Sunrise of McLean — 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

Sunrise of McLean was inspected 15 times between April 1, 2021 and August 18, 2025 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 25 violations under 23 distinct standards. 6 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. 14 of these 15 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

07/30/2026

Administrator

Julie Clouse

Licensing inspector

Alexandra Roberts

Inspector phone

(804) 845-6956

Approved for

Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

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

August 18, 2025Complaint survey0 violations

Inspection dates

08/18/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/18/2025 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 08/06/2025 regarding allegations in the area(s) of: Physical abuse Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents socializing and having visitors. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 8, 2025Inspection2 violations

Inspection dates

07/08/2025

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 GROUNDARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 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

Compile discharge notifications and documentation in easy to identify method. Ensure that if the regulations states to be within the record or chart that it is easily located withing that record or chart.

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: 07/08/2025 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: 72 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Observed residents medication administration, residents in the common area engaging with one another and lunch time. Additional Comments/Discussion: None. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov

Violations

22VAC40-73-260-C

Based on record review and staff interview, the facility failed to ensure that a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of this section, shall be posted in the facility so that the information is readily available to all staff at all times.

Evidence

LI requested Staff 1, Staff 3 and Staff 4 to show LI the posted listing of staff with current certification.
During the course of the onsite inspection on 07/08/2025, Staff 4 confirmed there is not a posting within the facility with staff CPR/First Aid credentials.
Staff 1 informed that HR keeps a binder of all staff credentials but there is no listing posted within the facility with staff CPR/First Aid credentials.

Plan of correction

With respect to the specific citation cited: A. HR completed audit of First Aid/CPR certifications for eligible team members and posted listing in the community. With respect to how the facility will identify residents/situations with the potential for the identified concerns: B. HR or designee will review first aid and CPR list monthly and update posting as needed. With respect to what systematic measures have been put into place to address stated concern: C. The HR or designee will be responsible for updating First Aid/CPR posting monthly. With respect to how the POC will be monitored: D. ED or designee is responsible for confirming implementation and on-going compliance with the components of the plan of correction.

22VAC40-73-50-A

Based on record review, the facility failed to ensure that the disclosure statement is on the current form developed by the department.

Evidence

Resident 1’s (admitted 03/06/2025) disclosure statement was not on the most current disclosure form published by the department as initial lines had been added to the bottom of each page and a signature page was added by the facility with the VDSS form revision identification numbers at the bottom of the page.

Plan of correction

With respect to the specific citation cited: A. ED updated Disclosure Statement with current form from VDSS (updated 7/16/25). With respect to how the facility will identify residents/situations with the potential for the identified concerns: B. ED or designee will remain up to date with messaging from VDSS to confirm community is utilizing current form. With respect to what systematic measures have been put in place to address stated concern: C. ED or designee will confirm residents with move in dates after 7/16/25 receive and acknowledge updated Disclosure Statement. With respect to how the POC will be monitored: D. ED or designee is responsible for ongoing implementation with the components of this Plan of Correction.

March 25, 2025Inspection2 violations

Inspection dates

03/25/2025

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: 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 (03/22/2025) regarding allegations in the area(s) of: Resident Supervision Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed residents in dining hall and going out on an outing. 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 Alexandra Roberts, Licensing Inspector at 804-495-5856 or by email at Alexandra.n.Roberts@dss.virginia.gov

Violations

22VAC40-73-460-D

Based on staff interview and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.

Evidence

On 03/22/25, LI received a self-reported incident that Resident 1, admitted 03/19/25, eloped from facility via main entrance on 03/22/25 and was found at a church across the street and escorted back to the facility.
LI observed video recording of the resident walking out of the facility around 2pm.
Staff 1 confirmed that Resident 1 left the facility without telling anyone, did not sign out and was having confusion due to diagnoses urinary track infection.

Plan of correction

A.)With respect to the specific resident/situation cited: The resident had no adverse outcomes due to elopement. She was safely escorted back to the community. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: ED re-educated current team members on proper procedures for signing out and signing in for current AL residents. C.) With respect to what systemic measures have been put into place to address the stated concern: ED conducted an audit of signing out log weekly for 1 month to confirm proper signing in and out procedures are followed. Issues identified and addressed as needed. ED reviewed proper procedures to sign in and out at resident council meeting.

