Virginia DSS · Assisted Living Facility

Brookdale Harrisonburg

📍 2101 Deyerle Avenue, Harrisonburg, VA, 22801

ID 27099One Year licenseActive
11
Inspections
On record
8
With violations
Visits that cited something
3
Clean visits
Nothing cited
28
Violations cited
Individual findings
22
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Brookdale Harrisonburg was inspected 11 times between March 15, 2021 and March 31, 2026 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 28 violations under 22 distinct standards. 2 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. 10 of these 11 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
04/30/2026
Administrator
Everette Harrison
Licensing inspector
Margaret Woods-Kane
Inspector phone
(804) 724-9618
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

11

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

March 31, 2026Inspection6 violations
Inspection dates
03/31/2026
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 PREPAREDNESS63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 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: March 31, 2026, from 9:10 a.m. until 2:30 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: 42 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspectors toured the community and observed the residents during activities and meals. The Licensing Inspectors reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-325-C
Based on resident record review and staff interview, the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls.
Evidence
  1. Resident 4, admit date 10/21/2025, had documented falls on 12/23/2025 and 01/21/2026.
  2. Record for resident 4 did not contain documentation of an analysis of the circumstances of the falls on 12/23/2025 and 01/21/2026 and interventions that were initiated to prevent or reduce the risk of subsequent falls.
  3. During an interview with the LI on 03/31/2026, staff 3 confirmed there was no documentation of an analysis of the circumstances of the falls on 12/23/2025 and 01/21/2026 and no interventions that were initiated to prevent or reduce the risk of subsequent falls as required by the standard.
Plan of correction
Executive Director (ED) or designee completed a fall assessment for Resident 4's falls. Interventions were added to Resident 4's care plan based on the findings. Staff were notified of updated interventions. The Health and Wellness Director (HWD) or designee will retrain direct care staff regarding management of falls. Fall assessments will be completed after every fall to identify and implement interventions to help reduce risk of subsequent falls. The Administrator/HWD or designee will conduct an audit of all fall events to verify that a fall assessment is completed, that interventions are identified, and implemented and that documentation is completed. To assist with ongoing compliance, the HWD or ED will conduct an audit of fall documentation monthly for three (3) months.
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained.
Evidence
  1. Record for resident 4, admitted 10/21/2025, contained a registered sex offender search dated 01/23/2026, which was after the date of admission.
  2. During an interview with the LI on 03/31/2026, staff 2 confirmed the registered sex offender search for resident 4 was not completed prior to admission.
Plan of correction
Thre ED or designee verified and documented the registered sex offender search for this resident in resident's record. The ED or designee will retrain all staff involved in the admissions process regarding the requirement to complete and document the registered sex offender search prior to admission, including documenting the date the search was completed. The facility's admission packet/admission checklist was reviewed to verify that sex offender registry search was included. The ED or designee will audit all new admissions monthly for three(3) months to verify the sex offender registry search has been completed prior to admission and documented. Any missing documentation will be obtained and addressed with staff.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission.
Evidence
  1. Record for resident 3, admitted 02/19/2026, contained a UAI dated 02/25/2025, which was after day of admission.
  2. Record for resident 4, admitted 10/21/2025, did not contain a UAI.
  3. Staff 3 acknowledged the UAI’s for residents 3 and 4 were not completed as required by the standard.
Plan of correction
The ED or designee completed and placed UAI in charts for Residents 3 and 4. Each UAI was reviewed to verify accuracy and alignment with the residents' current needs. The HWD or designee will retrain all nursing staff involved in admissions process regarding the requirement that a completed UAI must be obtained prior to admission for every resident. The Facility's admission workflow was updated so that Administrator /designee must sign off on the UAI prior to move-in approval. The Admistrator will audit all new admissions monthly for three (3) months to verify the UAI is completed prior to admission and properly filed in the resident's chart.
22VAC40-73-950-E
Based on facility record review and staff interviews, the facility failed to ensure the semiannual review of the emergency preparedness plan for all staff included all six elements of this subsection with the review documented by signing and dating.
