Virginia DSS · Assisted Living Facility

Davis & McDaniel Veterans Care Center

📍 4550 Shenandoah Ave., Roanoke, VA, 24017

ID 25901Two Year licenseActive
5
Inspections
On record
5
With violations
Visits that cited something
0
Clean visits
Nothing cited
16
Violations cited
Individual findings
15
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Davis & McDaniel Veterans Care Center was inspected 5 times between September 10, 2021 and October 7, 2025 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 0 with none. Across that history VDSS cited 16 violations under 15 distinct standards.

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

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

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
11/30/2027
Administrator
Todd Barnes
Licensing inspector
Angela Swink
Inspector phone
(276) 623-6575
Approved for
Assisted Living · Non-Ambulatory

Inspection History

5

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

October 7, 2025Inspection1 violation
Inspection dates
10/07/2025
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 PREPAREDNESS22VAC40-90 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: 10/7/2025 08:55 to 12:15 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: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication Pass, Medication Cart Audit, Lunch Meal A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-80-120-E-1
Based on physical plant observation and staff interview, the facility failed to ensure that certain documents related to the terms of the license are required to be posted on the premises of each facility to include the most recently issued license.
Evidence
  1. The facility’s most recently issued license is dated 8/19/2025. 2.During the inspection the licensing inspector (LI) observed the license posted on the premises was issued on 12/1/2023. 3.Interview with Staff 1 confirmed the facility had not updated the license posted on the premises with the license that was issued on 8/19/2025.
Plan of correction
Not published by VDSS.
September 17, 2024Inspection2 violations
Inspection dates
09/17/2024
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 PREPAREDNESS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/17/2024 08:45 to 13:10 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: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication Pass Observation, Activity, and Lunch meal 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on resident record review and staff interview, the facility failed to ensure the medications ordered for PRN administration were available for a resident.
Evidence
  1. The record for resident 1 had a physician’s order dated 9/9/2024 for Ondansetron Oral Tablet Disintegrating 4mg, Give 1 Tablet by mouth every 6 hours as needed for nausea and vomiting.
  2. During a medication cart review on 9/17/2024 with the licensing inspector and staff 1, staff 1 confirmed the medication was not in the cart or the medication room and not available for the resident.
Plan of correction
1. Nursing staff to be educated on verifying that a medication is present when orders are received 2. Orders for all DOM residents to be compared to medications in cart to verify that all medications ordered are present 3. During their biannual Medication Regimen Review, the pharmacist will recommend to discontinue any prn medication which has not been used within the prior 60 days and report results to the DON/Designee 4. Unit Manager/Designee will perform medication cart checks monthly to verify that all prescribed medications are present 5. Results of all checks will be reported to the QAPI committee at quarterly meetings
22VAC40-73-470-B
Based on resident record review and staff interview, the facility failed to ensure a resident's need for skilled nursing treatments within the facility was met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.
Evidence
  1. The record for resident 2 has a physician’s order dated 8/22/2024 with documentation for Clean right upper chest wound and right neck with mild soap and water and cover with dressing change every Monday and Thursday.
  2. The August 2024 Medication Administration Record has documentation of staff 5’s initials on 8/29/2024 for completion of this treatment. The September 2024 Medication Administration Record has documentation of staff 5’s initials on 9/5/2024 and 9/12/2024 for completion of this treatment.
  3. Staff 5 record contains documentation of staff 5 being a registered medication aide.
  4. On the day of inspection, during an interview with one licensing inspector and staff 4, staff 4 confirmed that staff 5 was a Registered Medication Aide and not a licensed healthcare professional. This treatment should have been completed by a licensed healthcare professional.
Plan of correction
1. Nursing staff and Med Techs will be educated that any treatments ordered for the DOM residents must be completed by a Licensed Nurse and documented 2. Unit Manager/Designee to verify Licensed Nurse signatures on Treatment Records weekly x 4 weeks, then once every 2 weeks x 4 weeks, then monthly x 4 months and prn. Any discrepancies will be immediately reported to the DON/Designee. 3. All results from audits will be reported to the QAPI Committee at the quarterly meetings.
September 26, 2023Inspection3 violations
Inspection dates
09/26/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/26/2023 from 09:00 AM until 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-210-D
Based on record review and staff interview, the facility failed to ensure that medication staff receive continuing education as required by the Virginia Board of Nursing.
Evidence
  1. The record for staff 1 did not contain evidence that staff 1 completed annual population-specific training in medication administration in the assisted living facility in which the aide is employed or an annual refresher course in medication administration, per section 18VAC90-60-100-B of the Virginia BON website continued competency for RMAs.
