Virginia DSS · Assisted Living Facility

Culpepper Garden III, INC

📍 4439 N. Pershing Drive, Arlington, VA, 22203

ID 23512One Year licenseClosed
14
Inspections
On record
7
With violations
Visits that cited something
7
Clean visits
Nothing cited
20
Violations cited
Individual findings
20
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Culpepper Garden III, INC was inspected 14 times between January 19, 2021 and August 26, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 20 violations under 20 distinct standards. 3 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 and no longer serves any of these on its site. All 14 are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
10/03/2026
Administrator
Angela Burton
Licensing inspector
Alexandra Roberts
Inspector phone
(804) 845-6956
Approved for
Non-Ambulatory · Assisted Living

Inspection History

14

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

August 26, 2025Inspection5 violations
Inspection dates
Aug. 26, 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 PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/26/2025 8:30am - 3:30pm 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Observer medication administration and residents eating lunch. 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 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 Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-200-C
Based on record review and interview, the facility failed to ensure direct care staff meet on of the requirements in this subsection within two months of employment if not met at the time of employment.
Evidence
  1. Staff 3 was hired as direct care staff on 12/18/2024.
  2. Staff 3's staff record included a certification as a nurse aide issued in the state of Maryland.
  3. Staff 1 confirmed Staff 3 record does not indicate or hold documentation of one of the requirements of direct care staff.
Plan of correction
Staff 3 was immediately removed from providing unsupervised direct care until verification of qualifications required by Virginia regulations is obtained and documented in the personnel file. Effective immediately, all new hire personnel files will be audited by the Executive Director and/or designee prior to the start of direct care duties to ensure that required documentation (Virginia CNA certification, or alternate qualification per regulation) is obtained and filed. HR and department managers will receive re-education on regulatory requirements for direct care staff qualifications and proper documentation during orientation and annual training by 9/30/2025
22VAC40-73-450-C
Based on record review and interview, the facility failed to ensure that the individualized service plan (ISP) is updated annually or as needed to include a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. Resident 6’s ISP dated 7/18/2025 (admitted 03/26/2021) did not include that the resident takes their Sodium Bicarb scheduled daily at 14:00 physically off-site to their outpatient treatment three times a week on Tuesday, Thursday and Saturday and self-administers.
  2. Resident 6’s MAR from March 2025 to August of 2025 indicate “Absent from home with meds”.
  3. Staff 4 confirmed that they provided Resident 6’s medication to them before Resident 6 got into a taxi to leave the facility independently.
  4. Staff 1 confirmed that the ISP is not accurately reflecting the resident self-administering during their outpatient treatment.
Plan of correction
All staff were re-educated by 09/_30_/2025 regarding facility policies for medication handling when residents are absent from the facility, including accurate MAR documentation and ensuring the ISP is consistent with resident care practices. A new audit process has been implemented: the Director of Nursing (DON) or designee, will review resident ISPs against MAR documentation monthly to ensure consistency. The DON or designee will audit all MARs weekly for 90 days to verify accuracy of entries, especially for residents who leave the facility with medications.
22VAC40-73-560-F
Based on observation, the facility failed to ensure that all records are treated confidentially.
Evidence
  1. During facility tour on 08/26/2025, licensing staff observed 4 residents? weights, vitals, and empty medication blister packs left unattended on the medication cart. No staff were using the medication cart at the time of observation.
Plan of correction
Conduct mandatory HIPAA refresher training for all staff by 9/30/2025
22VAC40-73-650-D
Based on record review and interview, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident 5 is prescribed Refresh Optive Advanced triple-action 0.5-1-0.5% drops instill 1 drop into left eye three times a day. 2 During medication pass observation on 08/26/2025 both licensing staff and Resident 5 alerted Staff 4 that they were
  2. During medication pass observation on 08/26/2025, both licensing staff and Resident 5 alerted Staff 4 that they were administering the eye drop into the right eye instead of the left eye. Staff 4 continued on and administered the eye drop into the right eye before proceeding to administer into the left eye.
