Virginia DSS · Assisted Living Facility

Woods Cove Assisted Living

📍 201 W. Criser Road, Front Royal, VA, 22630

ID 24389Two Year licenseActive
8
Inspections
On record
7
With violations
Visits that cited something
1
Clean visits
Nothing cited
42
Violations cited
Individual findings
37
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Woods Cove Assisted Living was inspected 8 times between February 25, 2021 and January 13, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 42 violations under 37 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. 7 of these 8 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
04/02/2027
Administrator
Jonathan (Jack) Norris
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

8

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

January 13, 2026Complaint survey16 violations
Inspection dates
01/13/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (16) Protection of adults and reporting22VAC40-80 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: January 13, 2026, from 9:04 a.m. until 2:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/22/2025 regarding allegations in the area(s) of: Resident Care and Related Services/ Buildings and Ground Number of residents present at the facility at the beginning of the inspection: 38 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Licensing inspector toured the community, reviewed resident record, including MAR, and interviewed staff. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to ensure that a fall risk rating was reviewed and updated after every fall.
Evidence
  1. Record for resident 1, admitted 09/07/2021 to assisted living level of care, contained three fall risk ratings dated 02/28/2024, 08/28/2024, and 03/03/2025.
  2. Review of resident 1’s record and communication log indicated resident 1 had a total of 31 documented falls from 02/15/2025 until 01/08/2026, with 14 of those falls occurring in December 2025, with no additional fall risk ratings completed.
  3. During an interview with the LI on 01/13/2026, staff 1 was asked about fall risk ratings being completed after each fall. Staff 1 acknowledged the facility did not review and update the fall risk rating after every fall as required.
Plan of correction
Staff were trained to complete a fall risk assessment after each resident fall. The completed fall risk assessments will be filed in the residents' chart.
22VAC40-73-930-B
Based on staff interviews and a tour of the facility, the facility failed to ensure there was a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During a tour of the facility on 01/13/2026, the LI did not observe any signaling devices in the facility.
  2. During an interview with the LI on 01/13/2026, staff 1 was asked about the signaling device system. Staff 1 acknowledged the building did not have a signaling device system and stated, “that one resident in assisted living had a hand bell that she rang when she needed assistance”.
  3. During an interview with the LI on 01/13/2026, staff 5 was asked how residents let staff know they needed help since the facility did not have a signaling device system. Staff 5 stated, “two residents on assisted living had hand bells they rang when they needed assistance. The other residents come up to staff and ask for help”.
  4. During an interview on 01/13/2026 with LI, staff 4 was asked about the requirements for a signaling device system. Staff 4 acknowledged the facility did not have a working signaling device system.
Plan of correction
The signaling device was determined by its manufacturer to be obsolete and that repairs/additional devices are no longer produced. Residents are on a two-hour check, and have been given hand bells, until a new signaling device can be installed.
22VAC40-73-1180-B
Based on observation and staff interviews, the facility failed to ensure that ordinary materials or objects which might be harmful to a resident were inaccessible in the safe, secure unit except under staff supervision.
Evidence
  1. During the facility tour on 01/13/2026, LI observed an unattended cleaning cart on the secure care unit with accessible bottles of cleaning liquids, including Clorox toilet cleaner, Scrubbing Bubbles, Tilex, Lysol, and other chemicals in spray bottles. Cleaning carts were open design and did not have a way to lock chemicals when unattended.
  2. During the facility tour on 01/13/2026, LI observed Dove bodywash, Tresemme shampoo, Luxury shaving cream, and body lotion in an unlocked bathroom on the secure care unit.
  3. Communication log dated 12/10/2025 documented resident 4 cut thumb on razor while shaving. Resident 4 resides in the secure care unit and should not have had access to a razor.
  4. During the facility tour of the secure care unit on 01/13/2026, LI observed an electronic cigarette in the desk drawer in the living room common area.
  5. During an interview with the LI on 01/13/2026, staff 3 stated the electronic cigarette belonged to resident 2.
  6. During an interview with LI on 01/13/2026, staff 4 acknowledged the facility failed to store cleaning supplies and other hazardous materials in a locked area and stated there was no way to secure the chemicals on the cleaning carts when unattended. Staff 4 also stated the electronic cigarette belongs to resident 2 but should be secured, not left in the desk drawer.
  7. Photo evidence taken.
Plan of correction
Housekeeping staff were informed that their carts cannot be left unattended in the hallway and that they must be put away. All staff were informed that memory care residents cannot be given a razor to shave. A wall dispenser for shampoo and body wash has been installed
22VAC40-73-210-B
Based on record review, the facility failed to ensure all direct care staff attended at least 18 hours of training annually.
Evidence
  1. LI requested staff training records/transcripts for staff 3 and staff 6 from staff 4.
  2. Staff 3, hired date 04/15/2007, had no documented annual training for year 2025.
  3. Staff 6, hire date 03/22/2019, had no documented annual training for year 2025.
  4. Staff 4 confirmed that staff 3 and staff 6 did not have any documented training in 2025.
Plan of correction
Staff are currently working on their annual training on Relias. The goal is to have all staff have complete all 18 hours of their annual requirement within the next 60 days.
22VAC40-73-520-E
Based on record review and staff interview, the facility failed to ensure at least 14 hours of scheduled activities were available to the residents each week for no less than one hour each day.