  2. Interview with staff 4 also could not verify that staff 1 had received the annual medication administration training.
Plan of correction
1. Staff 1 completed her annual refresher course in medication administration on 10/02/2023. 2. All RMA's have been educated on the requirement to complete the annual refresher course and submit proof of training. 3. The Director of Education/Designee will verify that each RMA employed by the facility has completed the annual refresher course as required. A report will be given to the DON/Designee monthly. The issue will be discussed at the quarterly QAPI meeting until resolved.
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to ensure that a fall risk rating is reviewed and updated after a fall.
Evidence
  1. The record for resident 4 contains an annual fall risk evaluation, dated 08/01/2023, which indicates that the resident has had no history of falls within the last six months; however, progress notes for resident 4, dated 06/18/2023, indicate that the resident self-reported to staff that she had fallen during the morning of 06/17/2023 and was transported to the hospital for treatment, but no corresponding fall risk evaluation was found in the record.
  2. The record for resident 6 contains an annual fall risk evaluation, dated 08/10/2023, which indicates that the resident had 1 to 2 falls in the last six months; however, progress notes for resident 6 indicate that the resident had falls on 06/02, 06/03, 06/04, 07/16, 07/28, and 07/31/2023, but not all corresponding fall risk evaluations were found in the record.
  3. Interview with staff 4 on the date of inspection revealed that staff were not aware that fall risk evaluations were required after a fall.
Plan of correction
1. A fall risk assessment for Resident 4 has been completed on 9/27/2023 to correspond with falls after the annual fall risk assessment was completed. 2. A fall risk assessment for Resident 6 has been completed on 9/27/2023 to correspond with falls after the annual fall risk was completed. 3. Education will be completed with all nursing personnel of the ALF that a fall risk evaluation will be completed after each fall incident sustained by the residents. 4. The Unit Manager/Designee will verify that a fall risk assessment has been completed following each incident and will report to the DON/Designee. !f a fall risk assessment has not been completed, the Unit Manager/Designee will re-educate the responsible staff member and verify that the assessment is completed. The issue will be discussed at the quarterly QAPI meeting until resolved.
22VAC40-73-640-A
Based on observation and staff interview, the facility failed to implement parts of its medication management plan, specifically regarding methods to ensure accurate counts of all controlled substances and infection control procedures related to blood glucose monitoring.
Evidence
  1. Page three of the facility’s medication management plan, last reviewed in June 2023, states that all controlled substances are verified by numerical count at the beginning and end of each shift by the current nurse and the oncoming nurse, including Registered Medication Aide. The facility’s narcotic count and card count form states the following: “BY SIGNING THIS FORM, YOU ARE STATING THAT THE NARCOTIC COUNT AND CARD COUNT IS CORRECT PRIOR TO LEAVING AND ARRIVING”.
  2. On the date of inspection, two Licensing Inspectors (LIs) and staff 1 observed that the September 2023 narcotic count and card count signature form for the “DOM” unit did not contain signatures on the following dates and shifts: a. On 9/1/2023 by the 11 PM – 7 AM leaving nurse. b. On 9/4/2023 by the 7 AM – 3 PM arriving nurse and by the 3 PM – 11 PM leaving nurse. c. On 9/5/2023 by the 7 AM – 3 PM arriving nurse and 3 PM – 11 PM leaving nurse shift.
  3. Page two of the facility’s same medication management plan states that all glucometers and necessary components are to be labeled within specifically labeled containers for each individual resident’s use only.
  4. On the date of inspection, two LIs and staff 1 observed that the glucometer unit for resident 6 was not labeled with the resident’s name.
Plan of correction
1. The narcotic count sheet has been corrected by the nursing staff who worked on those shifts. 2. The glucometer unit for resident 6 has been labeled with the residents name. 3. Education has been completed with all nursing staff on the medication management plan including the requirement to count narcotics and sign the narcotic count sheet by both the oncoming and outgoing nursing staff. All licensed nurses and RMA's have been educated on the labeling of glucometer units assigned to individual residents. An audit has been completed of all glucometer units and any necessary corrections made. 5. Audits will be conducted of narcotic count sheets by the Unit Manager/Designee 3 x week for 4 weeks, then 2 times a week for 4 weeks and then weekly for 4 weeks and prn. All audits will be turned in to the DON/Designee, 6. Audits will be conducted weekly of glucometer units assigned to individual residents weekly for 8 weeks and then prn. Audits will be turned in to the DON/Designee. These issues and audits will be discussed at the quarterly QAPI meeting until resolved.
August 29, 2022Inspection5 violations
Inspection dates
08/29/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
The LIs and facility management had a discussion regarding durable Do Not Resuscitate forms.
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: 8/29/2022, 8:35 am to 2:45 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: 13 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
22VAC40-73-990-C
