Lake Prince Woods — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Lake Prince Woods was inspected 6 times between October 5, 2021 and October 16, 2025 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 0 with none. Across that history VDSS cited 24 violations under 19 distinct standards.

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

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

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

09/29/2026

Administrator

Felita Creekmore

Licensing inspector

Darunda Flint

Inspector phone

(757) 807-9731

Approved for

Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

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

October 16, 2025Inspection1 violation

Inspection dates

10/16/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/16/2025 (arrival 10:04 a.m. / departure 5:44 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/12/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 46 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: 0 Number of interviews conducted with staff: 1 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 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. 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 For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757)807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

22VAC40-73-460-D

Based on documents reviewed and interviews, the facility failed to ensure it provided supervision of a resident’s schedule, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

Staff #1 notified the licensing inspector (LI) on 06/12/2025 via an email regarding an incident that occurred at the facility on 06/05/2025. The incident involved memory care resident #1 who exited the memory care gate that the staff left unlocked after the landscapers left the area.
In an interview conducted on 10/16/2025 staff #1 confirmed that resident #1 exited from the memory care unit, and that the incident occurred when the memory care courtyard’s gate was left unlocked. Resident #1 exited the gate and entered the healthcare courtyard for an undetermined amount of time. The memory care staff were notified by the healthcare staff that resident #1 was in the healthcare courtyard. Resident #1 was retrieved by the memory care staff. The memory care staff redirected resident #1 to the gate on the healthcare side of the facility and walked down the facilities outside sidewalk back to the memory care unit. 3.An interview was conducted on 11/03/2025 with a collateral contact, the collateral contact reported to the LI that a call was received from the healthcare unit that alerted staff that resident was in the healthcare unit’s courtyard. Upon receiving the call a staff member went to retrieved resident #1 and brought resident #1 back to the memory care unit.

Plan of correction

On 06/05/25, after an elopement involving Resident #1 a review of the process was began. Hourly checks are completed to ensure the courtyard door is secure & documented. Charge staff began the process of cosigning at the beginning & end of each shift. Effective action completed. During lawn service days the unit staff are on alert to assure the courtyard door is secured. . Maintenance or floor staff are responsible for unlocking & locking the doors at the time of entry and completion of lawn services. The AL Administrator or designee will audit documentation biweekly x 6 months. Ongoing monthly x 6 months.

October 16, 2025Inspection4 violations

Inspection dates

10/16/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/16/2025 ( arrival 10:04 a.m. / departure 5:44 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch was observed. A medication pass observation was completed. The following were reviewed: fire inspection report, health inspection report, first aid kit, and water temperatures were measured. 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 Darunda Flint, Licensing Inspector at (757)807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

22VAC40-73-550-G

Based on staff record review, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person.

Evidence

of this review shall be the staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence:
Staff #4’s date of hire was noted as 7-11-2017. Staff #4’s record contained last documentation of the review of resident rights annually on 07/16/2019.
Staff #1 acknowledged the aforementioned review of resident rights for staff #4.

Plan of correction

On 10/20/25 the AL Administrator reviewed all records for all employees that work on Assisted Living & Memory care for annual residents’ rights. All employees (to include housekeeping, activities, dietary, maintenance & environmental services) were included & are completed. The AL Administrator or designee will ensure all employees have a signed copy of the residents’ rights completed annually. Ongoing every 6 months x 1 year

22VAC40-90-40-C

Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes.

Evidence

Staff # 2, hired 09/03/2024, criminal record report contains a conviction for one barrier crime (18.2-308.4).

Plan of correction

On 10/20/25 an audit of all Criminal Background checks was initiated. The Human Resources Director will complete this audit to ensure no employees were hired with any convictions of a barrier crime. The audits will be completed by the Human resources Director or their designee within 90 days (1/20/25). Each time a Criminal Records report is sent on a prospective employee the HR manager will review it with the Assisted Living Administrator and the Chief HR Officer to assure the conviction is not a barrier crime. Ongoing

22VAC40-73-890-B

Based on observations made during the tour of the building, the facility failed to have all interior areas adequately lighted for the safety and comfort of residents and staff.

Evidence

In the nourishment medication room on the memory care unit, the overhead light contained several inoperable light bulbs.
Staff #1 acknowledged the aforementioned light bulbs were inoperable.