Evidence
  1. During the facility tour on 01/13/2026, there was no schedule of activities posted in the facility.
  2. During the inspection on 01/13/2026 no activities were observed in the facility.
  3. During an interview with staff 4 when asked if there were scheduled activities for the residents, staff 4 stated, “No, the activity director’s last day worked was 12/21/2025. Staff 4 confirmed no scheduled activities had occurred since 12/21/2025 other than a Christmas and New Year’s celebration.
Plan of correction
The activities director had taken personal leave without notice. The activities director has since returned.
22VAC40-73-460-F
Based upon a review of records and collateral contact and staff interviews, the facility failed to document in the resident record notification to the legal representative, designated contact person, or if applicable, any responsible social agency, of resident fall and must include date, time, caller, and person or agency notified.
Evidence
  1. During review of resident 1’s record and the facility communication log on 01/13/2026, there were a total of 31 documented falls for resident 1 from 02/15/2025 until 01/13/2026.
  2. The regional licensing office did not receive self-reported incidents for 29 of resident 1’s falls for the following dates: 02/15/2025, 02/17/2025, 04/01/2025, 05/01/2025, 09/11/2025, 10/09/2025, 10/14/2025, 11/21/2025, 12/10/2025 (2 falls), 12/11/2025, 12/12/2025 (2 falls), 12/13/2025, 12/15/2025, 12/16/2025 (2 falls), 12/18/2025, 12/19/2025, 12/22/2025, 12/25/2025, 12/31/2025, 01/04/2026, 01/06/2026 (3 falls), 01/07/2026 01/08/2026, and 01/13/2026.
  3. On facility accident/incident reports dated 02/15/2025, 02/17/2025, 04/01/2025, 05/01/2025, 09/11/2025, 10/09/2025, 10/14/2025, 12/31/2025, 01/04/2026,01/06/2026, 01/10/2026, and 01/11/2026, there was no indication the POA was notified.
  4. On facility accident/incident reports dated 10/14/2025, 11/21/2025, and 01/04/2026, there was no indication Hospice was notified.
  5. During an interview with LI on 01/12/2026, collateral contact 1 stated that Hospice would notify her if resident 1 had a fall if Hospice had been notified. Collateral contact 1 stated she was not notified directly of resident 1’s falls. Collateral contact 1 went on to state that on two occasions (02/15/2025 and 10/14/2025) the hospital had called to ask about resident 1’s code status and for permission to treat and that was how she had been made aware that resident 1 was injured from a fall.
  6. During interview with LI on 01/13/2026, staff 4 acknowledged the facility failed to notify all required parties and document the notification of a resident fall whether the fall resulted in an injury or not.
Plan of correction
Staff were trained in contacting the legal guardian after each major incident, such as falls, transport to the hospital, etc. All communication, such as call logs, will be documented
22VAC40-73-460-G
Based on staff interviews and observations, the facility failed to ensure care and services to each resident were provided by staff who are able to communicate with the resident in a language the resident understands to ensure an accurate exchange of information.
Evidence
  1. During the tour of the secure care unit on 01/13/2026, collateral contact 2 and 3 and LI were approached by residents 5 and 6. Both residents 5 and 6 were non-English speaking residents and were attempting to communicate.
  2. During an interview with LI on 01/13/2026, staff 2 was asked how the staff communicates with residents 5 and 6. Staff 2 stated, “They understand what we say but we don’t always understand them.” Staff 2 was asked how they were sure the residents understood them, staff 2 responded “resident 5 will do what we ask” but did not clarify how staff knew resident 6 understood their communication.
  3. During interview with LI on 01/13/2026, staff 1 was asked how they communicate with residents 5 and 6. Staff 1 stated that according to resident 6’s family, what she is saying does not make sense. Staff 1 stated that for resident 5, “I kind of figure out what he is saying. He understands us but we don’t understand him.”
  4. During interview with the LI on 01/13/2026, staff 4 was asked how staff communicate with residents with language barriers and if there was a system in place. Staff 4 confirmed the facility did not have a system.
Plan of correction
Additional communication boards in residents' native language were purchased. The residents in question respond appropriately to commands in English. This was documented on their respective ISPs.
22VAC40-73-450-F
Based on resident record reviews and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 1, admitted 09/07/2021 to assisted living level of care, contained a Do Not Resuscitate (DNR) order dated 03/08/2025. Resident 1’s ISP dated 07/01/2025 was not updated to reflect the DNR status until 08/08/2025.
  2. The record for resident 3, admitted 03/21/2023, contained an ISP dated 04/11/2024. When asked, staff 1 confirmed the 03/21/2023 ISP was the only ISP on hand.
  3. During an interview with the LI on 01/13/2026, staff 4 acknowledged the ISP for residents 1 and 3 had not been reviewed and updated at least every 12 months as required.
Plan of correction
All ISPs will be reviewed and will be updated if needed
22VAC40-73-870-A
Based on observation and staff interview, the facility failed to ensure that the interior of building was maintained in good repair and kept clean.
Evidence
  1. During the facility tour on 01/13/2026, LI observed a soiled wash basin under the assisted living side public restroom sink. The wash basin had brown residue on the bottom and sides. LI also observed a brown stain in the bottom of the sink vanity from a leaking pipe. Soiled socks and an old toothbrush were in the bottom cabinet of vanity. Four soiled wash clothes were in the bathroom.
  2. Resident 4’s bathroom located in the secure care unit had a strong odor of urine and the area surrounding the base of the toilet had a large yellow stain that appeared to be dried urine. Staff 2 acknowledged the restroom was soiled and requested housekeeping to clean.
