13
Inspections
On record
10
With violations
Visits that cited something
3
Clean visits
Nothing cited
59
Violations cited
Individual findings
39
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Blue Ridge Christian Home was inspected 13 times between November 19, 2020 and June 1, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 59 violations under 39 distinct standards. 2 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 12 of these 13 are still on the state's site; the other 1 has since dropped off it and is 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
01/31/2027
Administrator
Pamela Campbell
Licensing inspector
Jennifer Stokes
Inspector phone
(540) 589-5216
Approved for
Assisted Living · Non-Ambulatory

Inspection History

13

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

June 1, 2026Complaint survey0 violations
Inspection dates
06/01/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 06/01/2026 10:10AM to 11:15AM 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 05/22/2026 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2026Inspection4 violations
Inspection dates
01/15/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 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 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: 01/15/2026 7:20AM to 11:15AM 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: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: morning medication administration, medication cabinets, breakfast and an activity 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on staff record review and staff interview, 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 person 4 was hired on 12/03/2025; however, the staff person’s record does not contain the results of a criminal history record report. Interview with staff person 1 confirmed this is accurate.
Plan of correction
Beginning January 16, 2026 the Administrator will ensure all employees files are not put in the file cabinet until complete. The administrator will also mark a 30 day time frame and remove staff from schedule if criminal record results haven't been received.
22VAC40-73-1020-A
Based on facility schedules and staff interview, the facility failed to ensure when residents are present, there shall be at least two direct care staff members awake and on duty at all times in each building who shall be responsible for the care and supervision of the residents.
Evidence
  1. Interview with staff person 1 during the 01/15/2026 on-site inspection confirmed that the facility houses a mixed population of residents indicating that there must be at least two direct care staff persons on duty at all times.
  2. The facility’s staff schedule, dated 11/10/2025 through 01/04/2026, that was provided to the licensing inspector (LI) by staff person 1 during the on-site inspection contains documentation that staff person 1 was the only direct care staff member on duty during the night clock on the following dates: 11/10/2025, 11/15/2025, 11/16/2025, 11/20/2025, 11/21/2025, 11/22/2025, 11/23/2025, 11/24/2025, 11/25/2025, 11/26/2025, 11/27/2025, 12/03/2025, 12/06/2025, 12/07/2025, 12/08/2025, 12/09/2025, 12/10/2025, 12/11/2025, 12/27/2025, 12/28/2025 and 01/01/2026. The schedule also contains documentation that staff person 3 was the only direct care staff member on duty during the night clock on 12/15/2025 and 12/23/2025. Staff person 1 confirmed the aforementioned information is accurate.
Plan of correction
The administrator has begun a hiring process on January 19, 2026 to find staff to fill holes on the schedule at night. We will plan to have clocks stay over and come in early or the administrator will help to cover as the 2nd person until holes can be filled on the schedule.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 12/02/2025, for Calcitriol 0.25MCG take 1 capsule by mouth every day on Monday, Wednesday, and Friday at 5:00PM.
  2. Resident 1’s medication administration record (MAR) contains documentation that Calcitriol 0.25 MCG was administered to the resident at 8:00AM on 01/02/2026, 01/05/2026, 01/07/2026, 01/09/2026, 01/12/2026 and 01/14/2026.
Plan of correction
The administrator and nurse will immediately January 16, 2026 review all new orders and double check the MAR for accuracy.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure, for private pay individuals, that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110.
Evidence
  1. Page 2 of the UAI in the record for resident 1, dated 10/29/2025, does not contain the assessor’s signature, the agency/assisted living facility name, or the date the assessor completed the UAI and the UAI does not contain the signature of the administrator or the date. Staff person 1 confirmed this is accurate.
Plan of correction
The administrator will ensure when we have new residents forms are complete before filing the chart. The administrator will also work with the nurse and oversight to double check for accuracy beginning January 16, 2026.
April 21, 2025Complaint survey4 violations
Inspection dates
04/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 04/21/2025 8:50AM to 11:20AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/24/2025 regarding allegations in the area of: resident care and related services 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on staff interview, the facility failed to ensure medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same person.
Evidence
  1. During an interview with staff person 1 on 04/21/2025, staff person 1 informed the licensing inspector (LI) that they are not acting as a medication aide on a provisional basis as identified by the Virginia Board of Nursing (VBON) nor are they a registered medication aide (RMA) through the VBON.
  2. Staff person 1 informed the LI that they have removed medications from the pharmacy container and administered medications to resident 1 multiple times during February 2025, March 2025, and April 2025 as documented on the February 2025, March 2025 and April 2025 medication administration records (MARs) for resident 1 in the presence of staff person 2.