Based on document review and interview, the facility failed to do complete six month practices of the plan for resident emergencies.
Evidence
  1. The most recent practice exercise of resident emergencies was on 10/6/2021. This was noted on 8/29/2022.
  2. The practice exercise done on 10/6/2021 covered the missing resident situation, and lacked what to do in the event of a physical emergency or a mental health breakdown. This was confirmed in an interview with staff 7.
Plan of correction
1. A practice exercise for a physical emergency and for a mental health breakdown will be completed with staff. 2. Practice exercises will be conducted with staff every 6 months. 3. Unit Manager/Designee will verify that practice exercises are being completed with staff. The Unit Manager/Designee will submit a statement to the DON/Designee every 6 months with a list of completed exercises. 4. The issue will be discussed at the quarterly QAPI meeting until resolved.
22VAC40-73-450-F
Based on resident record review, the facility failed to update individualized service plans (ISP).
Evidence
  1. Oxygen for resident 1 was discontinued, but it is still on the SIP dated 6/1/2022.
  2. Resident 1 has allergies to latex, codeine, venflaxine [sic], PCN, quinapril, Effexor EW, terazosin, nifedipine, trazadone, ibuprofen, avelox, Cipro, and PPD serum. The ISP does not show what services are given to keep to make sure the resident does not get these medications.
Plan of correction
1. The ISP for Resident 1 has been revised to show that Oxygen has been discontinued. 2. The ISP for Resident 1 has been revised to show that Latex gloves will not be used in the care of the resident. Also any new medications will be compared to her allergy list and if there issues the PCP will be contacted prior to administration. 3. The Unit Manager/Designee will audit all ISP’s to verify that all discontinued items are reflected on the ISP. 4. The Unit Manager/Designee will audit new orders 3 x week for 4 weeks then 2 x week for 4 weeks then weekly for 4 weeks and prn to verify that any new orders are properly reflected on the ISP. Audits will be submitted to the DON/Designee as completed along with any changes. 5. Audit reports will be discussed at quarterly QAPI meetings until the issue is resolved.
22VAC40-73-40-A
Based on record review, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility’s own policies and procedures.
Evidence
  1. The record for resident 2 contained two annual TB Risk Assessment forms dated 1/1/2022 and 2/17/2021 in which resident 2 was assessed for TB symptoms and risk factors for developing TB. According to the screener’s signature on both forms, the two TB assessments were completed by a registered medication aide (RMA).
  2. The Virginia Department of Health Professions Board of Nursing regulations governing the registration of medication aides, effective 2/6/2020, indicate that a Registered Medication Aide shall not perform acts beyond those authorized by the Code of Virginia for practice as a medication aide, which include making an assessment of a client.
Plan of correction
1. The TB Assessment for Resident 2 has been completed with the required signature of a Licensed Nurse. 2. Education has been completed with all licensed personnel that TB Assessments must be signed by a Licensed Nurse and cannot be signed by a registered medication aide. 3. An audit has been conducted to verify that all TB assessments have been signed correctly. 4. Audits will be done by the Unit Manager/Designee 3 x a week for 4 weeks and then 2 times a week for 4 weeks then weekly for 4 weeks and prn to verify that TB Assessments have been signed by a Licensed Nurse. Audit reports will be submitted to the DON/Designee as completed with any corrections needed. 5. Audit reports will be discussed at quarterly QAPI meetings until the issue is resolved.
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that TB screenings for staff were done within time frames.
Evidence
  1. The TB screening forms for staff 1 and 3 lacked dates to show when the screenings were done.
Plan of correction
1. The TB screenings for staff 1 and 3 have been completed as required. 2. The TB screens for all ALF staff have been audited for completeness and timeliness. 3. The Director of Infection Control has established that all staff will have their TB Assessment completed on the Birth Month and will verify that all have been completed each month.
22VAC40-73-120-A
Based on document review and interview, the facility failed to have complete new staff orientation for new staff.
Evidence
  1. New staff orientation 1 and 2 was lacking some required sections: the purpose of the facility; the services provided; the daily routines; specific duties and responsibilities of their positions; required compliance with the regulations for assisted living facilities as it relates to their duties and responsibilities; procedures for reporting and documenting incidents as required in 22VAC40-73-70; and for direct care staff; the needs; preferences; and routines of the residents for whom they will provide care.
Plan of correction
1. New staff orientation 1 and 2 was corrected and completed to show: the purpose of the facility; the services provided; the daily routines; specific duties and responsibilities of their positions; required compliance with the regulations for assisted living facilities as it relates to their duties and responsibilities; procedures for reporting and documenting incidents as required in 22VAC4073-70; and for direct care staff; the needs; preferences; and routines of the residents for whom they will provide care. 2. All new staff will be audited and any corrections/completions will be done to reflect the above issues. 3. Any new hires for the DOM will have the complete education/orientation as set forth by the Code of Virginia for Assisted Living Facilities.
September 10, 2021Inspection5 violations
Inspection dates