  3. During an interview on 01/13/2026 with LI, staff 4 acknowledged that soiled linens were not handled appropriately in order to keep facility clean.
  4. Photo evidence taken.
Plan of correction
Laundry staff were informed that they must return the laundry baskets to the communal bathrooms in a prompt manner. This will ensure that soiled linens are placed within the laundry baskets instead of discarded on the floor.
22VAC40-73-710-C
Based on direct observation, record review, and staff interview, the facility failed to ensure if a restraint was used, that it was applied in accordance with a physician's written order and specified the condition, circumstances, and duration under which the restraint was to be used.
Evidence
  1. During the facility tour on 01/13/2026, LI observed a sounding bed alarm in resident 1’s room. Resident 1, who required two-person assist for repositioning and transfers, was in the living room seated in a high back wheelchair with the back reclined making it difficult for resident 1 to straighten/reposition himself or transfer from the wheelchair without assistance which restricted resident 1’s freedom of movement. Mechanism for adjusting the angle of recline on the wheelchair was inaccessible to resident 1.
  2. Record review for resident 1 did not contain a physician’s order for the bed alarm or the high back reclining wheelchair.
  3. During the facility tour on 01/13/2026, LI observed resident 3 in a Geri-Chair with the footrest elevated restricting the resident’s freedom of movement by making it difficult for the resident to exit/transfer from the chair independently when the footrest was elevated. Resident 3 also required two-person assist to reposition/transfer and was not able to lower the footrest of the Geri-Chair on command.
  4. Record review for resident 3 did not contain a physician’s order for the Geri-Chair.
  5. During an interview with staff 4, when asked if there was a physician’s written order for resident 1’s bed alarm and high back reclining wheelchair and resident 3’s Geri-Chair, staff 4 acknowledged they did not have the required physician orders.
  6. Photo evidence taken.
Plan of correction
Staff were informed that a reclining Geri-chair is a form of restraint if an ambulatory individual does not possess the ability to return the chair to its normal position and exit the chair. In the event that an ambulatory individual does not possess that ability to exit the chair, a physician's order is needed outlining the conditions of the restraint. The facility will work more closely with hospice services to see that these orders are in place.
22VAC40-73-870-E
Based on observation and staff interviews, the facility failed to ensure all equipment, was kept clean and in good repair and condition.
Evidence
  1. The foot board of resident 1’s bed had a large hole with sharp pieces of plastic accessible to the resident. During an interview on 01/13/2026, staff 4 stated the bed was broken when Hospice delivered it on 06/06/2025. The LI and Collateral Contact 2 observed the damaged footboard on 01/13/2026.
  2. The glass on the right side of the french doors leading out to the courtyard from the secure care unit was missing and replaced by a piece of unfinished plywood.
  3. During an interview on 01/13/2026 with LI, when asked how long the door glass had been broken, staff 2 and resident 2 stated it had been broken for about 2 years.
  4. During an interview on 01/13/2026 with LI, staff 4 stated that glass in the door had been broken since August 2025.
  5. Photo evidence taken.
Plan of correction
Replacement glass for the door arrived 3/19/2026, however the wrong size was delivered. Customer service was notified, and the correct size is expected to arrive 4/9/2026.
22VAC40-73-1150-B
Based on observation and staff interview, the facility failed to ensure there were protective devices on the bedroom and bathroom windows of residents and on windows in common areas accessible to residents in the safe, secure environment to prevent the windows from being opened wide enough for a resident to crawl through. The protective devices on the windows must be in conformance with the Virginia Uniform Statewide Building Code (13VAC5-63)
Evidence
  1. The facility is currently licensed as residential and assisted living care, with a 13-bed special care unit.
  2. During a tour of the secure care unit on 01/13/2026, the LI observed resident 4’s bedroom window was open wide enough for an individual to crawl through. There was no protective device on the window to prevent the window from opening all the way. The locking mechanism at the top did not work.
  3. During a tour of the secure care unit on 01/13/2026, collateral contact 3 and LI observed eight living room windows in the common area of the secure care unit that opened wide enough for an individual to crawl through. There were no protective devices on the windows to prevent them from opening all the way. The locking mechanism at the top did not work on several of the windows and the windows were secured with clear packing tape.
  4. During an interview on 01/13/2026 with the LI, staff 4 acknowledged the windows in resident 4’s bedroom and windows in the common area did not have protective devices as required.
  5. Photo evidence taken.
Plan of correction
A protective device on a resident window had been unknowingly removed by maintenance. The resident's window was connected to an interior, closed courtyard, and not to the outside premises. The device has been reinstalled. Protective window devices have been installed in the living room.
22VAC40-73-325-C
Based on resident record review and staff interview, the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls.
Evidence
  1. Resident 1, admit date 09/07/2021 to assisted living level of care, had a total of 31 documented falls from 02/15/2025 until 01/08/2026, with 14 of the falls occurring in December 2025.
  2. Record for resident 1 did not contain documentation of an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce the risk of subsequent falls.
  3. During an interview with the LI on 01/13/2026, staff 1 confirmed there was no documentation of an analysis of the circumstances of the falls and no interventions that were initiated to prevent or reduce the risk of subsequent falls as required.
Plan of correction
Staff were informed that the circumstances of each fall must be documented. The documentation can either be written on the eMAR or the lower border of the fall risk assessment.
22VAC40-73-460-D
Based on resident record review and staff and collateral contact interviews, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls.
Evidence
  1. A complaint received by the regional licensing office on 12/22/2025 alleged that resident 1 was observed with “3 big knots…going across his forehead” and his face was “really swollen”. Reporter alleged that when asked about the injuries, facility staff reported that resident 1 “falls…a lot”.
