Virginia DSS · Assisted Living Facility

Sunrise at Mount Vernon

📍 8033 Holland Road, Alexandria, VA, 22306

ID 25827One Year licenseActive
17
Inspections
On record
14
With violations
Visits that cited something
3
Clean visits
Nothing cited
41
Violations cited
Individual findings
30
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Sunrise at Mount Vernon was inspected 17 times between August 21, 2020 and November 18, 2025 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 41 violations under 30 distinct standards. 9 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. 15 of these 17 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
01/08/2027
Administrator
Ashley Custer
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

17

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

November 18, 2025Inspection2 violations
Inspection dates
11/18/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 11/18/2025 Time in: 3:44 PM Time out: 4:30 PM 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 10/26/2025 regarding allegations in the area(s) of: Administration and Administrative Services and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 82 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents engaged in scheduled activities and engaged with staff and peers. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-40-A
Based on staff record review and staff interview, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. On 10/28/2025, licensing inspector received a follow-up to the incident report submitted 10/26/2025 stating that resident 1 (admit date, 10/06/2025) signed out of the facility on 10/22/2025 with the intent to return to their residential home. Resident 1 was independent with Activities of Daily Living (ADL’s) and continued to drive their personal vehicle.
  2. Resident 1’s progress note, 10/26/2025 stated that staff attempted to contact resident 1 but the phone was “off,” so POA was contacted to request a wellness check.
  3. Resident 1 was found deceased in their residential home on 10/26/2025.
  4. Staff 2 and staff 3 documented that assessments and check-ins were provided to resident 1 on 10/22/2025 (overnight), 10/23/2025, 10/24/2025, and 10/25/2025; however, based on staff interview and resident sign in and sign out log, resident 1 had not been in the facility since 10/22/2025.
  5. On 10/29/2025, staff 2 was provided a Performance Counseling & Improvement Plan for Corrective Action for “failure to respond to a resident/family member” on 10/23/2025 and 10/25/2025; and “falsification of company records or timesheets” on 10/23/2025 at 2:25 PM and 10/25/2025 at 2:17 PM. Staff 2 was terminated from the facility on 10/29/2025.
  6. On 10/29/2025, staff 3 was provided a Performance Counseling & Improvement Plan for Corrective Action for “failure to respond to a resident/family member: on 10/22/2025, 10/23/2025, and 10/24/2025; and falsification of company records or timesheets on 10/23/2025 at 12:40 AM and 10/24/2025 at 12:44 AM. Staff 3 was terminated from the facility on 10/29/2025.
  7. During the onsite inspection, 11/18/2025, staff 1 confirmed that staff 2 and staff 3 were terminated on 10/29/2025 for not following company policy.
Plan of correction
Not published by VDSS.
22VAC40-73-70-C
Based on record review, the facility failed to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident. The report should be signed and dated by the administrator.
Evidence
  1. The regional licensing office received an incident report on 10/26/2025 at 9:22 PM stating that a resident signed out of the facility to visit their residential home and did not return. Following a wellness check, the resident was found deceased in their home.
  2. On 11/05/2025, licensing inspector requested a written formal report indicating the circumstances surrounding the resident’s death.
  3. The facility failed to submit a written report within seven days to include the required information from the date of the incident, 10/26/2025.
Plan of correction
Not published by VDSS.
November 18, 2025Inspection8 violations
Inspection dates
11/18/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Licensing Inspector reviewed the following standards with the facility: 22VAC40-73-45, 22VAC40-73-325, and 22VAC40-73-970.
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2025 Time in: 10: 23 AM Time out: 5:55 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: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector observed residents engaged in scheduled activities, entering and exiting the facility for community outings, and dining for lunch and dinner. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to have, keep current, and implement a written plan for medication management. The facility’s medication management plan should address procedures for administering medication and include methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. On 09/09/2025, Resident 2 was prescribed and ordered to start Cyanocobalamin 1000 MCG (take 1 tablet by mouth once daily) on 09/10/2025; however, the medication was not transcribed onto Resident 2’s September 2025’s MAR as well as October – November 2025 MARs.
  2. During the onsite inspection, 11/18/2025, staff 6 confirmed that resident 2’s Cyanocobalamin 1000 MCG 09/09/2025 order was not transcribed within 24 hours of receipt to their September 2025 MAR.
Plan of correction
A. Resident #2 did not have any negative outcomes because of incorrect transcription of medication. Provider notified and Cyanocobalamin 1000 mcg was transcribed to the MAR. B. Resident care Director audited current residents’ orders to medication records to confirm that there are no medications with incorrect transcriptions. Issues identified were corrected. The Wellness Nurses were re-educated by the Resident Care Director (RCD) regarding the process of proper transcription of physician orders C. The Resident Care Director or wellness designee will conduct weekly audits for 1-month, monthly audits for 2 months, to confirm accuracy between physician orders, and the EMAR. Issues that may be identified will be addressed and resolved and refresher training is initiated as needed. The results of the audits will be presented by the Resident Care Director or wellness designee at QAPI (Quality Assurance and Performance Improvement) for 3 months. During and at the end of the 3 months, the QAPI committee will evaluate the results of the medication cart audits and determine if additional focus or action is warranted. D. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to prepare and provide a statement to the prospective resident and the prospective resident’s legal representative, if any, that discloses information about the facility. The statement should be on a form developed by the department.
Evidence
  1. Upon request, the disclosure statement was not provided on a current form developed by the department.
  2. During the onsite inspection, 11/18/2025, staff 9 confirmed that the disclosure statement was not prepared on a form developed by the department.
Plan of correction
A. The facility obtained the current VDSS-developed disclosure statement form and immediately completed and provided it to the affected resident(s) and their legal representative(s), where applicable. Documentation of receipt was placed in the resident record. B. A review of current resident admission files was conducted by Executive Director to ensure that each file contains a completed disclosure statement on the current VDSS form. Any missing or outdated disclosure statements were immediately corrected. C. The Director of Sales or designee will continue to audit admission charts to confirm the correct VDSS form is in place prior to each move in monthly for three months. Issues identified will be addressed and presented at QAPI. D. The Executive Director will audit admission files monthly for three months, then quarterly thereafter, to confirm continued compliance. Audit results will be documented and retained on site.
22VAC40-73-1110-A
Based on resident review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee, should determine whether placement in the special care unit is appropriate. The determination and justification for the decision should be in writing and retained in the resident’s file.
Evidence
  1. Upon request on 11/18/2025, resident 1’s (admit date, 10/18/2025) appropriateness of placement to a safe, secure environment was not provided.