Evidence
  1. LI requested the semi-annual review of the emergency preparedness and response plan for staff, residents, and volunteers.
  2. During document review on 03/31/2026, LI observed the semiannual review of emergency preparedness with staff only occurred once in 2025.
  3. Staff 2 confirmed the reviewed emergency preparedness and response training only occurred once in 2025 with staff, not twice as required.
Plan of correction
The ED and designee will review the Emergency Preparedness and reponse plan with all staff. The review will include all six requirements of subsection E. Documentation will be completed, dated, and signed by staff to verify compliance with the standard. All department managers and supervisors will be re-educated by the ED or designee on the requirment that the Emergency Preparedness and Response Plan which must be reviewed with all staff at least semi-annually, and that the review must include all six elements outlined in 22VAC40-73-959 E. Emergency Preparedness Review will be added to the inservice calendar to schedule reviews for all shift. The emergency preparedness binder will be reorganized to separate annual and semi-annual trainings. The ED or designee will conduct a monthly audit for three (3) months to verify semi-annual reviews are scheduled and completed each shift, documentation includes all six required elements, staff signatures and dates are present, and records are filed in the correct section of the emergency preparedness binder.
22VAC40-73-450-A
Based on resident record review and staff interviews, the facility failed to ensure that the preliminary plan of care was developed to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident on or within seven days prior to admission and signed by the licensee, administrator, or his designee and by the resident or his legal representative.
Evidence
  1. Record for resident 1, admitted to memory care on 02/26/2026, contained a preliminary plan of care dated 03/03/2026, which was not on or within seven days prior to admission. The preliminary plan of care was unsigned.
  2. Record for resident 3, admit date 02/19/2026, contained a preliminary plan of care dated 03/05/2026, which was not on or within seven days prior to admission.
  3. Record for resident 4, admit date 10/21/2025, contained a preliminary plan of care that was unsigned.
  4. During an interview with the LI on 03/31/2026, staff 1 and 3 acknowledged the facility failed to ensure the preliminary plan of care was developed to address the basic needs of resident 1 and 3 on or within seven days prior to admission. Staff 1 and 3 also acknowledged preliminary plan of care for resident 1 and 4 was unsigned.
Plan of correction
The ED or designee reviewed the residents's records. Preliminary plans of care were completed and signed for Residents 1, 3, and 4, and placed in charts. Each plan was reviewed to verify it addressed the residents' basic needs and accurately reflected their current status. Re-education will be provided by HWD or designee to all staff involved with admissions documentation on the requirement that a preliminary plan of care must be completed on or within seven (7) days prior to admission and must be signed by the Adminstrator or designee and the resident or their legal representative. The admission workflow will be updated so that the ED or designee must sign off on the Preliminary plan of care upon move-in. The ED or designee will audit all new admissions to verify that the preliminary plan of care is completed within the required time frame and that the documentation in filed in the residents' charts.
22VAC40-73-990-C
Based on document review and staff interview, the facility failed to ensure at least once every six months staff on duty on each shift participated in an exercise in which procedures for resident emergencies were practiced.
Evidence
  1. On 03/31/2026, LI requested documentation of practice exercises for resident emergencies.
  2. During document review on 03/31/2026, LI observed the semiannual review of resident emergencies only occurred once in 2025.
  3. Staff 2 confirmed the review of resident emergencies only occurred once on 03/17/2025 with staff, not semi-annually as required.
Plan of correction
The ED or designee will conduct a resident emergency practice exercise with all staff. Documentation of the completed exercise, including staff participation will be placed in the emergency preparedness binder. The ED or desingee will re-train all staff on the requirement that resident emergency practice must occur at least once every six months and must include staff on duty for each shift. The in-service calendar will be updated by the ED or designee to include scheduled semi-annual practice exercises for all shifts. The ED or designee will review the emergency preparedness binder monthly for three (3) months to verify that practice exercises are scheduled and that exerciss are documented and filed correctly.