Plan of correction
Administrator will ensure that only staff with proper training have access to medications and med room. This has been completed 4/28/2025
22VAC40-73-670-1
Based on resident record review and staff interview, the facility failed to ensure each staff person who administers medications to residents shall be authorized by § 54.1-3408 of the Virginia Drug Control Act and all staff responsible for medication administration shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. The February 2025 medication administration record (MAR) for resident 1 contains the initial of staff person 1 administering Escitralopram 20MG to resident 1 on 02/10/2025 at 8:00AM and Buspirone 15MG to resident 1 on 02/10/2025 at 8:00AM and on 02/07/2025, 02/08/2025, 02/10/2025, 02/14/2025, 02/17/2025, 02/21/2025, and 02/26/2025 at 2:00PM and administering as needed (PRN) acetaminophen 500MG on 02/12/2025 at 4:30PM and 02/13/2025 at 12:30AM. The March 2025 MAR for resident 1 contains the initial of staff person 1 administering Buspirone 15MG at 2:00PM to resident 1 on 03/03/2025, 03/05/2025, 03/10/2025, 03/18/2025, 03/24/2025, 03/26/2025, and 03/31/2025 and administering Tylenol 650MG suppository to resident 1 on 03/01/2025, 03/16/2025, 03/19/2025, and 03/29/2025 at 8:00AM; on 03/03/2025, 03/05/2025, 03/10/2025, 03/24/2025, 03/28/2025, and 03/31/2025 at 8:00AM and 2:00PM; and on 03/18/2025 at 2:00PM. The April 2025 MAR for resident 1 contains the initial of staff person 1 administering Buspirone 15MG at 2:00PM to resident 1 on 04/04/2025, 04/05/2025, 04/07/2025, 04/08/2025, 04/11/2025, 04/14/2025, and 04/18/2025 and administering acetaminophen 650MG suppository to resident 1 on 04/04/2025 at 6:00AM and at 2:00PM on 04/04/2025, 04/05/2025, 04/07/2025, 04/08/2025, 04/11/2025, 04/14/2025, 04/18/2025, and 04/19/2025.
  2. During an interview with staff person 1 on 04/21/2025, staff person 1 informed the licensing inspector (LI) that they are not acting as a medication aide on a provisional basis as identified by the Virginia Board of Nursing (VBON) nor are they a registered medication aide (RMA) through the VBON and confirmed that they have administered medications to resident 1 multiple times during February 2025, March 2025, and April 2025 in the presence of staff person 2.
Plan of correction
Administrator will ensure all staff have completed all steps of training before stepping into any position or administering any medications. This has been completed 4/28/2025.
22VAC40-73-650-B
Based on resident record review and staff interview, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. The record for resident 1 contains a nurse’s note by staff person 2, dated 02/23/2025, that an enema was given to the resident per the medical doctor’s instruction.
  2. During an interview with staff person 1 on 04/21/2025, staff person 1 informed the licensing inspector (LI) that the facility has a standing order from Collateral 1 for all residents who reside at the facility for saline enema medication/treatment as needed (PRN) and therefore the order does not include resident 1’s name, the route, and the strength of the drug.
Plan of correction
Facility will work with our physician and get a PRN order for each individual elder instead of a standing order for treatments. We will make sure to include all information for each elder. This will be completed with our 6-month reviews in May 2025.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall include all required components.
Evidence
  1. The record for resident 1 contains a nurse’s note by staff person 2, dated 02/23/2025, that an enema was given to the resident per the medical doctor’s instruction; however, the February 2025 MAR for resident 1 does not contain documentation that the resident was given an enema. Interview with staff person 1 confirmed that the resident was given an enema by staff person 2 and confirmed that it was not included on the February 2025 MAR.
  2. The record for resident 1 contains a signed physician’s order, dated 02/17/2025 and signed by Collateral 1 on 02/25/2025, for Tylenol 650MG suppository three times daily at 6:00AM, 2:00PM, and 8:00PM for pain. The February 2025 MAR contains documentation that the aforementioned medication was only administered on 02/28/2025 at 2:00PM and on 02/26/2025 and 02/27/2025 at 8:00PM and does not contain documentation for the other dates/times the medication was administered. Interview with staff person 1 confirmed that the medication was administered but that it was not included on the February 2025 MAR. The February 2025 MAR for the resident contains documentation that the medication was administered to the resident on 02/26/2025 at 8:00AM; however, interview with staff person 1 stated that the medication was administered at 6:00AM. The March 2025 MAR contains documentation that the aforementioned medication was administered to the resident daily at 8:00AM from 03/01/2025 to 03/13/2025 and 03/15/2025 to 03/31/2025; however, interview with staff person 1 revealed that the resident was administered this medication at 6:00AM and 8:00AM was documented in error.
Plan of correction
The administrator and nurse will double-check the MAR with the physician orders to ensure all information is correct in both places. We will also review with all the medication aides to make sure all information is correct to prevent documentation errors. This began 4/28/2025 and will continue with each new MAR or medication.