  2. Upon request on 11/18/2025, resident 2’s (admit date, 04/06/2025) appropriateness of placement to a safe, secure environment was not provided.
  3. During the onsite inspection, 11/18/2025, staff 9 confirmed that the determination and justification for the decision to admit residents with a psychiatric diagnosis of dementia to a safe, secure environment was not documented and retained in resident 1 and resident 2’s files.
Plan of correction
A. Written determinations and justifications for Residents 1 and 2 regarding placement in a safe, secure environment. B. A review of all residents residing in the safe, secure environment was conducted to confirm documentation of appropriateness of placement. C. The move in and care plan process was updated to require written justification for placement in a secure environment prior to admission. Staff responsible for move-ins were retrained on this requirement. D. The Executive Director or designee will audit secure unit resident records quarterly to ensure continued compliance.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section should be reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person.
Evidence
  1. Upon request on 11/18/2025, a semiannual review of resident emergencies with staff was not provided.
  2. During the onsite inspection, 11/18/2025, staff 9 confirmed that a review of resident emergencies was not documented as completed at least every 6 months with staff.
Plan of correction
A. Emergency preparedness education was scheduled and completed for staff, residents, and volunteers. Attendance was documented with signatures and dates. B. All personnel, residents, and volunteers were reviewed to ensure participation in the required education C. Emergency preparedness reviews were added to the facility’s compliance calendar with designated responsible parties. Documentation tools were standardized. D. The Executive Director will review compliance semi-annually and maintain records for inspection readiness.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident 2 was prescribed Cyanocobalamin 1000 MCG (take 1 tablet by mouth once daily) on 09/09/2025 with the start date of 09/10/2025; however, Resident 2’s September medication administration record (MAR) did not include Cyanocobalamin 1000 MCG for administration.
  2. During the onsite inspection, staff 6 confirmed that Resident 2 was prescribed Cyanocobalamin 1000 MCG with instructions to start on 09/10/2025. Staff 6 further confirmed that Resident 2 did not start Cyanocobalamin 1000 MCG on 09/10/2025 as ordered and currently has not been administered the medication.
Plan of correction
A. Resident 2’s did not have any negative outcome, and the medication was ordered an available for administration B. The Resident Care Director conducted a EMAR to medication cart audit to confirm medications were available per physician’s order. Refresher training with Medication Care Managers and Nurses was conducted by the Resident Care Coordinator regarding procedures to follow to administer medications in accordance with the physician’s order. When Medication Care Manager is unable to locate a medication, the MCM is to check the cart to verify it has not been stored incorrectly, and to report to the Resident Care Director and notify the physician. If the medication is not located the medication will be reordered. C. The RCD or wellness designee will conduct weekly audits for 1-month, monthly audits for 2 months, to confirm accuracy between physician orders, and the EMAR. Issues that may be identified will be addressed and resolved and refresher training is initiated as needed. The results of the audits will be presented by the RCD or wellness designee at QAPI (Quality Assurance and Performance Improvement) for 3 months, the QAPI Committee will evaluate the results of the medication cart audits and determine if additional focus or action is warranted. D. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section should be reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person.
Evidence
  1. Upon request on 11/18/2025, a semiannual review of resident emergencies with staff was not provided.
  2. During the onsite inspection, 11/18/2025, staff 9 confirmed that a review of resident emergencies was not documented as completed at least every 6 months with staff.
Plan of correction
A. Resident Emergency Procedures were reviewed with staff, and documentation of attendance was completed. B. Staff files were reviewed to ensure completion of the emergency procedures review. C. Emergency procedure training was integrated into required biannual in-service education and tracked through the facility training log. D. Training completion will be reviewed semi-annually by the Executive Director, with documentation retained.
22VAC40-73-610-E
Based on record review and staff interview, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation.
Evidence
  1. During the onsite inspection, 11/18/2025, staff 7 was unable to locate the diet manual upon request.
  2. During the onsite inspection, staff 7 and staff 9 confirmed that a diet manual was not kept current and readily available to personnel responsible for food preparation.
Plan of correction
A. A current, approved diet manual was obtained and placed in the kitchen in an accessible location for food service staff. Dietary staff were notified of its location and availability. B. Dining Services Coordinator reeducated dining staff as to where the manual was located. C. Dining Services Coordinator will continue to verify with dietary staff monthly for 3 months to ensure staff understands where diet manual is located. D. The Executive Director or designee will verify the presence and currency of the diet manual during monthly kitchen audits and document findings. Monthly for three months, then quarterly thereafter, to confirm continued compliance.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to ensure that the facility developed and implemented a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual’s respective responsibilities. The review should be documented by signing and dating.
Evidence
  1. The emergency preparedness and response plan was reviewed with staff on 06/17/2025 and 06/26/2025.
  2. Upon request on 11/18/2025, a semiannual review of the emergency preparedness and response plan with volunteers and residents was not provided.
  3. During the onsite inspection, 11/18/2025, staff 9 confirmed that a semi-annual review was not documented as completed with staff, residents, and volunteers.
Plan of correction
Not published by VDSS.
May 16, 2025Complaint survey2 violations
Inspection dates
05/16/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 05/16/2025 Time in: 11:51 am Time out: 2:45 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/12/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Resident Care and Related Services, and Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 82 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector observed residents participating in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Resident Accommodations and Related Provisions A violation notice was issued; any violation(s) not related to the complaints 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours.
Evidence
  1. Resident 1 was transferred to the hospital on 05/09/2025; however, this was not reported to the regional licensing office.
  2. On 05/16/2025, LI interviewed staff 1 who confirmed that resident 1’s hospital visit was not reported to the regional licensing office within 24 hours.
Plan of correction
Not published by VDSS.
22VAC40-73-130-A
Based on record review, the facility failed to ensure that staff who are mandated reporters reported suspected abuse or neglect of residents.
Evidence
  1. Resident 1’s progress notes indicated skin discoloration on face, 05/03/2025 and was treated by home health agency.
  2. Resident 1 was transferred to the emergency room on 05/09/2025 and alleged that they were punched in the face.
  3. On 05/16/2025, LI interviewed staff 1 who confirmed that staff did not report resident 1’s allegations of being punched in the face to the nurse in charge.
Plan of correction
Not published by VDSS.
December 18, 2024Inspection7 violations
Inspection dates
12/18/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Licensing Inspector reviewed the following standards with the facility: 22VAC40-80-150, 22VAC40-73-640, and 22VAC40-73-990.