July 31, 2025Inspection0 violations
Inspection dates
07/31/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 7/17/2025 regarding allegations in the area(s) of: Medication Administration Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/31/2025 9:30 a.m. - 10:15 a.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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed medication administration records and narcotic count records. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 1, 2025Inspection2 violations
Inspection dates
04/01/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS22VAC40-90 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: 4/1/2025, 11:00 a.m. - 3:15 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: 48 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on record review and staff interview, the facility failed to ensure the acknowledgment of having received the orientation was signed by the resident.
Evidence
  1. The records for resident 1 (admitted 3/7/2025), resident 2 (admitted 11/27/2024), and resident 3 (admitted 2/18/2025), had documentation of completed resident orientations in the residents’ records that were not signed by the residents.
  2. During an interview with staff 1, when asked if residents 1, 2, and 3 had the resident orientation signed by the residents, staff 1 answered “No.”
  3. This regulation was cited previously during the 6/14/2024 inspection.
Plan of correction
The Executive Director, Health and Wellness Director or designee audited and obtained if needed, signed resident orientations for all current residents in Clare Bridge.
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure fire and emergency evacuation drills were completed quarterly.
Evidence
  1. The facility shifts included 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.
  2. The record of facility fire drills listed the following: 7/17/2024 at 10:40 a.m., 8/24/2024 at 10:10 p.m., September 2024 (no date) at 1:00 p.m., 10/31/2024 at 3:30p.m., 11/10/2024 at 3:20 p.m., and 12/3/2024 at 8:49 a.m.
  3. During an interview with staff 1, when asked if the fire drills were completed as required, staff 1 indicated that the drills were not completed as required.
Plan of correction
The Executive Director, Maintenance Manager or designee will completed Fire Drills according to the proper rotation. The Executive Director added to the Maintenance Managers outlook calendar the proper rotation for Fire Drill assigned shifts. Executive Director will monitor for completion.
January 29, 2025Complaint survey3 violations
Inspection dates
01/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/29/2025, 10:19 a.m. - 11:45 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/19/2024 regarding allegations in the area(s) of: Resident Care and Related Services, Admission and Retention of Residents, Incidents. Number of residents present at the facility at the beginning of the inspection: 52 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: 1 Observations by licensing inspector: The licensing inspector observed residents in their apartments and common areas. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-1090-A
Based on record review and staff interview, the facility failed to ensure prior to the admission into a safe, secure environment, the resident had been assessed 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
  1. During the record review on 1/29/2024, resident 1 (admitted 5/22/2024) had an assessment of serious cognitive impairment dated 5/23/2024.
  2. During an interview with staff 1 on 1/29/2024, when asked if there was an assessment completed prior to the resident’s admission, staff 1 stated, “Yes there was, but we had our physician complete another, I’ll have to find the original.”
  3. The facility did not provide the original assessment.
Plan of correction
The Executive Director completed an audit of all current resident files for proper completion of the Cognitive Impairment Forms and verified that a Cognitive Impairment Form was on file, no other noncompliance was noted.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. A complaint was received by the regional licensing office on 12/19/2024 alleging that a bed had collapsed on a resident causing the resident to be sent to the emergency room for evaluation.
  2. During a record review on 1/29/2025, it was confirmed in an alert charting note in Resident 1’s record that resident 1 was sent to the hospital on 12/17/2024 “due to the resident bed collapsing and landing on right side of hip area.”
  3. The regional licensing office did not receive a report of the incident that occurred on 12/17/2024.
  4. During an interview with staff 1 on 1/29/2025, when asked about the incident, staff 1 confirmed that resident 1 was sent to the hospital on 12/17/2024 due to hip pain following a slat supporting the mattress falling out and the mattress sliding through the bed frame causing the resident to fall with the mattress. When asked if an incident report was sent to licensing, staff 1 stated, “No.”
Plan of correction
The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee beginning 2.1.2025 will report all incidents requiring a third party assessment outside of the community to the Licensing Inspector within the required 24 hour time frame. The Executive Director reviewed reportable incidents with all designated associates on 3.14.2025.
22VAC40-73-320-A
Based on record review and staff interview, the facility failed to ensure each resident had a physical examination completed by an independent physician within 30 days preceding admission.