  2. During inspection on 01/13/2026, resident 1 was observed sitting in his wheelchair in the living room. Resident 1’s face still had some visible bruising and swelling.
  3. Review of resident 1’s record and communication log indicated resident 1 had a total of 31 documented falls from 02/15/2025 until 01/08/2026, with 14 falls occurring in December 2025.
  4. Record for resident 1, admitted 09/07/2021 to assisted living level of care, did not contain evidence of analysis of the circumstances of the falls or documented interventions to prevent or reduce the risk following any of the 31 falls.
  5. While at the facility on 01/13/2026, LI reviewed the communication log for the secure care unit.
  6. On 12/10/2025, communication log documented resident 1 “fell and hit head Hospice aware” and “refused to get off the floor and be put to bed”.
  7. On 12/15/2025, communication log documented resident 1 “fell in hallway, has knot med-tech aware and Hospice aware” and “fell out of chair after getting up from being put in bed”.
  8. On 12/16/2025 communication log documented resident 1 “fell in hallway check over is o.k.”
  9. On 12/18/2025 communication log documented resident 1 fell at 2 a.m. “staff checked over and was fine”.
  10. On 12/19/2025 communication log documented resident 1 “laying on floor with blanket, staff tried multiple times fighting against us”.
  11. On 12/30/2025 at 11 p.m. communication log documented resident 1 “on floor and refused to get up”.
  12. On 01/05/2026 communication log documented resident 1 “every time staff would put him in his bed; he would slide himself to floor and lay there when staff tried to get him up, he said no he [sic] hot”.
  13. On 01/06/2026 at 6:35 a.m. communication log documented resident 1 “fell in room pee everywhere got him dress [sic] and cleaned up put in chair for breakfast” and a separate entry later on 01/06/2026 “fell in bathroom floor went to check on him on floor check over is ok Hospice was called”.
  14. On 01/06/2026 at 1:22 p.m. communication log documented resident 1 “woke up saying he [sic] got to go to the bathroom staff tried to help him but wouldn’t listen got up and fell in dayroom check over is o.k.”
  15. On 12/10/2025 communication log documented resident 4 cut thumb on razor while shaving.
  16. Collateral contacts 2 and 3 and LI went to residents 1’s room. The floor of the bedroom was covered in a square linoleum tile over a cement floor. There was no fall mat in the room. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
The facility will ensure that documentation of specialized needs, such as the prevention of falls, be kept. Additionally, the facility will monitor these specialized needs more closely with hospice services to ensure that an individual has access to fall prevention devices, such as a fall mat.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or threatened the life, health, safety, or welfare of any resident.
Evidence
  1. On 12/22/2025, the regional licensing office received a complaint from Adult Protective Services that alleged that resident 1 was observed with “3 big knots…going across his forehead” and face was “really swollen”. Reporter alleged that when asked about the injuries, facility staff reported that resident 1 “falls…a lot”.
  2. During review of resident 1’s record and the facility communication log on 01/13/2026, there were a total of 31 documented falls for resident 1 from 02/15/2025 until 01/13/2026, with 14 occurring in December 2025.
  3. The regional licensing office did not receive self-reported incidents for resident 1 related to falls for the following dates: 02/15/2025, 02/17/2025, 04/1/2025, 05/1/2025, 09/11/2025, 10/09/2025, 10/14/2025, 11/21/2025, 12/10/2025 (2 falls), 12/11/2025, 12/12/2025 (2 falls), 12/13/2025, 12/15/2025, 12/16/2025 (2 falls), 12/18/2025, 12/19/2025, 12/22/2025, 12/25/2025, 12/31/2025, 01/04/2026, 01/06/2026 (3 falls), 1/7/2026 1/8/2026, and 1/13/2026.
  4. During an interview with the LI on 01/13/2026, staff 4 was asked if reports of resident 1’s falls were sent to the regional licensing office. Staff 4 acknowledged the facility failed to report 29 of the 31 incidents.
  5. LI was notified by staff 4 on 02/12/2026 that resident 1 passed away on 02/07/2026, which was not within 24 hours of a major incident as required.
Plan of correction
Staff were trained on completing an incident report after each major incident and the importance of faxing each incident report to the licensing department. Although the fax number to the licensing department is posted above the fax machine, staff were informed of its location.
22VAC40-73-310-A
Based on record review and staff interviews, the facility failed to ensure that no resident be retained who required a level of care or service or type of service for which the facility was not licensed.
Evidence
  1. The facility is currently licensed as residential and assisted living care, with a special care unit.
  2. Virginia Uniform Assessment Instrument (UAI) for resident 1, dated 03/03/2025 showed he required physical assistance with toileting, dressing, washing, ambulating, and feeding.
  3. Comments on UAI from 03/03/2025, facility staff reported resident 1 “is a fall risk and requires supervision.”
  4. Northwestern Community Services Board reported on UAI from 03/03/2025 that resident 1 “now requires physical assistance with bathing, dressing, and toileting. This requires staff to help him get in the shower, wash his hair and body and make sure he does not fall. Resident 1 is currently on a puree diet and requires staff to feed him during meals as he is a risk for choking and he will not get food in his mouth. It is also reported that (resident 1) often experiences shortness of breath and will present with slow or slurred speech.”
  5. During an interview with the LI on 01/13/2026, staff 4 acknowledged that resident 1 has been requiring more care than could be provided in assisted living.