22VAC40-73-220-A

Based on record review and staff interview, facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: • Before direct care or companion services are initiated, the facility shall obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to the home care organization regarding any needed changes. • The facility shall provide orientation and training to private duty personnel regarding the facility's policies and procedures related to the duties of private duty personnel.

Evidence

Resident 1, admitted 03/19/25, started receiving private duty personnel (PDA) services from licensed home care organization on 3/23/25.
During inspection on 3/25/25, the private duty record did not contain any written information on the type and frequency of the services to be delivered to the resident by private duty personnel or evidence of orientation and training to private duty personnel regarding the facility's policies and procedures related to the duties of private duty personnel.
Staff 1 confirmed that documentation was not completed for the private duty for Resident 1.

Plan of correction

A.) With respect to the specific resident/situation cited: The resident had no adverse reactions hiring a Private Duty Aide (PDA) who was not properly oriented to facility procedures related to the duties of PDA. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: ALC conducted an audit of PDA usage in the community and provided facility orientation training and documented types/frequency of services for private duty personnel from licensed home care organizations. C.) With respect to what systemic measures have been put into place to address the stated concern: ALC/RC or designee completed facility orientation with private duty personnel from licensed home care agency. ALC/RC or designee obtained in writing the type and frequency of services to be delivered by licensed home care organization. Prior to initiation of services, ALC/RC will confirm orientation and type/frequency of services to be delivered. D.) With respect to how the plan of correction will be monitored: 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 to correct any deficient practices

September 23, 2024Complaint survey0 violations

Inspection dates

09/23/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 23, 2024Complaint survey3 violations

Inspection dates

9/23/2024

Areas reviewed

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: 9/23/24 1pm - 4:30pm 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 9/13/2024 regarding allegations in the area(s) of: Resident Care - Physical Abuse Number of residents present at the facility at the beginning of the inspection: 75 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: Medication pass and lunch Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s) area(s) of non-compliance with standard(s) or law were: Resident documentaiton and incident reporting. A violation notice was issued; any violation(s) not related to the complaint(s)but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on observation and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

Resident 1‘s (admitted 8/21/2024) file contained an incident report dated 8/25/2024 indicating a sustained fall with bruising to the left knee.
LI received complaint on 9/12/2024 regarding injuries. LI did not receive an incident report for the incident and resulting injuries.
During interview on 09/23/2024, staff 1 confirmed that the 08/25/2024 incident was not reported to the regional licensing office.
Photo evidence obtained.

Plan of correction

Resident 1 had a fall on 8/25/24. No negative outcome from the failure to report incident to LI. ED provided training to staff on reporting major events, including falls, as required to LI. ED or designee shall submit a written report to LI of major incident that negatively affects or that threatens the life, health, safety or welfare of any resident. IDT team will review major incidents reported to LI. The verification of this process will be evaluated and confirmed by ED or designee at QAPI meeting. The ED or designee is responsible for implementation and ongoing compliance of reporting major events to LI.

22VAC40-73-930-D

Based on record review, the facility failed to ensure that each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: 1.This inability shall be included in the resident's individualized service plan. 2. The plan shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.

Evidence

Resident 1’s ISP indicated that the resident is unable to use signaling device.
ISP only stated facility will complete night rounds for resident.
ISP did not include a plan of frequency of daily rounds to be made by direct care staff.
Staff 1 confirmed that Resident 1’s ISP did not specify frequency of daily rounds.
Photo evidence obtained.

Plan of correction

Resident #1 was discharged to inpatient hospice, thus staff unable to update frequency of rounding on ISP. RC audited ISPs for residents who are unable to use their signaling device; if missing, added minimal frequency of daily rounds to be made by care staff to monitor for emergencies or other unanticipated resident needs. The RCD or designee will conduct audits of ISPs to confirm that safety checks multiple times per shift are included for residents who are unable to use their signaling device. The RC/ALC or designee is responsible for implementation and ongoing compliance of ISP completion with ED oversight.

22VAC40-73-450-E

Based on record review and interview, the facility failed to ensure that individualized service plan shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.

Evidence

The ISP for resident 1, dated 08/26/2024, has not been signed by the licensee, administrator, or his designee and by the resident or his legal representative.
During interview on 09/23/2024, staff 1 confirmed resident 1’s ISP was not signed.
Photo evidence obtained.

