Virginia DSS · Assisted Living Facility

The Dunlop House

📍 235 Dunlop Farms Boulevard, Colonial Heights, VA, 23834

ID 23195Two Year licenseActive
13
Inspections
On record
6
With violations
Visits that cited something
7
Clean visits
Nothing cited
20
Violations cited
Individual findings
14
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

The Dunlop House was inspected 13 times between March 10, 2021 and May 14, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 20 violations under 14 distinct standards. 8 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 11 of these 13 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
10/29/2027
Administrator
Christopher Seyler
Licensing inspector
Tyia Venable
Inspector phone
(804) 393-2157
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

13

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

May 14, 2026Complaint survey0 violations
Inspection dates
05/14/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/14/2026, 10:45am-11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/19/2026 regarding allegations in the area(s) of: administration and administrative services Number of residents present at the facility at the beginning of the inspection: 117 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Licensing inspector observed all required postings Additional Comments/Discussion: Licensing inspector spoke with the administrator and several staff members privately. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 22, 2025Inspection2 violations
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025, 10:15am-2:30pm 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: 119 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed all required postings, medication pass, lunch, and the facility scheduled activity. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on a review of staff records, the facility did not ensure there was written acknowledgement of an annual review of the rights and responsibilities of residents in the staff person’s record.
Evidence
  1. Staff 1’s record did not contain written acknowledgment of an annual review of the rights and responsibilities of residents in assisted living facilities.
  2. Staff 2’s record did not contain written acknowledgment of an annual review of the rights and responsibilities of residents.
  3. When asked, Staff 3 was unable to provide a record of Staff 1 and Staff 2’s acknowledgement of an annual review of the rights and responsibilities of residents.
Plan of correction
Annual all staff resident rights training meeting held 10/7/2025, staff member 1 and 2 were unable to attend meeting. Staff members to be in compliance with this regulation by 11/14/2025.
22VAC40-73-210-B
Based on a review of staff records, the facility did not ensure all direct care staff attended at least 18 hours of training annually.
Evidence
  1. Staff 1’s record did not contain at least 12 hours of annual training for direct care staff who are licensed.
  2. When asked, Staff 3 was unable to provide documentation of 12 hours of annual training for staff 1.
Plan of correction
Audit complete of Staff member 1’s training record, staff member had 13.81 number of training hours on record. Staff member will complete remaining 4.19 hours by 11/30/2025
August 1, 2025Complaint survey0 violations
Inspection dates
Aug. 1, 2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2025, 10:20am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/3/2025 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: Licensing Inspector reviewed resident’s chart and business file. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804)393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 25, 2025Complaint survey1 violation
Inspection dates
07/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/25/2025, 8:52am-11:30am 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 6/3/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: Licensing Inspector observed facility documentation and reviewed resident record. Additional Comments/Discussion: 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; area(s) of non-compliance with standard(s) or law were: resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804)393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on a review of the resident’s record, the facility failed to review and update the individualized service plan (ISP) as needed for significant changes of resident’s condition.
Evidence
  1. 1: Licensing inspector (LI) reviewed progress notes (7/29/2024-5/29/2025) and there was a documented change of the resident’s condition, to include aggression toward staff and other residents, refusal of medication, and wandering into female resident’s rooms. The ISP also did not contain a plan of how to protect the resident nor the other residents. Evidence 2: LI reviewed resident’s most recent ISP (12/20/2024) and it had not been updated to reflect the change in condition.
Plan of correction
Not published by VDSS.
July 10, 2025Complaint survey0 violations
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2025, 10am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/27/2025 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector reviewed incident reports, fall risk assessments, and the resident record. Additional Comments/Discussion: Resident is deceased as of 2/26/2025 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804)393-2157 or by email at Tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 10, 2025Complaint survey0 violations
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2025, 9:42 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/7/2025 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector reviewed fall risk assessments and the resident record. Additional Comments/Discussion: Resident is deceased as of 1/2/2025. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804)393-2157 or by email at Tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 10, 2025Complaint survey0 violations
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2025, 11:20am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/22/2025 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector reviewed the resident record. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804)393-2157 or by email at Tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 10, 2025Complaint survey0 violations
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2025, 10:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/18/2024 regarding allegations in the area(s) of: staffing and supervision Number of residents present at the facility at the beginning of the inspection: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector reviewed the staff schedule for June and July. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804)393-2157 or by email at Tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 6, 2024Inspection1 violation
Inspection dates
08/06/2024
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: On 08/06/2024 approximate time 10:15-4:10p.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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: A medication administration pass was observed Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov. Violation Notice Issued: Yes
Violations
22VAC40-73-320-B
Based on the review of staff interviews and staff interviews the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident #2-Documented date of admission 04/25/2023 Upon request on 08/06/2024 the facility did not submit for the inspectors’ review documented evidence that a risk assessment documenting the absence of tuberculosis in a communicable form was obtained for resident #2.