Plan of correction

On 10/20/25 the Plant Operations Director thoroughly inspected all interior areas for adequate lighting. All lighting fixtures were adequate or replaced. The nursing staff on the memory care unit will sign a log weekly in the nourishment/medication room affirming that all the light fixtures are in working order. When light fixtures are not in working order, they will notify the Plant Operations Director. The Plant Operations Director or appointed designee will audit all lighting fixtures monthly x 6 months for accuracy. Ongoing every month x 6 months, then as scheduled per

22VAC40-90-30-B

Based on the staff record review, the facility failed to complete the sworn statement or affirmation for all applicants for employment.

Evidence

The Sworn statement for staff #3 dated 09/01/2025 did not include documentation of responses for Questions # 1 and # 2.
The Sworn statement for staff #5 was not dated.

Plan of correction

On 10/20/25 an audit of all Sworn Disclosures already completed was initiated. This audit will be completed within 90 days (1/20/25). Going forward all Sworn Disclosures will be signed electronically upon hire as a part of the onboarding process. The Human Resources Director will review quarterly to ensure completion. Ongoing quarterly x 6 months.

August 20, 2024Inspection5 violations

Inspection dates

08/20/2024

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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical assistance

22VAC40-73-930 22VAC40-73-1140

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: 08/20/2024 from 8:45 am to 3:08 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed on 3 residents. The following were reviewed: resident and staff records, resident fire and resident emergency drills, and medication carts. Water temperature was measured, and the call bell system was monitored. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-1120-B

Based on observation and interview, the facility failed to ensure there be at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day.

Evidence

The activity calendar in safe, secure environment does not include two hours of scheduled activities on Saturdays and Sundays.

Plan of correction

On 8/28/24 The Activities Director updated the Activity calendar with 21 hours of Activity for all residents on the safe, secure unit. Those hours include two hours of scheduled activities on Saturdays and Sundays. The AL Administrator or designee will audit the calendars quarterly to ensure accuracy.

22VAC40-73-640-A

Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications.

Evidence

The following expired medications were observed in the medication carts at the facility: Duloxetine 60 mg capsules expired 08/03/2024 for Resident #7 and Westab Max tablets expired 07/14/2024 for Resident #8.

Plan of correction

On 8/20/204 all expired medications were disposed of. All medication carts were audited for expired medications by the Clinical Coordinator. Cart audits for expired medications will be completed biweekly by two different shifts to ensure there are no expired medications on any carts. The medication management plan was reviewed with all staff. The cart audits will be reviewed by the Clinical Coordinator or their designee biweekly.

22VAC40-73-550-G

Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or their legal representative or responsible individual as stipulated in subsection H of this section.

Evidence

The records of Resident #2, Resident #3, and Resident #4 did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year.

Plan of correction

On 8/28/24 the AL Administrator reviewed all residents’ records to ensure an annual review of the Resident’s Rights & Responsibilities was in place. Residents #2, #3 & #4 had a review done and placed in their records. The Clinical Coordinator or appointed designee will audit all records every 6 months for accuracy.

22VAC40-73-1110-B

Based on record review, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee perform a review of the appropriateness of each resident's continued residence in the special care unit.

Evidence

Resident #4 has resided in the safe, secure environment since 6/2023; however, there was no review of appropriateness for continued residence in the special care unit in Resident #4’s record.

Plan of correction

On 8/28/24 the AL Administrator reviewed all records for residents on the special care unit. All records were complete with a Review of Appropriateness for Continued Residence in a special care unit. Resident #4’s record was updated on 8/21/24. The AL Administrator will audit all Special care Unit residents’ records for appropriate every 6 months for accuracy.

22VAC40-73-650-A

Based on record review and interview, the facility failed to ensure no medication be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.

Evidence

Resident #4 is being administered Donepezil 10 mg tablet once daily starting 7/19/2024; however, the facility was unable to provide a valid order from a physician or other prescriber for this change in medication.

Plan of correction

On 8/28/24 the AL Administrator & Clinical Coordinator reviewed all monthly Physician Orders for accuracy. Resident #4’s Physicians Orders were reviewed and updated. The Clinical Coordinator will do a monthly Physician Order to Medication Administration Record comparison. The Al Administrator will review quarterly.

October 5, 2023Inspection5 violations

Inspection dates

10/05/2023

Areas reviewed

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: 10/05/2023. 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, water temperatures, and the call bell system. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-640-A

Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications.

Evidence

The following expired medications were observed in the medication carts at the facility: PRN Acetaminophen 325 mg tablets expired 09/27/2023 for Resident #6, PRN Acetaminophen 500 mg tablets expired 09/30/2023 for Resident #7, and Ondansetron 4 mg tablets expired 08/23/2023 for Resident #8.