January 7, 2025Inspection0 violations
Inspection dates
01/07/2025
Areas reviewed
22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 01/07/2025 11:05AM to 11:23AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 13, 2024Inspection8 violations
Inspection dates
11/13/2024
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 GROUNDS22VAC40-73 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 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: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2024 7:45AM to 12:15PM 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: 16 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: morning medication administration, medication storage, breakfast 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-210-F
Based on staff record review and staff interview, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention and when adults with mental impairments reside in the facility, at least four of he required hours shall focus on topics related to residents’ mental impairments.
Evidence
  1. The record for staff person 1, date of hire 09/10/1975, did not contain documentation that staff person 1 had at least two hours of infection control and prevention training and at least four hours of training on topics related to residents’ mental impairments during the training year 09/10/2023 to 09/09/2024. Interview with staff person 5 confirmed this is accurate.
Plan of correction
Administrator will work to ensure all direct care staff receive infection control training (2hrs) and cognitive impairment training (4hrs) in their 18 hours of yearly training. We will have staff watch a video provided by the instructor on infection control to be completed by all staff in the next 30 days.
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. The record for staff person 1, date of hire 09/10/1975, did not contain documentation that staff person 1 had at least 18 hours of training during the training year 09/10/2023 to 09/09/2024. Interview with staff person 5 confirmed this is accurate.
Plan of correction
Administrator will work to ensure all direct care staff receive 18 hours of training each year. The staff member has been added to Relias and will begin training immediately.
22VAC40-73-325-A
Based on resident record review and staff interview, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive individualized service plan is completed, a written fall risk rating shall be completed.
Evidence
  1. Resident 1 was admitted to the facility on 09/27/2024. Interview with staff person 4 confirmed the resident is assisted living level of care.
  2. The record for resident 1 does not contain a written fall risk rating. Interview with staff person 4 confirmed this is accurate.
Plan of correction
Administrator will work to ensure all new admissions have a fall risk completed with their comprehensive ISP.
22VAC40-73-620-A
Based on facility document review and staff interview, the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.
Evidence
  1. Facility documentation indicated the last oversight of resident special diets was conducted on 01/12/2024. Interview with staff person 5 confirmed this is accurate.
Plan of correction
Administrator will work with our dietitian to ensure that oversight is completed every 6 months. Will call and schedule consult in the next 30 days.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for staff person 2, date of hire 01/29/2024, contains a certificate that the staff person completed first aid training on 11/12/2024. Interview with staff person 5 revealed that staff person 2 was not certified in first aid until 11/12/2024.
Plan of correction
Administrator will work to get new staff enrolled in CPR/first aid within 60 days of hire. Staff received first aid Nov. 12 2024.
22VAC40-73-1030-B
Based on staff record review and staff interview, the facility failed to ensure within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment.
Evidence
  1. Interview with staff persons 4 and 5 revealed that the facility has in care residents who have cognitive impairments.
  2. The record for staff person 2, date of hire 01/29/2024, does not contain documentation that staff person 2 attended six hours of training in working with individuals who have a cognitive impairment within four months of their start date of employment. Interview with staff person 5 confirmed this is accurate.
Plan of correction
Administrator will work to ensure all direct care staff receive annual training in working with individuals with cognitive impairments and will also work to make sure this happens in the correct time frame. A class has been scheduled for December 20th.
22VAC40-90-40-B
Based on staff record review and staff interview, 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. The record for staff person 3, date of hire 09/13/2024, did not contain a criminal history record report. Interview with staff person confirmed this is accurate.
Plan of correction
Administrator will review new hire files and check for completion of all documents before reaching their 30 days of employment. Background information faxed 11/18/2024.
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110 for private pay individuals.
Evidence
  1. The UAI for resident 1, dated 09/23/2024, does not indicate on page 2 whether the resident is residential living or assisted living level of care. Interview with staff person 4 revealed the resident is assisted living level of care.
Plan of correction
UAI for resident 1 will be updated on 11/19/2024
January 17, 2024Inspection1 violation
Inspection dates
01/17/2024
Areas reviewed
22VAC40-73 PERSONNEL
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: Phone call held on 01/17/2024 with facility. The Acknowledgement of Inspection form was emailed to the facility for signature. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-150-B-6
Based on collateral documentation and staff interview, the facility is currently being operated by an acting administrator for longer than 150 days.
Evidence
  1. The licensing inspector (LI) had been informed by Collateral 1 via email on 07/31/2023 that staff person 1 was accepted into the administrator in training (AIT) program and would become the acting administrator of the facility starting 08/07/2023; therefore, from 08/07/2023 staff person 1 would only have 150 days to be the facility’s acting administrator.
  2. During phone call with staff person 1 on 01/17/2024, staff person 1 verified to the LI that they are still the facility’s acting administrator.