Plan of correction
FACILITY'S RESPONSE: "Complete a one hundred percent audit of all resident charts to ensure full compliance with standard 22VAC40-73-320.B. Date of completion: 8/29/2024 Clinical leadership re-educated on regulatory requirements regarding standard 22VAC40-73-320.B. Date of completion: 8/29/2024 DON and Clinical Care Coordinator will complete annual audit and update of tuberculosis screenings each year, in January, regardless of admission date. The Administrator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction, along with addressing and resolving variances that may occur."
October 18, 2023Inspection0 violations
Inspection dates
10/18,24/2023
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 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: 102 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed:5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 18, 2022Inspection6 violations
Inspection dates
10/18/2022, 10/20/2022
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/18/2022 11:12 a.m -2:15p.m. 10/20/2022 10:12a.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: 97 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on the review of facility records the facility failed to ensure that the individualized service plans (ISP) were updated as needed for a significant change of a resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident #6 Documented date of admission 02/07/2020 The facility’s Weight documented that was submitted for the inspector’s review noted the following weights for resident #6: 07/01/2022: 145.1 lbs. 08/01/2022: 140.2 lbs. 09/01/2022: 134 lbs. The facility’s Nutritional Consultation Concerns and Recommendations document dated 09/20/2022 notes under the heading Problem: “wt. loss” and recommends that the resident is to be offered “snacks/shakes”. The resident’s 06/27/2022 ISP notes in part under the heading Eating/Feeding “snacks and fruit available throughout the day”. The resident’s 06/27/2022 ISPs was not updated to identify that based on the concerns and recommendation of the Nutritionist regarding the resident’s weight loss -snacks and fruit are now a dietary need for the resident rather than being available. Resident #7 Documented date of admission 03/31/2022 The resident’s 03/24/2022 ISP notes that the resident feeds self but needs supervision and physical cueing to complete a meal and that facility staff are to report changes in the resident’s participation in eating/feeding. Facility documentation submitted for the inspector’s review noted significant weight loss beginning 07/01/2022 until 10/04/2022. The resident’s 03/24/20222 ISP was not updated to identify appropriate adjustments regarding staff’s responsibility and guidance for facility staff to implement to address the resident’s ongoing weight loss.
Plan of correction
FACILITY'S RESPONSE: "Both residents’ weights are stable. All service plans will be updated upon any change in condition. 11/1/2022"
22VAC40-73-620-B
Based on the review of facility records the facility failed to ensure that the nutritionist oversight was conducted as required.
Evidence
  1. The facility’s most recent Nutritional Consultation Concerns and Recommendations document dated 09/20/2022 is not documented to clarify that an evaluation of the adequacy of the resident's special diet and the resident's acceptance of the diet.
Plan of correction
TFACILITY'S RESPONSE: "he dietician did not have this specific concern; dietician will document this in writing during their quarterly evaluations. 2/1/2022"
22VAC40-73-450-E
Based on the review of facility records the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
  1. Resident #3 ISP dated 10/13/2022 Resident #4 ISP dated 10/13/2022 Resident #6 ISP dated 06/27/2022 Resident #8 ISP dated 07/07/2022 The residents’ ISPs that were submitted for the inspector’s review did not note the signature for residents or the legal representative(s) signature.
Plan of correction
FACILITY'S RESPONSE: "All service plans for new admissions will be signed by administrator or designee and by the resident or legal representative. Effective 11/1/2022. Existing service plans will be audited for signatures and signed by the above parties. Effective 2/1/2023"
22VAC40-73-450-C
Based on the review of facility records the facility failed to ensure that the comprehensive individualized service plan was completed within 30 days after admission. Resident #7 Documented date of admission 03/31/2022 The most recent ISP that was submitted for the inspector’s review is dated 03/24/2022. Upon request the facility did not submit documented
Evidence
  1. that a comprehensive ISP has been developed for resident #7.