Evidence
  1. During the record review on 1/29/2024, resident 1 (admitted 5/22/2024) had an admission physical examination and report dated 5/28/2024.
  2. During an interview with staff 1 on 1/29/2024, when asked if there was a physical examination and report completed prior to the resident’s admission, staff 1 stated, “Yes there was, but we had our physician complete another, I’ll have to find the original.”
Plan of correction
The Executive Director completed an audit of all current resident files for proper completion of the Physician’s Plan of Care and verified that an admission Physician’s Plan of Care was on file, no other noncompliance was noted.
October 3, 2024Inspection1 violation
Inspection dates
10/03/2024
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: 10/03/2024, 11:30am-12:26pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/02/2024 regarding allegations in the area(s) of: Medication Administration Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The inspector observed medication storage, resident and staff records. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. A self-reported incident was received by the regional licensing office regarding a medication error in which resident 1 received resident 2’s Oxycodone 5mg tab as opposed to residents 1 Alprazolam 0.25 mg tab.
  2. During interview on 10/03/2024, staff 1 confirmed that staff 2 administered resident 1 medication prescribed for resident 2.
Plan of correction
Not published by VDSS.
June 14, 2024Inspection4 violations
Inspection dates
06/14/2024
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 SERIOUSCOGNITIVE 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 REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2024 08:35am – 02:08pm 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 staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov.
Violations
22VAC40-73-700-1
Based on record review and staff interview, the facility failed to ensure oxygen orders contain all required information.
Evidence
  1. Resident 5 has a physician’s order for oxygen dated 04/24/2024 that states “Oxygen on 3 Liter while sleeping via nasal canula at bedtime for hypoxia”
  2. The oxygen order does not contain the oxygen source.
  3. Staff 2 stated in an interview that they were unaware of the oxygen order requirements.
Plan of correction
The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will audit and, if needed, obtain orders identifying oxygen source for all residents with oxygen orders by 7/5/2024. The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will provide re-education to current nurses and RMA’s accepting orders on proper parameters for oxygen orders by 7/5/2024
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to review and update the fall risk rating after a fall.
Evidence
  1. Resident 1 had a documented fall on 4/29/2024, Resident 2 had a documented fall on 5/16/2024, Resident 3 had a documented fall on 5/23/2024 and resident 4 had a documented fall on 1/1/2024.
  2. Upon request the facility did not provide a fall risk assessment after each fall.
  3. Staff 2 stated “We don’t do those”
Plan of correction
The Executive Director, Health and Wellness Director or designee will update the Individualized Service Plans with Fall Risk Ratings for residents with falls during the last 12 months by 8/2/2024. The Executive Director or designee will provide re-education for the Health and Wellness Directors, Health and Wellness Coordinators on the practice of completing and adding the fall risk rating to the Individualized Service Plans by 7/5/2024. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans monthly for three months.
22VAC40-73-410-A
Based on record review and staff interview, the facility failed to ensure that the orientation to the facility be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. Resident 1 admitted 5/3/2023 has a resident orientation signed only by staff #1. There is no signature of the resident or responsible party present.
  2. Resident 2 admitted 6/22/23 has a resident orientation that is not signed by the resident.
  3. Upon request the facility did not provide a resident orientation for resident 3 admitted 5/19/2022.
  4. Staff 3 stated during an interview that they could not find the orientation for Resident 3.
Plan of correction
The Executive Director, Business Office Manager or designee will audit all resident files for completed resident orientations by 8/2/2024. The Executive Director, Business Office Manager or designee will complete all missing or incomplete resident orientations by 8/2/2024. The Executive Director or designee will provide re-education for the Health and Wellness Directors, Health and Wellness Coordinators, Business Office Manager and Sales Director on the practice of completing the resident orientation on admission by 7/5/2024. To assist with ongoing compliance, The Executive Director or designee will audit all admissions for Resident Orientation completion for three months
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) was updated following a change in condition.
Evidence
  1. Resident 2 has a physician’s order for home health services dated 1/4/2024. The ISP for resident 2 dated 3/8/2024 does not include home health services.