Plan of correction
Staff person 1 will proceed to have all paperwork completed, become registered and take the NAB. Staff 1 will work diligently to ensure a passing score and strive to become the licensed administrator in a time frame of no longer than 60 days.
December 13, 2023Inspection5 violations
Inspection dates
12/13/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE 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 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: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/13/2023 8:50AM until 2:00PM 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: 14 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: breakfast and noon-time meals, activities, medication passes, medication audit. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 5 was admitted to the facility on 04/07/2023 and resident 6 was admitted to the facility on 03/23/2023. During on-site inspection on 12/13/2023, the records for residents 5 and 6 contained Virginia State Police sex offender registry searches dated 10/23/2023 for both residents 5 and 6. Interview with staff person 1 confirmed that this was accurate.
Plan of correction
Sex offender registry searches will be done as part of admission before resident arrives at facility. Will correct with future admissions.
22VAC40-73-250-D
Based on staff record review and staff interview, the facility failed to ensure each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: Staff person 5 was hired on 05/31/2022. During on-site inspection on 12/13/2023, the most recent TB screening in the record for this staff person was dated 06/03/2022. Interview with staff person 1 confirmed that this was accurate.
Plan of correction
Staff person #5 had TB screening on 12/2/2023. The administrator will ensure TB screenings are completed on time.
22VAC40-73-550-G
Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual.
Evidence
  1. During on-site inspection on 12/13/2023, the record for resident 2 contained documentation that the most recent review of the rights and responsibilities of residents in assisted living facilities for the resident was 08/23/2022. Interview with staff person 1 confirmed that this was accurate.
Plan of correction
Administrator will ensure annual review with family is done annually.
22VAC40-73-650-C
Based on resident record review, the facility failed to ensure physician’s or other prescriber’s oral orders shall be reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. During on-site inspection on 12/13/2023, the record for resident 2 contained the following telephone/verbal/oral orders taken by staff person 6 dated 08/08/2023, 08/22/2023, 09/28/2023 and 11/09/2023.
  2. The aforementioned orders did not contain documentation that a physician or other prescriber reviewed and signed them within 14 days.
Plan of correction
Nurse will work with Household MD to get verbal telephone orders signed within 14 days of being written. All orders reviewed with Dr. and signed. Completed 12/21/2023
22VAC40-73-720-A
Based on resident record review, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest is included in the individualized service plan (ISP).
Evidence
  1. During on-site inspection on 12/13/2023, the record for resident 6 contained a signed DNR, dated 08/23/2023 order; however, the ISP for the resident, dated 03/23/2023, did not contain documentation that the resident has a DNR order.
Plan of correction
Resident #6 ISP has been updated and corrected.
July 27, 2023Inspection1 violation
Inspection dates
07/27/2023
Areas reviewed
22VAC40-73 PERSONNEL
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: 07/27/2023 via phone call with a representative for the facility. The Acknowledgement of Inspection form was e-mailed to the facility representative. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-150-A
Based on collateral interview, the facility failed to ensure to have an administrator of record.
Evidence
  1. The licensing inspector (LI) for the facility received a phone call from Collateral 1 on 06/29/2023 and a follow-up email on 07/03/2023 that staff person 1 is no longer the administrator of record for the facility effective 06/30/2023.
  2. Phone interview with Collateral 1 on 07/27/2023 revealed that the facility has not had an administrator of record since 06/30/2023.
Plan of correction
Night supervisor and Administrator-in-training (AIT) will assume role as administrator of record week of August 7-11.
January 10, 2023Inspection0 violations
Inspection dates
01/10/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date of inspection and time of the inspection 1/10/2023. This inspection was conducted to follow-up on high-risk violations cited during the facility's renewal inspection that was conducted on 12/06/2022. 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.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
December 6, 2022Inspection12 violations
Inspection dates
12/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE 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 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: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 12/06/2022 9:20AM until 12:45PM. 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication audit and medication pass 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1030-B
Based on staff record review and staff interview, the facility failed to ensure a direct care staff person attended six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment.
Evidence
  1. The record for staff 2, date of hire 05/31/2022, did not include documentation of training within the first four months of employment pertaining to working with residents who have a cognitive impairment. Interview with staff 4 confirmed this was accurate.
Plan of correction
The staff member was signed up for online training to the required six hours of training in working with individuals who have a cognitive impairment. To be completed by Jan. 1, 2022
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that physical examinations were obtained within 30 days prior to the date of admission.
Evidence
  1. The physical examination in the record for resident 4, admitted on 08/27/2022, has documentation that the actual examination was completed was 06/10/2022.
Plan of correction
An administrative meeting was held to review the admission process. The focus of the meeting was the history and physical. Steps were put into place to ensure that there is proper documentation of physical examinations. 12/8/2022
22VAC40-73-350-B
Based on resident record review, the facility failed to document in resident records, prior to admission, that the facility ascertained residents were not registered sex offenders.