Plan of correction

The ISP for Resident 1 was updated to include ED signature. No negative outcome from the failure to obtain ED (or designee) signature and RP signature. The RCD or designee completed an audit of residents’ ISPs for ED (or designee) and RP signatures and obtained any missing signatures for active residents. ED or designee completed training with the RC or designee on ISP compliance and requirements including RP and ED or designee signatures. The RC/ALC or designee is responsible for implementation and ongoing compliance of ISP completion with ED oversight.

June 5, 2024Complaint survey0 violations

Inspection dates

06/05/2024

Areas reviewed

Comments

Type of Inspection: Complaint Inspection Date of Inspection: June 5th 2024 4pm - 5pm 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 3, 2024Inspection5 violations

Inspection dates

06/03/2024

Areas reviewed

Comments

Type of Inspection: Renewal Inspection Date of Inspection: June 3, 2024 thru June 5 2024 - 8am - 5pm 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. 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 applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations

22VAC40-73-550-G

Based on record review and staff interview, facility failed to ensure that Resident Rights are reviewed annually with each resident or his legal representative or responsible individual.

Evidence

Resident 1’s record (DC’d 5/25/2024) last resident rights was dated 04/28/2023.
Resident 3 and resident 4’s record did not obtain a signed resident rights statement. LI requested updated resident rights. Staff 5 stated that they have not been completing resident rights for everyone.

Plan of correction

The Resident Care Director (RCD) audited resident files for annual review of resident rights signed by the resident or responsible party. Assisted Living Coordinator (ALC) / Reminiscence Coordinator (RC) were re-educated on process for annual review of resident rights to include resident or responsible party signature. The ED or designee will complete quarterly audits of resident files to verify compliance (QAPI meeting). 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.

22VAC40-73-980-C

Based on record review and staff interview, facility failed to ensure month first aid kits are checked at least monthly to ensure all items are present.

Evidence

LI requested evidence of monthly check of first aid kit.
Staff 1 stated that facility does not have any evidence that facility has been completing a monthly check.

Plan of correction

RCD audited first aid kits in designated locations for accuracy according to the list of first aid requirements. RCD was re-educated on regulatory requirements regarding first aid kits in the facility. RCD or designee will complete monthly audit for 3 months. Any discrepancies identified will be rectified. 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.

22VAC40-73-950-F

22VAC40-73-950-F Based on record review and staff interview, facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Such revisions shall be communicated to staff, residents, and volunteers.

Evidence

LI requested updated documentation of the annual review of emergency preparedness. The last dated update was in 2018 and 2017.
Staff 1 stated that the facility does not have any documentation for the years after 2018 of any emergency preparedness plan review for staff or residents.

Plan of correction

Emergency Preparedness binder was audited and updated with phone numbers for emergency situations to include disaster preparedness. MC or designee will review Emergency Preparedness (EP) resource binder with staff, residents, and volunteers semi-annually and document review. ED and MC or designee will review the emergency preparedness plan annually, make any necessary revisions, and document the review by signing and dating the plan. 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.

22VAC40-73-980-A

Based on observation and staff interview, the facility failed to ensure a complete first aid kit is on hand.

Evidence

First aid kit on hand did not include: Antiseptic wipes or ointment, any assorted band aids, only 1 triangular bandage for entire facility.
Staff 1 stated that she did not know that additional items were needed for first aid kit on hand.

Plan of correction

22VAC40-73-950-E

Based on record review and staff interview, facility failed to implement an orientation and 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 shall be documented by signing and dating.

Evidence

LI requested semi-annual review documentation.
Staff 1 stated she does not have any documentation and had not known of this required review.

Plan of correction

Maintenance Coordinator (MC) and Area Facilities Manager (AFM) reviewed and updated Emergency Preparedness binder and procedures. Area Facilities Manager completed re-education with MC or designee on the Emergency Preparedness process. MC or designee will audit staff, resident, and volunteer compliance quarterly during QAPI meeting to verify compliance. 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.

November 15, 2023Complaint survey0 violations

Inspection dates

11/15/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE 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: 11/15/2023 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 11/3/23 regarding allegations in the area(s) of: Administration and Administrative Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of Interviews conducted: 3 Observations by licensing inspector: Facility documentation 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.

August 23, 2023Complaint survey1 violation

Inspection dates

08/23/2023

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: 8/23/23 (1:45 PM - 5:30 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 7/25/23 regarding an allegation in the area 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: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 2 The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (I) type the plan on a separate Word document, (II) identify the standard violation number being addressed, (III) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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

22VAC40-73-460-B

Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.

