Virginia DSS · Assisted Living Facility

Brighter Living Assisted Living and Memory Care

📍 5301 Plaza Drive, Hopewell, VA, 23860

ID 23226Two Year licenseActive
20
Inspections
On record
8
With violations
Visits that cited something
12
Clean visits
Nothing cited
37
Violations cited
Individual findings
22
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

Brighter Living Assisted Living and Memory Care was inspected 20 times between January 26, 2021 and November 5, 2025 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 37 violations under 22 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. 18 of these 20 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
08/13/2026
Administrator
Carrie Jackson
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

20

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

November 5, 2025Complaint survey0 violations
Inspection dates
11/05/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection related to a complaint was completed on November 05, 2025. 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 November 03, 2025, regarding allegations in the area(s) of: PERSONNEL, STAFFING AND SUPERVISION; RESIDENT CARE AND RELATED SERVICES 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 Coy Stevenson, Licensing Inspector at (804) 972 - 4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Complaint survey0 violations
Inspection dates
11/05/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection related to a complaint was completed on November 05, 2025. 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 October 07, 2025, regarding allegations in the area(s) of: PERSONNEL 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 Coy Stevenson, Licensing Inspector at (804) 972 - 4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 7, 2025Inspection0 violations
Inspection dates
07/07/2025
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 IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Technical assistance provided included: Discussed with the administrator that incidents involving residents where emergency medical professionals respond to the facility, or the resident is transported to an area hospital for treatment, need to be reported. This same requirement applies to residents interactions with law enforcement; whether this interaction occurs at the facility or in the community.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection of the facility was completed on July 07, 2025. The Acknowledgement of Inspection form was signed and left at the facility for each date 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/interviewed: 6 Number of staff records reviewed/interviewed: 4 Observations by licensing inspector: Resident were observed engaging in staff-led and self-directed activities, eating meals, interacting with each other and staff, and moving about the facility freely: both indoors and outdoors. There were no signs of unsafe or unsanitary conditions. Additional Comments/Discussion: 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 24, 2024Complaint survey0 violations
Inspection dates
10/24/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 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: Licensing inspector was on-site on October 24, 2024, related to complaint received. An interview was completed with the administrator and an inspection of the resident’s room was completed. No conditions were observed to indicate the residents room and accommodations are in disrepair. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 30, 2024Inspection0 violations
Inspection dates
07/30/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
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 renewal process occurred on July 30, 2024. A tour of the facility was conducted to assess the physical conditions of the facility and surrounding grounds. Observations of medications being give the residents by qualified/authorized employees occurred. Audits of several resident and employee files occurred. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: No conditions were observed to indicate the facility is not being maintained in a safe condition. Additionally, interactions between residents and employees were appropriate. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 3, 2024Inspection0 violations
Inspection dates
01/03/2024
Comments
Self-report about medication best practice and administration. Additionally, medications and records reviewed. No findings supported allegation of non-compliance for this self-report.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 3, 2024Complaint survey0 violations
Inspection dates
01/03/2024
Comments
Complaint regarding cleanliness of wheelchairs and beds. No concerns noted. No violations.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 8, 2023Inspection3 violations
Inspection dates
08/08/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 8-08-2023 – 9:10am - noon The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alex Poulter, Licensing Inspector at 804-662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on observation, record review and interview with staff, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident #4’s Physician’s Orders dated June 2023 documented “Lidocaine 5% patch; apply one patch topically to the affected area once daily… on 12 hours – off 12 hours”. According to Staff #2 during the medication administration observation on 8-08-2023, the patch was to be removed on 8-07-2023 at 9:00 p.m. per the order and Medication Administration Record (MAR); however, the patch was still on during the morning medication pass at approximately 9:30 a.m. Staff #2 confirmed during the observation that Resident #4’s lidocaine patch was supposed to be removed the previous shift and was still there during the present shift on 8-08-2023. Staff #2 removed the patch and noted it on the August 2023 MAR.
Plan of correction
We will have a med tech meeting on 12/15/23 to go review with med techs.
22VAC40-73-1090-A
Based on record review, the facility failed to ensure prior to his admission to a safe, secure environment (SSE), the resident was assessment by a physician as being unable to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #1 admitted 1-13-2023 to the SSE. Resident #1’s Assessment of Serious Cognitive Impairment dated 1-10-2023 answered “No” for the question, “Is the individual named above unable to recognize danger or protect his/her own safety and welfare?”; however, for placement in the SSE, the answer should be “yes”.
Plan of correction
Form was corrected by MD. Moving forward Director of Marketing will ensure that forms are properly filled out moving forward.
22VAC40-73-680-I
Based on record review and interview with staff, the facility failed to ensure that the date and time given and initials of direct care staff administering the medication was included on the medication administration record (MAR).
Evidence
  1. Resident #3’s Clonidine was reported as administered on 7-01-2023 by the RMA on staff; however, the staff didn’t sign off as having administered the medication. Staff #1 confirmed the RMA administered the medication.
Plan of correction
We had a med tech meeting with staff to review the importance of documentation. RCC will monitor on going to ensure staff are signing off.