Plan of correction
FACILITY'S RESPONSE: "Facility completed the comprehensive service plan 7 days prior to admission. Facility will review all service plans for new admissions at 30 days and document no changes or will revise service plan accordingly. Effective 11/1/2022"
22VAC40-73-660-B
Based on observation the facility failed to ensure that a resident who has not been assessed as independent in medication administration was permitted to keep medication in the room.
Evidence
  1. Resident #2 Documented date of admission 06/11/2018 10/18/2022: As evidenced by the photographs taken during the mid-morning medication administration pass with facility staff #3 over the counter medications were observed in the resident’s bathroom medication cabinet. The most recent 03/15/2022 UAI assessment that was submitted for the inspector’s review assessed the resident as being dependent on qualified facility staff to administer her medications.
Plan of correction
FACILITY'S RESPONSE: "Resident family brought over the counter medicines into the room. All resident rooms were re-assessed regarding whether medications are present. All are safe and compliant. Effective 10/18/2022. Family education will be made during admission process regarding over-the-counter medicines. Effective 10/18/2022"
22VAC40-73-440-H
Based on the review of facility records the facility failed to ensure that annual reassessments and reassessments due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. Resident #6 Documented date of admission 02/07/2020 The resident’s most recent 06/27/2022 UAI assessed the resident as needing no assistance with eating/feeding. The facility’s Weight document charting for July, August and September 2022 and the facility’s 09/20/2022 Nutritional Consultation Concerns and Recommendations document that was submitted for the inspector’s review indicates weight loss as a problem. Based on the facility’s documented weights and the concerns noted by the nutritionist the facility did not reassess the resident to determine whether appropriate adjustments regarding the resident’s dietary consumption is needed and whether the resident’s needs can continue to be met by the facility.
Plan of correction
FACILITY'S RESPONSE: " During 7 month period from April 2022 to November 2022 resident’s weights have fluctuated within 7 pounds of 141.0 both up and down. Residents weight remains stable. All resident weights are reviewed at least monthly, and any 5% gain/loss is followed up on. Effective 11/1/2022"
March 16, 2022Inspection5 violations
Inspection dates
03/16/2022, 03/17/2022
Comments
An unannounced monitoring inspection was Initiated at the facility on 03/16/2022 and concluded on 03/17/2022. The Inspector conducted the entrance interview with the facility Administrator. The facility offered eighty-nine residents in care to include the residents In the facility's safe and secure environment. The Inspector reviewed along with the facility Administrator five resident records, five staff records, facility policies and procedures as well as current Standards for Licensed Assisted Living Facilities. A walk through of the physical plant conducted on both days revealed no obvious concerns. The onsite inspection conducted at the facility on 03/16/2022 was conducted between the approximate time of 9:30a.m and concluded at approximately 1 :30p.m. The onslte Inspection conducted at the facility on 03/17/2022 was conducted between the approximate time of 9:52a.m and concluded at approximately 4:12p.m. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. An exit interview was conducted where findings of 03/16, 17 /2022 were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the Inspection. Please contact me at Angela.r.reaves@dss.virginia.gov or (804) 840-0253 if you have any questions.
Violations
22VAC40-73-580-F
Based on Interviews conducted with facility staff and the review of facility records, the facility failed to ensure that the facility Implement Interventions as soon as a nutritional problem is suspected and that notification was made to the attending physician If a significant weight loss Is identified In any resident who is not on a physician-approved weight reduction program.
Evidence
  1. Resident #5- The facility's Nutrition Consultation document dated 1/18/2022 for resident #5 that was sub- mitted for the inspector's review notes under the heading Problem "wt/loss•. Upon request the facility did not submit for the inspector's review documentation that the residents' physician had been made aware of the resident's weight loss.
Plan of correction
FACILITY'S RESPONSE "Current enhanced diet plan is in place. Resident’s weight is stable, and physician has been notified of their current weights and changes. Audit all nutrition consultation documentation for any current residents to ensure all recommendations have been sent to attending physician and physician orders implemented. All resident weights will be taken monthly and will be monitored monthly for any significant change. Any resident experiencing a significant change in weight will have this change documented, their RP notified, and their physician notified. Physician orders regarding diet plan will be implemented and documented. Educate all Licensed staff on process. All resident weights will be monitored for compliance monthly with audit tool. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED."