Evidence

Call bell reports (for 30 days) were reviewed for Residents #1, #2, and #3. Resident # 1's call bell report indicated that there were five occasions when it took staff at least 20 minutes to respond to the resident's call bell (out of 36 call alarms). Resident #2’s call bell report indicated that there were 41 occasions when it took staff at least 20 minutes to respond to the resident’s call bell (out of 314 call alarms). Resident #3’s call bell report indicated that there were seven occasions when it took staff at least 20 minutes to respond to the resident’s call bell (out of 82 call alarms).

Plan of correction

No negative outcome to residents' #1, #2, and #3 as a result of excessive call bell responses. ED or Designee completed an audit of residents' call response times with no other violations. The ED or designee will continue to audit resident call bells for 3 months to confirm response times are not unreasonable to circumstances. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the ED or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 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.

August 23, 2023Inspection1 violation

Inspection dates

08/23/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced focused monitoring inspection was conducted on 8/23/23 to follow-up on a high-risk violation that was cited on 6/1/23. Resident records and facility documentation was observed. Violation was discussed and an exit meeting was held. 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

22VAC40-73-680-D

Based on record review, the facility failed to ensure that medications are administered in accordance with the physician’s instructions.

Evidence

Resident #1’s record contained an order for Metoprolol, dated 12/15/21, that calls for the medication to be held when Resident #1’s heart rate is less than 60 and her systolic blood pressure (SBP) is less than 120. Resident #1’s MAR and progress notes state that her Metoprolol was held on the following dates when only one of the medication parameters was met: 8/23/23 (BP= 117/65; P= 63) 8/18/23 (BP= 115/61; P= 66) 8/18/23 (BP= 110/63; P= 66) 8/16/23 (BP= 116/63; P= 63) 8/9/23 (BP= 119/64; P= 63) 8/9/23 (BP= 118/62; P= 66) 8/5/23 (BP= 113/52; P=61) 8/4/23 (BP= 106/68; P= 61) 8/1/23 (BP= 115/64; P= 64)

Plan of correction

Resident #1 did not have any negative outcomes, and the physician changed order to remove parameters. The Resident Care Director (RCD) or designee completed an audit of residents' orders with parameters, and in conjecture with doctors' orders removed those that were not required. The RCD completed training with the Wellness Nurses, and Coordinator on order requirements and compliance. Resident Care Director (RCD) or designee will conduct chart audits 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.

June 1, 2023Inspection4 violations

Inspection dates

06/01/2023

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 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

An unannounced monitoring inspection was conducted on 6/1/23. At the time of entrance, 72 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. 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

22VAC40-73-640-A

Based on record review, the facility failed to implement the medication management plan: 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

Resident #11's May medication administration record (MAR) was reviewed during the inspection. Resident #11's MAR stated that her Galamantine was not administered on 5/17/23 and 5/18/23, as the medication was "pending delivery.” The MAR also stated that Resident #11’s multivitamin was not administered on 5/25/23 and 5/26/23, as the supplement was "pending delivery." Resident #11's notes indicated that the pharmacy was contacted to get additional information about the resident’s Galamantine on 5/16/23. No documentation was provided, during the inspection, to indicate whether Resident #11's physician was contacted for administration guidance regarding the Galamantine and multivitamin.

Plan of correction

No negative outcome to resident #11 as a result of missing Galamantine. RCD or Designee completed an audit of residents' medications administration and current supply. No other negative findings. The Resident Care Director (RCD) and the clinical team audited the medication orders and medication carts to confirm that medications prescribed were available per doctor's orders. Issues identified were resolved. The Well ness Nurses and Medication Care Managers (MCMs) were re-educated by the RCD regarding the process on reordering medication and what to do when a medication isn't available from the pharmacy. The RCD or designee will continue to audit physician orders for 3 months to confirm orders are present in the medication cart. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the medication orders 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.

22VAC40-73-250-D

Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment documenting that the individual is free of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Tuberculosis risk assessments were not provided, during the inspection, for Staff #2 (hired 12/13/16) or Staff #4 (hired 3/3/23).

Plan of correction

Staff member #2 and #4 completed annual tuberculosis risk assessment and documentation are in employee's file. BOC or Designee completed an audit of TM files not surveyed, to verify compliance of initial and annual Tuberculosis risk assessment are completed within the required timeframe. BOC or Designee to complete a quarterly audit of TM files for TB risk assessments for 6 months. Issues identified will be resolved. 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.