  2. Staff 2 stated resident 2 is still receiving home health services
Plan of correction
The Executive Director or designee will provide re-education for the Health and Wellness Directors, Health and Wellness Coordinators and Resident Care Coordinators on Individualized Service Plans requirements and Third Party Care Services by 7/5/2024. To assist with ongoing compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit Individualized Service Plans and Third Party Care Services for current residents by 8/2/2024. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans monthly for three months
November 17, 2023Complaint survey0 violations
Inspection dates
11/17/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
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: LI entered the facility at 10:15 am on 11/17/2023 and exited at 10:35 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/10/2023 regarding allegations in the area(s) of resident are and related services and building and grounds. 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: Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 2, 2023Inspection3 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 05/31/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of staff interviewed: 1 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on communication received from the facility on 05/31/202, documentation and an interview, the facility failed to ensure supervision of resident’s schedules, care, and activities, including specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Communication received from the facility via email on 05/31/2023 indicates resident #1 wandered from the premises on 05/31/2023 at approximately 9:00am.
  2. The LI interviewed staff #1 on 05/31/2023 who indicated resident #1 was picked up by a Good Samaritan approximately 0.7 miles from the facility and taken to the local hospital and resident returned to the facility at approximately 10:02am.
  3. Progress notes dated 12/01/2022 at 1:57pm indicates “Resident went outside without informing staff and was found behind the shed. Resident stated he was looking for his truck.”
  4. Progress notes dated 02/02/2023 at 5:42 am indicates “Resident exit seeking this morning looking for his truck, cannot be re-directed.
  5. The Uniform Assessment Instrument dated 12/19/2022 indicates resident #1 is disoriented to some spheres all of the time.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on review of resident’s record and am interview, the facility failed to update the Individualized Service Plan when there is a significant change in the resident’s condition.
Evidence
  1. The Individualized Service Plan for resident #1, dated 12/19/2022 does not reflect the current status of the resident.
  2. Progress notes dated 12/01/2022 at 1:57pm indicates “Resident went outside without informing staff and was found behind the shed. Resident stated he was looking for his truck.”
  3. Progress notes dated 02/02/2023 at 5:42 am indicates “Resident exit seeking this morning looking for his truck, cannot be re-directed.”
  4. The LI interviewed staff #1 on 05/31/2023 who confirmed resident #1 has had a significant change in condition.
Plan of correction
Not published by VDSS.
22VAC40-73-440-H
Based on review of resident’s record, the facility failed to ensure a reassessment was completed when a resident has a significant change in condition, using the UAI to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. The Uniform Assessment Instrument for resident #1, dated 12/19/2022 indicates resident #1 is disoriented to some spheres all of the time.
  2. The Uniform Assessment Instrument for resident #1, dated 12/19/2022 indicates resident has appropriate behavior pattern.
  3. Progress notes dated 12/01/2022 at 1:57pm indicates “Resident went outside without informing staff and was found behind the shed. Resident stated he was looking for his truck.”
  4. Progress notes dated 02/02/2023 at 5:42 am indicates “Resident exit seeking this morning looking for his truck, cannot be re-directed.”
  5. The LI interviewed staff #1 on 05/31/2023 who confirmed resident #1 has had a significant change in condition.
Plan of correction
Not published by VDSS.
April 25, 2023Inspection5 violations
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 REPORT
Technical assistance
Ensure resident social data sheet has all areas complete. Ensure all areas of Serious Cognitive Impairment Form (SCI) are complete.
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: Two Lis conducted a renewal inspection on 04/25/2023. 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: fire drills, menu, activities calendar, dietary and healthcare oversight, pharmacy review. A medication pass was also observed by the LI. 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 number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observations made during the tour of the building and resident record review, the facility failed to ensure there were no medications in residents’ rooms for one resident who is rated depended in medication administration.
Evidence
  1. Resident #5 has a Uniform Assessment Instrument (UAI) dated 11/10/2022 which documents medication administration is performed by a layperson in the facility.
  2. Resident #5 was being observed by the LI during the morning medication pass. The LI observed a cup of gel on the bedside table.