22VAC40-73-430-H-1
Based on the review of facility records and staff interviews conducted the facility failed ensure that at the time of discharge, the assisted living facility provided to the resident and, as appro- priate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains all of the required information.
Evidence
  1. Resident #s 6, 7 and 8 During interviews the facility Administrator reported that resident #s 6, 7 and 8 were deceased but did not submit upon request doc- umentation of the date of discharge from the facilrty. The facility's discharge document for these three residents that was submitted for the inspector's review only notes the residents names and has no other information documented.
Plan of correction
Discharge statements have been completed for the 3 reported that discharge statements were incomplete. All discharged records will be audited to ensure discharge statements are being completed timely, with all required information, and appropriate signatures. All discharges will have discharge statement sent to legal representative and/or designated contact person as appropriate. Educate licensed staff on process. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED."
22VAC40-73-450-C
Based on the review of facility records and staff interviews conducted the facility failed ensure that a resident comprehensive individualized service plan is completed within 30 days after admission.
Evidence
  1. Resident #3-Documented date of admission 08/14/2021 The ISP that was submitted for the inspector's review is dated 08/16/2021 two days after admission. Upon request the facility did not submit for the Inspector's review documenta- tion that a comprehensive ISP had been devel- oped for resident #3.
Plan of correction
FACILITY RESPONSE "Comprehensive ISP to be completed on all new residents within 30 days of move in. Audit all new resident charts to ensure comprehensive ISP completed within specified time and signed by all required parties. Educate licensed staff on process. Monitor quarterly to ensure compliance. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED."
22VAC40-73-450-E
Based on the review of facility records and staff interviews conducted the facility failed ensure that resident individualized service individual- ized service plan is signed and dated by the licensee, administrator, or his deslgnee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was Involved in the development of the plan shall be included. These requirements shall hall also apply to reviews and updates of the plan.
Evidence
  1. Resident# 1-Documented date of admission 05/22/2019 The resident's Individualized Service Plan document that was submitted for the inspector's review that notes a needs identification date of 2/17 /22 is not signed and dated by the licensee, administrator, or his designee, (Le., the person who has developed the plan), and by the resident or his legal representative. The ISP document also does not indicate any other individuals who contributed to the development of the plan. Resident #2-Documented date of admission 08/10/2018 The resident's ISP dated 06/25/2021, is not signed by the resident or his legal representative. Resident #4- Documented date of admission 08/17/2020 The resident's Individualized Service Plan document that was submitted for the inspectors review that notes a needs identification date of 09/24/2021 is not signed or dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The ISP document also does not indicate any other individuals who contributed to the development of the plan.
Plan of correction
FACILITY RESPONSE " All ISPs will be reviewed and updated as necessary. Setting up ISP meetings with Residents and legal representatives, to review and sign ISP. Educate all Licensed staff on process. Monitor for compliance monthly with audit tool created to ensure ISPs are updated with new orders, interventions and services received. Ensure all ISP’s have all required signatures, to include Resident and /or Family representative, person or persons updating ISP and Administrator/ Licensee or designee. Responsible person for implementing and monitoring for continued compliance Unit Coordinators, DON and ED. "
22VAC40-73-450-F
Based on interviews conducted with facility staff and the review of facility records, the facility failed to ensure that resident Individualized ser- vice plans (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.
Evidence
  1. Resident #1-Documented date of admission 05/22/2019 Facility records that was submitted for the inspector's review notes that the resident's occupational therapy services began January 2022 to the present and speech therapy was initiated on 03/01/2022. The resident's ISP that notes a needs identifica- tlon date of 2/17 /22 is not updated to note that the resident Is receiving occupational and speech therapy. Resident #3-Documented date of admission 08/14/2021 The resident's 08/17/2021 ISP that was submit· ted for the inspectors review on 03/16-17/2022 does not note that therapy for the resident was initiated 03/07/2022. Resident #5- The facility's Nutrition Consultation document dated 1/18/2022 for resident #5 that was sub- mitted for the inspector's review notes under the heading Problem "wt/loss•. The resident's ISP dated 03/24/2021 and 02/22/2022 is not updated to note that dietary intervention(s) have been Implemented to address the resident's unplanned weight loss.