July 14, 2023Inspection0 violations
Inspection dates
07/14/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 7-14-2023, 8:59 – 10:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on April 24, 25, and May 1, 2023 regarding allegations in the areas of: Admission, Retention and Discharge of Residents; Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 70 Number of resident records reviewed: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident records 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 20, 2023Inspection6 violations
Inspection dates
04/20/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 4-20-2023, 10:01 – 11:29 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report incident was received by VDSS Division of Licensing on 2-28-2023 regarding allegations in the areas of Admission, Retention and Discharge of Residents and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 72 Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-650-B
Based on record review, the facility failed to ensure physician’s orders identified the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. Resident #1’s Physician’s Orders dated 3-06-2023 did not identify diagnosis, condition, or specific indications for the following medications: Acidophilus capsule, Aspirin, Calcium, Dicyclomine, Escitalopram, Fexofenadine, Namzaric, Potassium CL, Preservision Areds, and Zolpidem Tartrate. Staff #1 acknowledged during interview that Resident #1’s physician’s orders did not contain the identification for the medications.
Plan of correction
DON will call MD office to have orders updated with diagnosis. DON/RCC will audit all charts to ensure diagnosis is on all orders.
22VAC40-73-450-H
Based on record review and interview with staff, the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident.
Evidence
  1. Resident #1’s ISP dated 9-15-2022 documented under Safety Checks, “Staff to check on resident every 2 hours or as needed to maintain safety and well-being. Staff to ensure resident call bell is in resident’s reach.”
  2. Round logs provided by Staff #1 dated 3-15-2023 to 6-13-2023 demonstrated that two-hour checks that were not being completed; primarily not completed during overnight hours. A sample showed that on 5-04-2023, only two checks were documented, as well as four checks on 5-16-2023, and four checks on 4-15-2023.
  3. Staff #1 acknowledged during interview that two-hour checks on Resident #1 had not been conducted consistently.
Plan of correction
Timers have been put in place to go off every 2 hours. (as of 6/9/2023) Staff will be in-service on the importance of safety checks and documentation by DON/.
22VAC40-73-325-B
Based on record review and interview with staff, the facility failed to ensure the fall risk rating was reviewed and updated after a fall.
Evidence
  1. Resident #1 had falls that occurred on 2-26-2023 per incident report received by Staff #1, and 4-17-2023 per the resident’s Charting Notes; however, no fall risk ratings were completed for the resident falls.
Plan of correction
DON/RCC will audit all charts for Fall risk assessments, all residents will be scheduled in a calendar for when assessments are due. Administrator will audit monthly.
22VAC40-73-40-A
Based on record review, the licensee failed to ensure compliance with the facility's own policies and procedures.
Evidence
  1. The “Fall Management Policy” dated 2009-2020 documented, “An individualized service plan [ISP] is maintained and includes: a. Identified fall risk factors, b. Identified realistic and attainable goals and interventions, c. Initiation on admission and updates every six months, with a significant change in status in condition, and post-fall”.
  2. Resident #1’s ISP dated 9-15-2022 documented the resident as a “fall risk”; however, no updated fall risk ratings were completed in March 2023 at six months, nor was an update completed post fall on 4-17-2023 which was seen on Resident #1’s “Charting Notes”.
  3. Additionally, a final incident report received from Staff #1 on 3-08-2023 documented that on 2-26-2023, “Agency staff heard a loud fall, went to check everyone and that’s when [Agency Staff] saw [Resident #1] standing at [Resident #1’s] door… [Resident #1] stated to the aide that [Resident #1] fell and hit [Resident #1]’s head…”
  4. There were no updates for risk ratings either fall on 2-26-2023 nor 4-17-2023 were documented in Resident #1’s ISP.
Plan of correction
DON/RCC will audit all charts for Fall risk assessments, all residents will be scheduled in a calendar for when assessments are due. Administrator will audit monthly.
22VAC40-73-680-I
Based on record review, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug or supplement.
Evidence
  1. Resident #1’s December 2022 MAR did not include diagnoses, conditions, or specific indications for the following drugs: A. Acidophilus capsule; B. Aspirin 81 mg; C. Lexapro 20 mg; D. Fexofenadine HCL 180 mg; E. Namzaric 28-10 mg; F. Potassium CL ER 10 meq; G. Preservision AREDS; H. Vitamin D3; I. Clonidine 0.1 mg; J. Genteal Tears; K. Systane PF Vials; L. Zolpidem Tartrate 5mg.
Plan of correction
DON will call MD office to have orders updated with diagnosis. DON/RCC will audit all charts to ensure diagnosis is on all orders and fax diagnosis to pharmacy to have MAR updated.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications were administered in accordance with the physician’s or other’s prescriber’s instructions.
Evidence
  1. Resident #1’s blood pressure orders written 8-19-2022 are as follows: “Check BP [blood pressure] prior to giving Entresto doses. Hold if BP is below 110, recheck BP 2 hours later. If BP systolic is >120, give entresto” and is scheduled at 9:00 a.m. and 7:00 p.m. A second order written 9-08-2022 documented, “Check blood pressure when giving her entresto doses, repeat in two hours for both morning and evening dose” and is scheduled at 11:00 a.m. and 9:00 p.m.