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: Date: 12/18/2024 Time In: 1:00 PM Time Out: 5:28 PM Date: 12/19/2024 Time In: 10:27 AM Time Out: 5:54 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed residents entering and exiting the facility for community outings. LI observed residents in the dining room, eating breakfast, lunch, and dinner. LI observed physical therapy occurring in the sitting room, engaging in scheduled activities, and interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-950-E
Based on facility record review and staff interview, the facility failed to develop and implement an orientation and semi annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. The review was documented by signing and dating.
Evidence
  1. The emergency preparedness and response plan was not reviewed semi-annually with staff, residents, and volunteers.
  2. On 12/18/2024, licensing inspector (LI) interviewed Staff 5 who confirmed that the emergency preparedness and response plan was not reviewed semi-annually.
Plan of correction
A. The residents had no adverse outcomes due to the Emergency Preparedness Plan not being reviewed by staff members. Executive Director held a review of the Emergency Preparedness Plan with staff present in the community. B. The Executive Director and/or designee with conduct quarterly audits to confirm staff have reviewed the Emergency Preparedness Plan and identify any trends of staff members who have not completed a semiannual review of the Emergency Preparedness Plan C. The Executive Director and/or designee will conduct semi-annual Emergency Preparedness Plan reviews with the staff as well as confirm new hires reviewed the Emergency Preparedness Plan with the Executive Director or designee. D. During and at the end of the year The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur.
22VAC40-73-50-A
Based on resident record review, the facility failed to ensure that the statement disclosing information about the facility included the current name of the licensee.
Evidence
  1. Resident 1’s (admit date, 11/27/2024) disclosure statements included the licensee’s name as Inova Healthcare Systems. The licensee’s name is Inova Healthcare Services.
Plan of correction
A. The Executive Director updated the disclosure statement to include the licensee’s name “Inova Healthcare Services”. B. Executive Director or designee will perform quarterly audits to confirm all new resident’s disclosure statements include the licensee’s name “Inova Healthcare Services”. C. Executive Director or designee will review the updated disclosure statement with all new move-ins during the contract signing to confirm that the disclosure statements include the licensee’s name “Inova Healthcare Services”. D. During and at the end of the year The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur
22VAC40-73-950-F
Based on facility record review and staff interview, the facility failed to ensure that the emergency preparedness plan was reviewed annually or more often as needed, document the review by signing and dating the plan, and making necessary revisions.
Evidence
  1. The emergency preparedness and response plan was not reviewed annually.
  2. On 12/18/2024, licensing inspector (LI) interviewed Staff 5 who confirmed that the emergency preparedness and response plan was not reviewed annually.
Plan of correction
A. The residents had no negative outcome due to the annual review of the Emergency Preparedness Plan not being completed and documented. The Maintenance Coordinator and Executive Director reviewed Emergency Preparedness Plan and documented the review by signing and dating the Emergency Preparedness Plan. B. The Executive Director and/or designee with conduct quarterly audits during the Quality Assurance and Performance Improvement (QAPI) committee meeting to confirm that the Emergency Preparedness Plan has been reviewed annually or more as needed, and documentation of the review has been completed. C. The Executive Director and/or designee will conduct Quarterly Emergency Preparedness Plan reviews to confirm that the plan has been reviewed and that the review has been documented annually or more as needed. D. During and at the end of the year the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur.
22VAC40-73-980-H
Based on facility record review, licensing inspector’s (LI) observation, and staff interviews, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water. At least 48 hours of supply was on site at any given time.
Evidence
  1. On 12/19/2024, LI toured the kitchen and observed that there was not emergency drinking water on-site.
  2. On the date of inspection, while performing a physical plant walk through, staff 5 and LI were unable to access the emergency food and drinking water supply behind a locked door with the keys and resources that were available in the facility.
Plan of correction
A. The residents had no adverse outcomes due to the 96-hour supply of emergency drinking water not being available. The Dining Service Coordinator immediately ordered the 96-Hour Supply of drinking water, and it was delivered to the community and stored in an area accessible to team members. B. Executive Director or designee will preform quarterly audits to confirm that a 96-day supply of drinking water is available in the community. C. The Dining Service Coordinator will report Quarterly to the Quality Assurance and Performance Improvement (QAPI) committee if the 96-hour supply of water is available in the building and not expired. D. During and at the end of the year The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur
22VAC40-73-610-E
Based on facility record review and staff interview, the facility failed to ensure a copy of a diet manual was kept current and readily available to personnel responsible for food preparation.
Evidence
  1. The facility did not keep a current diet manual available to personnel responsible for food preparation.
  2. On 12/19/2024, licensing inspector (LI) interviewed Staff 9 who confirmed that diet manual was not available to personnel responsible for food preparation.
Plan of correction
A. The residents had no adverse outcomes due to the Diet Manual not being available. The Executive Director obtained the community’s diet manual and placed it in the kitchen labeled and available to staff. B. Executive Director or designee will perform quarterly audits to confirm that the diet manual is labeled in the kitchen and available to staff. C. The Dining Service Coordinator will report Quarterly to the Quality Assurance and Performance Improvement (QAPI) committee if the diet manual is labeled in the kitchen and available to staff. D. During and at the end of the year The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur
22VAC40-73-310-M
Based on resident record review, the facility failed to ensure that a written agreement between the assisted living facility and hospice program was developed.
Evidence
  1. Resident 2’s (admit date, 10/11/2019) hospice plan of care indicated that services began on 12/17/2022. Resident 2’s records did not include an agreement between the facility and the hospice program.
Plan of correction
A. The Executive Director obtained the agreement between the hospice program and the facility, and the Resident Care Director put the agreement in the resident’s record. B. The Resident Care Director or designee will preform monthly audits for 3 months on resident’s records who are receiving hospice services to confirm that a written agreement between the assisted living facility and the hospice program are in the resident’s records. C. When a resident begins hospice services the Resident Care Director or designee will confirm that that a written agreement between the assisted living facility and the hospice program are in the resident’s records. The Resident Care Director or designee will report to the Quarterly to the Quality Assurance and Performance Improvement (QAPI) committee if all residents who are receiving hospice services have a written agreement between the assisted living facility and hospice program in their record. D. During and at the end of the 3 month period the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur
22VAC40-73-290-B
Based on licensing inspector (LI) observation and staff interview, the facility failed to ensure to develop and implement a procedure for posting the name of the current on-site person in charge, in a place in the facility that was conspicuous to the residents and the public. E vidence: 1. On 12/18/2024, licensing inspector entered the facility and asked Staff 10 who the current on-site person in charge. Staff 10 stated, “I don’t know. I will check.” Staff 10 made a phone call, got up from his chair, and walked away, stating that he was going “to find someone.” Staff 10 returned alone and stated, Staff 13 would meet LI shortly. 2. On 12/18/2024, while waiting for the on-site person in charge, LI toured the common areas and observed a sign stating the on-site person in charge, Staff 5. LI recognized Staff 5’s name as the administrator at another facility. 3. On 12/18/2024, LI interviewed Staff 5 who confirmed being the administrator at another facility. Staff 5 confirmed a transfer, start date of 12/20/2024. Staff 5 stated that the on-site person in charge posting should not include their name.