Plan of correction
FACILITY RESPONSE "Resident charts reviewed at time of survey, those receiving therapy services, seen by RD, pharmacy, and/ or MD, any recommendations or new orders will be updated to resident’s ISP. ISP meetings being set up with families/residents to obtain necessary signatures. Audit all resident’s ISP that receives therapy service, seen by RD and / or pharmacy to ensure ISP shows services received, recommendations and new orders. Educate all Licensed staff on process. Monitor for compliance quarterly with audit tool created to ensure ISPs are updated with new orders, interventions and services received. Ensure all ISP’s have all required signatures, to include Resident and /or Family representative, person or persons updating ISP and Administrator/ Licensee or designee. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED.
March 10, 2021Complaint survey5 violations
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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. Responding to allegations made against the facility a complaint investigation was initiated on 03/10/2021 and concluded on 07/19/2021. The licensing inspector emailed the administrator a list of documents required to complete the investigation. The evidence gathered during the investigation supported the determined non-compliance(s) with applicable standards or law and determined the complaint to be valid. Violations were documented and are on the violation notice issued to the facility. The inspector conducted interviews with facility staff and others and reviewed facility records. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. 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). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov
Violations
22VAC40-73-150-C
Based on the review of facility records and interviews conducted the administrator failed to be responsible for the general administration and management of the facility. This shall include responsibility for: Maintaining compliance with applicable laws and regulations and implementing all policies and procedures, and services required by this chapter and ensuring the development, implementation, and monitoring of an individualized service plan for each resident.
Evidence
  1. Resident #1- Documented date of admission 06/11/2019; Documented date of discharge 02/1/2021 The complainant reported that resident #1 was discharged from a local hospital on hospice care back to the facility on 01/25/2021. Regarding the resident’s 01/25/2021 hospital discharge the complainant also reported that ?they (the facility) failed to contact me to update and create (resident #1 identified) care plan.? The facility’s Hospice Policy noting a revised date of 02/01/2019 that was submitted for the inspector’s review from the facility Administrator via email dated 04/14/2021 notes under the heading Procedure #3: ?After the resident and their representative make their choice of a preferred hospice vendor, the facility social worker or designee will assist the resident in contacting that vendor in order to set up the appointment for the hospice assessment.? During interviews the facility Administrator acknowledged that the resident does have a Power of Attorney (POA) The identified hospice agency’s agreement signed and dated by the facility Administrator on 01/23/2021 notes on page 3/14 under the heading Notification of Services ?Facility shall fully inform Hospice Patients of Facility Services and Uncovered Items and Services to be provided by Facility.? The signed Hospice agreement also notes on page 4/14 under the heading Design of Plan of care: ?In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice Patient. Hospice retains primary responsibility for development of the Plan of Care.? In response to the inspector’s inquiry whether the facility contacted the Hospice agency or the resident’s Power of Attorney (POA) to discuss and develop a plan of care prior to or after the resident’s hospital discharge back to the facility; the facility Administrator responded in part via an email dated 04/14/2021 ?No community involvement. Discussion was held in hospital between family and hospital staff.? Th 06/18/2020 I di id (ISP) f The 06/18/2020 Individualized Service Plan (ISP) for resident #1 was not updated per the resident’s assessed needs. The facility Administrator did not implement the facility’s hospice policy or the signed hospice agreement ensuring that the hospice agency, the facility and the resident’s Power of Attorney had discussed and updated a plan of care identifying each entity’s responsibility for ensuring that the assessed service needs of the resident would be carried out by facility staff.
Plan of correction
Not published by VDSS.