  2. Resident #1’s Charting Notes document the following regarding late blood pressure checks: A. 5/25/23, 11:30 a.m.: “BP taken a few minutes late due to working with another resident”; B. 4-21-2023 11:32 a.m.: “B/S [sic] was taking [sic] late due emergency issues going on with another resident”; C. 4-17-2023 11:36 a.m.: “B/P was taken late due to assisting another resident”; D. 3-19-23 12:40 pm: “B/P was taking 21 minutes late this afternoon due to med tech assisting another resident”
Plan of correction
DON will have in-service with Medication aides to make sure they are aware that they do not have an hour before or after scheduled time like normal. Timers have been put in place for scheduled BP times. (as of 6/9/2023)
April 20, 2023Complaint survey0 violations
Inspection dates
04/20/2023
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: 4-20-2023, 11:30 a.m. – 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 April 17, 2023 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 74 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 22, 2022Inspection6 violations
Inspection dates
11/22/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11-22-2022 10:50 – 11:15 a.m.; 4-20-2023 8:45 – 10:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 11-09-2022 regarding allegations in the areas of: Admission, Retention and Discharge of Residents; Resident Care and Related Services; and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 75/72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility and review of records along with staff interviews. Number of resident records reviewed: 2 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on record review and interview with staff, the facility failed to ensure the fall risk rating was updated after a fall.
Evidence
  1. Per Staff #2’s written statement of a resident falling on the floor, Resident #2 had a fall on 11-09-2022. Staff #1 confirmed during interview that Resident #2 had fallen on 11-09-2022 and sustained no injuries; however, no Fall Risk Rating was completed for the fall.
Plan of correction
DON/RCC will audit all charts for fall risk assessment, all residents will be scheduled in a calendar for when assessments are due. Administrator will audit monthly.
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement a written plan for medication management, including standard operating procedures.
Evidence
  1. The facility’s medication management plan dated August 2011 documented under facility’s documentation leave policy: “Medications not given 1. Staff member should circle his or her initials on the front of the MAR and document on the back why medication was not administered…”
  2. Resident #1’s November 2022 Medication Administration Record [MAR] was signed by Staff #6 as having administered Oxycodone HCL 5 mg tablet on 11-10-2022 at 5:00 p.m.; however, the resident not in the facility on 11-10-2022. The MAR documented, “**RESIDENT OUT OF FACILITY 09 Nov 2022 TO 21 Nov 2022: **”
  3. Staff #1 confirmed the documentation did not follow standard operating procedures for medication documentation by not circling staff’s initials and documenting why the medication was not administered.
Plan of correction
DON/RCC will have in-service with medication aide as well as schedule refresher course.
22VAC40-73-1090-A
Based on record review and interview with staff, the facility failed to ensure that prior to his admission to a safe, secure environment (SSE), the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #2 admitted 11-03-2022 to the SSE. Resident #2’s “Assessment of Serious Cognitive Impairment” documented “No” under the question, “Is the individual named above unable to recognize danger or protect his/her own safety and welfare?”; however, the resident was placed in the SSE as of 11-03-2022 and remained there until Resident #2’s discharge on 2-28-2023.
  2. Staff #1 acknowledged during interview that Resident #2 had been placed in the SSE and that the physician’s assessment of Resident #2 did not assess the resident as unable to recognize danger or protect his own safety and welfare.
Plan of correction
Sales Director will look over all secure environment paperwork prior to move-in. DON will audit all current resident’s charts to ensure proper paperwork is in place.
22VAC40-73-460-B
Based on record review and interview with staff, the facility failed to ensure personalization of care and services were tailored to the resident’s circumstances including prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #1 admitted into care at 100 years old on 11-09-2022. Resident #1’s “Report of Resident Physical Examination” dated 11-01-2022 documented the resident has “senile degeneration of brain”. Resident #1’s UAI (dated 10-26-2022) and ISP (dated 11-09-2022) documented the resident was wheelchair bound and admitted under hospice care. 2.Routine round checks were scheduled every 30 minutes, and the resident’s log showed 3:30p.m. as the last documented time. Rounds conducted by Staff #5 that took place on 11/09/2022 found the resident was not on the unit at approximately 5:55 p.m. Resident #1 was found approximately 50 minutes later by Staff #3 and #4 at the bottom of the flight of stairs outside of the memory care unit (after staff reviewed the floor video). 3.Statements from each of the four staff working on 11-09-2022 document that staff #3 turned the door alarm off after it sounded, but did not check the exits upon hearing the door alarm. Approximately 50 minutes later it was discovered that Resident #1 exited a door on the special care unit and fell down a flight of 18 stairs. The resident was transported to a local hospital by emergency response personnel.
Plan of correction
-All staff have been in-serviced and trained on elopements, door alarms, and what to do in emergency situations. -All nursing staff have been in-serviced on the importance of 30 min checks and documentation. -Going forward all staff are trained on elopement policy, what to do when alarms go off on memory care, and documentation. -Elopement drills are conducted monthly.