  6. Resident 1 was re-screened on 01/13/2026 and approved for long term car placement pending appointment of new guardian.
Plan of correction
The facility has reexamined its protocol in determining the level of care needs of an individual. It will work more closely with additional agencies, such as DSS, CSBs, and hospice services in the evaluation of these care needs and whether the individual needs to be placed in a Skilled Nursing Facility. CSBs that complete annual public UAis, as well as hospice services providing care, will be asked if an ALF continues to suit the needs of individual under their care and their response will be documented.
April 2, 2025Complaint survey6 violations
Inspection dates
04/02/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/2/2025 from 9:30 a.m. to 3:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/7/2025 regarding allegations in the area of resident care. Number of residents present at the facility at the beginning of the inspection: 38 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector (LI) observed residents in the secure unit during lunch and relaxation time. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-300-B
Based on document review and staff interview, the facility failed to ensure the staff followed procedures for use of the shift-to-shift communication log to keep staff on all shifts informed.
Evidence
  1. On 2/28/2025, the shift-to-shift staff communication log included a note to notify the nurse of a scratch on the forearm of resident 1.
  2. On 3/6/2025, the shift note communicated that first aid was given for resident 1’s forearm with a note to change the bandage in two days. On the 3/8/2025 shift note, there was no note to communicate the status of the injury or if the bandage had been changed.
  3. On 4/2/2025, staff 2 acknowledged there was no shift note about changing the bandage and that the procedure for keeping all staff aware of first aid care was not followed.
Plan of correction
Staff have been further trained in the importance of shift-to-shift communication. The nurse practitioner was informed that a follow-up of any scratch, or any injury for that matter, needs to be documented in the system. Corrected.
22VAC40-73-750-B
Based on observations and staff interview, the facility failed to ensure that the bedroom for resident 1 had a chair as required.
Evidence
  1. On 4/3/2025, two licensing inspectors (LIs) observed that resident 1’s room had no chair.
  2. Staff 1 acknowledged that a chair was not provided in resident 1’s room as the layout made it too crowded.
  3. Photo evidence taken.
Plan of correction
All rooms will contain a chair for each occupant. Estimated time of completion is 06/30/25.
22VAC40-73-450-C
Based on a record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included a description of who would provide shower service.
Evidence
  1. The ISP (dated 9/26/2024) for resident 1 described needs as dependent for set-up of shower only. The ISP did not identify who would provide this service.
  2. On 4/3/2025, staff 3 acknowledged that the ISP for resident 1 did not identify who would provide set up for showers.
Plan of correction
All ISPs will be reviewed to make sure that for any services provided to a resident, all individuals providing those services will be properly identified. Estimated time of completion is 07/31/25.
22VAC40-73-920-A
Based on observations and staff interview, the facility failed to ensure that at least one bathtub or shower for each ten persons was available.
Evidence
  1. On 4/2/2025 during a tour of the secured unit, two LIs observed that of the two full bathrooms, the one next to room 23 did not have a showerhead or faucet.
  2. Staff 1 stated that the current census for the secured unit was 13 residents and acknowledged that the faucet and showerhead had been removed a few months ago in the bathroom next to room 23.
  3. Photo evidence taken.
Plan of correction
Shower was in the process of being remodeled when licensing inspectors toured the facility. The remodel was completed immediately. Corrected.
22VAC40-73-1040-B
Based on observations, the facility failed to ensure protective devices were on bedroom windows of residents with serious cognitive impairments, to prevent the windows from being opened wide enough for a resident to crawl through.
Evidence
  1. On 4/3/2025, during a tour of the secured unit, two LIs observed that the windows in rooms 16, 18 and 19 had no protective devices installed. The LIs were able to open the windows wide enough for a resident to crawl through.
  2. Photo evidence taken.
Plan of correction
Protective devices were immediately installed on windows that were found to be deficient. Corrected.
22VAC40-73-450-H
Based on record review and staff interviews, the facility failed to ensure that the care and services specified in the ISP were provided to the resident.
Evidence
  1. The ISP for resident 1 (admission 9/26/2024) specified shower set up would be provided three times a week.
  2. On 4/3/2025, staff 2 and 3 stated that showers were given twice a week, not three times a week to resident 1.
  3. A review of the March 2025 personal care record for resident 1 documented showers by the symbol SH. SH was marked on 3/20/2025. For all the other days and shifts staff recorded “0”.
  4. On 4/3/2025, staff 2 and 3 acknowledged that there was no documentation to show when showers were provided.
Plan of correction
Not published by VDSS.
February 24, 2025Inspection4 violations
Inspection dates
02/24/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/24/2025 from 9:30 a.m. to 4:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 38 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 and one partial record. Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, lunchtime meal and medication administration. Additional Comments/Discussion: The following were reviewed at the time of inspection: menu, activity calendar, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight, Virginia Department of Health inspection. Licensing inspector reviewed corrective actions completed since the last inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540) 418-2631 or by email at Jill.James@dss.virginia.gov
Violations
22VAC40-73-290-A
Based on documentation review and staff interview, the facility failed to ensure the written work schedule included an indication of who was in charge at any given time.
Evidence
  1. On 2/24/2025, the licensing inspector reviewed the monthly work schedule for February 2025. The schedule did not indicate who was in charge at any given time.
  2. On 2/24/2025, staff 1 acknowledged that the February 2025 schedule did not indicate who was in charge at any given time.
Plan of correction
The work schedules will highlight the person-in-charge for each shift. This will be done before schedules are posted.
