Virginia DSS · Assisted Living Facility

Whispering Pines Assisted Living Facility

📍 200 Leaksville Road, Luray, VA, 22835

ID 24772One Year licenseActive
8
Inspections
On record
6
With violations
Visits that cited something
2
Clean visits
Nothing cited
21
Violations cited
Individual findings
20
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Whispering Pines Assisted Living Facility was inspected 8 times between October 25, 2021 and September 25, 2025 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 21 violations under 20 distinct standards.

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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
10/02/2026
Administrator
Ginger Wright
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Assisted Living · Non-Ambulatory

Inspection History

8

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

September 25, 2025Inspection2 violations
Inspection dates
09/25/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
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: 9/24/2025 10:15 a.m. to 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 8/9/2025 regarding allegations in the area of: RESIDENT CARE AND RELATED SERVICES. Number of residents present at the facility at the beginning of the inspection: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector observed residents gathering for lunch time meal. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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 Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-190-C
Based on staff record review and staff interview, the facility failed to ensure that prior to being placed in charge, the staff member in charge was informed of and received training on duties and responsibilities and provided written documentation of duties and responsibilities.
Evidence
  1. During the inspection on 9/24/2025 the licensing inspector reviewed the employee and training record for staff 1 (hire date 11/19/2023).
  2. During an interview with the LI on 9/24/2025, staff 2 stated there was not a designated person in charge training and acknowledgement form which provided written documentation of duties and responsibilities.
Plan of correction
Not published by VDSS.
22VAC40-73-460-D
Based on record review and staff interview, the facility failed to provide supervision of resident care and activities including attention to specialized needs such as to prevent wandering.
Evidence
  1. Regional licensing office received a self-reported incident from the facility indicating resident 1, assessed at risk for wandering and wore a Wanderguard pendant, exited the facility through the front door on 8/29/2025 at approximately 6:30 a.m. Resident 1 walked through the parking lot and fell at the edge of the road sustaining an “open injury to her forehead”.
  2. During an interview with the LI on 9/24/2025, staff 1 stated resident 1 was a “follower and followed staff through the lobby”. Resident 1 was observed on video leaning on the front door delayed egress bar allowing the front door to open. Facility staff observed resident 1 outside and immediately provided assistance.
Plan of correction
Not published by VDSS.
September 24, 2025Inspection0 violations
Inspection dates
09/24/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/24/2025 from 9:30 a.m. to 10:15 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7/25/2025 regarding allegations in the area of: RESIDENT CARE AND RELATED SERVICES Number of residents present at the facility at the beginning of the inspection: 40 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:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents were in the common areas and staff w Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2025Inspection6 violations
Inspection dates
09/24/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION
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: 9/24/2025 9:30 a.m. to 7:00 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: 40 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:3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Residents were observed resting, interacting with activities staff, during meals and during a medication pass. Additional Comments/Discussion: Review included: current Liability insurance, Virginia Department of Health inspection, fire marshal inspection, medication oversight, healthcare oversight, pharmacy oversite. 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
22VAC40-73-950-A
Based on staff interview, the facility failed to document annual contact with the local emergency coordinator to determine the: (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency.
Evidence
  1. On 9/24/2025, the Licensing inspector requested documentation of annual contact with the emergency coordinator.
  2. During an interview with the LI on 9/24/2025, staff 1 acknowledged that they had not had any contact with the local emergency coordinator.
Plan of correction
Administrator will ensure annual contact with emergency coordinator for emergency preparedness assistance.
22VAC40-73-990-C
Based on a review of facility documentation and resident interview, the facility failed to ensure that at least once every six months all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced.
Evidence
  1. On 9/24/2025, a review of facility documentation for in-service drills did not include practice drills on procedures for handling mental health emergencies, procedures for medical emergencies, making medical history available, or who to notify.