09/10/2021, 09/13/2021, 09/14/2021, 09/20/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
A renewal inspection was initiated on 09/10/2021 and concluded on 09/20/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 18. The inspector emailed the Administrator and Assistant Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, activities calendar, menu, staff schedules, policies, fire and health inspections submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 09/14/2021. An exit interview was conducted with on 09/16/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-640-A
Based on document review, the facility failed to have some required sections in their written plan for medication management.
Evidence
  1. The facility's written plan for medication management did not address methods for verifying medications orders have been accurately transcribed to medication administration records with in 24 hours or receipt of a new order or change in order, methods to ensure that medication administration records are maintained as part of the resident's record, and methods to ensure that staff who administer medications meet current qualification requirements.
Plan of correction
1. The medication management policy has been reviewed and corrected to show methods for verifying medication orders have been accurately transcribed to medication administration records within 24 hours of receipt of a new order or change in order, methods to ensure that medication administration records are maintained as part of the residents record, and methods to ensure that staff who administer medications meet current qualification requirements. 2. Staff have been educated to all aspects of the medication management policy. 3. The Unit Manager/designee will audit orders 3 times a week for 4 weeks then 2 times a week for 4 weeks then prn to verify that the medication management policy is being followed. 4. Audits results will be reported and reviewed at the quarterly QAPI meeting until resolved.
22VAC40-73-450-C
Based on resident record review, the facility failed to address some assessed needs on comprehensive individualized service plans (ISP).
Evidence
  1. The UAI dated 2/19/2021 for resident 1 showed this resident is disoriented to Place, some of the time, and this is not addressed on the ISP dated 2/19/2021.
Plan of correction
1. The ISP for resident 1 has been reviewed and corrected to show disorientation to place some of the time. The corrected ISP has been reviewed with the resident. 2. All ISP’s will be audited to verify that any disorientation listed on the UAI is correctly documented on the ISP. 3. The ALF Unit Manager/Designee will audit all UAI/ISP on a quarterly basis to verify accuracy. 4. Audit results will be reported and reviewed at the quarterly QAPI meeting until resolved.
22VAC40-73-680-B
Based on observation and interview, the facility failed to keep medications in the pharmacy container until they were to be administered to the residents.
Evidence
  1. On 9-14-2021 at approximately 3:30 PM, approximately 12 to 15 soufflé cups filled with medications were sitting on top of the medication cart. Staff 3 stated they were pre-poured and to be administered between 4 and 5 PM.
Plan of correction
1. ALF staff has been educated that medications must be kept in the pharmacy container until administered. 2. The Unit Manager/Designee will audit medication carts 3 times a week for 4 weeks, then 2 times a week for 4 weeks and then weekly for 4 weeks and prn. 3. Audit results will be reported and reviewed at the quarterly QAPI meeting until resolved.
22VAC40-73-290-A
290-A Based on document review, the facility failed to maintain a written work schedule that indicates who is in charge at any given time.
Evidence
  1. The written work schedule failed to show who was in charge the following times: night shift 8/22, 8/29, 8/29, day shift 8/30, night shift 9/4, 9/5, and evening shift 9/8, 9/9, 9/10/2021.
Plan of correction
1. The current work schedule has been corrected to show the person in charge of the unit. 2. The Unit Manager/Designee will check the work schedule daily to verify that it is correct and shows the staff member in charge. 3. Any issues with the daily work schedule will be reported to the quarterly QAPI meeting.
22VAC40-73-650-E
Based on resident record review, the facility failed to have prescribers signed written orders in resident records.
Evidence
  1. Resident 2 was administered acetaminophen on 9/1/2021 and 9/2/2021 and the order signed on 3/21/2021 documents that this order has expired and is inactive.
  2. The September 2021 medication administration record (MAR) for Resident 2 shows the following as needed (PRN) medications may be administered: fluticasone, Genteal eye drops, Imodium, docusate sodium, and emetrol solution. The medications were available to administer, and there are no signed orders for them.
Plan of correction
1. The medication administration record for Resident 2 has been reviewed and corrected to reflect only active signed physician orders. Medications have been audited to reflect the signed orders and any medications without signed orders have been destroyed per facility policy. 2. The medication administration record for all DOM residents has been reviewed and corrected to reflect active signed orders and medications have been audited to show the same with any medications without signed physician orders destroyed per facility policy. 3. All resident charts will be reviewed on night shift to verify that orders are transcribed correctly. 4. The Unit Manager/Designee will audit orders 3 times a week for 4 weeks then 2 times a week for 4 weeks and then weekly and prn to verify that orders are accurate and that any orders which have expired are removed from the medication administration record. 5. Audit results will be reported and reviewed at the quarterly QAPI meeting until resolved.