22VAC40-73-460-D
Based on record review and interview with staff, the facility failed to provide supervision of resident care including attention to specialized needs, such as prevention of falls and wandering.
Evidence
  1. Staff #2 was assigned oversite of Resident #1 who was admitted 11-09-2022 to the special care unit (SCU). 2.Staff #1 confirmed Staff #2 did not provide constant staff oversight to ensure safety of Resident #1. Resident #1 who was in a wheelchair, left the special care unit through one of the two exits via stairwell with a delayed egress system and alarm. The resident wheeled herself into a stairwell where she exited the wheelchair and fell down a flight of 18 stairs. Video surveillance reviewed by staff and the staff incident report noted that resident #1 was on the floor at the bottom of the stairwell for approximately 50 minutes. Staff statements documented that upon hearing the alarm, a staff member (staff #3) turned it off and did not immediately look for the source of the alarm.
Plan of correction
-All nursing staff are in-serviced upon hire on specialized needs, fall prevention, wandering, & elopement.
22VAC40-73-320-A
Based on record review and interview with staff, the facility failed to ensure a person’s physical exam contained a description of the person’s reactions to any known allergies.
Evidence
  1. Resident #2’s “Report of Resident Physical Examination” dated 10-27-2022 documented, “Codeine PCN [penicillin] and eggs” as allergies; however, no reactions were described on the physical exam.
Plan of correction
Sales Director and DON will ensure all new admissions have description of reactions to any known allergies prior to admission.
July 29, 2022Inspection4 violations
Inspection dates
7/29/2022
Areas reviewed
¿22VAC40-73 GENERAL PROVISIONS¿22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿22VAC40-73 PERSONNEL¿22VAC40-73 STAFFING AND SUPERVISION¿22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿22VAC40-73 BUILDINGS AND GROUND¿22VAC40-73 EMERGENCY PREPAREDNESS¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿63.2 GENERAL PROVISIONS¿63.2 PROTECTION OF ADULTS AND REPORTING¿63.2 LICENSURE AND REGISTRATION PROCEDURES¿63.2 FACILITIES AND PROGRAMS¿22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿22VAC40-80 THE LICENSE¿22VAC40-80 THE LICENSING PROCESS¿22VAC40-80 COMPLAINT INVESTIGATION¿22VAC40-80 SANCTIONS
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: 7/20/22; 8:30 a.m. – 12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on record review and interview, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there is a significant change in the resident's condition.
Evidence
  1. Resident #3 admitted 5-02-2022. Resident #3’s Uniform Assessment Instrument (UAI) dated 4-15-2022 documented resident uses a walker to ambulate; however, Resident #3 is non-ambulatory and uses a wheelchair per the resident’s ISP dated 7-18-2022.
Plan of correction
DON will complete audit on all UAIs to ensure they are up to date and moving forward all UAIs will be updated within 30 days of significant change in condition.
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #2 admitted 12-31-2019. Resident #2’s uniform assessment instrument (UAI) dated 12-30-2021 documented resident uses wheelchair “mechanical help” and for mobility “mechanical help, wheelchair”; however, the resident’s ISP dated 7-5-2022 does not address wheeling or mobility assistance.
  2. Resident #6 admitted 11-01-2001. Resident #6’s UAI dated 1-28-2022 documented no assistance with bathing or dressing; however, the resident’s ISP dated 7-27-2022 documented “unable to safely bath independently; Gather necessary supplies. Explain procedure to Resident. Cue Resident to assist where he/she can...” for bathing and “unable to dress independently; Staff will supervise Resident with dressing, allowing maximum participation from Resident, and putting on ted hose in the morning and removing at night” for dressing. The UAI also said no assistance with toileting is needed; however, the ISP documented, “supervision with toileting; Cue Resident and direct to bathroom every 2 hours and as needed. Use proper incontinence products…”
  3. Resident #7 admitted 1-30-2020. Resident #7’s UAI dated 5-02-2022 documented resident uses rollator walker for walking; however, walking assistance with a rollator walker is not addressed on the ISP dated 5-02-2022.
  4. Resident #9 admitted 9-20-2021. Resident #9’s UAI dated 8-13-2021 documented the resident uses a wheelchair; however, use of a wheelchair is not documented on the resident’s ISP dated 2-06-2022.
Plan of correction
DON will complete audit on all ISPs to ensure they are up to date and moving forward all ISPs will be updated within 30 days of significant change in condition and yearly.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. An incident report received by the facility to the regional licensing office on 7-20-2022 documented that “Agency RMA [registered medication aide] gave wrong medication to the above-named resident.”
  2. Hospital documentation from 7-20-2022 documented, “Tonight in the last couple of hours patient [Resident #3] was incorrectly given another patient’s medications, these are Mucinex 60mg, fiberlax, melatonin 5mg, rosuvastatin 40mg and calcium…”
  3. Staff #1 confirmed Resident #3 was administered medications not in accordance with the physician’s or other prescriber’s instructions.