Plan of correction
A. Staff #5’s name was removed from the posted on site person in charge until official start date of 12/20/25 and Resident Care Director’s name was then posted as the on site person in charge. B. Once a day for 1 week the Manager on duty will confirm that the posted on site person in charge is correct then 1 weekly for 3 months C. Executive Director or designee will send a monthly manager on duty schedule to the concierge so that the concierge can post the name of the current on-site person in charge. The concierge will confirm daily that the person in charge is scheduled and or in the building. D. During and at the end of the 3-month period The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing components of the Plan of Correction and addressing variances that may occur
December 18, 2024Complaint survey0 violations
Inspection dates
12/18/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/18/2024 Time In: 10:41 AM Time Out 1:00 PM 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 12/13/2024 regarding allegations in the area(s) of: Resident Care and Related Services, Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 83 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector toured the physical plant of the facility. LI observed breakfast and physical therapy being facilitated in the dining area. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 7, 2024Complaint survey5 violations
Inspection dates
10/07/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Date: 10/07/2024 Time In: 2:35 PM Time Out: 5:15 PM 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 09/26/2024 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 76 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed residents engaging in individual pursuits, entering and exiting the facility to participate in community activities, and interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non- compliance with standard(s) or law were: Personnel, Resident Care and Related Services, and Complaint Investigation A violation notice was 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 1 (admit date, 07/23/2021) had an order for Sertraline HCI Oral Tablet 25 MG (give 2 tablets by mouth one time a day for anxiety). Resident 1’s Medication Administration Record (MAR) reflected that there were nine missed doses of Sertraline HCI 25 MG, 09/04 – 09/11/2024.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1 did not experience a negative outcome due to missed dose of Sertraline per MD order. B. With respect to how the facility will identify residents/situations for the identified concerns: Resident Care Director conducted EMAR to medication cart audit to confirm medications were available per Physicians Orders. Refresher training completed with Wellness Nurses and Medication Care Managers that was conducted by Resident Care Director to review medication reorder process. C. With respect to what systemic measures have been put into place to address the stated concern: RCD and or Designee will conduct weekly med cart audit for one-month, monthly audits for 2 months, to confirm availability of medication per MD orders. Issues that may be identified will be addressed and resolved at time of audit. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
22VAC40-73-220-B
Based on resident record review and staff interview, the facility failed to ensure that when private duty personnel who were not employees of a licensed home care organization provided direct care or companion services to residents in an assisted living facility, information on the type and frequency of the services delivered to the resident by private duty personnel was obtained in writing, the information to determine if it was acceptable was reviewed, and notification to whomever had hired the private duty personnel regarding any needed changes was provided.
Evidence
  1. Resident 1’s (admit date, 07/23/2021) individualized service plan (completed, 08/28/2024) stated, “I need companion services. The providing individual/company (Specify: Name, Address and Phone Number may be contacted at (Specify: Contact Information) and routinely visits community on (Specify: Contact Information). Services will be billed to (Specify)
  2. The Resident Companions Policy stated, “The Resident Care Director (RCD)/designee documents that the Resident has retained a companion in the resident’s electronic health record (eHR) and Service Plan (SP). The resident’s retention of a companion is documented with every comprehensive assessment (within the eHR) and with each monthly wellness visit; the SP is updated as needed.”
  3. On 10/07/2024, Licensing Inspector (LI) interviewed Staff 1 who stated, Resident 1’s family privately hired Private Duty Aide 2 and Private Duty Aide 3, so the facility was unaware of hire dates or the arrangement between Private Duty Aides and family.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1 experienced no negative outcome regarding frequency and type of services rendered. ISP has been updated. B. With respect to how the facility will identify residents/situations for the identified concerns: Resident Care Director conducted an audit to confirm residents with that received companion services have frequency and types of services of companion care outlined in ISP. C. With respect to what systemic measures have been put into place to address the stated concern: Executive Director and or designee will continue to conduct ISP audits monthly for the next 3 months for residents receiving companion services to confirm required type of services rendered that is noted on the ISP. Any identified issues will be address and resolved. Refresher training with Resident Care Director, Wellness Nurses and Care Coordinators was completed to review VA DSS Private Duty Personnel Standard to ensure compliance. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
22VAC40-73-680-K
Based on resident record review, the facility failed to ensure that the resident was capable of determining when PRN medication was needed or to obtain an order included symptoms that indicated the use of the medication, the exact time frames the medication was to be given in a 24-hour period, and directions as to what to do if symptoms persist. Medication Aides administer medications, including PRN medications.
Evidence
  1. Resident 1 (admit date, 07/23/2021) had a PRN order for Systane Ophthalmic Gel 0.4-0.3 % (Polyethlene Glyocol-Propylene Glycol (Ophth) (instill 1 drop in both eyes every 6 hours as needed for dry eyes). The order did not include symptoms that indicated the use of the medication, the exact time frames the medication was to be given in a 24-hour period, and directions as to what to do if symptos persisted.
  2. Resident 1’s record contained a progress note, 08/28/2024, that stated, “…writer told Resident 1’s daughter that Staff 1will initiate a change in condition assessment to re'ect resident’s current condition…” The change in condition assessment was completed on 08/28/2024. Resident 1’s assessment category was Severe Impairment; scored 6.0.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1 experienced no negative outcome. The Resident Care Director contacted residents MD and obtained clarified order detailing further instructions if symptoms persist and has been noted on order. B. With respect to how the facility will identify residents/situations for the identified concerns PRN order audit will be completed for all as needed medication to ensure further instructions are noted on order if symptoms persist (or no relief in 24 hrs). C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director, Wellness Nurse and or designee will, at the time of admission and at six month Physician Order Sheet review, when new prn medication orders are obtained and will ensure prn orders have specific instructions if symptoms persist. Resident Care Director will provide training to Wellness Nurses and Medication Care Managers regarding the requirements of PRN orders per VA DSS Standards. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for qua1ter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
22VAC40-73-250-D
Based on private duty record reviews and staff interview, the facility failed to ensure that each person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submitted the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall not be no older than 30 days. Evidence:
  2. Private Duty Aide 2’s (hire date, unknown) tuberculosis screening was completed 03/15/2024. Resident 1’s companion care services started on 08/30/2024.
