 months to confirm all hazardous items are inaccessible to residents in Memory Care. D. With respect to how the plan of correction will be monitored: The results of room rounds will be presented to the Quality Assurance and Performance Improvement Committee quarterly starting December 17th,2024 for two quarters. During and at the conclusion of one year, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-410-A
Based on resident record review, the facility failed to ensure that upon admission, the assisted living facility provided an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. Resident #3 was admitted to the facility on 06/20/2020.
  2. Resident #3 's record did not include an orientation form signed by the resident and legal representative.
  3. On 9/20/2024, Staff# 1 confirmed the orientation form was not in the record.
Plan of correction
A. With respect to the specific resident/situation cited: Resident admission record did not include orientation acknowledgement signed by both the resident AND responsible party. Business Office Coordinator and/or designee corrected the wording on the Orientation document to reflect requirement for both signatures. Resident orientation was signed by both RP and resident. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Business Office Coordinator and/or designee audited resident administrative files to check for compliance and obtained required signatures. C. With respect to what systemic measures have been put into place to address the stated concern: Business Office Coordinator and/or designee will add compliance of both signatures to the orientation to the New Move-In Debrief D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary. The results of new checklist will be presented to the next Quality Assurance and Performance Improvement Committee on December 17th 2024 and reviewed for 1 year. During and at the conclusion the QAPI committee will re-evaluate and initiate necessary action or extend the review period.
22VAC40-73-970-E
Based on documentation review and interview with staff, the facility failed to ensure a record of he required fire and emergency evacuation drills included identity of the person conducting the drill; the method used for notification of the drill; any special conditions simulated; and the time it took to complete the drill; and problems encountered (if any).
Evidence
  1. The 09/10/2024 fire drill documents show four staff members participated in fire drills, but no resident names are listed as participating. However, there is a section printed on the form labeled" Resident Participation". 2.The 08/21/2024 fire drill documents show thirteen staff members participated in fire drills, but no resident names are listed as participating. However, there is a section printed on the form labeled" Resident Participation".
  2. On 9/20/2024, during an interview Staff #1 stated that residents did participate, but they didn't document the participation or names of those participating.
Plan of correction
A. With respect to the specific resident/situation cited: Facility provided a record of the required fire and emergency evacuation drills including a printed list of current residents for purposes of participation as the facility form has a section for this. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Maintenance Coordinator (MC) or designee will have participating residents sign the attendance record following every fire and emergency drill or have this section removed from facility form. C. With respect to what systemic measures have been put into place to address the stated concern: Maintenance Coordinator (MC) or designee will conduct monthly audits for three months and then quarterly for three quarters to check that the form is following company policy and/or current regulations. D. With respect to how the plan of correction will be monitored: The results of the fire and emergency drill audits will be presented to the Quality Assurance and Performance Improvement Committee quarterly starting on December 17th, 2024. During and at the conclusion of one year, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-290-B
Based on the Licensing inspector's (LI) direct observation and staff interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public
Evidence
  1. The name of the current person in charge was not present or in a conspicuous place for residents or the public to view.
  2. During an interview on 09/19/2024, with Staff 2, it was stated that the "person in charge" sign was in a neighboring room that was covered up during the remodeling and redecoration project. 3.Photos taken as evidence.
Plan of correction
A. With respect to the specific resident/situation cited: Manager On Duty Sign was still hanging in its original spot on the wall but had just been covered by the construction crew the morning of the inspection. The Concierge had not yet moved it to a temporary, but visible place prior to the inspector walking in. Manager On Duty Sign was immediately made visible for all to see. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Concierge or designee will check daily that MOD sign is visible including during renovations when sign may be inadvertently covered by construction crew. C. With respect to what systemic measures have been put into place to address the stated concern: Concierge or designee will create checklist that includes checking that MOD sign is posted and visible daily. The results of new checklist will be presented to the next Quality Assurance and Performance Improvement Committee D. With respect to how the plan of correction will be monitored: During and at the conclusion the QAPI committee will re-evaluate and initiate necessary action or extend the review period.The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary. Next QAPI meeting is scheduled for December 17th, 2024 and will also be reviewed during Quarter 1 QAPI on March 17th, 2025.
22VAC40-73-460-B
Based on the record review and resident interviews, the facility failed to ensure care provision and service delivery shall be resident­centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #3 was interviewed by the Licensing Inspector (LI) and mentioned their call bells are not answered quickly.
  2. Record review of the call bells: A. Resident #3 on 09/02/2024, 33minutes. B. Resident #3 's call bell, on 09/06/2024, 1 hr 3minutes 18 seconds. C. Resident #3 's call bell, on 09/10/2024, 1 hr 3minutes 1 seconds.