Evidence
  1. Resident 3 was admitted to the facility on 08/25/2022 and resident 4 was admitted to the facility on 08/27/2022; however, the Virginia State Police search that was in the record for the resident did not contain the date that the search was conducted.
Plan of correction
Virginia State Police sex offender record will be printed in portrait mode instead of landscape so it will include the date of the search Date: 12/8/2022
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The record for resident 1 has documentation that the resident has allergies to Amoxicillin and Aricept. The ISP for resident 1, dated 11/29/2022, contains documentation of the allergies listed at the top of the form but does not include information on services to be provided, who, when and where services will be provided and the expected outcome.
  2. The uniform assessment instrument (UAI) dated 10/21/2022 in the record for resident 2 contains documentation that the resident requires mechanical and human help assistance with transferring. Interview with staff 4 expressed that the UAI is correct. The ISP dated 10/23/2022 in the record for resident 2 does not address this identified need.
  3. The ISP for resident 3, dated 08/25/2022, indicated that the resident has physical therapy ordered by a physician; however, interview with staff 4 revealed that the resident does not receive physical therapy.
Plan of correction
1. Record was updated to include allergies documented in the correct section of the ISP 2. ISP was updated to include the need for assistance with transferring 3. The ISP was updated to not include physical therapy Date: 12/8/2022
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure a direct care staff member obtained first aid certification within the first 60 days of employment.
Evidence
  1. The record for staff 2, date of hire 05/31/2022, contained documentation that the staff person did not obtain first aid certification until 11/09/2022. Interview with staff 4 confirmed this was accurate.
Plan of correction
The administration will ensure that direct care staff will be certified in CPR and First Aid in the first 60 days of employment. 12/10/2022
22VAC40-73-120-A
Based on staff record review, the facility to ensure that orientation for new staff was completed within the first 7 working days of employment.
Evidence
  1. The record for staff 1, date of hire 09/19/2022, did not contain documentation of an orientation as of the day of inspection.
Plan of correction
Administration located the orientation form signed by the staff member and filed it in the correct employee file. 12/8/2022
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure a medication was administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 5 has an order for “Digoxin 0.125MG tablet take two tablets by mouth every morning for heart. Hold if pulse is below 60”. The November 2022 medication administration record (MAR) for the resident indicated that the resident’s pulse was 56 on 11/24/2022; however, the MAR indicated that the aforementioned medication was administered to the resident.
Plan of correction
An in-service training was done with the RMAs by the nurse manager. The main focus of training was reading physician’s orders and documentation. Date: 12/10/2022
22VAC40-73-950-E
Based on document review, the facility failed to ensure a semi-annual review of the facility’s emergency preparedness and response plan was conducted for residents.
Evidence
  1. The facility’s semi-annual review of it’s emergency preparedness and response plan, conducted on 06/17/2022, was not completed with residents. Interview with staff 4 confirmed this was accurate.
Plan of correction
A plan for the facility to review the emergency preparedness and response plan was made. A designated staff person will meet with the legal representative of each resident, every six months, to review the emergency plan To be corrected by Jan 31, 2022
22VAC40-73-200-D
Based on staff record review and staff interview, the facility failed to obtain a copy of the certification issued or other documentation indicating that the staff person has met the requirements to be employed as a direct care staff.
Evidence
  1. Interview with staff 4 indicated that staff 2 is a personal care aide and that staff 4’s date of hire was 05/31/2022. The record for staff 2 did not contain a copy of the certification issued or other documentation indicating that staff 2 has obtained the required training to be employed as a personal care aide in an assisted living facility. As of 12/08/2022, the aforementioned documentation was still not received from the facility.
Plan of correction
Staff member is enrolled in direct care class which will completed by 12/16/2022
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure an individualized service plan (ISP) for a resident was signed by the resident or his legal representative.
Evidence
  1. The ISP for resident 5, with a review date of 11/05/2022, was not signed by the resident or the resident’s legal representative.
Plan of correction
ISP for resident 5 was mailed to legal representative for signature Date: 12/8/2022 To be corrected by Jan. 1, 2022
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 2 was hired 05/31/2022; however, the results of a criminal record report for the staff person were not received until 09/16/2022.
Plan of correction
Administration cleared up the clerical error with the VA State Police to continue to be able to submit criminal record checks. Administration will ensure that criminal record checks are complete prior to the 30th day of employment. 12/8/2022
22VAC40-73-210-B
Based on staff record review, the facility failed to ensure that direct care staff received 18 hours of training annually.
Evidence
  1. The record for staff 3, date of hire 06/10/2019, did not contain documentation of staff 3 receiving the required 18 hours of annual training from 06/10/2021 through 06/10/2022.