Plan of correction
Facility notified agency of medication error and RMAs from Brighter Living received in-service on medication administration and The Five Rights of Medication Administration.
22VAC40-73-520-I
Based on record review, the facility failed to ensure the written schedule of activities included the hour of the activity.
Evidence
  1. During the months of June and July 2022, there was no hour of activity listed on the activity schedule for the following dates: June 5, July 2, July 16, July 30, and July 31.
Plan of correction
Activities Director will ensure all activity calendars have the time and date each day for all activities.
April 27, 2022Inspection5 violations
Inspection dates
04/27/2022
Technical assistance
Consultation: Fire drill time Personal data updates
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: 4/27/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: medication pass observation, fire and emergency drawing, meal, activity, first aid kit, resident and staff records, tour Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Alexandra Poulter, Licensing Inspector at (804)662-9971 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed at least annually.
Evidence
  1. Resident #3 admitted 10-03-2016. Resident #3’s most current UAI on file was dated 06-28-2020.
  2. Staff #1 confirmed that Resident #3’s UAI was not updated at least annually.
Plan of correction
DON/RCC/ Administrator will meet at the beginning of each month to ensure all ISP are up to date according to their due date or if conditions have changed. Due dates will be kept in a calendar as well as a binder with all the ISP/UAI filed for the month they need to be completed.
22VAC40-73-450-C
Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included the description of identified needs and date identified based upon the UAI; and home health services of the resident.
Evidence
  1. Resident #2’s physician’s orders dated 12-20-2021 documented, “Re: Wound care sacral ulcers Thank you”. Resident #2’s “Home Health Certification and Plan of Care” documented services “start of care” date 12-23-2021 and was ongoing through 04-21-2022. As of the date of inspection, home health was still involved treating two wounds, one to right heel and one to right hip per Staff #1. Resident #2’s home health services were not identified on Resident #2’s ISP dated 12-30-2021.
  2. Resident #3 admitted 10-03-2016. Resident #3’s ISP dated 06-28-2020 did not document resident needing assistance with walking, wheeling, or mobility; however, Resident #3’s UAI dated 06-28-2020 documented, “human help, physical assistance” with walking, “mechanical help” with wheeling, and “mechanical help, human help physical assistance” with mobility.
  3. Resident #4 admitted 02-11-2022. Resident #4’s ISP dated 02-11-2022 did not document resident needing assistance with walking or mobility; however, Resident #4’s UAI dated 02-08-2022 documented, “mechanical help” (cane) for walking and “mechanical help” (cane) for mobility.
  4. Staff #1 confirmed the home health services were not documented on Resident #2’s ISP, and that Resident #3 and Resident #4’s ISPs did not contain services identified from the UAI.
Plan of correction
DON/RCC will meet weekly to ensure all new orders are reflected on the ISP/UAI for Home health orders.
22VAC40-73-710-E
Based on record review and interview with staff, the facility failed to ensure restraints were used in accordance with the resident's service plan.
Evidence
  1. Resident #1 admitted 12-07-2021 to the safe, secure environment (SSE). Resident #1’s physician’s orders dated 12-07-2021 documented, “1/2 Side Rails for Safety and Fall Prevention: Define the edge of the bed and provides comfort and security.” Resident #1’s individualized service plan (ISP) dated 12-07-2021 documented, “side rails for hospital bed 12-13-21” but did not document the use of the restraints.
  2. Resident #2 admitted 12-15-2021 to the facility. Resident #2’s physician’s orders dated 01-14-2022 documented, “Hospital Bed Semi-electric with ½ side rails”. Resident #2’s ISP dated 12-30-2021 did not document the resident’s side rails nor the use of the restraints.
Plan of correction
DON/RCC will audit all charts for residents with restraints to ensure restraint orders are in place and that ISP are up to date with restraints. DON/RCC and Administrator will meet weekly to make sure all new orders for restraints are up to date on ISPs.
22VAC40-73-560-D
Based on record review and interview with staff, the facility failed to ensure copies of all agreements between the facility and the resident and official acknowledgment of required notifications, signed by all parties involved, shall be retained in the resident's record.
Evidence
  1. Resident #1’s “Residence and Service Agreement” and “New Resident Orientation” were not signed by all parties involved as there was no resident or responsible party signature.
  2. Resident #6’s “Residence and Service Agreement”, “New Resident Orientation”, and “Acknowledgement of Receipt of Disclosure Statement” were not signed by all parties involved as there was no resident or responsible party signature.
Plan of correction
Marketing Director will ensure all documentation is signed prior to move-in. Administrator will look over all paperwork once completed to make sure everything is completed
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months.
Evidence
  1. Resident #3 admitted 10-03-2016. Resident #3’s most current ISP on file was dated 06-28-2020. Staff #1 confirmed that Resident #3’s ISP was not updated at least once every 12 months.
Plan of correction
DON/RCC/ Administrator will meet at the beginning of each month to ensure all ISP are up to date according to their due date or if conditions have changed. Due dates will be kept in a calendar as well as a binder with all the ISP/UAI filed for the month they need to be completed.