  3. Resident #3 's Individualized service plan (ISP) documents resident's needs such as requiring human and mechanical aid for mobility, eating, and dressing.
Plan of correction
A. With respect to the specific resident/situation cited: Residents did not experience any negative outcomes with regards to call bell response times by staff not prompt. Staff was immediately re-educated as to the importance of a prompt response and how to request assistance if they are occupied with another resident. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Neighborhood Coordinator or designee will conduct a daily audit of the previous 24 hrs. of call bell response times to determine if any do not qualify as prompt, and address as necessary. C. With respect to what systemic measures have been put into place to address the stated concern: Neighborhood Coordinator re-educated all frontline team members on the importance to answering call bells promptly. Neighborhood Coordinator or designee will check the daily audits for three months to note that call bell response times are trending in the right direction. D. With respect to how the plan of correction will be monitored: The results of audit will be presented to the next Quality Assurance Performance Improvement Committee meeting. During and at the conclusion of the QAPI meeting, the committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-90-30-B
Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. Staff #l3, date of hire 02/28/2005, most recent Sworn Statement was not completed or signed.
  2. Form was missing answers to questions two, three, and four. a.Question two: Have you ever been convicted of a crime? b. Question three: Are you subject to any pending criminal charges? C. Question four: Affirming the truth and completion of the form and signature.
Plan of correction
A. With respect to the specific resident/situation cited: Team member file contained a blank sworn disclosure to be completed by end of 2024. File also contained completed form for 2023, 2016 as well as the original signed 2/25/2005. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Business Office Coordinator (BOC) or designee will complete an audit of team member records for regulation compliance with respect to sworn disclosure requirements. Any records identified to be deficient will be addressed. C. With respect to what systemic measures have been put into place to address the stated concern: The BOC or designee will audit team member files on a quarterly basis to ensure compliance with VA DSS regulation 22 VAC 63.21720. D. With respect to how the plan of correction will be monitored: The results of the quarterly audit will be presented to the Quality Assurance and Performance Improvement Committee for one year. During and at the conclusion of one year, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
August 5, 2024Complaint survey0 violations
Inspection dates
08/05/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/5/24, 9:45-12:00 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 7/24/24 regarding allegations in the areas of: extreme weight loss and medication effects. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities and lunch. Additional Comments/Discussion: 1 Collateral contact interviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 20, 2024Inspection1 violation
Inspection dates
06/20/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/20/2024 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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed residents eating breakfast and lunch and participating in activity programs. This Licensing Inspector also observed medications being administered to residents. Additional Comments/Discussion: An exit meeting was 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-1090-A
Based on resident record review and staff interview, the facility failed to have an assessment of serious cognitive impairment completed prior to admission to a safe, secure environment.
Evidence
  1. Resident 2, admitted to a safe, secure environment on 9/29/2023, had an assessment of serious cognitive impairment completed on 10/2/2023.
Plan of correction
A. With respect to the specific resident/situation cited: Resident did not experience any negative outcomes from residing in the reminiscence neighborhood prior to the physician completing the Assessment of Serious Cognitive Impairment form. Form was completed two days after the resident transitioned to memory care. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The RCD conducted an audit of current residents’ records who were internal transfers to confirm clinical psychologist or physician completed the Assessment for Serious Cognitive Impairment form prior to transition into the reminiscence neighborhood. All forms for Assessment of Serious Cognitive impairment were completed prior to internal transfers to the reminiscence neighborhood except for resident listed in citation. C. With respect to what systemic measures have been put into place to address the stated concern: The RCD or designee will conduct quarterly audits to confirm the Assessment for Serious Cognitive Impairment Form is completed prior to internal transfer from assisted living to the reminiscence neighborhood. Findings will be discussed at quarterly QAPI meeting. The QAPI committee will evaluate the results of the audits after 9 months and determine if additional action is warranted or if the review period needs to be extended. D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
January 22, 2024Inspection0 violations
Inspection dates
01/22/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/22/24 (2:00 PM – 4:00 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An incident report was received by VDSS Division of Licensing on 1/12/24 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents; Staffing and Supervision; Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Three Number of interviews conducted with residents: None Number of interviews conducted with staff: Two Observations by licensing inspector: Resident Records An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 9, 2023Inspection2 violations
Inspection dates
06/09/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULT63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Documentation was discussed with the provider.
Comments
An unannounced renewal inspection was conducted on 6/9/23. At the time of entrance, 62 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (I) type the plan on a separate Word document, (II) identify the standard violation number being addressed, (III) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment.