22VAC40-73-720-A

Based on record review, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation are included on the individualized service plan (ISP).

Evidence

Resident #1's record contained a DNR order, dated 8/2/22. Resident #1's ISP, dated 4/3/23, lists the resident as full code. Resident #4's record contained a DNR order, dated 5/18/23. Resident #4's ISP, dated 5/19/23, lists the resident as full code. Resident #6's ISP, dated 4/7/23, states that the resident has a DNR order. No DNR order was observed in the record for Resident #6.

Plan of correction

Code status for resident's #1, #4 and #6 who were updated per Physician's order. Residents experienced no negative outcome. The Resident Care Director (RCD) or designee completed an audit of residents' code status to doctor's orders. Issues identified were resolved. The RDC completed training with the Wellness Nurses, and Coordinator on ISP requirements and compliance. Resident Care Director (RCD) or designee will conduct chart audits 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.

22VAC40-90-40-B

Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police within 30 days of hiring an employee.

Evidence

The criminal history record reports were observed for new staff members. No criminal history record report was provided, during the inspection, for Staff #6 (hired 10/10/22).

Plan of correction

Criminal record check for staff member #6 is completed and in employee's files. BOC or Designee completed an audit of TM files not surveyed, to verify compliance of criminal background checks being completed within 30 days of hire and in staff members files. BOC will complete quarterly audits of new hires to confirm criminal background checks are in staff member files. 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.

October 14, 2022Inspection0 violations

Inspection dates

10/14/2022, 10/17/2022, 11/04/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) the licensing inspector was on-site at the facility for each day of the inspection: 10/14/22, 10/17/22, 11/04/22 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 9/29/22 regarding allegations in the area of: Resident Care and Related Services. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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.

September 16, 2022Inspection2 violations

Inspection dates

09/16/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

Comments

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection (10:00 AM – 11:50 AM) 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) of law. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov

Violations

22VAC40-73-860-I

Based on record review and observation, the facility failed to keep cleaning supplies and other hazardous materials in a locked area.

Evidence

Nail polish remover and air freshener spray were observed to be unlocked and unattended in the shared bedroom of Residents #2 and #3, of the memory care unit. Resident #2’s record contained an assessment of serious cognitive impairment form, dated 9/1/21, that states that she has a serious cognitive impairment, and that she is unable to recognize danger or protect her own safety and welfare. Resident #3’s record contained an assessment of serious cognitive impairment, dated 3/19/19, that states that she has a serious cognitive impairment, and that she is unable to recognize danger or protect her own safety and welfare.

Plan of correction

No negative outcome occurred to residents with unsecured chemicals found. Chemicals were removed and properly secured immediately.A whole house sweep of all resident suites was conducted. Team members were re-educated by Sr. M C on procedures for safe handling and storage of chemicals. Reminiscence lead care manager and wellness nurse or designee to conduct weekly checks for next three months. 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.

22VAC40-73-660-A-1

Based on observation and documentation, the facility failed to use a locked medicine cabinet, container, or compartment for the storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice.

Evidence

Wound ointment, ordered 4/22/22 for Resident #1, was observed to be unlocked and unattended in the resident’s bathroom. Resident #1’s UAI, dated 5/16/22, states that he needs his medication to be administered/monitored by professional nursing staff. Resident #1’s record contained an assessment of serious cognitive impairment, dated 8/3/21, that states that he has a serious cognitive impairment, and that he is unable to recognize danger or protect his own safety and welfare.

Plan of correction

No negative outcome occurred to residents with unsecured medications found. Medicated creams were removed and properly secured immediately. A whole house sweep of all resident suites was conducted. Team members were re-educated by RCD and ALC on procedures for safe storage of medications. Vendor contracted to update all memory care suite locks to ensure compliance. Reminiscence lead care manager and wellness nurse or designee to conduct weekly checks for next three months. All cabinet locks to be updated. RCD has communicated with hospice representatives regarding appropriate protocol for medicated creams. 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.

June 14, 2022Inspection4 violations

Inspection dates

06/14/2022

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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

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: 6/14/22 (8:30 AM – 7:35 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 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 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. The certification must either be in adult first aid or include adult first aid. Each direct care staff member shall receive certification in first aid within 60 days of employment.