February 11, 2022Inspection8 violations
Inspection dates
02/11/2022, 03/01/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 The Sworn Statement or Affirmation
Comments
An unannounced renewal inspection was conducted at the facility on February 11, 2022 from 8:49 am to 12:30 pm with an exit call conducted by phone March 1, 2022 to conclude the inspection. There were 44 residents in care on the date of inspection. A tour of the facility was conducted onsite to include a medication observation, meal observation, and activity observation. The following records were reviewed: Resident and staff records, menus, activities calendars, buildings and grounds, resident council, fire and emergency drills, pharmacy and healthcare oversight. Thank you for your cooperation during this inspection. I can be reached at alex.poulter@dss.virginia.gov or (804) 662-9771.
Violations
22VAC40-73-680-D
Based on record review, observation, and interview with staff, the facility failed to ensure medications were administered in accordance with the physician’s instructions.
Evidence
  1. Resident #1’s physician’s orders dated 5-24-2021 documented, “Latanoprost 0.005% ophthalmic solution, 1 drops, Eye-Both, bedtime”.
  2. Staff #12 administered Latanoprost 0.005% ophthalmic solution on 2-11-2022 at approximately 9:35 a.m. from the medication cart “West Cart” during inspection.
  3. Resident #1’s February 2022 Medication Administration Record (MAR) documented for 2-11-2022 at 9:00 a.m. the initials “AP” for “Agency People” per the “Caregiver Key”.
  4. Staff #1 acknowledged the physician’s orders instructed for Resident #1’s medication to be administered at bedtime and that the medication was administered in the morning.
Plan of correction
All staff administering medications will receive in-service from pharmacy on proper way to administer medications.
22VAC40-73-325-B
Based on record review, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. Resident #5’s record contained “Physician Notification of Resident Condition (Fall)” for falls on the following dates: 1-04-2022, 1-10-2022, 1-11-2022, 1-17-2022, and 1-18-2022.
  2. There were no fall risk ratings for Resident #5’s aforementioned falls.
Plan of correction
DON/RCC will ensure all fall risk ratings are completed/updated after each fall. Administrator will full up each monthly to ensure they have been completed. Incident/fall reports will be kept in binder according to month as well as a copy of fall risk rating.
22VAC40-73-450-C
Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) documented the date of identified needs based upon the Uniform Assessment Instrument (UAI) and admission physical exam.
Evidence
  1. Resident #2 admitted 2-01-2021 to the facility. Resident #2’s ISP dated 1-26-2021 did not contain a date identified for any of the services listed. Additionally, Resident #2’s ISP did not contain the resident’s allergies or allergy reactions that were identified on the “Report of Resident Physical Examination” documenting allergies to Penicillin and Codeine.
  2. Resident #5 admitted 1-04-2022 to the facility. Resident #5’s ISP dated 12-21-2021 did not contain a date identified for any of the services listed. Additionally, Resident #5’s ISP did not contain the resident’s allergy or allergy reactions identified on the “Report of Resident Physical Examination” documenting allergies to Amoxicillin and Lisinopril. Resident #5’s UAI dated 12-08-2021 documented hearing issues, using a rollator walker, and disorientation that was not on the resident’s ISP.
  3. Resident #7 admitted 2-01-2021. Resident #7’s ISP dated 2-01-2021 did not contain a date identified for any of the services listed. Resident #7’s ISP did not contain the resident’s allergy or allergy reactions identified on the “Report of Resident Physical Examination” documenting an allergy to Codeine.
  4. Staff #1 confirmed Resident #2, Resident #5, and Resident #7’s most current ISPs did not contain the date of identified needs for any needs listed and that allergies and allergy reactions were not listed for the aforementioned residents on their ISPs.
Plan of correction
RCC/DON/designee will ensure all dated of identified needs are documented on ISP. Administrator will review monthly to ensure it is completed.
22VAC40-73-640-A
Based on record review and interview with staff, the facility failed to implement a written plan for medication management including methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs).
Evidence
  1. Resident #1’s physician’s order dated 5-24-2021 for “Latanoprost 0.005% ophthalmic solution, 1 drops, Eye-Both, bedtime” was documented on the February 2022 MAR as to be administered at 9:00 a.m. instead of bedtime as ordered.
  2. The facility’s “Medication Administration Plan” revised August 2011 documented, “5. Transcribing Medication Orders. a. The medication order should be transcribed exactly as it is written on the physician’s order.”
  3. Resident #1 was administered Latanoprost 0.005% ophthalmic solution at approximately 9:35 a.m. on 2-11-2022 during the medication administration observation.
  4. Staff #1 acknowledged during interview that the facility staff did not accurately transcribe the medication order to the MAR and stated that, “A nurse had reportedly changed the order due to Resident #1 stating she was not receiving the medication at bedtime” and acknowledged there was not a new order documented.
Plan of correction
DON/RCC will do weekly order to MAR audits to ensure orders match the MAR. Med techs will completed New Med Order Checklist (See attachment 1), once completed forms will be placed in box for RCC/DON to review, once reviewed forms will be kept in binder for three months.