  3. Private Duty Aide 3’s (hire date, unknown) record did not contain a tuberculosis screening.
  4. On 10/07/2024, LI interviewed Private Duty Aide who confirmed that Private Duty Aide 3’s records was missing a tuberculosis screening.
  5. Resident Companions Policy stated, “Prior to beginning work in the community, it is the responsibility of the ED/designee to validate that all companions have TB (tuberculosis) screening.”
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1 experienced no negative outcome from missing TB screening. B. With respect to how the facility will identify residents/situations for the identified concerns: Executive Director contacted NP and TM 2 & TM 3 TB screenings were updated and obtained and are on record in TM file. C. With respect to what systemic measures have been put into place to address the stated concern: Prior to a new companion TM's first day, the Care Coordinator and or designee reviews the required paperwork, including TB Screening. The TB screening will be reviewed to validate that its within 30days from the first day of service. For the next 3 months companion team members that are new to the community, the Executive Director (ED/Administrator) or designee will review required documents, including TB screening prior to initiation of services. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
22VAC40-73-220-A
Based on record reviews and staff interview, the facility failed to ensure orientation and training were provided to private duty personnel regarding the facility’s policies and procedures related to the duties of private duty personnel.
Evidence
  1. Private Duty Aide 2 (hire date, unknown) and Private Duty Aide 3’s (hire date, unknown) records did not contain documentation of completion of orientation trainings.
  2. On 10/07/2024, Licensing Inspector (LI) interviewed Staff 1 who confirmed that orientation trainings were not present in Private Duty Aide 2 and Private Duty Aide 3’s records. Staff 1 stated, “I don’t know” when asked why the trainings were not completed.
  3. The Resident Companion Policy stated, “Companions complete the Sunrise volunteer orientation program.”
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1 experienced no negative outcome regarding missed orientation. Orientation was completed. B. With respect to how the facility will identify residents/situations for the identified concerns Resident Care Director completed orientation with companions. Refresher training with Resident Care Director, Wellness Nurses and Care Coordinators was completed to review VA DSS Private Duty Personnel Standard to ensure compliance. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director completed Community Orientation with TM #2 & TM # 3. This documentation has been updated in TM record. Executive Director and or designee will continue to conduct companion TM orientation audits monthly for the next 3 months for residents receiving companion services to verify that orientation was conducted on or before the first day of services rendered. Any identified issues will be address and resolved. D. With respect to how the plan of correction will be monitored: POC and monitoring results are reviewed and evaluated by the ED and coordinators at the Quality Management (Quality Assurance and Performance Improvement/QAPI) meeting for quarter four and quarter one to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again.
April 1, 2024Complaint survey0 violations
Inspection dates
04/01/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/01/2024 Time In: 10:30 am Time Out: 1:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/13/2024 regarding allegations in the areas of: resident mattress soiled with urine and chuck pads Number of residents present at the facility at the beginning of the inspection: 78 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: 0 Observations by licensing inspector: LI reviewed the investigation statements of the staff present during the time of the alleged incident. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. 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 Nina Wilson, Licensing Inspector at 703) 635-6074 by email at nina.wilson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 1, 2024Complaint survey0 violations
Inspection dates
02/01/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 2/1/2024 (9:50 AM - 11:30 AM), (3:30 PM – 4:40 PM); 2/5/24 (10:00 AM – 11:00 AM) 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 1/26/24 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: One Number of interviews conducted with residents: One Number of interviews conducted with staff: Three An exit meeting was 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 Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 18, 2023Inspection1 violation
Inspection dates
12/18/2023
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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 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
Documentation was discussed with the provider.
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: 12/18/23 (8:30 AM - 4:35 PM) Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 10 Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meals, medication administration, activities 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that the medication storage area remains locked.
Evidence
  1. The medication cart, on the facility's special care unit, was observed to be unlocked and unattended at approximately 8:44 AM.
Plan of correction
There was no negative outcome as a result of the unlocked med cart. Med cart secured immediately once identified. The Executive Director conducted a refresher training with the specific medication manager regarding the importance of keeping the medication cart locked. The Resident Care Director or designee will continue to conduct unannounced medication cart observations weekly for 3 months to confirm medication carts are locked when not in use. The Resident Care Director or designee will present the results of the medication-pass observations to the Quality Assurance and Performance Improvement Committee (QAPI) committee monthly for three months. During and at the end of 3 months, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.
December 6, 2022Inspection4 violations
Inspection dates
12/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 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
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: 12/6/22 (8:30 AM - 6:00 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct care staff member maintains certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid.
Evidence
  1. The record of Staff #2 was reviewed during the inspection. Staff #2’s record contained a first aid certification that expired in October 2022. No documentation was provided, during the inspection, to confirm that Staff #2 has current certification in first aid.
Plan of correction
Staff #2 completed first aid training, on 12/13/2020, the certificate was provided to Surveyor on 12/14/2022. The Business Office Coordinator/Designee has reviewed the files of all team members responsible for direct care and ensured that each person has first aid and CPR training and that the training is current. The BOC and/or designee will audit new team members files monthly for three months to confirm that new team members have a current first aid certification, for staff identified first aid certification will be completed within 60 days of employment and required documentation placed in file. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training in order to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-1090-A
Based on record review, the facility failed to ensure that each resident is assessed by an independent clinicalpsychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, before they are admitted into the safe, secure environment.
Evidence
  1. The record for Resident #7 was reviewed during the inspection. Resident #7 was admitted into the memory care unit on 5/25/22, but the resident’s Assessment of Serious Cognitive Impairment was not completed until 5/27/22.
Plan of correction
The Primary Care Physician completed the Assessment of Serious Cognitive Impairment form for Resident #7. There was no negative outcome because of the form being completed incorrectly. The RCD and designee completed an audit of Residents medical records to verify the Assessment of Serious Cognitive Impairment form was completed by the physicians correctly; identified issues were addressed and resolved. Upon receipt of an Assessment of Serious Cognitive Impairment form for a resident the RCD or designee will review the form to verify it is completed correctly; any identified issues are addressed and resolved. The RCD and/or designee will complete a medical record audit specific Assessment of Serious Cognitive Impairment form for the next 3 months to identify issues and ensure appropriate follow-up. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designee coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-450-E
Based on record review, the facility failed to ensure that individualized service plans (ISPs) are signed and dated by the administrator, or their designee, and by the resident, or their legal representative.
Evidence
  1. The ISPs for the following residents were not signed by the resident or their legal representative: Resident #1 (dated 11/6/22), Resident #2 (dated 11/6/22), Resident #3 (dated 10/26/22), Resident #4 (dated 10/26/22), and Resident #8 (dated 8/25/22).