22VAC40-73-350-A
Based on staff interview, the facility failed to ensure registration with the Virginia Department of State Police (VDSP) to receive notice of any sex offender within the same or a contiguous zip code area in which the facility was located.
Evidence
  1. On 2/24/2025, the licensing inspector requested documentation of VDSP notifications.
  2. On 2/24/2025, staff 1 acknowledged that there were no notifications as the facility had never been registered with VDSP and they were not aware this needed to be done.
Plan of correction
The facility/administrator is signed up to receive notifications regarding sex offenders in the same zip code as the facility.
22VAC40-73-610-B
Based on observation and staff interview, the facility failed to ensure the menu for meals and snacks for the current week was posted in an area conspicuous to residents.
Evidence
  1. On 2/24/2025, two licensing inspectors toured the facility and observed a white board with the lunch menu listed but did not observe a weekly menu posted in any area conspicuous to residents.
  2. On 2/25/2025, staff 7 acknowledged that the facility practice was to write the current meal being served on the white board in the dining room, while the weekly menu was kept in a binder in the kitchen.
Plan of correction
Kitchen staff have been instructed that the weekly menu must be posted at the facility’s entryway.
22VAC40-73-250-C
Based on record review and staff interview, the facility failed to ensure that each staff person had received a copy of his or her current job description.
Evidence
  1. On 2/24/2025, staff records were reviewed for staff 2 (hire date 9/9/2024), staff 3 (hire date 7/30/2023) and staff 6 (hire date 6/11/2024). Records did not contain a signed job description or verification that the staff received a copy of their job description.
  2. On 2/24/2025, staff 1 acknowledged that staff 2, 3 and 6 did not have a signed job description or verification that the staff received a copy of their job description.
Plan of correction
Job descriptions will be added to employee orientation packets for their signature. When individuals change positions, i.e. from direct care to medication aide, they will be required to sign a new job description before beginning work.
June 7, 2024Inspection7 violations
Inspection dates
06/07/2024
Areas reviewed
22VAC40-73 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
Technical assistance
Discussed keeping the dietary manual kept in a conspicuous place to make readily available for dietary staff to review as needed.
Comments
Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/7/24 10:00am – 4:15 pm. 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: 41 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch meal pass, memory care unit dining area, food storage, building grounds. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: ¿Yes¿
Violations
22VAC40-73-440-H
Based on record review and staff interview, it was determined that the facility did not ensure that an updated uniform assessment instrument (UAI) was completed at least annually to determine whether a resident's needs can continue to be met by the facility, and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. Resident 1 (date of admission 12/5/2018) UAI was last completed on 4/28/23.
  2. Resident 4 (date of admission 9/13/2021) UAI was last completed on 4/27/23.
  3. Staff 7 acknowledged the UAIs were not completed annually.
Plan of correction
The UAl's for both Resident 1 and Resident 4 were completed while inspectors were onsite. The facility will monitor resident UAI completion dates more closely going forward. Correction completed July 18, 2024. .. Creating an excel document that highlights upcoming expiration dates is a possibility and is being considered.
22VAC40-73-620-A
Based on record review and staff interview, the facility failed to ensure dietary oversight was conducted every six months for special diets by a dietitian or nutritionist.
Evidence
  1. Dietary oversight was completed on 3/13/2023 and 5/21/2024.
  2. Staff 7 acknowledged that the dietary oversight was not completed every six months.
Plan of correction
The previous dietician had moved to another state, which resulted in noncompliance. A new dietician was hired, and a dietary oversight was completed in May of 2024. The dietician will remain contracted and perform another dietary oversight in November of 2024.
22VAC40-73-290-B
Based on observation and staff interview, the facility failed to ensure it posted the name of the current on-site person in charge in the facility that is conspicuous to the residents and the public.
Evidence
  1. During the building tour on 6/7/2024 licensing inspectors did not observe the person in charge conspicuously posted for the public.
  2. Staff 7 acknowledged that the person in charge was not posted.
Plan of correction
The facility has begun to highlight all in-charge persons on its available and posted schedules. Additional signage is currently being looked into and will be purchased when it is determined that it meets the appropriate criteria. Expected to be completed by August 31 , 2024.
22VAC40-73-980-H
Based on observation and staff interview, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water. At least 48 hours of the supply must be on site at any given time.
Evidence
  1. During a tour of the facility on 6/7/2024 licensing inspectors observed emergency water was not present.
  2. Staff 7 stated there currently is not emergency water.
Plan of correction
Stackable water storage units have been ordered, but not yet delivered. Once they arrive, the appropriate amount of water will be ordered and stored. Expected to be completed by August 31 , 2024
22VAC40-73-940-A
Based on record review and staff interview, the facility failed to ensure the annual fire inspection was completed.
Evidence
  1. Record of the last fire inspection was completed on 6/16/2022.
  2. Staff 7 acknowledged the fire inspection was not current.
Plan of correction
An annual fire inspection will be performed before year's end. The facility had believed that the fire inspection was up to Warren County Fire Dept. to schedule all inspections. The facility will have better communication with the Warren County Fire Dept. in establishing a time for the yearly inspection.
22VAC40-73-610-B
Based on observation and staff interview, the facility failed to ensure the menu with meals and snacks for the current week shall be posted.
Evidence
  1. During observation of lunch on 6/7/2024 the lunch meal was posted on a white board and mislabeled as breakfast.
  2. Staff 7 acknowledged a weekly menu with a list of available snacks was not posted.
  3. Photo evidence taken.
Plan of correction
The weekly menu is now posted. Kitchen staff has been informed that a weekly menu must be posted in a conspicuous place for residents and staff. Correction completed.