Evidence
  1. No documentation was provided, during the inspection, to confirm that Staff #4 (hired 12/2/22) has current first aid certification. Staff #4's record contained documentation of current CPR certification, but not first aid.
Plan of correction
Staff #4 will attend First Aid training on June 27, 2023. A copy of the certificate of completion will be filed in Staff #4's personnel record and a copy will be presented to Surveyor. The Business Office Coordinator (BOC) will complete an audit of First Aid training records for all team members to verify that they have a current First Aid certification. Any staff person identified as missing First Aid training will be scheduled for the next available training. New team members will be asked to present current First Aid certification on the first day of hire to the community. A copy of certification will be kept in the appropriate HR file in accordance with regulation. If a new team member is found not to have First Aid certification, they will be enrolled in a certification course for completion within 60 days of employment. The BOC and/or designee will audit team member files monthly to maintain compliance with First Aid regulations. For team members identified, First Aid recertification will be completed within 30 days and required documentation placed in HR file. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-1100-B
Based on record review, the facility failed to ensure that a review of continued appropriateness is completed annually for each resident in the special care unit.
Evidence
  1. Resident #6's record was reviewed during the inspection. The most recent review of continued appropriateness, included in Resident #6's record, was dated 4/26/22. The review was more than a year old, at the time of the inspection.
Plan of correction
The VA REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT for Resident #6 was signed by The Executive Director and placed it in the resident’s chart on 6/9/2023. The Executive Director re-educated the neighborhood coordinator on the requirements for REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT for all residents living in the Reminiscence neighborhood. The Neighborhood Coordinator (RC) or Designee will audit all the resident’s medical charts in the Reminiscence Neighborhood to verify a review of appropriateness of continued residence in special care unit was completed annually for each resident in the special care unit and is filed in the medical record. The Neighborhood Coordinator (RC) or Designee will verify the VA REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT is signed and placed in the medical chart for residents in the Reminiscence Neighborhood at 6 months, and annually thereafter. The results of the audit for the presence of the most up to date form will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
June 3, 2022Inspection4 violations
Inspection dates
06/03/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES2VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULT63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
An unannounced monitoring inspection was conducted on 6/3/22. At the time of entrance, 60 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of four staff records and eight resident records. The violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-840-B
Based on documentation, the facility failed to ensure that pets living at the facility have regular immunizations.
Evidence
  1. Pet records were reviewed during the inspection. Pet #1’s rabies vaccination expired on 3/26/22.
Plan of correction
Not published by VDSS.
22VAC40-73-680-M
Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
  1. A PRN Glucagon emergency kit, ordered 5/10/22 for Resident #9, was not present at the time of the medication cart inspection. Facility staff confirmed that the medication was not present, at the time of the cart inspection.
Plan of correction
Resident experienced no negative outcome due to PRN glucagon not being available. Resident's order for PRN Glucagon was discontinued on 6/6/22 per physician's order. The Resident Care Director (RCD) or Designee re-educated the Wellness Nurses and Med Care Managers to monitor the availability of PRN medications for the residents per physician's orders. The Resident Care Director (RCD) or Designee audited 100% of the medication carts and PRN orders to verify their availability. The Resident Care Director (RCD) or Designee will perform weekly medication cart audits to monitor that PRN medications are available for one month and then monthly for three months. The results of the audit for the availability of PRN medications on medication carts will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. The results of the audit for the availability of PRN medications on medication carts will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
22VAC40-73-660-B
Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication.
Evidence
  1. Medication administration for Resident #1 was observed during the inspection. Two bottles of Tylenol were observed on Resident #1’s shelf. Resident #1’s Uniform Assessment Instrument (UAI), dated 2/1/22, states that the resident needs her medication administered/monitored by professional nursing staff.
Plan of correction
Resident experienced no negative outcomes from having OTC Tylenol in her room. Team member who observed Tylenol in the room was re-educated on the policy for medications at the bedside on the day of the inspection by the RCD. All Med Care Managers and Care Managers will be re-educated by the Resident Care Director (RCD) or designee on the policy for medications at the resident's bedside. The Resident Care Director (RCD) or designee conducted an audit on 100% of residents who do not administer their own medications to verify medications are not present in their room without a physician's order or indicated on their ISP. Resident Care Director (RCD) or designee will conduct weekly resident room audits for one month and then monthly for three months to make sure proper storage of medications are being adhered to per policy and regulations. The results of resident room audits regarding proper storage of medications will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation an ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
22VAC40-73-660-B
Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication.
Evidence
  1. Medication administration for Resident #1 was observed during the inspection. Two bottles of Tylenol were observed on Resident #1’s shelf. Resident #1’s Uniform Assessment Instrument (UAI), dated 2/1/22, states that the resident needs her medication administered/monitored by professional nursing staff.