Plan of correction
The community reviewed the UAI and service plan for resident #1 and resident #2. The community agents signed the UAI and service plan, contacted the families of each resident, reviewed the service plan with the families, and had the families sign the plans. The Assisted Living Coordinator and Reminiscence Coordinator reviewed the files for all residents to ensure that the UAI and service plan for each resident has been completed according to policy and signed by the appropriate parties. Any plans found to be out of compliance with the associated regulation or company policy was addressed and corrected to comply. The care coordinators will be responsible for collecting signatures on the UAI and the ISP as new UAIs are completed. Newly completed UAIs and ISPs will be reviewed during Interdisciplinary Meetings that occur 2 to 3 times per month or as needed. The results of the review during the IDT meetings will be presented at the QAPI Meeting for 3 months. During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place in the monthly QAPI meeting.
22VAC40-73-660-B
Based on observation and record review, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents, whose UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents.
Evidence
  1. Calmoseptine ointment was observed on a shelf in the room of Resident #2, of the memory care unit. Resident #2’s record contained an order, dated 7/28/22, for Calmoseptine ointment. Resident #2’s UAI, dated 11/3/22, states that the resident needs his medication to be administered by professional nursing staff.
Plan of correction
Resident #2 experienced no negative outcome from the medication left in the apartment unattended. The medication was removed from sight and was properly stored. The Executive Director/Designee spot checked 25% of the community’s occupied apartments for chemicals improperly stored and will present any violations at the monthly QAPI meeting. The Resident Care Director/Designee retrained the clinical team on the importance of following treatment orders related to medication storage starting at the all-team town hall conducted on 12/15/22. Reminiscence Coordinator/designee , will perform spot checks for unsecured medications and findings for 3 months, which will be presented at the QAPI meeting for 3 months. During the 3 months, the QAPI Team will re-evaluate and initiate necessary action or extend the review period, as needed based on issues identified or trends observed. The Executive Director or designee is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction; along with addressing and resolving variances that may occur.
July 22, 2022Complaint survey1 violation
Inspection dates
07/22/2022, 08/04/2022, 08/11/2022, 08/23/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Unannounced complaint inspections were conducted on 7/22, 8/4/, 8/11, and 8/23. The inspections were in response to a complaint received by the licensing office on 5/26/22 regarding Resident Care and Related Services. Interviews were conducted, staff records were observed, and resident records were observed. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and the violation was 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-580-E
Based on record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber be provided according to his instructions and documented.
Evidence
  1. Resident #1’s resident record was observed during the inspection. Resident #1’s record contained an order for Calmoseptine ointment, dated 3/31/22. Resident #1’s ISP states that Resident #1 needs assistance with medication administration and assistance to the bathroom. No documentation was provided, during the inspection, to document the administration of Calmoseptine to Resident #1, during his time at the facility in July. Resident #2’s resident record was observed during the inspection. Resident #2’s record contained an order for Ketoconazole shampoo, dated 10/11/21. Resident #2’s ISP states that the resident needs assistance with bathing, medication administration and grooming. No documentation was provided, during the inspection, to document the administration of Resident #2’s Ketoconazole shampoo in July.
Plan of correction
Residents #1 and #2 experienced no negative outcomes. Resident Care Director (RCD) immediately communicated the importance of verifying all orders are being followed to the registered medication aides, wellness nurses, and care managers. Resident Care Director (RCD) or designee conducted a medication refresher training with Medication Care Managers/Nurses regarding following orders and documentation. The Resident Care Director or designee will continue to conduct documentation audits weekly for 3 months to confirm that medications are being administered per the physician's order. The Resident Care Director or designee will continue to conduct documentation audits weekly for 3 months to confirm that medications are administered and that staff initials found for the application of prescribed medications are noted. The results of the audits will be presented by the resident care director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. The resident Care director will re-evaluate and initiate necessary action or extend the review period if necessary. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place in the monthly QAPI meeting.
July 11, 2022Inspection1 violation
Inspection dates
07/11/2022, 08/04/2022, 08/11/2022, 08/23/2022
Areas reviewed
63.2 FACILITIES AND PROGRAMS
Comments
Unannounced monitoring inspections were conducted on 7/22, 8/4/22, 8/11/22 and 8/23/22. Interviews were conducted and one staff record was observed. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
63.2-1808-A-11
Based on documentation and interview, the facility failed to ensure that each resident is treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity.
Evidence
  1. A facility reported incident, involving Residents #1 and #2, was provided to the licensing office on 6/3/22. Staff #1 was hired on 7/1/21 as a care manager. The care manager job description includes information about promoting the dignity and physical safety of each resident. The care manager description also indicates that the staff member will adhere to standards of resident rights and Sunrise principles of service. Resident and staff statements indicate that Staff #1 yelled at Resident #2 on 6/1/22.
Plan of correction
Residents #1 and #2 experienced no negative outcomes and Staff #1 is no longer employed in our community.Following being informed of an allegation, the Executive Director immediately placed Staff #1 on administrative leave and began a comprehensive investigation. The Executive Director was unable to complete the investigation as Staff #1 declined and failed to cooperate with the investigation process. The Executive Director terminated Staff #1 for failure to participate in an active investigation of the alleged abuse. The Executive Director/Designee retrained all team members on resident rights and mandated reporting. The Resident Care Director/Designee will evaluate the resident for signs and symptoms of abuse through verbal interview and/or physical evaluation for 90 days. The Executive Director and/or designee will conduct monthly Elder Abuse Preventative and Resident Rights Training at Town Hall Meetings, over the next 3 months. The results of the monthly wellness visits, actual investigations conducted, and the training sessions will be presented at the Quality Assurance and Performance Improvement (QAPI) Meetings for 3 months. The QAPI meetings will include tracking and trending. During and after each month, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction; along with addressing and resolving variances that may occur.
April 26, 2022Complaint survey1 violation
Inspection dates
04/26/2022
Areas reviewed
PART VI. RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced complaint inspection was conducted on 4/26/22. The allegations were determined to be valid, as a preponderance of evidence supported the allegation. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-460-B
Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Facility call bell documents were reviewed during the inspection. The facility’s call bell system does not provide information about the reason for the call, when the call button is pushed or the call cord is pulled. Resident #1’s April 2022 call bell report indicated that the bell or cord was used 50 times. The report indicated that there were 19 instances when staff members took at least 30 minutes to acknowledge the call bell, or the alert was never responded to. Resident #2’s April 2022 call bell report indicated that the bell or cord was used 119 times. The report indicated that there were 64 instances when staff members took at least 30 minutes to acknowledge the call bell, or the alert was never responded to.