Plan of correction
Staff member will have all 18 hours of annual training by June 10, 2023 which is the anniversary of hire. 12/8/2022
February 17, 2022Inspection1 violation
Inspection dates
02/17/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A focused non-mandated, monitoring inspection was initiated on 02/17/2022 and concluded on 02/17/2022 to follow-up on high risk violations cited during the facility's renewal inspection. The licensing inspector (LI) contacted the facility via phone and spoke with the Nurse Manager regarding reviewing information needed to conduct the inspection. An exit interview was conducted with the Nurse Manager via phone 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. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that the medication administration record (MAR) included all required information.
Evidence
  1. The record for resident 1 contained a physician's order, dated 12/16/2021, with the following information: "change digoxin to 125 mcg take 2 tabs (0.25mg) by mouth every morning for heart. Hold if pulse <60. MD to review bpm readings at 6 month reviews. Contact MD if bpm is < 40." The February 2022 MAR for the resident did not contain information for staff to contact MD if bpm is <40.
Plan of correction
Pharmacy printed new MAR with correct MD order.
December 15, 2021Inspection17 violations
Inspection dates
12/15/2021
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 1Subjectivity32.1 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
Technical assistance
To ensure that the facility had a thorough understanding of the standards, the two licensing inspectors and the Nurse Manager had a discussion regarding standards 450-F, 550-G, 650-A, 940-A and 980-A.
Comments
The licensing inspector (LI) for Blue Ridge Christian Home, along with another LI, conducted an unannounced renewal study on 12/15/2021 from 9:30am until 1:30pm, finding 13 residents in care. The inspection included a tour of the physical plant, observation of two medication passes, review of the medication storage and resident interviews. Six resident records were thoroughly reviewed, and an additional two were partially reviewed in relation to the observation of the medication pass. Sworn disclosure statements and criminal record checks were examined for all newly hired staff still employed since the facility's last mandated inspection, and the records of three staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Nurse Manager 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. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-90-30-B
Based on staff record review, the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment.
Evidence
  1. The record for staff 3, date of hire 09/24/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 09/29/2021. The record for staff 4, date of hire 06/08/2021, contained documentation that the sworn statement or affirmation was completed after the date of hire on 06/10/2021. The record for staff 5, date of hire 12/07/2021, contained documentation that the sworn statement or affirmation was completed; however, the document did not include the date it was completed by staff 5.
Plan of correction
Administrator will ensure all paperwork for New Hire will be completed before staff is put on schedule. Review of regulations for applicants for employment was done by nurse manager with staff responsible for application processing.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid received certification in first aid within 60 days of employment.
Evidence
  1. The record for staff 4, date of hire 06/08/2021, contained documentation that staff 4 did not contain certification in first aid until 10/27/2021 which was not within 60 days of employment. Interview with staff 1 confirmed this was accurate.
Plan of correction
2 staff members without CPR/First Aid will be enrolled in class by Dec 31, 2021.
22VAC40-73-680-D
Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all medications were administered in accordance with physician instructions.
Evidence
  1. The record for resident 1 has a physician order dated 11/05/2021 for Digoxin 125mcg, 2 tablets every morning for heart, hold if pulse is less than 60 or greater than 110 and call MD. The December 2021 MAR for resident 1 has documentation of the resident’s pulse being 60 at 8am on 12/01/2021. Staff initials are signed as not administering this medication at 8am on 12/01/2021 even though the resident’s pulse was not less than 60.
Plan of correction
In service on Medication Admin. was done on 12/16/21. In service focused on reading MD orders and proper documentation.
22VAC40-80-120-E-2
Based on observation and staff interview, the facility failed to ensure that the findings of the most recent inspection of the facility was posted.
Evidence
  1. The findings from the facility's most recent inspection, dated 11/19/2020, was not posted in the facility. Interview with staff 1 confirmed that the findings were not posted.
Plan of correction
A copy of the most recent inspection of facility was posted - a copy of the most recent inspection will be posted outside of business office.
22VAC40-73-700-2
Based on observation and staff interview, the facility failed to post "No Smoking-Oxygen in Use" signs when oxygen therapy is provided.
Evidence
  1. One licensing inspector (LI) observed resident 1 using oxygen during the day of inspection. There were no "No Smoking-Oxygen in Use" signs posted within the facility. Interview with staff 1 confirmed that there were no "No Smoking-Oxygen in Use" signs within the facility.
Plan of correction
No smoking - oxygen in use sign has been posted at bedroom door and posted in common areas where O2 is in use.
22VAC40-73-350-B
Based on a review of resident records, the facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.
Evidence
  1. The record for resident 1, admitted on 11/5/2021 has documentation that a sex offender screen was not completed until 11/18/2021.
  2. The record for resident 3, admitted on 01/26/2021 has documentation that a sex offender screen was not completed until 7/23/2021.