  3. Staff 4 acknowledged the medication error.
Plan of correction
All medication technicians and nurses were re-educated on 08/27/2025 regarding correct administration of ophthalmic drops and the requirement to stop and verify if questioned by a resident or observer. “ A medication administration refresher in-service focusing on ”5 Rights of Medication Administration? will be completed by all direct care staff by 9/30/2025 “ The Medication Administration Record (MAR) has been updated to clearly highlight ”LEFT EYE ONLY? for Resident 5 to prevent future errors. The DON or designee will conduct random medication pass observations on at least 3 staff members weekly for the next 90 days to ensure accuracy of administration and staff adherence to physician orders
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure that the MAR include any medication errors or omissions.
Evidence
  1. During a medication pass observation on 08/26/2025, Staff 4 incorrectly administered Resident 5's Refresh Optive Advanced eye drops in their right eye instead of the left eye as ordered.
  2. Resident 5's August MAR did not include the error on 08/26/2025 or any associated notes related to or following the error.
  3. Staff 1 confirmed Resident 5's August MAR did not include the medication error on 08/26/2025.
Plan of correction
A facility-wide in-service will be conducted by 9/30/2025 focusing on medication error reporting, MAR documentation, and notification protocols. The DON or designee will audit 100% of MARs daily for 90 days to ensure proper documentation of all medication administration.
July 22, 2025Complaint survey0 violations
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 GROUND22VAC40-80 COMPLAINT INVESTIGATION
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: 07/22/2025 8:45am - 11am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/13/2025 regarding allegations in the area(s) of: Quality of Care. Number of residents present at the facility at the beginning of the inspection: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed residents in the common area engaging with one another, walking the grounds outside in the garden and eating in the dining hall. Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 8, 2025Inspection0 violations
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 IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS
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: 5/08/2025 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: 101 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed residents in the common area engaging with one another. Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 24, 2025Inspection3 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS
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: 5/08/2025 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: 101 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed residents in the common area engaging with one another. Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. 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 Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-1040-A
Based on staff interview, the facility failed to ensure that doors leading to the outside have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms.
Evidence
  1. On 03/16/25, LI received a self-reported incident that Resident 1 eloped from facility via stairwell door on 03/16/25 at 10:33pm and was found on the ground in the garden with ambulance arriving and securing Resident 1 at 10:56pm.
  2. Staff 1 confirmed that the cameras with motion sensors and door alarms were not actively monitored at the time of this event.
Plan of correction
Residents with an assessment of severe cognitive impairment or a history of or new behavior of wandering will be required to have private sitters in place to ensure adequate supervision; if private supervision cannot be secured, the facility will initiate discharge to a setting that can safely meet the resident’s needs. The Administrator or Designee will conduct regular audits to ensure compliance and resident safety.
22VAC40-73-280-B
Based on interview, the facility failed to ensure having a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. LI requested written plan that determines staffing numbers and type of direct care staff required.
  2. Staff 1 confirmed that the facility does not have a written plan that is directly related to staffing and resident acuity levels.
Plan of correction
The facility has updated its written staffing plan to align with resident acuity levels, categorizing residents as level 1, level 2 or level 3 acuity and assigning staff accordingly based on defined ratios for each shift. This plan ensures that staffing levels meet the day-to-day and care needs for the residents. Resident acuity will be reviewed ongoing or as needed, with staffing adjusted to reflect changes. The Administrator or Designee will conduct ongoing audits to ensure continued compliance and effectiveness.
22VAC40-73-460-D
Based on staff interview and record review, 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. On 03/16/25, LI received a self-reported incident that Resident 1 eloped from facility via stairwell door on 03/16/25 and was found on the ground in the garden.
  2. LI observed video recording of the resident 1 leaving their apartment, going down 3 flights of steps and exiting via stairwell door and then falling into the mulch.
  3. Staff 1 confirmed that the resident 1 eloped on 03/16/25 at 10:33pm, ambulance arrived and secured the resident at 10:56pm and then ambulance alerted staff at 11pm.
Plan of correction
Residents with an assessment of severe cognitive impairment or a history of or new behavior of wandering will be required to have private sitters in place to ensure adequate supervision; if private supervision cannot be secured, the facility will initiate discharge to a setting that can safely meet the resident’s needs. The Administrator or Designee will conduct regular audits to ensure compliance and resident safety.