22VAC40-73-460-D
Based on record review and interview with staff, the facility failed to provide attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident #6 admitted 11-11-2019 to the facility. Resident #6’s “Physician Progress Note” dated 6-28-2021 documented, “Interval History: Staff c/o (complains of) ' (increased) confused, wandering was “lost outside”…” and “Plan: ….monitor closely needs chaperone to go outside”.
  2. A self-reported incident received by the licensing office via email on 12-21-2021 documented that on 12-18-2021 at approximately 6:45 a.m., “Resident [#6] left facility with [Resident #6] coat on but did not sign out. [Resident #6] was found at the Moose Lodge. [Resident #6] was returned approx. 1 hour later by Hopewell police… Resident does have a diagnosis of dementia.”
  3. A subsequent “Physician Progress Note” dated 12-20-2021 documented, “Interval History: Wandered out of facility ' confusion…”.
  4. Resident #6’s ISP dated 11-09-2021 documented, “Resident needs to be checked on in their rooms to attempt to maintain safety and well-being due to wandering and insomnia.”
  5. Staff #1 confirmed during interview that Resident #6 exhibited wandering behaviors and wandered from the premises on 12-18-2021.
Plan of correction
DON/RCC/Administrator will address all specialized needs when they arise and update ISP accordingly.
22VAC40-90-30-C
Based on record review and interview with staff, any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor.
Evidence
  1. The following staff checked “no” on the question “Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?” on the sworn statement or affirmation; however, the staff had been convicted that was documented on the Criminal Record Reports (CRR): a. Staff #2: date of hire (DOH) 10-24-2021 (CRR dated 8-12-2021); b. Staff #3: DOH 1-02-2020 (CRR dated 12-19-2019); c. Staff #6: DOH 12-07-2021 (CRR dated 9-30-2021); d. Staff #7: DOH 10-05-2021 (CRR dated 9-21-2021); e. Staff #8: DOH 11-30-2021 (CRR dated 11-10-2021); f. Staff #9: DOH 9-21-2021 (CRR dated 9-14-2021); g. Staff #10: DOH 8-17-2021 (CRR dated 8-10-2021); and h. Staff #11: DOH 1-25-2022 (CRR dated 1-12-2022).
  2. Staff #1 confirmed the aforementioned staff made materially false statements on the sworn statement/affirmation regarding convicted law violations.
Plan of correction
All sworn statements will reflect CRR. Moving forward BOM will ensure all sworn statements reflect CRR. Administrator will audit all new hires monthly to ensure sworn statements are correct.
22VAC40-73-320-A
Based on record review and interview with staff, the facility failed to ensure that the physical examination required within the 30 days preceding admission contained the date of the physical examination and the description of the person's reactions to any known allergies.
Evidence
  1. Resident #2 admitted 2-01-2021. Resident #2’s’s “Report of Resident Physical Examination” did not contain the date of examination, nor the allergy reactions to “PCN” and “codeine” that were listed on the examination.
  2. Resident #3 admitted 9-30-2021. Resident #3‘s “Report of Resident Physical Examination” did not contain the date of examination.
  3. Resident #5 admitted 1-04-2022. Resident #5’s “Report of Resident Physical Examination” did not contain the date of examination.
  4. Resident #7 admitted 2-01-2021. Resident #7’s “Report of Resident Physical Examination” did not contain the resident’s allergy reaction to “codeine” that was documented on the examination.
Plan of correction
Sale Director will ensure all new admissions will have the date of the physical examination and description of reactions to any known allergies prior to admission. Administrator will check all paperwork prior to admission to ensure this has been completed.
22VAC40-73-440-A
Based on record review and interview with staff, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed whenever there is a significant change in the resident's condition.
Evidence
  1. Resident #6 admitted 11-11-2019 to the community, and 12-21-2021 to the safe, secure environment (SSE). Resident #6’s ISP dated 11-09-2021 documented wandering behaviors; however, Resident #6’s UAI dated 11-08-2021 did not document wandering behaviors.
  2. Resident #8 admitted 2-19-2021 to the SSE. Resident #8’s UAI dated 8-19-2021 did not document aggressive behaviors; however, three incident reports were received regarding Resident #8 striking other residents on 11-13-2021, 12-04-2021, and 2-18-2022.
  3. Staff #1 confirmed the UAIs were not updated to reflect Resident #6 or Resident #8’s behaviors.
Plan of correction
DON/RCC will ensure all UAIs stay current and up to date. Administrator and DON/RCC will meet bi-weekly to discuss resident changes and address UAIs as needed.