  3. The record for resident 4, admitted on 7/27/2021 has documentation that a sex offender screen was completed on 12/31/2019.
Plan of correction
Sex offender screenings for residents will be part of admission paperwork before resident admit date.
22VAC40-73-860-I
Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. Interview with staff 1 confirmed that the facility is a mixed population that includes residents with serious cognitive impairments.
  2. At approximately 9:48AM during the tour of the facility's physical plant, the door to the laundry room was found to be unlocked by one licensing inspector (LI). A container of "Dreumex Disinfecting wipes", a container of "latex seam sealer", and a container of "releasable pressure sensitive adhesive" were noted to be located in the laundry room.
Plan of correction
Disinfecting wipes will be kept in locked cabinet in laundry room with other cleaning supplies. Seam sealer and adhesive were returned to contractor. In service done with all staff to ensure that in the future, all hazardous materials and cleaning supplies are kept in a locked cabinet.
22VAC40-73-250-D
Based on staff record review and staff interview, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a tuberculosis (TB) risk assessment.
Evidence
  1. The record for staff 3, date of hire 09/24/2021, contained documentation that staff 3 did not obtain the results of a TB risk assessment until 10/18/2021. Interview with staff 1 confirmed that this was accurate.
Plan of correction
TB risk assessments will be done by the office of the facility's medical director to ensure the results are submitted to facility.
22VAC40-73-450-F
Based on a review of resident records, the facility failed to update resident individualized service plans (ISPs) to address all identified needs.
Evidence
  1. A fall risk-rating tool dated 01/26/2021 in the record for resident 3 has documentation that the resident is a high risk for falls. The uniform assessment instrument (UAI) dated 01/25/2021 in resident 3’s record has documentation that the resident requires physical assistance with transfers and that the resident is disoriented to some spheres some of the time with place and time being the spheres affected. Interview with staff 1 expressed that these needs are correct. The ISP dated 01/26/2021 in the record for resident 3 does not address these identified needs.
  2. A fall risk-rating tool dated 02/16/2021 in the record for resident 5 has documentation that the resident is a high risk for falls. The UAI dated 02/16/2021 in resident 5’s record has documentation that the resident is disoriented to some spheres some of the time with person, place and time being the spheres affected. Interview with staff 1 express that these needs are correct. The ISP dated 03/12/2021 in the record for resident 5 does not address these identified needs.
Plan of correction
ISP will be corrected and submitted to oversight nurse.
22VAC40-73-200-D
Based on staff record review and staff interview, the facility failed to obtain a copy of the certificate issued or other documentation that indicated that the person has met one of the requirements of standard 200-C 1 through 8.
Evidence
  1. The record for staff 2, date of hire 09/24/2021, did not contain a copy of the certificate issued or other documentation indicating that staff 2 has met one of the requirements of 200-C 1 through 8. Interview with staff 1 confirmed that this was accurate.
Plan of correction
Staff member has been enrolled in direct care class. Adm. will obtain a copy of applicant's certificate before hiring or enroll applicant in direct care class upon hiring.
22VAC40-73-560-I
Based on a review of resident records, the facility failed to ensure that a resident photo or current narrative description was in the record.
Evidence
  1. The record for resident 1, admitted on 11/05/2021, did not contain a photo or narrative description of the resident on the day of inspection.
Plan of correction
A photo has been added to resident's chart. If a photo isn't available upon admission, a narrative description will be added to record until a photo is taken.
22VAC40-73-390-A
Based on a review of resident records, the facility failed to ensure all required information was included in resident agreements.
Evidence
  1. The signed resident agreements in the records for residents 1, 3 and 4 do not contain all information that is required by this standard.
Plan of correction
Resident agreement form will be updated.
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure all direct care staff attended at least 18 hours of annual training.
Evidence
  1. The record for staff 2 did not contain documentation that staff 2 had attended 18 hours of annual training for year of 09/10/2020 through 09/09/2021. Interview with staff 1 confirmed that this was accurate.
Plan of correction
All staff will be caught up with training. Facility signed up with online training agency.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The records for staff 3, date of hire 09/24/2021 and staff 4, date of hire 06/08/2021, did not contain a criminal history record report. Interview with staff 1 confirmed that the facility did not have criminal history records for staff 3 and 4.
Plan of correction
Facility signed up with VA state police to do criminal record checks. Adm. to ensure criminal record checks are completed on or prior to 30th day of employment.
22VAC40-73-1030-B
Based on staff record review and staff interview, the facility failed to ensure that all direct care staff attended six hours of training in working with individuals who have a cognitive impairment within four months of the stating date of their employment.
Evidence
  1. Interview with staff 1 confirmed that the facility does have in care residents that have cognitive impairments.
  2. The record for staff 4, date of hire 06/08/2021, did not contain six hours of training in working with individuals who have a cognitive impairment. Interview with staff 1 confirmed that this was accurate.