August 6, 2024Inspection7 violations
Inspection dates
Aug. 6, 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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Inspection Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/6/2024 - 8/7/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed activities, lunch and medication passes for residents. 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 Alexandra Roberts, Licensing Inspector at (804) 845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov.
Violations
22VAC40-73-450-F
22VAC40-73-450-F Based on record review, facility failed to ensure that Individualized service plans are reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 1’s (admitted on 06/23/2023) ISP completed on 07/12/2024 indicated the resident is Full Code.
  2. Resident 1 had a Do Not Resuscitate Order (DNR) signed by the physician on 12/11/2023.
  3. Resident 1’s ISP, dated 7/12/2024, was not updated to include the DNR order.
Plan of correction
CPG Nursing team completed a 100% audit of all resident code statuses. The code status for each resident was checked and verified against DNR Form, H & P, ISP, and PCC order. Going forward we will verify code status at the time of move in. Code status will also be verified during scheduled ISP Meetings
22VAC40-73-550-F
Based on observation and record review, facility failed to ensure that the Rights and Responsibilities of Residents of Assisted Living Facilities is posted in a conspicuous place with the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services' toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate(i.e., local) ombudsman program serving the area, and the toll-free telephone number of the disability Law Center of Virginia.
Evidence
  1. During 8/06/2024 inspection, LI did not observe posted resident rights in a public place. LI asked Staff 1 where Rights and Responsibilities of Residents of Assisted Living Facilities was posted. Staff 1 stated that Rights and Responsibilities of Residents of Assisted Living Facilities are posted on the 6th floor. Staff 1 stated that the 6th floor is the main dining area for residents and her office.
  2. Posted Rights and Responsibilities of Residents of Assisted Living Facilities had incorrect names and telephone numbers of appropriate contacts.
  3. Rights and Responsibilities of Residents of Assisted Living Facilities that were in Resident 1 (dated 06/07/2024), resident 2 (dated 06/21/2024) & resident 3 (dated 06/07/2024) charts also had incorrect name and telephone numbers of appropriate contacts.
Plan of correction
Resident Rights posters were re-located to the first floor during the DSS Audit process. Contact information for the correct inspector was added. All residents have received and signed an updated copy of the resident rights. During the annual resident rights review, and as notified of changes, CPG staff will check the DSS website to ensure the contact information is correct and update the postings accordingly.
22VAC40-73-620-B
Based on record review and staff interview, facility failed to ensure that action taken in response to the oversight of special diets is documented in the resident’s record. 1. Resident 3’s (admitted 9/21/2023), ISP completed 9/22/2023, noted NAS as a dietary restriction. The dietary review completed on 3/13/2024, noted that the diet was updated to a regular diet. 2. Resident 3 did not have an updated record to reflect the change. 3. Staff 1 confirmed that the incorrect diet was shown for the resident throughout the record.
Plan of correction
CPG Nursing team completed a 100% audit of all resident diet orders. Diet orders were checked and verified against H & P, Diet Form, Diet Order, PCC, Dietician Notes, and ISP. Going forward we will verify diet order against all sources at the time of move in. Diet status will also be verified during scheduled ISP Meetings and as needed.
22VAC40-73-650-C
Based on record review and staff interview, facility failed to ensure Physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. Resident 2’s record contained a verbal hospice order taken on 7/3/2024 by Staff 3. The order had not been signed by MD as of date of inspection on 08/06/2024.
  2. Staff 1 confirmed there was no signature on the verbal order.
Plan of correction
CPG will no longer accept telephone orders for hospice admission. Orders must be signed at the time the patient is admitted. Alternatively, orders can be faxed to the pharmacy. Compliance will be spot checked during quarterly oversight reviews
22VAC40-73-860-I
Based on observation, facility failed to ensure cleaning supplies and other hazardous materials are in a locked area.
Evidence
  1. Facility serves a mixed population.
  2. On 8/06/2024, LI observed bleach wipes unattended with no staff present on the 3rd floor window seal in the dining area.