22VAC40-73-930-B
Based on observation and staff interview, the facility failed to ensure a building licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During a tour of the facility on 6/7/2024 the licensing inspectors observed signaling devices in resident rooms were not operational.
  2. Staff 7confirmed the signaling system was not operational and resident rooms did not have a signaling device. Staff 7 stated they have been getting quotes and working on updating the call system.
Plan of correction
A call/signaling system will be installed once the appropriate permits are issued. Residents will use handbells until a call/signaling system is installed. There is no timeline currently for its installation. The facility's architect has been in communication with the Building and Zoning Department regarding any changes that must be made to the facility's architectural plans for the permits to be approved. The facility will inform the state licensee once the installation is completed.
March 27, 2024Complaint survey0 violations
Inspection dates
03/27/2024
Areas reviewed
Resident Accommodations and Related ProvisionsBuilding and Grounds
Comments
Type of inspection: Complaint Inspection Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/27/2024 Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were in the dining room finishing lunch, walked grounds of facility. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 16, 2023Inspection2 violations
Inspection dates
03/16/2023
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 PROCESS
Technical assistance
1.Recommend kitchen staff discuss the menu with dietician to look at viable alternatives when texture changes are required. 2. Reviewed and discussed behavior plans and the difference between one for a resident and one that serves as guidance for staff interaction with a resident. 3. Facility needs to give themselves credit when they have actual mental health or other resident emergencies then review that documentation with the staff not present at the time. 4. Keep in mind the 18 hours of training required for staff is hire date to anniversary date. 5. Discussed with administrator progress toward the change for assisted lining level of care only as it relates to the need for some residents to be relocated. Work continues on new agreement and disclosure moving forward. 6. Reviewed documentation administrator was maintaining of efforts to get outside parties to complete the public pay UAI – facility will continue to update a private pay and ISPs until they can obtain these. 7. Discuss with consultant assistance with dementia training.
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: 03/16/2023 The Acknowledgement of Inspection form was signed and left at the facility for the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Bathrooms previously being remodeled or added had been completed. Work is continuing in the medication area and in various rooms as residents move. Previously identified issues had been corrected. Number of resident records reviewed: 7 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 plus two collaterals. Observations by licensing inspector: Much improvement noted in medication management and related activities. Staff continue to receive training from the nurse consultant and monitoring for documentation and administration. Residents’ records were more organized than previously. It is understood that due to staffing issues some service plans for new admissions have a plan in place, but the 30-day update has not been fully completed. Additional Comments/Discussion: Outside inspections complete including a new dietician review – menus and special diet book were reviewed. Related drills were all current. Fire: 6/16/22 Health: 12/31/22 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with two applicable standard(s) or law, and violations 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov
Violations
22VAC40-73-250-C
Based on a random review of five staff records, one medication tech and three direct care staff did not have job descriptions. Two direct care staff did not have documentation of complete orientation in the time required although there were some pieces identified as complete. Interviews with staff and observation indicated they were aware of their job duties and open to asking questions when not sure.
Plan of correction
The administrator is in the process of updating the direct care job descriptions. There is a med tech job description, but it was simply overlooked for updating when staff recently acquired med tech registration. The administrator will also look at consolidating the single sheets for orientation and following the checklist. The administrator and assistant assume responsibility for correction and future compliance.
22VAC40-73-550-G
Based on a random review of five staff records, one staff who had worked at the facility for over one year had not had their annual resident rights review. The administrator confirmed this. Three new staff had no documentation in their file of having received review of resident rights. Resident rights were observed to be posted as required and documentation of initial and annual review with residents was available.
Plan of correction
All applicable staff will receive the annual resident rights review and it will further be documented along with orientation for new staff. Consideration may be given to requesting the local ombudsman come do the review with staff. The administrator and assistant assume responsibility for correction and future compliance.
March 16, 2022Inspection5 violations
Inspection dates
03/16/2022
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 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 Protection of adults and reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
Discuss with pharmacy adding units to all sliding scales. Recommend twice monthly review of all medication administration records. Review with pharmacy your ordering process for more timely receipt of medication.
Comments
An unannounced monitoring inspection was completed on site by two licensing inspectors. The current facility census was reported to be 46. Outside inspections were current and postings were as required. Five areas of noncompliance were identified during this monitoring inspection process. They were in the areas of medication administration and management, staff records, staff training, resident admission records and service plans. Details can be found in the violations portion of this report. The systemic violation is under review for requiring an intensive plan of correction. It was noted for physical plant that the facility is continuing with their remodeling process throughout the facility. The facility also has a new administrator who started a week prior to this inspection. Thank you to residents and staff for your cooperation during this inspection process. Should you have additional questions or concerns please call (540) 292-5930 or email this inspector at sharon.deboever@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on a review of resident records resident C admitted 10/25/21 did not have a comprehensive service plan. The service plan for Resident D does not indicate the special diet required of meals being pureed accompanied by thickened liquids with no directions for thickening. The service plan and UAI also were not reviewed after six months as required for individuals living on a memory care unit. The service plan for Resident O was pulled after medication administration record review due to multiple medication being given for stealing which is not described on the service plan as a sign of anxiety. Only aggression is addressed on the plan.