Plan of correction
Facility has signed up w/ online training agency. All staff will be current with training.
22VAC40-73-450-G
Based on resident record review, the facility failed to ensure that the master individualized service plan (ISP) was filed in resident records.
Evidence
  1. The record for resident 1, admitted on 11/5/2021, did not contain an ISP for this resident.
Plan of correction
ISP will be returned to resident record. A copy of the ISP to be signed will be mailed but the original will remain in chart.
22VAC40-73-650-E
Based on a review of resident records, the facility failed to ensure that physician orders were filed in resident records.
Evidence
  1. Resident 1 was observed receiving 2 liters of oxygen via a nasal cannula and an oxygen tank on the day of inspection. The record for resident 1 did not contain a physician order for the use of oxygen.
Plan of correction
A copy of the O2 order has been added to resident's record.
November 19, 2020Inspection6 violations
Inspection dates
Nov. 19, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 SANCTIONS
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 11/19/2020 and concluded on 11/24/2020. The designated person in charge was contacted by telephone to initiate the inspection. The designated person in charge reported that the current census was 12. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedule, fire and emergency drills, and most recent fire inspection submitted by the facility to ensure documentation was complete. The ensure that the facility has a thorough understanding of the standards, the LI had a discussion with the designated person in charge regarding standards 270, 320 A and 690 B. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-270-1
Based on staff record review and staff interview, the facility failed to ensure that training prior and annually for staff in assisted living facilities that accept, or have in care, residents who are or who may have aggressive behavior included demonstration in self-protection and in the prevention and de-escalation of aggressive behavior.
Evidence
  1. The record for staff 1, date of hire 10/14/2017, did not contain documentation of annual training that staff 1 had demonstration in dealing with residents who may have aggressive behavior for the training year 10/14/2019 through 10/13/2020.
  2. The record for staff 2, date of hire 09/30/2020, did not contain documentation that staff 2 had demonstration in dealing with residents with aggressive behavior prior to working with residents who may have aggressive behavior.
  3. Interview with staff 3 confirmed that staff 1 and 2 did not complete the required demonstration portion of the training.
Plan of correction
Annual training updated to include dealing with aggressive behaviors - including a demonstration - All staff will have this training now and their annually.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure the physical examination was completed as required prior to a resident’s admission.
Evidence
  1. The “REPORT OF ELDERLY PHYSICAL EXAMINATION” for resident 1, dated 07/28/2020, did not contain whether the resident is or is not capable of self-administering medication.
Plan of correction
Admission H&P form has been updated to include whether a resident is capable of self adm. meds
22VAC40-73-320-B
Based on resident record review and staff interview, the facility failed to ensure that tuberculosis (TB) testing was completed annually for residents.
Evidence
  1. The record for resident 2, admitted on 07/02/2018, contained documentation that the most recent TB test completed for resident 2 was on 11/30/2018.
  2. Interview with staff 3 confirmed that resident 2 did not have a TB test completed in 2019.
Plan of correction
TB screenings will be done with six month med reviews by household doctor
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed as required.
Evidence
  1. The private pay uniform assessment instrument (UAI) for resident 2, dated 09/10/2020, showed the resident needs assistance with dressing but does not indicate what kind of assistance with dressing the resident needs.
  2. Interview with resident 3 revealed that resident 2 needs mechanical and physical assistance with dressing.
Plan of correction
UAI has been updated - all other UAI's and ISP have been reviewed
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs.
Evidence
  1. The private pay uniform assessment instrument (UAI) for resident 2, dated 09/10/2020, showed the resident has weekly or more bowel incontinence and the resident needs mechanical help with mobility. The ISP for resident 2 does not include these identified needs.
  2. The private pay UAI for resident 2, dated 09/10/2020, showed the resident needs mechanical help and physical human help with toileting. The ISP, with an identified need date of 09/10/2020, showed the resident needs ?mechanical assistance of grab bar when toileting?. Interview with staff 3 revealed that the UAI is correct, and the ISP is incorrect.
  3. Interview with staff 3 revealed that resident 2 has a DNR order. The ISP for resident 2 does not address that resident 2 has a DNR order.
Plan of correction
ISP has been updated to address the identified needs
22VAC40-73-690-B
Based on resident record review and staff interview, the facility failed to ensure that for each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, performed a review every six months of all the medications of the resident.
Evidence
  1. The private pay uniform assessment instrument (UAI) for resident 2, dated 09/10/2020, showed that the resident was assessed as assisted living level of care and needs medications administered by a lay person.
  2. The record for resident 2, admitted on 07/02/2018, contained documentation that the last six month review of medications for the resident was conducted on 11/19/2019.
  3. Interview with staff 3 confirmed that the last medication review conducted for resident 2 was on 11/19/2019.
Plan of correction
Facility working with medical director to do six month medication reviews