  2. During an interview with the LI on 9/24/2025, staff 1 acknowledged that practice drills were not completed for procedures for handling mental health emergencies, procedures for medical emergencies, making medical history available, or who to notify as required.
Plan of correction
The resident emergency drill schedule was revised to ensure that each drill is performed once every six months. Following each drill sign in sheet to verify employees participation in resident emergency drills.
22VAC40-73-950-E
Based on staff interview, the facility failed to ensure a semi-annual review on the emergency preparedness plan with all staff, residents, and volunteers.
Evidence
  1. On 9/24/2025, the licensing inspector requested a copy of the training records for the semi-annual review of the emergency preparedness plan for staff, residents, and volunteers.
  2. During an interview with the LI on 9/24/2025, staff 1 acknowledged that a semi-annual review of the emergency preparedness plan for staff, residents, and volunteers had not been completed as required.
Plan of correction
-Emergency preparedness was conducted for all staff and volunteers for November 2025. -Moving forward the facility will conduct and document emergency preparedness training annually and semi annually.
22VAC40-73-680-M
Based on observation and staff interview, the facility failed to ensure that medications ordered for PRN (as needed) were available.
Evidence
  1. On 9/24/2025 the Licensing inspector along with staff 3 completed a medication cart audit for resident 4.
  2. It was observed that one medication for resident 4 was not available in the facility (artificial tears as needed when eyelids remain open (order 8/15/2025) 3.During an interview with the LI on 9/24/2025, staff 1 acknowledged that the artificial tears were not available.
Plan of correction
-RMA will be educated to ensure that medication is present when order is received. - During the medication regiment review, the pharmacist will recommend discontinuing any medication which has not been used within the prior 60 days. -DON will perform medication cart checks monthly to verify that all medications are present.
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 9/24/2025 the Licensing inspector along with staff 3 completed a medication cart audit for resident 4.
  2. Three medications currently ordered for resident 4 were available but unlabeled. Brimonide 2% eye drops 2 times a day right eye (order 8/15/2025). Dorzolamidel 1 drop right eye two times daily (order 8/15/2025) Latanoprost solution 1 time nightly (order 8/15/2025).
  3. During an interview with the LI on 9/24/2025, staff 1 acknowledged three of the ordered medications should have been stored in the pharmacy issued container with the prescription label and directions attached.
Plan of correction
RMA will be in-serviced by 11/12/25on medication management policies. Biannual healthcare oversight will be conducted to assure adherence to policy. DON will randomly audit medication cart for compliance with policy and procedure.
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct staff person received first aid certification within 60 days of employment.
Evidence
  1. During the inspection on 9/24/2025, of the three staff records reviewed, two did not contain documentation of certification of first aid within 60 days of hire. Staff 5 (hire date 11/12/2024) first aid certification on 2/14/2025. Staff 7 (hire date 7/15/25) had no first aid certification as of the date of the inspection 9/24/2025.
  2. During an interview with the LI on 9/24/2025, staff 1 acknowledged that staff 7 did not have the required first aid certification and staff 5 did not receive first aid certification within the first 60 days of employment.
Plan of correction
Administrator will ensure all new hires receive first aid/CPR within 60 days of hire dates.
July 17, 2025Inspection0 violations
Inspection dates
07/17/2025
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/17/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 2/6/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.
May 30, 2024Inspection8 violations
Inspection dates
05/30/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 5/30/2024 8:45am – 6:30pm; 5/31/2024 8:30am - 6:25 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: 26 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 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch and dinner. This LI also observed staff assisting residents, activities, and medication pass. 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
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that the medication storage area was locked.
Evidence
  1. During the physical plant walk through on 5/31/2024 a medication cart was not locked and the door leading into the medication room was also not locked.
  2. Photo evidence was taken and presented to Staff 5.
Plan of correction
All staff were retrained to ensure medication storage areas are locked. All RMA will be re-educated on the medication management policy which includes procedures for proper storage.
22VAC40-73-930-D
Based on staff interview, the facility failed to ensure that documentation of staff rounds was completed that included the name of the resident, date and time of rounds, and the staff member who made the rounds for residents who were unable to use the signaling device.
Evidence
  1. The LI requested Staff 5 provide a resident round log sheet.
  2. Staff 5 stated the previous administrator discontinued this process months before she left. Staff 5 confirmed the resident round log were not utilized.