  3. Resident #5 and staff #2 confirmed substance as Voltaren Gel.
  4. Resident #5’s file does not contain a physician’s order to allow this resident to self-administer any medication.
Plan of correction
The Executive Director, Health and Wellness Director or designee immediately removed Voltarin gel from resident # 5 apartment. · The Health and Wellness Director or designee will provide re-education on medication administration and orders and complete medication administration observation for associate # 2 no later than 5/31/2023. · The Executive Director, Health and Wellness Director or designee will provide re-education for current LPN’s and RMA’s on medication administration and not leaving medication at bedside by 6/01/2023. · To assist with ongoing compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will conduct Medication Administration Observation for current nurses and RMA’s no later than 6/01/2023.
22VAC40-73-450-C
Based on review of residents’ records, the facility failed to ensure all assessed needs are identified on the ISP.
Evidence
  1. The UAI for resident 1, dated 10/03/2022 indicates supervision is needed with stairclimbing. This is not reflected on the ISP dated 09/28/2022.
  2. The ISP for resident #3 dated 11/16/2022 indicates resident is a full code. Resident #3 has a DNR effective 03/14/2023.
  3. The UAI for resident #4, dated 01/20/2023 Indicates mechanical assistance is needed with dressing, toileting and mobility. The ISP dated 01/20/20/2023 indicates resident is independent.
  4. The UAI for resident #4, dated 01/20/2023 Indicates only mechanical assistance is needed with bathing. The ISP dated 01/20/2023 indicates mechanical assistance as well as supervision is needed.
  5. The UAI for resident #4, dated 01/20/2023 Indicates only mechanical assistance is needed with stairclimbing. This is not indicated on the ISP date 01/20/2023.
Plan of correction
The Executive Director, Health and Wellness Director or designee will update the Individualized Service Plans with current care needs for resident’s number 1, 3, and 4 by 5/31/2023. The Executive Director or designee will provide education for the Health and Wellness Directors, Health and Wellness Coordinators on Individualized Service Plans and Care needs by 5/31/2023. The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit current residents Individualized Service Plans and Care needs by 8/11/2023. To assist with ongoing compliance, The Health and Wellness Director or designee will audit 5% of current resident Individualized Service Plans and care needs monthly for two months.
22VAC40-73-870-A
Based on observations made during the tour of the building, the facility failed to ensure the interior of the building is maintained in good repair and kept clean.
Evidence
  1. During a walk through of the facility, the bathroom sink in room #205 was observed to have standing water and not draining properly; the toilet paper holder broken and a strong smell of urine.
Plan of correction
• The Executive Director or designee will implement a work order request and tracking system for associates to report needed repairs to the Maintenance Manager to allow maintenance repairs to take place in a timely manner by 5/15/2023. • The Executive Director or Designee will provide reeducation on timely reporting of maintence repairs for current associates no later than 6/1/2023. • To assist with ongoing compliance, The Executive Director or Designee with randomly audit maintenance repair reporting for timeliness and repairs monthly for 2 months.
22VAC40-73-700-1
Based on document review, the facility failed to ensure physician’s orders for oxygen included all required components.
Evidence
  1. The physician order for resident #1 dated 04/06/2023 does not identify the oxygen source.
  2. The physician order for resident #7 dated 05/05/2022 does not identify the oxygen source.
Plan of correction
· Unable to retroactively correct original Oxygen order for resident #1. · The Health and Wellness Director or designee received updated Oxygen order for resident #1 on day of survey 4/25/23. · The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will audit and, if needed, obtain orders identifying oxygen source for all residents with oxygen orders by 5/15/2023. · The Executive Director, Health and Wellness Director, Health and Wellness Coordinator, Resident Care Coordinator or designee will provide re-education to current nurses and RMA’s accepting orders on proper parameters for oxygen orders by 6/1/2023
22VAC40-73-450-D
Based on review of residents’ records, the facility failed to ensure hospice services are included on the Individualized Service Plan.