  3. Photo evidence was taken of the bleach wipes.
Plan of correction
All wipes were removed All wipes were removed immediately and stored in a secure area. CPG staff will complete an Inservice on the important of keeping cleaning supplies and other chemicals, stored away in secure areas.
22VAC40-73-950-E
Based on record review and staff interview, facility failed to ensure semi-annual review on the emergency preparedness and response plan for all staff and residents.
Evidence
  1. LI requested Emergency preparedness policy (Revised on 04/2024) and supporting documentation that a review was conducted with staff and residents over the past year.
  2. Staff 1 stated that facility does not have any documentation for the semi-annual reviews for the past year to present.
Plan of correction
CPG is developing and updating the emergency plan in accordance with DSS standards. Upon completion, the plan will be reviewed with staff at scheduled meetings with signatures obtained. Going forward, emergency plan review will be added to the new hire orientation process with signatures obtained. Additionally, the plan will be reviewed semi-annually during safety week.
22VAC40-73-950-F
22VAC40-73-950-F Based on record review and staff interview, the facility failed to ensure that the annual emergency preparedness plan review was documented by signing and dating the plan.
Evidence
  1. Staff 1 provided Emergency preparedness policy with a review date of March 2024 at the footer of the policy.
  2. LI requested documentation with exact date and signatures of the review. Staff 1 stated that facility does not have any documentation for the review with signature or the exact dates.
Plan of correction
CPG is developing and updating the emergency plan in accordance with DSS standards. Upon completion, the plan will be reviewed with residents at scheduled meetings with signatures obtained. Going forward, emergency plan review will be added to the new resident orientation process with signatures. Additionally, the plan will be reviewed semi-annually during safety week.
September 14, 2023Inspection2 violations
Inspection dates
Sept. 14, 2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population
Comments
Date of Inspection: September 14, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 69 Number of records reviewed and interviews conducted- 9 records (both staff and residents), 7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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). The Licensing Inspector observed the residents at lunch and activities. The Licensing Inspector reviewed the following at the time of inspection: resident council reports, activity calendars, menus, fire drills, dietician report and healthcare oversight.
Violations
22VAC40-73-250-B
Based on staff record review and staff interview, it was determined that the facility failed to have a staff record at the facility as required.
Evidence
  1. Staff Z's record was not at the facility as required.
Plan of correction
An audit was conducted to ensure all employee files were on site within the community.
22VAC40-73-450-D
Based on resident record review and staff interview, it was determined that the facility failed to have a coordinated plan of care between the hospice agency and the facility on the Individualized Service Plan (ISP).
Evidence
  1. Resident Bs ISP had no documentation of a coordinated plan of care between the hospice agency and the facility as required.
Plan of correction
An audit has been conducted for all residents receiving hospice services to ensure coordination of hospice care. ISPs for residents receiving hospice services have been reviewed and updated to reflect the coordination of care on each resident's individualized ISP.
July 14, 2023Complaint survey0 violations
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
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: LI entered the facility at 10:25 am on 7/14/2023 and exited at 1:23 pm on 7/14/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/10/2023 regarding allegations in the area(s) of admission, retention, and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 72 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: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 14, 2023Inspection0 violations
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: LI entered the facility at 10:25 am on 7/14/2023 and exited at 1:23 pm on 7/14/2023. 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: 72 Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: LI conducted a focused monitoring inspection to ensure correction of previous B-2 violation that was cited during an inspection that occurred on 3/14/2023. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 14, 2023Inspection1 violation
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: LI entered the facility at 8:15 am on 3/14/2023 and exited at 3:36 pm on 3/14/2023. 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch and engaging in activities. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-680-D
Based upon a review of records and observation, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards or practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. According to the record for Resident #1, there is a physicians? order for polyethylene 3350 powder that is to be administered “every three days.”
  2. LI (licensing inspector) observed Staff #5 administer polyethylene 3350 powder to Resident #1 on 3/14/2023 at approximately 8:55 am.
  3. The Medication Administration Record for March 2023 indicates that Resident #1 was administered polyethylene on 3/13/2023 before lunch. The Medication Administration Record also documents that Staff #5 administered polyethylene before lunch on 3/14/2023 (which was observed by LI).