Plan of correction
Residents #1 and #2 experienced no negative outcomes and was provided assistance. The call bell pull stations and pendants were tested to ensure batteries are in working order by the Maintenance Coordinator. The Executive Director (ED) conducted an in-services on-call bell management and how vital it is to the life-safety of residents. The Maintenance Coordinator or designee will continue to conduct random call bell audits weekly for 3 months to confirm that call bells are responded to timely. The Call bells will be pulled randomly by the Maintenance Coordinator or Designee and response time noted starting on 5/30/22. Issues identified will be addressed and resolved timely. Any pulls that do not register accordingly will be reported to the vendor for resolution. This audit will be done weekly for 3 months to identify any concerns. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place in the monthly QAPI meeting.
February 23, 2022Complaint survey2 violations
Inspection dates
02/23/2022, 04/26/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Unannounced inspections were conducted on 2/23/22 and 4/26/22. Resident records and facility documents were reviewed. The allegations were determined to be valid, as a preponderance of evidence supported the allegations. The violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are 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.
Evidence
  1. Resident #1's medication administration record (MAR) was reviewed during the inspection. Resident #1's Iron and Vitamin D were not administered on 1/5/22. The MAR states that the medications were not administered, as they were "pending delivery." Resident #2's MAR was reviewed during the inspection. Resident #2's Losartan was not administered on 11/11/21. The MAR states that the Losartan was not administered, as it was "pending delivery." Resident #2's Oxycodone was not administered on 12/2/21 (3 AM administration). Resident notes stated that the medication was not administered, because the staff member was attending to three emergencies.
Plan of correction
A. With respect to the specific resident/situation cited: Residents #1 and #2 experienced no negative outcomes and medications are available for administration per physician’s orders. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Resident Care Director (RCD) conducted an eMAR medication cart audit to confirm medications were available per physician order. Any identified unavailable medication was reordered and arrival was confirmed. Resident Care Director (RCD) or designee conducted a refresher training with Medication Care Managers and Nurses regarding the process of timely ordering, reordering, and administration of prescribed medications. The Resident Care Director or designee will continue to conduct eMAR to medication cart audits weekly for 3 months to confirm that medications are available and administered per the physician’s order. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director or designee will continue to conduct eMAR to medication cart audits weekly for 3 months to confirm that medications are available and administered per the physician’s order. The results of the audits will be presented by the resident care director and/or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. The resident Care director will re-evaluate and initiate necessary action or extend the review period if necessary. D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place in the monthly QAPI meeting.
22VAC40-73-470-C
Based on record review, the facility failed to ensure that services are provided to prevent clinically avoidable complications.
Evidence
  1. Resident #2's record was reviewed during the inspection. A progress noted, dated 12/2/21, indicates that Resident #2 has a stage 2 sacral wound and that the resident should have frequent repositioning. Resident #2's individualized service plan (ISP) indicates that treatment to her pressure ulcer will be provided as ordered. The ISP did not document Resident #2's need for frequent repositioning. No additional documentation was provided to indicate that Resident #2 was frequently repositioned.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #2 experienced no negative outcome to the sacral wound with the wound healed at the time of discharge (Dec. 2021). B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director/Designee retrained the clinical team on the importance of following treatment orders related to wound management with updates to the Care Plan. The Resident Care Director/Designee will review all wounds during the IDT meeting with the interdisciplinary team. C. With respect to what systemic measures have been put into place to address the stated concern: In order to confirm that the processes outlined above are sustained: The Resident Care Director and/or Designee will report audits of the electronic Medical Record that show supporting documentation related to wound treatment orders including Care Plan updates and the findings at the QAPI meeting for 90 days. After concluding the 90-day reviews, the QAPI committee will re-evaluate and initiate the necessary action needed at that time. D. With respect to how the plan of correction will be monitored: The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction; along with addressing and resolving variances that may occur.
December 2, 2021Inspection4 violations
Inspection dates
12/02/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
An unannounced renewal inspection was conducted on 12/2/21 (8:45 AM - 6:10 PM). At the time of entrance, 80 residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-1090-A
Based on record review, the facility failed to ensure that each resident is assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare, prior to his/her admission to the safe, secure environment.
Evidence
  1. The record for Resident #3 was reviewed during the inspection. Resident #3 was admitted into the safe, secure environment on 8/2/21. Resident #3's Assessment of Serious Cognitive Impairment form, dated 7/28/21, states that the resident has the ability to recognize danger or protect his own safety and welfare.
Plan of correction
The Primary Care Physician completed the Assessment of Serious Cognitive Impairment form for Resident #3. There was no negative outcome because of the form being completed incorrectly. The RCD and designee completed an audit of Residents medical records to verify the Assessment of Serious Cognitive Impairment form was completed by the physicians correctly; identified issues were addressed and resolved. The RCD and designee conducted a refresher training with the coordinators on verifying that the Assessment of Serious Cognitive Impairment form it is completed correctly. Upon receipt of an Assessment of Serious Cognitive Impairment form for a resident the RCD or designee will review the form to verify it is completed correctly; any identified issues are addressed and resolved. The RCD and/or designee will complete a medical record audit specific Assessment of Serious Cognitive Impairment form for the next 3 months to identify issues and ensure appropriate follow-up. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designee coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-720-A
Based on record review, the facility failed to ensure that Do Not Resuscitate (DNR) Orders are included in the individualized service plan (ISP).
Evidence
  1. The record for Resident #2 was reviewed during the inspection. The record included a DNR order, dated 4/18/21. The DNR order was not included in Resident #2's ISP, dated 10/21/21, as she was listed as full code.
Plan of correction
Resident #3's ISP was updated to include current DNR order. The neighborhood coordinator educated resident #2's designated care managers on the resident's change DNR status. The Wellness Team and designee completed an audit of resident's ISPs to verify the DNR orders were documented correctly; identified issues were addressed and resolved. The RCD and designee conducted a refresher training with the wellness nurses and coordinators on properly documenting DNR orders on resident ISPs. As DNR orders are received the RCD or designee will review the orders and update the residents ISP. The designated care managers will be informed of the change. The RCD and/or designee will complete an audit to verify DNR orders are correctly documented on the ISP for up to 3 months. Any inconsistencies identified will be corrected. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designee coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-680-D
Based on observation and record review, the facility failed to ensure that medications are 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.
Evidence
  1. The morning medication administration for Resident #3 was observed during the inspection. Resident #3 received one 10mg tablet of Donepezil, during the medication administration. The record for Resident #3 includes an order for Donepezil, dated 8/11/21, that calls for the resident to receive two 10mg tablets.