Plan of correction
Resident experienced no negative outcomes from having OTC Tylenol in her room. Team member who observed Tylenol in the room was re-educated on the policy for medications at the bedside on the day of inspection by the RCD. All Med Care Managers and Care Managers will be re-educated by the Resident Care Director (RCD) or designee on the policy for medications at the resident’s bedside. The Resident Care Director (RCD) or designee conducted an audit on 100% of residents who do not administer their own medications to verify medications are not present in their room without a physician’s order or indicated on their ISP. Resident Care Director (RCD) or designee will conduct weekly resident room audits for one month and then monthly for three months to make sure proper storage of medications are being adhered to per policy and regulations. The results of resident room audits regarding proper storage of medications will be presented to the Quality Assurance and Performance Improvement Committee monthly for three months. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur
July 30, 2021Inspection1 violation
Inspection dates
07/30/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 7/30/21 and concluded on 9/2/21. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The licensing inspector conducted on-site observations at the facility on 7/30/21 and 9/2/21. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs.
Evidence
  1. On 7/10/21, Resident #1 was observed outside of the facility by a staff member that was returning from a lunch break. Staff #1 reported that Resident #1 was observed near the gate of the facility's secure outdoor area. Resident #1's UAI (Uniform Assessment Instrument), dated 3/16/21, indicates that the resident has a history of wandering and refusing care. Resident #1's ISP (Individualized Service Plan), dated 4/5/21, states that the resident is an exit seeker, that can be combative and aggressive at redirection. The record for Resident #1 includes an assessment of serious cognitive impairment form that states that he has a serious cognitive impairment, and that he is unable to recognize danger or protect his own safety and welfare.
Plan of correction
Resident #1 was immediately located right outside exit doors and returned to the secured unit by a staff person. The resident was assessed and found to have no injury or other clinical concerns. An immediate head count of all residents was conducted by the Lead Care Manager to verify that all residents were present. An inspection of all exit doors was performed by Care Managers. The Maintenance Coordinator secured all exit doors from the secured neighborhood and verified the magnetic locks were operational. An audit of all doors is performed by the Lead Care Manager at the start of each shift to verify the exit doors are operational, for the secured neighborhood. Shift audit sheets will be turned in by the Lead Care Managers to Reminiscence Coordinator (RC) or designee at the end of each shift. The RC or designee will review audits for competition, and follow up with responsible Lead Care Manager for any deficits. The Executive Director conducted in person Team Member education on "Responding to Exit-Seeking Behaviors" and "Preventing Elopement" The Maintenance Coordinator or designees continue to conduct monthly elopement drills. The Maintenance Coordinator or designee performs an audit of all doors following any fire drill, during which magnetic locking mechanism becomes disabled to allow for egress in the event of an emergency. The results of the audits will be presented by the Reminiscence Coordinator or designee at QAPI (Quality Assurance and Performance Improvement) for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the exit door audits and determine if additional focus or action is warranted. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
June 11, 2021Inspection0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 6/11/21 and concluded on 7/1/21. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2021Inspection1 violation
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 4/28/21 and completed on 4/30/21. The administrator's designee was contacted by telephone to initiate the inspection. The administrator's designee reported that the census was 57. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #4's March MAR (medication administration record) was reviewed during the inspection. Resident #4's record contained an order for Gabapentin, dated 2/26/21, that called for the resident to receive a 100mg capsule three times per day. The MAR documented that Resident #4's Gabapentin was not administered on 3/26 (8 PM administration), 3/27 (8 PM administration), 3/28 (all administrations), and 3/29 (all administrations). Resident #4's progress notes and MAR indicated that the medication was not administred on those dates, because the medication was not present at the facility.
Plan of correction
There were no negative outcomes as a result of resident #4 not receiving medication, gabapentin. The Wellness Nurse ordered the medication immediately. The medication has been received, is available in the medication cart, and is being administered per physicians' orders. The Resident Care Director conducted EMAR to medication cart audits to confirm medications were available per physician order. Refresher training with medication care managers and nurses was conducted by the Resident Care Coordinator regarding procedures to follow when unable to administer a medication and process to obtain the medication. The Resident Care Director or designee will continue to conduct EMAR to medication cart audits weekly for 3 months to confirm that medications are available per physician order. The Resident Care Director or designee will present the results of the medication cart audits to the Quality Assurance and Performance Improvement (QAPI) Committee for 3 months. During and at the end of the 3 months the Quality Assurance and Improvement Committee will evaluate the results of the EMAR to medication cart audits and determine if additional focus or action is warranted. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.