22VAC40-73-440-H
Based on the review of facility records and interviews conducted the facility failed to ensure that reassessments due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 The complainant reported that resident #1 was sent out from the facility on 01/14/2021 to the hospital for emergency medical intervention; was subsequently admitted and then discharged back to the facility on 01/25/2021 after an eleven day hospital stay. During interviews the complainant also reported that resident #1 was discharged back to the facility on hospice care and that the facility did not asked her to participate in the assessment process, which would have provided a clear picture of (resident #1 identified) current health needs or wishes. Interviews conducted with the facility Administrator, facility staff #1 and the review of facility records to include the resident’s 01/25/2021 hospital discharge documentation that was submitted for the inspector’s review,- revealed that resident #1 was not receiving hospice services prior to the resident’s hospital admission on 01/14/2021. Facility records submitted for the inspector’s review also noted that the facility conducted the most recent Uniform Assessment Instrument (UAI) on resident #1 on 06/10/2020; seven months prior to the resident’s 01/14/2021 hospitalization. Facility records that were submitted by the facility for the inspector’s review and interviews conducted with the facility Administrator indicates that at the time that the 01/23/2021 hospice agreement was signed the facility was aware of the resident’s change in condition. Upon request the facility did not submit for the inspector’s review documentation that the facility conducted a reassessment on resident #1 prior to or since the resident’s hospital discharge back to the facility to ensure that the assessed needs of the resident would be carried out by facility staff.
Plan of correction
Not published by VDSS.
22VAC40-73-450-D
Based on the review of facility records and interviews conducted the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident and that the services provided by each is included on the individualized service plan.
Evidence
  1. Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 For example the resident’s HOSPICE CERTIFICATION AND PLAN OF CARE document with a faxed date of 01/27/2021 that the facility submitted for the inspector’s review notes in part on page 3/5 ?Home health aide service for assistance with personal care, hygiene and activities of daily living? (ADL). The facility did not include this hospice service on the resident’s facility care plan. While the resident’s most recent 06/18/2020 Individualized Service Plan (ISP) that the facility submitted for the inspector’s review does include a handwritten entry dated 01/25/2021 that notes that the resident will receive hospice services the ISP does not identify the specific services that the hospice agency identified in their plan of care that they would be responsible for. Facility staff #1 clarified that 01/27/2021 is the fax date noting when the facility received the resident’s HOSPICE CERTIFICATION AND PLAN OF CARE document.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on the review of facility records and interviews conducted the facility failed to ensure that Individualized service plans are updated as needed for a significant change of a resident’s condition. The update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 For example prior to the resident’s 01/14/2021 hospitalization the facility assessed the resident on 06/10/2020 as needing mechanical assistance only (walker/wheelchair) for Ambulation. The resident’s hospice care plan that was submitted for the inspector’s review notes that resident #1 was assessed by the hospice agency as needing two person bili ifi assist for bed mobility and transfers; indicating a significant change in the resident’s condition. The resident was assessed by the facility on 06/10/2020 as being independent with continence care. The hospice agency documented that the resident is totally dependent on facility staff to provide incontinence care. The hospice agency assessed the resident as having aspiration problems, malnutrition, dehydration, respiratory failure. The hospice care plan also notes that the resident ?will tolerate PO trials without clinical indicators of aspiration given minimal cues within 7 day?. The resident’s most recent Individualized Service Plan (ISP) dated 06/18/2020 that was submitted for the inspector’s review was not updated to note that based on the assessment of the hospice agency significant changes had occurred in the resident’s condition.
Plan of correction
Not published by VDSS.
22VAC40-73-460-B
Based on the review of facility records and interviews conducted the administrator failed to ensure care provision and service delivery was resident-centered to the maximum extent possible and included the residents? participation in decisions regarding the care and services provided to him.
Evidence
  1. Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 The complainant reported that the facility did not contact her to discuss the current health status of the resident or to assist with the development of an updated Individualized Service Plan (ISP). The investigation revealed that at the time that the facility Administrator signed the hospice agreement on 01/23/2021; the facility was aware that the resident had an assigned Power of Attorney (POA). The facility Administrator reported that the facility had no involvement with ensuring that the resident’s POA and hospice agency was involved with developing and updating the resident’s facility ISP; stating ?No community involvement. Discussion was held in hospital between family and hospital staff.? However, the review of the facility’s hospice policy and at the time that the facility Administrator signed the hospice agreement the facility Administrator indicated an acknowledgement and an understanding of the facility’s and the hospice agency’s responsibilities regarding the assessed needs of the resident and that requires that the resident’s POA be included in the decisions regarding care and services for resident #1. Upon request the facility did not submit for the inspector’s review facility documentation that an ISP was developed based on the assessed needs identified by the hospice agency or that input regarding the resident’s care was obtained from the resident’s POA.
Plan of correction
Not published by VDSS.