November 30, 2021Complaint survey0 violations
Inspection dates
11/30/2021
Areas reviewed
None
Comments
An onsite complaint investigation was initiated and concluded on November 30, 2021 regarding staffing and personnel. The Administrator and Director of Nursing were present on the date of inspection. A review of records and interviews were conducted. It was determined the complaint was not valid based on the allegations.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 29, 2021Complaint survey0 violations
Inspection dates
11/29/2021, 11/30/2021
Areas reviewed
None
Comments
A non-mandated complaint inspection was initiated on November 9, 2021 and concluded on November 30, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services relating to diabetic medication management. 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 licensing inspector conducted an on-site observation at the facility on November 30, 2021. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 7, 2021Complaint survey4 violations
Inspection dates
09/07/2021, 09/21/2021, 10/08/2021
Comments
A non-mandated complaint inspection was initiated on September 7, 2021 and concluded on October 8, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, and staffing. 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 licensing inspector conducted an on-site observation at the facility on September 21, 2021. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-1130-C
Based on record review and interview with staff, the facility failed to ensure during night hours, at least two direct care staff members were awake and on duty at all times in each special care unit with 22 or fewer residents present.
Evidence
  1. On the following dates, there were less than two staff in each special care unit during the night shift (N – 11pm – 7 am): a. July 2021: 7-02-2021, 7-04-2021,7-08-2021, 7-13-2021, 7-20-2021 (3a – 7a), 7-22-2021, 7-25-2021; b. August 2021: 8-01-2021 – 8-02-2021, 8-04-2021 – 8-05-2021, 8-07-2021 – 08-09-2021, 8-13-2021 – 8-15-2021, 8-19-2021 – 8-21-2021, 8-23-2021, 8-26-2021 – 8-29-2021.
  2. Staff #1 confirmed during interview that staffing minimums were not met in the special care unit during the night hours on the aforementioned dates.
Plan of correction
Administrator has enlisted assistance of agency nursing to assist with staffing needs.
22VAC40-73-1130-A
Based on record review and interview with staff, the facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit.
Evidence
  1. On the following dates, there were less than two staff in each special care unit during the day (D – 7am – 3 pm) and evening (E – 3pm- 11 pm) shifts: a. July 2021: 7-03-2021: E (8p-11p), 7-11-2021: D, 7-18-2021: D, 7-19-2021: E (7p-11p); b. August 2021: 8-2-2021: D, 8-13-2021: E, 8-16-2021: E.
  2. Staff #1 confirmed during interview that staffing minimums were not met in the special care unit during day and evening shifts on the aforementioned dates.
Plan of correction
Administrator has enlisted assistance of agency nursing to assist with staffing needs.
22VAC40-73-460-D
Based on record review and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. A note from Staff #2 dated 9-27-2021 documented, “On January 6th 2021, an incident report was completed for [Resident #1] by this writer as instructed by Resident Care Coordinator. A charting note about resident [#1] wandering away from facility was completed by this writer as well. Resident Care Coordinator notified previous Administrator about the incident. This writer is unaware of the location of the incident report after it was given to previous administrator…” (signed by Staff # 2).
  2. A second note from Staff #3 dated 9-27-2021 documented, “On March 14, 2021 an incident report was completed for [Resident #1] by this writer as instructed by Resident Care Coordinator. A charting note about this incident (resident [#1] wandering away from facility) was done also. Resident Care Coordinator notified previous Administrator about the incident. I [Staff #3] who is writing this report is unaware of what happened to the report after it was given to previous Administrator. (signed by Staff #3).
  3. Resident #1’s Charting Notes from 3-14-2021 electronically signed by Staff #3 documented, “Change in Condition: At 9:30pm resident [#1] on purple with another resident brought back to his neighborhood and to room. At 10:15pm while making rounds resident unable to be found...(MOD) ntfd, Brighter Living side ntfd. Employee and a resident from BL side spotted resident [#1] coming out of woods and saw him fall down the hill…” Progress Note by Physician #1 dated 3-15-2021 documented resident #1 received abrasions from the fall.
  4. Staff #1 confirmed during interview that Resident #1 wandered from the premises on two occasions as reported by Staff #2 and Staff #3.
Plan of correction
Administrator/Designee ensure that rounds are made approximately every 30 minutes and all residents are accounted for on secure unit.
22VAC40-73-70-A
Based on record review and interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Resident #1 admitted on 12-28-2020 to the Safe, Secure Environment (SSE).
  2. Resident #1’s Progress Notes with Physician #1 documented the resident eloped on 1-08-2021 and 3-15-2021 from the SSE of the facility.
  3. The regional licensing office received no report of either incident taking place.
  4. Staff #1 confirmed during interview that the incidents took place and the licensing office had no record of either incident.
Plan of correction
Administrator/Designee will report to DSS any/all reportable incidents within 24 hours.
February 11, 2021Inspection0 violations
Inspection dates
Feb. 11, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
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 and concluded on 02/11/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, conducted a live video tour of the physical plant to include observation of resident rooms on assisted living and memory care, observation of room temperatures, call bell systems, emery food and water supplies and additional documents submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 26, 2021Inspection1 violation
Inspection dates
Jan. 26, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
A monitoring inspection was initiated on 01/26/2021 and concluded on 01/26/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported the current census. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, and additional documents submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-550-G
Based on resident record review the facility failed to ensure 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 in subsection H of this section and each staff person.
Evidence
  1. On 01/26/2021 while reviewing the annual resident rights for resident #4, documents resident #4's responisible party last reviewed and signed the resident rights on 02/04/2019.
Plan of correction
Not published by VDSS.