Plan of correction
All staff will complete rounding on all residents and document in rounding log. Rounding log will be reviewed at the end of each shift. Administrator/RCC will review log daily.
22VAC40-73-960-C
Based on observation and staff interview, the facility failed to ensure the telephone numbers of the fire department, rescue squad or ambulance, police, and Poison Control Center were posted by each telephone shown on the fire and emergency evacuation plan.
Evidence
  1. On May 30, 2024, during a tour of the facility, the two licensing staff observed the emergency numbers were not posted near telephone shown on the facility evacuation plan.
  2. Staff 5 acknowledged that emergency numbers were not posted.
  3. Photo evidence taken.
Plan of correction
Corrected while inspectors were on site. Posted telephone numbers for fire department, rescue squad, police, and poison control center by each telephone.
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure required resident personal and social information was obtained prior to or at the time of admission.
Evidence
  1. The record for Resident 3 (admitted 2/2/2024) and Resident 4 (admitted 2/2/2024) did not contain lifetime vocation and hobbies. 2.Staff 5 acknowledged that the personal and social information was not complete for these two residents.
Plan of correction
Current resident social data forms will be reviewed and updated. Social data form will be completed prior to admission to the community. Administrator or designee will review for completion prior to admission.
22VAC40-73-990-A
Based on staff interview the facility failed to ensure there were written policies and procedures for resident emergencies.
Evidence
  1. LI requested written policies and procedures for resident emergencies, and they were not provided.
  2. Staff 5 acknowledged that there were no written procedures for resident emergencies.
Plan of correction
The Executive Director or designee will ensure the Resident Emergency Review shall be reviewed by all staff at the community every 6 months and during general orientation.
22VAC40-90-40-B
Based record review, the facility failed to ensure the criminal history record report were obtained on or prior to the 30th day of employment.
Evidence
  1. The record for Staff 2 (date of hire 12/13/2023) did not contain a criminal history record (CHRRs). 2.The record for Staff 3 (date of hire 12/21/2023) the CHRR was dated 2/12/2024.
  2. The record for Staff 6 (date of hire 10/9/2023) the CHRR was dated 11/29/2023. 3.Staff 5 acknowledged the CHRR for Staff 2 was not in the staff record and Staff 3 verified the dates on the CHRR were correct.
Plan of correction
: All staff records will be audited for criminal background compliance.
22VAC40-73-200-D
Based on record review and staff interview the facility failed to ensure qualifications for 1 of 4 staff records reviewed included certification or other documentation.
Evidence
  1. The record for Staff 3 (date of hire 12/21/2023) and Staff 4 (date of hire 5/1/2017) did not contain documentation of completion of direct care staff training. 2.Staff 5 acknowledged the qualifications were not at the facility.
Plan of correction
The Executive Director or designee will ensure documentation of staff qualifications is on file in staff records. The ED or designee will audit staff records to ensure compliance.
22VAC40-73-350-C
Based on staff interview, the facility failed to ensure an annual review of information on the sex offender registry, including how to obtain such information and to ensure that written acknowledgment of having been so informed was provided to the resident or his legal representative and shall be maintained in the resident's record.
Evidence
  1. 1 LI requested documentation of resident acknowledgement of receipt.
  2. Staff 5 acknowledged that annual review and documentation of informing residents of the sex offender registry was not completed and on file.
Plan of correction
All resident or legal representative will be notified and will complete Sex Offender acknowledgment form. The administrator registered with the State Police to be listed for notification from the Department of State Police sex offender registry notification.
May 30, 2024Inspection3 violations
Inspection dates
05/30/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (16) PROTECTION OF ADULTS AND REPORTING
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: 5/30/24 8:45am-3:10pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on May 18, 2024 regarding allegations in the area of: Resident Care and related services. Number of residents present at the facility at the beginning of the inspection: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch and dinner. The LI also observed the operation of the front door locking system to avoid residents wandering out of the building. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: ¿Yes¿
Violations
22VAC40-73-460-D
Based on record review and staff interviews, the facility failed to ensure that supervision of resident care was provided, including prevention from wandering from the premises.
Evidence
  1. The facility had a mixed population and did not have a secure unit.
  2. The facility policy was reviewed and section Pre-Admission Wandering and Elopement Risk Screening part 1 states an “The approved Pre-Admission Wandering Risk and Elopement Screening forms will be used to complete a screening on all potential admissions prior to the admission date.” The Elopement Screening will be completed quarterly, when there is a change in cognition, or post elopement episode.