Evidence

The record of Staff #5, hired 2/15/22, was reviewed during the inspection. Staff #5's record did not contain first aid certification, at the time of the inspection.

Plan of correction

Staff member #5 will be in attendance for first aide training scheduled to take place within 30 days. BOC or Designee to complete audit of TM files not surveyed over the next 3 months to ensure compliance of up-to-date CPR certifications. The community will work with either The American Red Cross and/or independent contractor to ensure TM's without valid CPR certification have completed the training within 60 days. 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.

22VAC40-73-250-D

Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment, documenting that the individual is free of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The records of Staff #2 and Staff #3 were reviewed during the inspection. The records, for Staff #2 and Staff #3, did not contain a tuberculosis risk assessment that was completed within the past year.

Plan of correction

Staff member #2 and #3 Tuberculosis skin tests to be completed on 6/24/2022. BOC or designee to complete audit of TM files not surveyed by 6/24/2022 to ensure compliance of Tuberculosis risk assessment annual completion. BOC or Designee to complete a monthly audit of TM files for TB risk assessments for 3 months. Issues identified will be resolved. 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.

22VAC40-73-860-I

Based on record review and observation, the facility failed to keep cleaning supplies and other hazardous materials in a locked area.

Evidence

Polident and nail polish remover were observed to be unlocked and unattended in the bathroom of Resident #4, of the memory care unit. Lysol spray cleaner was observed to be unlocked and unattended in a common area of the memory care unit. The record for Resident #4 contained an assessment of serious cognitive impairment, dated 7/12/21, that states that she has a serious cognitive impairment and that she is unable to recognize danger or protect her own safety and welfare.

Plan of correction

No negative outcome occurred to resident. Chemical were properly secured and disposed of immediately. A community evaluation sweep of unsecured chemicals was conducted. Team members were re-educated by MC on procedures for safe handling and storage of chemicals. MC or designee checks to confirm that chemicals are properly stored 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.

22VAC40-73-250-C

Based on record review, the facility failed to ensure that an original criminal record report is included in the staff record.

Evidence

The criminal record checks, of new staff members, were observed during the inspection. A criminal record report was not included in the records of Staff #6 and Staff #7, at the time of the inspection.

Plan of correction

Criminal record checks for staff members #6 and #7 were completed within 30 days of hire and are in their employee files. BOC or Designee to complete audit of TM files not surveyed by 6/24/2022 to ensure compliance of criminal background checks being completed within 30 days of hire and in staff member files. BOC will complete quarterly audits of new hires to ensure criminal background checks are in staff member files. 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.

April 1, 2021Inspection1 violation

Inspection dates

April 1, 2021 and April 5, 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 LICENSE

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 inspection was initiated on 4/1/2021 and concluded on 4/5/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 58. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records and four staff records. Criminal record checks and sworn statements of all staff hired since last inspection. Incident reports and other documentation submitted by the facility was reviewed to ensure documentation was complete. 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

22VAC40-73-320-A

Based on record review, facility failed to ensure that a person shall have a physical examination and shall contain a statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter.

Evidence

Resident #3 was admitted on 11/20/2020 with a physical examination dated 11/06/2020 that documents the resident is "ambulatory" and that the resident used a "hoyer lift for transfer" and does not meet the chapter definition of ambulatory as a condition of a resident who is physically capable of self-preservation by evacuating in response to an emergency to a refuge area.

Plan of correction

The Resident Care Director (RCD) contacted resident #3’s primary care physician (PCP). The Executive Director (ED) provided training to the Resident Care Coordinator (RCC) on review of the assessment and physical examinations to verify the ambulatory or non-ambulatory status is accurate per resident. The ED provided training to the RCD on review of the assessment and physical examinations to verify the ambulatory or non-ambulatory status is accurate per resident. The PCP has updated the physical examination to indicate the resident is non-ambulatory. The RCC and RCD conducted an audit of all resident physical examinations and assessment of ambulatory status to verify accuracy. The RCC and/or RCD review the assessment and physical examinations upon receipt, to verify the ambulatory or non- ambulatory status is accurate. The ED conducts monthly audits of physical examinations in comparison to the assessments, to verify the ambulatory or non-ambulatory status is accurate. The Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits for up to three months following implementation of the plan and determine if additional focus or action is warranted. The ED 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.