Plan of correction
Upon review of the medication administration record, it was identified that the medication was enter into the system incorrectly. This was corrected immediately on March 14,2023. A training on how to properly input medications into the EMR will be conducted with all licensed clinical staff. A review of all resident’s medications will be conducted to ensure all medications are entered into the system correctly by the clinical staff inputting medication orders and follow up will be completed by the director of nursing.
October 5, 2021Inspection1 violation
Inspection dates
Oct. 5, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Comments
A renewal inspection was initiated on 09/30/2021 and concluded on 10/5/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 71. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed four resident records, four staff records, menus, postings, activities calendar, staff schedules, and other documentation submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/05/2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Exit interview with the Administrator. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-90-40-B
Based on record review the facility failed to ensure The criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 4 was hired on 03/29/2021 and the criminal history record was dated 08/26.2021.
Plan of correction
During an internal audit it was identified that staff #4 was missing the background check documentation. The facility attempted to retrieve background check from VA state police but was unable to obtain due to it being past 90 days since background check was initially completed. The facility then re-ran the background check to ensure compliance. The status of the report received 8/26/2021 read NO IDENTIFIABLE RECORD(S) The business office manager shall complete another internal audit of all employees to ensure background checks are present in each employee file. If background check is not found during the audit, the facility shall re-run the background check to ensure compliance. The AL administrator will follow up to review team member files to ensure compliance upon hire.
May 12, 2021Inspection0 violations
Inspection dates
May 12, 2021 and May 13, 2021
Areas reviewed
22VAC40-73 PERSONNEL
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/12/2021 and concluded on 5/13/2021. A self-reported incident was received by the department regarding allegations in the areas of personnel. 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. Exit interview with the administrator on 5/25/2021. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 19, 2021Complaint survey1 violation
Inspection dates
Jan. 19, 2021 and Jan. 23, 2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 1/19/2021 and concluded on 1/23/2021. A complaint was received by the department regarding allegations in the areas of Buildings and Grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-870-D
Based on documentation and interviews, facility failed to ensure that buildings shall be kept free of infestations of insects
Evidence
  1. Interview with Resident #1's daughter on telephone on 1/11/2021 and email on 1/12/2021 stated pests were observed and photographed in Resident #1's apartment #240 on 1/2/2021 and on 1/3/2021 while removing Resident #1s personal items after Resident #1's discharge on 12/24/2020; resident's daughter stated Staff #1 was notified by email on 1/4/2021 regarding pests with photographs. Interview with Staff #1 on 1/19/2021 stated that she was notified on 1/4/2021 by Resident #1's daughter of the pests by email; facility staff and pest control management on-site observed pests in room #240 on 1/4/2021 and treatment was started. Staff #1 stated a call was made to the daughter on 1/4/2021 to discuss observation and plan of action. Pest management company documented pest treatment in Resident #1's apartment #240 and noted on 7/28/2020 "Heavy activity found" and on 12/3/2020 "Some activity in kitchen" and on 1/4/2021 "Treated the unit thoroughly for cockroaches. Treated all the furniture, kitchen, bathroom and bedroom with closets and baseboards".
Plan of correction
An inspection of room 240 was immediately conducted by the Assisted Living Administrator, Director of Plant Operations, and the Pest Control Vendor on 1/4/2021, the day that the problem was reported. The Pest Control Vendor was immediately notified to provide additional treatment for pests to apartment 240 that same day and additional treatments to room thereafter. A room-by-room inspection was completed by the Assisted Living Administrator and the Director of Plant Operations on 1/6/2021. An intensive treatment of each room was completed by the Pest Control Vendor. The Assisted Living Administrator and Director of Plant Operations along with the Pest Control Vendor completed training for the nursing staff, the housekeeping, and other support services on 1/7/21 and 1/11/21. The training included how to properly identify pest control opportunities and proper reporting of those opportunities. Weekly inspections will be completed by a designated maintenance team member with a Bi-Weekly follow up by the Director of Plant Operations. The Assisted Living Administrator will complete a subsequent review monthly for 3 months.
N/AInspection0 violations
Inspection dates
N/A
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
N/AInspection0 violations
Inspection dates
N/A
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.