Plan of correction
Forthcoming
22VAC40-73-1140-B
Based on a review of four staff records, staff A (hired 4/20/21) and D (hired 2/24/20) had did not have 10 hours of training in cognitive impairment in the first four months of employment nor did they have 10 hours of training in cognitive impairment within the first year of employment. Staff B and C, both employed 1/3/22 and 1/4/22 respectively, had less than one hour of documented training related to cognitive impairments. The requirements for mental health and behavior management training were further not met for any of the staff based on interviews.
Plan of correction
Forthcoming
22VAC40-73-680-D
Based on a review of 12 medication administration records, medication was not administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Due to the limited space for typing violations and areas of overlap, specific details have been incorporated into a word document. Areas identified include: 1. Medication not available; 2. Self administration without physician's order; 3. Not following sliding scales for insulin administration; 4. Missed dosages; 5. Medication not administered within parameter given; 6. Medication not given in order prescribed; 7. Medication given outside physician diagnosis; 8. Failure to contact physician for repeated refusals or repeated request as outlined; 9. Orders missing diagnosis or parameters; and 10. Documentation related to medication administration does not meet curriculum guidelines in regards to detail and appropriateness.
Plan of correction
Forthcoming
22VAC40-73-250-B
Four staff records were reviewed. The following items were identified as missing from the staff records: Staff B: Hired 1/3/22. No signed orientation, CPR/First Aid to be completed in sixty days or background check to be processed within thirty days was in the file. Staff C: Hired 1/4/22. No signed orientation, CPR/First Aid to be completed in sixty days or updated background check to be processed within thirty days and required for rehires was in the file.
Plan of correction
Forthcoming
22VAC40-73-390-A
Five resident records were reviewed. The following items were identified as missing from the resident records: Resident A: Resident agreement, disclosure and resident rights Resident B: Fall Assessment, Has Agreement but no other paperwork Resident C: Resident agreement, disclosure, resident rights Resident D: Resident agreement, disclosure, resident rights, no physical or TB, no serious cogniitive impairment form or related documentation Resident E: Resident agreement, serious cognitive impairment form and related paperwork Reviews and interviews with administrative staff indicated that the majority of the individuals being funded through Discharge Assistance Planning (DAP) funds do not have facility agreements and many have outdated or unsigned DAP contracts. There is further no documentation regarding resident orientation for any of the residents reviewed or interviewed.
Plan of correction
Forthcoming
February 25, 2021Inspection2 violations
Inspection dates
Feb. 25, 2021 and March 11, 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 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
1. Clarify 4pm lantus order for resident D as discussed. 2. A sliding scale order is considered a regular order and not a standard PRN order. When the scale is not used staff can document zero units given and it is not necessary to make an additional note on the back of the MAR. 3. When noting zero or that medication was not given due to blood glucose level be sure to indicate what the reading was consistently. This would be good to include in your insulin documentation training discussed during the exit. 4. As per discussion resident F has two medications indicated for pain. Although the need for pain medication can be expressed asking for one or the other by the resident does not happen. The orders need clarification as to which should be given and under what circumstances., 5. As per discussion only the back portion of your building is considered a secure unit and those individuals must have a diagnosis of some form of dementia.
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 2/25/2021 and concluded on 3/011/2021. The administrator and assistant director were contacted by email to initiate the inspection. The administrator reported that the current census was 40. The inspector emailed the administrator a list of things required to complete the inspection. The inspector reviewed three resident charts including notes and an additional nine medication records. Three staff records that included training, any certification requirements and staff scheduling. Background checks and sworn disclosures were reviewed for eight additional staff that are new since the last inspection in April 2020.The facility has a current fire and health inspection. Additionally emergency drills, health care, dietary and pharmacy over site were all submitted by the facility to ensure documentation was complete. Information gathered during this renewal inspection determined non-compliance with two applicable standards or law, and the violations were documented on the violation notice issued to the facility. These were reviewed with the administrator and assistant director. Thank you to staff and administration for your patience and assistance during this desk review process. You will be notified by mail regarding your renewal status which is determined by the risk assessment profile generated within the system and following review by the licensing administrator. Should you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.
Violations
22VAC40-73-680-D
Resident J has an order for Lantus 22 units at bedtime and Lispro insulin 10 units with breakfast. The order has no parameters related to circumstances under which the medication would be held. Documentation on the medication administration record (MAR) indicates that Lantus was held on 2/1 and 2/20. Lispro insulin was held on 2/2-2/4, 2/7, 2/13, 2/16, 2/21 and 2/28. Documented reason for not giving states " withheld per DR/RN order". No harm was noted to the resident as insulin is not by standards of practice administered when fasting blood glucose levels are less than 100 which they were, however, the physicians order was not followed.
Plan of correction
Administrator will contact physician to determine if parameters should be included and they will be added to the MAR. Staff assisting with medication will receive refresher training on following physicians orders and if there is a question physician or nurse should be contacted as it relates to insulin administration. The administrator assumes responsibility for compliance and future monitoring.
22VAC40-73-680-I
Resident H has an order for application of a salonpas each morning and removal each night. Documentation is clear that the resident refused placement in the morning every day in February except 2/1,2/1,2/4,2/7 and 2/9. Staff initials for removal are indicated every night for the month of February with no indication that the patch was not there to remove. Initials with no explanation indicate the medication was given or treatment occurred which in this case it did not as per an interview with the administrator.
Plan of correction
Staff assisting with medication will receive refresher training on documentation via the nurse. All areas of documentation related to the MAR will be included. The administrator assumes responsibility for setting up the training, compliance and future monitoring. As per discussion with licensing, this resident is on hospice. They are aware of the refusals and wish to continue with the medication as listed.