Plan of correction
Resident #3 did not experience a negative outcome because of Donepezil (Aricept) was not administered per the physician's order. The Resident Care Director (RCD) notified the Nurse Practitioner who provided an order for a one-time dose of Aricept tablet so that resident #3 could receive the correct dose that day. The pharmacy was contacted by the RCD and issued a corrected label for the blister pack. The RCD and designee performed an audit of the medication orders with the pharmacy orders; identified issues were addressed and resolved. The RCD conducted a re-education training with the Medication Care Managers (MCM) on the process for clarifying discrepancies with medication orders. The RCD educated the Wellness Nurses and the MCM's on the process of reconciling medication orders when discrepancies are identified during medication administration. MCMs are to refer to the current medication orders in the medical records and obtain corrected medication labels when discrepancies are identified. The RCD conducts medication pass observations annually for MCM to verify medications are being administered according to administration practices. The MCMs conduct medication cart audits weekly to verify that medications labels match the medication orders. The RCD or designee conduct medication cart audits monthly to verify that medications labels match the medication orders. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designee coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-860-I
Based on observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. The Beauty Salon was observed to be unlocked and unattended. Virex Tb disinfectant cleaner, Ship-Shape, and Casticide disinfectant cleaner were observed in the room, at the time of the inspection.
Plan of correction
The Maintenance Coordinator (MC) locked the Beauty Salon door. There were no negative outcomes. The MC replaced the door lock with a Schlage Coded Lock that automatically relocks after entry. The MC re-educated team members, including the beauty salon attendant, that the beauty salon closets, cabinets, and areas where chemicals are maintained need to be properly locked. The MC or designee checks to confirm that chemicals are properly stored and secured weekly for the next 3 months. Issues identified will be resolved. For up to 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director or designee coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
December 9, 2020Inspection2 violations
Inspection dates
Dec. 9, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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 12/9/20 and completed on 12/18/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the census was 71. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-250-D
Plan of correction
Team member #3 completed a TB risk assessment on 12/10/2020. Reviewed and signed by Nurse Practitioner verifying TM was negative for signs and symptoms of TB. The assessment was added to Team Member #3's record. The Business Office Coordinator (BOC) and ED will conduct an audit of team member files to confirm TB assessment requirements. BOC and ED will conduct monthly audits of newly hired team members TB records and annual TB assessments for 3 months. The Business Office Coordinator (BOC) and Executive Director (ED) will utilize software tracking system to manage TM annual requirement compliance. Business Office Coordinator (BOC) will provide ED monthly report for additional verification of compliance. Additionally, BOC contacted contracted Employee Health Provider and shared TM screening requirements to further manage compliance with further TB screening. Regional Human Resource Representatives will provide additional oversight to support compliance. Each month, for 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the Team Record audits specific to TB Screening and determine if additional focus or action is warranted. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The November medication administration record (MAR) for Resident #2 was reviewed during the inspection. The MAR stated that Resident #2 did not receive his Lidoderm patch on 11/2/20. The MAR stated that the patch was "pending delivery." The November MAR for Resident #4 was reviewed during the inspection. The MAR stated that Resident #4 did not receive her Coreg on 11/30/20 (8 AM administration). The MAR stated that the Coreg was "pending delivery."
Plan of correction
Resident #2 Lidoderm Patch was received from the pharmacy on November 2, 2020 and administered on 11/3/2020 as ordered by physician and confirmed by the Resident Care director (RCD). Resident #2 demonstrated no known negative outcomes. Resident #4 Coreg was received from the pharmacy on November 30, 2020 and was administered upon arrival that evening to Resident #4. Resident #4 demonstrated no negative outcomes from delayed administration. Resident Care Director (RCD) performed an audit of the medication administration records and medication carts as it relates to medication pending delivery; No issues were identified. Resident Care Director (RCD) has conducted refresher training with the Medication Managers on the process for following up with the pharmacy, the physician, proper documentation and measures to prevent unavailable medications. Resident Care Director (RCD) will discuss this process at the monthly Medication Managers meetings over the next 3 months. The Medication Managers (MCM) and Wellness Nurses were re-educated by the RCD regarding the process to follow when a medication is pending delivery. Resident Care Director (RCD), or designee will conduct weekly audits for 2 weeks, monthly audits for 2 months to confirm medications are available per physician's orders on the medication cart. Issues that may be identified will be addressed and resolved. A refresher training initiated as needed. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the medication administration audits specific to medication pending delivery and determine if additional focus or action is warranted. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
August 21, 2020Complaint survey1 violation
Inspection dates
Aug. 21, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 8/21/20 and concluded on 11/18/20. A complaint was received by the department regarding allegations in the areas of: Administration and Administrative Services, Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-40-A
Based on documentation and reports, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. The facility’s COVID-19 Mitigation and Response Plan (3/18/20) calls for team members to have their temperature taken, to screen for fever, at the beginning of each shift. The plan also calls for a mask to be placed on team members and that they immediately be sent home, should they develop fever at work. The facility’s team member screening flow chart indicates that staff members; that have a fever, cough or shortness of breath; should be asked to go home and that the ED (Executive Director) or manager on duty be notified. The facility’s COVID-19 Mitigation and Response Plan states that it is the facility’s policy to manage suspected and confirmed COVID-19 cases in accordance with Organizational, Federal, State/Provincial and Local laws, regulations and guidelines and guidance from the Centers for Disease Control & Prevention (CDC) and applicable public health authorities. CDC considers a person to have a fever when he or she has a measured temperature of 100.4“ F (38” C) or greater, or feels warm to the touch, or gives a history of feeling feverish. Team member screening logs from March and April were reviewed. The following did not comply with the facility’s policy: The log is missing a temperature reading for Staff # 1 on 3/20/20. The log is missing a temperature reading for Staff #2 on 3/24/20. The log is missing temperature readings for two unknown individuals on 3/26/20. The log is missing a temperature reading for an unknown individual on 4/6/20. The log is missing a temperature reading for Staff #3 on 4/15/20. The log is missing a temperature reading for Staff # 4 on 4/25/20. The log is missing a temperature reading for Staff #5 on 4/26/20. Staff #6’s temperature was documented as 100.7 on 4/23/20 at 6:18. The screening log did not indicate whether the temperature check occurred at 6:18 AM or 6:18 PM. The facility’s punch detail report indicates that Staff #6 worked from 6:25 AM until 2:31 PM on 4/23/20. The information was discussed with Staff #s 7-9, and no additional documentation was provided.
Plan of correction
Not published by VDSS.