Plan of correction

On 10/5/23 all expired medications were disposed of. All carts were audited for expired medications by the AL Administrator. The facilities Medication Management Plan was reviewed with all staff. Cart Audits for expired medications will be completed weekly to ensure all expired medications (including OTCs) are removed from the carts. The Cart Audits will be reviewed by the AL Administrator or their designee weekly.

22VAC40-73-660-A-3

Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration shall keep the keys to the storage area on their person.

Evidence

At approximately 11:25 am on 10/05/2023, one of the medication carts across from the nursing station in the assisted living was observed to be unlocked and unattended. Later, at 12:55 pm, the medication cart in the living area in the assisted living was observed to be unattended and unlocked with the key in the lock.

Plan of correction

On 10/9/23 the AL Administrator in-serviced all direct care staff & Licensed Nurses on proper storage of the keys to the medications carts on their person and ensuring the carts are locked. The AL Administrator or designee will do random audits on all cart, all shifts weekly to ensure staff compliancy.

22VAC40-73-680-D

Based on record review and interview, the facility failed to ensure medications be 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

A self-reported incident was received on 08/10/2023 regarding a medication error. Resident #4 was given the wrong dose of insulin which resulted in the resident being admitted for observation for 2 days due to hypoglycemia. Staff #1 provided additional information during the onsite inspection and acknowledged the medication error occurred.
Resident #1 has an order to be administered an Amlodipine 5 mg tablet once daily and a Losartan 50 mg tablet two times daily with both medications having a parameter to hold if SBP<110 and or Pulse <60. On 10/03/2023, Resident #1’s vitals were documented as 120/58 with a pulse of 61 at 8 am; however, the MAR for Resident #1 indicates the resident was not administered either Amlodipine or Losartan.
Resident #2 has an order to be administered an Amlodipine 5 mg tablet and a Lisinopril 40 mg tablet every morning with both medications having a parameter to hold if SBP<110, DBP<60, and or pulse <60. On 10/02/2023, Resident #2’s vitals were documented as 142/75 with a pulse of 57; however, the MAR for Resident #2 indicates the resident was administered both Amlodipine and Lisinopril.

Plan of correction

1. On 8/10/23 the AL Administrator reviewed all insulins orders for all residents. All staff were immediately in-serviced on the difference between insulin syringes & pens, correct reading of insulin orders & skills competency completed on insulin. Insulin double verification forms were put onto each resident’s chart to be completed daily. Each insulin dose drawn up will be verified by a qualified medication team member. The AL Administrator or their designee will review the audits daily x 45 days (completed on 9/24/23). Then the AL Administrator or their designee will monitor the audits weekly x 45 days (to be completed 11/8/23). 2. On 10/5/23 the AL Administrator reviewed all residents on blood pressure medications with parameter orders. An audit sheet was completed for each person with the parameters orders on it and is to be completed daily. The staff must document in the resident’s chart if the vital signs are outside of the parameters and what actions were taken. The AL Administrator or their designee will review this audit daily x 4 weeks, then weekly on a monthly basis.

22VAC40-73-450-F

Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident’s condition.

Evidence

Resident #2 obtained a DNR on 05/09/2023; however, Resident #2’s ISP (dated 05/23/2023) indicates the resident as a full code.

Plan of correction

On 10/5/23 the AL Administrator updated resident #2’s UAI & ISP to reflect accurate and current information for a significant change of condition (DNR) obtained 5/9/23. On 10/5/23 the AL Administrator placed a current, updated UAI & ISP onto resident #2’s chart to reflect the code status as a DNR. All UAI’s, ISPs, orders and advanced directives will be audited for accuracy by the AL Administrator or designee.

22VAC40-73-260-A

Based on record review, the facility failed to ensure each direct care staff member maintain current 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.

Evidence

Staff #4 works as direct care staff and does not have a current certification in first aid.

Plan of correction

On 10/5/23 the AL Administrator reviewed all employee’s 1st Aid & CPR certifications to ensure each direct care staff members were current and have both components. Staff #4 completed and supplied a copy of her 1st Aid certification on 10/9/23. The HR Director or appointed designee will audit all direct care staff’s certifications monthly and notify the Administrator & staff member if they need recertification.

August 23, 2022Inspection4 violations

Inspection dates

08/23/2022

Areas reviewed

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: 08/23/2022 from 8:55 am to 3:20 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: 30 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: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-640-A

Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications.