  3. A Pre-Admission Elopement Screening was completed on 7/25/2023, (Resident 1 was admitted 7/27/2023). Resident 1 scored 10 on the elopement screening with a score of 10 or greater qualifying for interventions including being placed on the elopement risk list and a wander alert system. A handwritten note included on Resident 1 screening form stated, “resident has no history of elopement will monitor if additional procedures need to be followed.”
  4. On 5/30/24 Staff 5 stated Resident 1 did not have a wander guard at the time of this incident.
  5. Review of Resident 1 record did not contain evidence of quarterly monitoring, elopement screening documentation, and post elopement episode documentation per facility Wandering and Elopement Policy and Procedure.
  6. Resident 1 assessment completed on 8/28/2023 by Staff 6 stated Resident 1 “has episodes of confusion with hallucinations and needs redirection.” Also, “she has impaired judgement and memory.”
  7. Individual Service Plan dated 9/14/2023, identified Resident 1 being disoriented to time and place and for staff to reorientate resident to highest ability.
  8. On 5/18/24 at 1:15pm, Resident 1, who has a diagnosis of dementia, exited the building and was found standing on the edge of the facility parking lot near the primary two-lane road. Resident 1 was brought back to the facility by a concerned citizen at 1:25pm.
  9. Staff 2 stated they were in the dining area when an older gentleman approached them and said they were going down the road and saw Resident 1 in the parking lot by the bushes and the garage, realized Resident 1 resided at the facility and brought the resident back to the front door.
  10. Photo evidence of exterior of facility.
Plan of correction
Residents with wander guard will be monitored per facility’s policy. Staff will review wander guard policy and complete annual elopement training.
22VAC40-73-290-A
Based on record review and staff interview, the facility failed to ensure the staff schedule included the job classification of all staff working each shift and indicated who was in charge at any given time.
Evidence
  1. Staff schedules were requested and reviewed from 4/19/2024 through 5/30/2024. Schedule did not include the job classification and who was in charge at any given time.
  2. Staff 6 acknowledged that the job classification and who was in charge at any given time was not on the schedule.
Plan of correction
Staff schedule was corrected to show name, job classification, and shift. Corrected while inspector was on site.
22VAC40-73-70-C
Based on communication with the facility, the facility failed to provide a written report of a major incident that threatened the health, safety, or welfare of the resident to the regional licensing office within seven days from the date of the incident.
Evidence
  1. Staff 5 emailed an initial self-report of the resident wandering out of the building on 5/18/2024.
  2. On 5/26/2024 the LI requested the 7 day follow up regarding this incident from Staff 5.
  3. The licensing office did not receive the written report until May 30, 2024.
Plan of correction
All major incidents that threatened the health, safety, or welfare of the resident will be reported within seven days of the incident.
September 29, 2022Inspection1 violation
Inspection dates
09/29/2022
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 PREPAREDNESS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: from approximately 12:00pm-3:00pm 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: 18 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 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 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 Rhonda Whitmer, Licensing Inspector at (540) 241-2504 or by email at rhonda.whitmer@dss.virginia.gov
Violations
22VAC40-73-620-A
Based on document review and an interview, the facility failed to ensure that an oversight of special diets by dietician or nutritionist was completed at least every six months.
Evidence
  1. The dietary oversight on file is dated 10/23/2021.
  2. An interview with the administrator on 09/29/2022 confirmed that an oversight of special diets had not been completed since 10/23/2021.
Plan of correction
The Licensee will seek out and hire a Dietician/Nutritionist to work with the Administrator and provide a dietary oversight.
October 25, 2021Inspection1 violation
Inspection dates
10/25/2021
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 EMERGENCY PREPAREDNESS63.2 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 Report
Comments
A monitoring inspection was initiated on 10/25/2021 and concluded on 11/04/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 19. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, fire drills, fire drills and criminal history reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and a violation was documented on the violation notice issued to the facility.
Violations
22VAC40-73-450-C
Based on record review, the facility failed to ensure that Individual Service Plans (ISPs) included all required components.
Evidence
  1. Nursing note for resident 1, dated 09/29/2021 indicates use of a Geri Chair; however, this is not addressed on the ISP.
  2. The ISP for resident 2, dated 08/12/2021 indicates resident is disoriented to place and time, but does not include a written description of the services to be provided to address this need.
  3. The ISP for
Plan of correction
All resident ISPs will be audited to ensure completeness and all required components are included.