Evidence
  1. Resident #1 receives hospice services effective 04/13/2023. This is not included on the resident’s ISP dated 09/28/2022.
Plan of correction
The Executive Director, Health and Wellness Director or designee will review and update the Individualized Service Plans with current care needs and third party services for resident’s number 1 by 5/31/2023. • The Executive Director or designee will provide education for the Health and Wellness Directors, Health and Wellness Coordinators and Resident Care Coordinator on Individualized Service Plans requirements and Third Party Care Services by 5/31/2023. • To assist with ongoing compliance, The Executive Director, Health and Wellness Director, Health and Wellness Coordinator or designee will audit Individualized Service Plans and Third Party Care Services for current residents by 8/11/2023.
March 31, 2022Inspection4 violations
Inspection dates
03/31/2022
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 1Subjectivity22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
Discussion occurred with the ED on the following topics: 1. Ensure the Social Data sheet is completed 2. Describe resident behaviors on the ISP
Comments
A mandated monitoring inspection was conducted by two LIs on 03/31/2022. there were 51residents in care. A walk through was completed and the facility was clean and free from any foul odors. The menu and activities calendar were reviewed in addition to outside inspections and fire drills. Five resident and four staff records were reviewed. There were four violations during this monitoring inspection. Details of non-compliance can be viewed on the violation notice section of this report. If you have any questions, please contact the licensing inspector at (540) 292-5932 or email rhonda.whitmer@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on review of residents' records, the facility failed to ensure the Individualized Service Plan (ISP) included all required components.
Evidence
  1. The Uniform Assessment Instrument (UAI) for resident 1 dated 03/21/2022 indicates physical and mechanical assistance is needed with dressing. The ISP indicates only physical assistance is needed .
  2. The UAI for resident 1 dated 03/21/2022 indicates stairclimbing is not performed. The ISP dated 03/21/2022 indicates mechanical and physical assistance is needed with stairclimbing.
  3. The UAI for resident 2 dated 03/29/2022 indicates physical assistance is needed with dressing. The ISP dated 03/30/2022 indicates mechanical and physical assistance is needed.
  4. The file for resident 4 admitted 12/10/2021 does not include a comprehensive ISP.
Plan of correction
The ED will educate the Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator on UAI and ISP Requirements. The ED, Health and Wellness Director, Health and Wellness Coordinator or Resident Care Coordinator will audit and update all resident UAIs and ISPs by 6/30/2022 making sure that resident needs are addressed, accurate and match on both the UAI and ISPs.
22VAC40-73-450-F
Based on review of residents' records, the facility failed to ensure the Individualized Service Plan (ISP) is reviewed and updated annually.
Evidence
  1. The ISP for resident 3 is dated 03/22/2021.
Plan of correction
The ED will educate the Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator on ISP Requirements. The ED, Health and Wellness Director, Health and Wellness Coordinator or Resident Care Coordinator will audit and update all resident ISPs by 6/30/2022.
22VAC40-73-440-A
Based on review of residents' records, the facility failed to ensure the Uniform Assessment Instrument is completed annually as required.
Evidence
  1. The UAI on file for resident 3 is dated 03/22/2021.
Plan of correction
The ED will educate the Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator on UAI Requirements. The ED, Health and Wellness Director, Health and Wellness Coordinator or Resident Care Coordinator will audit and update all resident UAIs by 6/30/2022.
22VAC40-73-320-A
Based on a review of residents' records, the facility failed to ensure a physical examination was completed within 30 days of admission.
Evidence
  1. Resident 1 was admitted to the facility on 03/21/2022. The physical examination report is dated 02/14/2022.
Plan of correction
The ED will educate the Sales Manager, Health and Wellness Director, Health and Wellness Coordinator and Resident Care Coordinator on the Physical Examination Requirements.
March 15, 2021Inspection0 violations
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 reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 03/15/21 and concluded on (03/31/21. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 50. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, staff schedule, fire drills and outside inspections submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you to the staff and administration for your patience and assistance during this desk review process. You will be notified by mail regarding your renewal status which is determined by the risk assessment profile generated within the DSS licensing system and following review by the licensing administrator.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.