Evidence

The following expired medications were observed in the medication carts at the facility: Acetaminophen 500 mg caplets expired 11/2015 for Resident #5 and Vitamin D2 25mg softgels expired 10/2020 for Resident #8.

Plan of correction

The AL Director reviewed the facility’s Medication Management Plan with all staff on 8/25/22. Staff responsible for each medication cart has completed the Cart Audit for expired medications. Staff will audit each medication cart twice monthly to ensure all expired medications (including the over-the-counter meds) are removed timely. The cart audits will be given to the Clinical Coordinator for review.

22VAC40-73-1090-A

Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents have been 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.

Evidence

Resident #2 admitted to the safe, secure environment on 06/08/2021; however, there is not an assessment of serious cognitive impairment completed in the resident’s record.

Plan of correction

On 8/25/22, the Clinical Coordinator reviewed all current resident’s records for the need of an “assessment by 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”. The Clinical Coordinator will complete the chart audit to ensure to ensure all paperwork is present on all current resident’s charts. When items are found missing, the document (s) will be replaced if possible and if not, a MISSING ITEM form will be placed in the chart to acknowledge the missing documentation.

22VAC40-73-450-C

Based on record review, the facility failed to ensure the comprehensive individualized service plan be completed within 30 days after admission and include the required items listed in the standard.

Evidence

The most current ISP in the record for Resident #2 was completed by the facility on 6/8/21. Several of the identified needs such as transferring, dressing, assistance with oral care, etc. on the 6/8/21 ISP indicated the date of the expected outcomes/goals as 12/12/2021.
Resident #3 admitted to the facility on 01/27/2022; however, there was not a comprehensive ISP in their resident record.

Plan of correction

On 8/25/22 the AL Director updated residents #2 & #3’s UAI’s & ISP’s to reflect accurate and correct information is on each resident’s ISP based off information from the UAI. On 8.25/22 the AL Director placed Resident #3’s ISP into her chart. All UAI’s & ISP’s are currently being audited and verified for accuracy. All updated UAI’s and ISP’s copies are kept in each resident’s chart and in a binder kept by the AL Director.

22VAC40-73-980-A

Based on observation, the facility failed to ensure a first aid kit for the building contain items as identified in the standard.

Evidence

The building first aid kit did not include scissors and contained expired antiseptic ointment (expired 11/2021).

Plan of correction

On 8/25/22, the AL Director inspected all first aid kits maintained by AL to ensure all items identified in the standard were present and all expired items were removed. The First Aid Kit audit will be completed twice monthly for all first aid kits to ensure all items are present and items with expired dates are removed from the first aid kits prior to the expiration dates. This audit will be forwarded to the Clinical Coordinator for review.

October 5, 2021Inspection5 violations

Inspection dates

10/05/2021

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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 1Subjectivity

Comments

A renewal inspection was initiated on 10/5/2021 and concluded on 10/20/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator/AL Director reported that the current census was 28. The inspector emailed the Administrator/AL Director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. Two inspectors conducted the on-site portion of the inspection on 10/19/2021. An exit interview was conducted with the Administrator/AL Director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-640-A

Based on documentation review and interview, the facility failed to implement their written plan for medication management which includes methods to ensure that each resident's prescription medications and any over-the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.

Evidence

During review of the MAR for Resident #1, Fentanyl 25 mcg transdermal patch to be applied every three days was not administered to Resident #1 as the medication was not available on 09-04-2021.
During review of the MAR for Resident #2, Memantine 10 mg tablet to be administered one time daily was not administered to Resident #2 as the medication was not available on 10-05-2021. Additionally, during review of the MAR for Resident #2, Donepezil 5 mg tablet to be administered one time daily was not administered to Resident #2 as the medication was not available on 09-22-2021, 09-24-2021, 09-25-2021, 09-26-2021, and 09-27-2021.
During review of the MAR for Resident #3, Sodium Chloride 1 gram tablet to be administered three times daily was not administered to Resident #3 as the medication was not available from 09-11-2021 to 09-15-2021.

Plan of correction

The Clinical Coordinator & AL Director have in-serviced all staff and the Pharmacy on the written medication management plan. All staff were reeducated on reordering and refilling medications in a timely manner. A review was done with the Pharmacy on the plan for use of the backup pharmacy when medications are not available at their location, in order to receive all medications timely. Medication reorder dates have been set for Mondays & Thursdays on 11pm -7am shifts. When the medications are reordered a copy is left for the Clinical Coordinator to review. Compliance will be reported to the AL Director monthly.

22VAC40-73-620-A

Based on documentation review and interview, the facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.

Evidence

During documentation review, Resident #4 has an order for a No Added Salt diet dated 08-01-2021.
During interview, Staff #4 could not provide documentation that Resident #4 has been seen by a dietitian or nutritionist for oversight of special diet.

Plan of correction

All records were audited and reviewed with the dietitian and all residents with special diets have been seen. The dietitian will leave a list of all residents on special diets after each review with the AL Director. The AL Director will ensure all residents with special diets have been seen.

22VAC40-73-450-C

Based on documentation review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident’s identified needs based on the Uniform Assessment Instrument (UAI).

Evidence

Resident #1’s UAI dated 07-06-2021 documented the need of supervision with dressing; however, the current ISP states Resident #1 needs physical assistance with dressing on 07-06-2021. Resident #1’s UAI also documented the need of assistance with laundry; however, the current ISP does not include documentation of the need of assistance with laundry. Resident #1’s UAI and ISP also does not document Resident #1 as a high fall risk; however, the most recent fall risk rating completed on 09-02-2021 documents Resident #1 as a high fall risk. Resident #1’s UAI does not document the code status of Resident #1; however, the current ISP documents Resident #1 as a Full Code as of 02-01-2021. Additionally, Resident #1’s UAI does not document the use of psychoactive medications; however, the current ISP identified a need of mental health services/psychoactive medications on 09-22-2021. Lastly, Resident #1’s UAI does not document the diet of Resident #1; however, the current ISP documents the nutrition needs to include no added salt dietary restrictions on 02-01-2021. The dietary clinical note dated 08-18-2021 further states the need of a no added salt diet.
Resident #2’s UAI dated 07-14-2021 documented the need for supervision with toileting; however on the current ISP, a need for mechanical and physical assistance with toileting was identified on 04-15-2021. Resident #2’s UAI does not document Resident #2 as a high fall risk; however, the current ISP identified that Resident #2 is at risk for falls due to unsteady gait, history of falls and cannot remember to ask for assistance on 11-10-2020. Additionally on 09-02-2021, the most recent fall risk rating documents Resident #2 as a high fall risk.
Resident #3’s UAI dated 06-20-2021 documented there is not a need for dressing; however on the current ISP, a mechanical need of utilizing a shoe horn was documented on 06-25-2021. Resident #3’s UAI also does not document the code status of Resident #3; however, the current ISP documents Resident #3 as a Full Code as of 06-25-2021.

Plan of correction

The Clinical Coordinator and AL Director updated residents #1, #2 & #3’s UAI’s & ISP’s to reflect accurate and correct information is on each resident’s ISP based off of information from the UAI. Each UAI & ISP that are completed by the Clinical Coordinator or any UAI certified personnel will be reviewed and verified for accuracy by the AL Director prior to filing in the resident’s chart.

22VAC40-73-960-B

Based on observation, the facility failed to ensure a fire and emergency evacuation drawing include areas of refuge and assembly areas.

Evidence

During an inspection of the facility on 10-19-2021, adjacent to the posted activity calendar, a fire evacuation plan of the first floor was present. In the legend, the area of refuge and assembly area were noted; however, the actual placement of these two areas were not on the map of the fire evacuation plan posted.
During interview on 10-20-2021, Staff #4 acknowledged the posted fire and emergency evacuation drawings did not include the area of refuge or assembly area.

Plan of correction

All fire and evacuation drawings have been updated to reflect areas of refuge and areas of assembly throughout the facility by our Director of Plant Operations.

22VAC40-73-650-E

Based on observation, the facility failed to ensure the resident's record contained the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order.

Evidence

During an inspection of the facility on 10-19-2021 with Staff #4, the Licensing Inspector observed two bottles of TUMs in Resident #5’s bathroom. Staff #4 removed the items from apartment and stated these items may have been brought in with or from family members.
During an inspection of the facility on 10-19-2021 with Staff #4, the Licensing Inspector observed a container of roll-on Aspercreme on Resident’s #6 walker.
During interview on 10-20-2021, Staff #4 confirmed Resident #5 and Resident #6 did not have a physician’s order for the medications observed.

Plan of correction

All resident’s rooms have been checked for any medications without physician’s orders and obtained any orders as needed. A schedule has been set up for review weekly of all rooms. The Clinical Coordinator will monitor weekly and make the AL Director aware of any non-compliance.