The Glebe

April 21, 2026Inspection3 violations

Inspection dates

04/21/2026

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- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/21/2026 08:30 am – 1:45 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 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 Mari Gentry, Licensing Inspector at 804-845-0851or by email at mari.gentry@dss.virginia.gov

Violations

22VAC40-73-640-A

Based on resident record review and staff interview, the facility failed to have a medication management plan with all the required elements. The plan failed to include a plan for medication management to ensure that each resident’s prescriptions are refilled in a timely manner to avoid missed dosages.

Evidence

On the date of on-site inspection, a review of the facility’s medication plan, showed that the plan did not include a policy and/or procedure to ensure that each resident’s prescriptions are filled and refilled in a timely manner to avoid missed dosages.
On the date of on-site inspection, an interview with staff person 5, confirmed a refill policy or procedure is not contained in the current medication management plan (MMP).
The record for resident 5 has a physician order signed on 02/18/2026 for Cephalix 250mg at night for UTI prophylaxis. On the date of on-site inspection, the April medication administration record (MAR) for resident 5 had documentation on 4/19/2026 that the medication was not available to be given to the resident.
Interview with staff person 3, confirmed that on the night of 4/19/2026, the medication was not on the cart and unavailable to be given to the resident as the refill was not available.

Plan of correction

1.The attending physician reviewed the documentation for resident 4 on 4/21/26 and found that the assessment was inaccurately marked “NO” to resident having “a serious cognitive impairment due to a primary psychiatric diagnosis of dementia” by the nurse practitioner. The attending physician immediately completed a new form, noting and correcting this error for resident 4. 2.All residents who reside in the Memory Support Unit were at risk. A review of all Memory Support Unit resident medical records was completed by the Director of Social Services on 4/21/26 to ensure that all residents had documentation of having a “serious cognitive impairment due to a primary psychiatric diagnosis of dementia”. No other issues were noted. 3.The Social Workers were educated by the Administrator on to ensure that all new admits to the memory support unit have documentation of having a “serious cognitive impairment due to a primary psychiatric diagnosis of dementia” prior to admission to the unit on 4/21/26. 4.The Administrator/designee will audit medical records of planned new residents to the Memory Support Unit prior to admission to ensure that residents have documentation of having a “serious cognitive impairment due to a primary psychiatric diagnosis of dementia”. Resident’s without documentation of “a serious cognitive impairment due to a primary psychiatric diagnosis of dementia” will not be admitted to the Memory Support Unit. 5.Compliance was attained on 4/21/26.

22VAC40-73-1090-A

Based on resident record and staff interview, the facility failed to ensure that prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include all required documentation.

Evidence

Resident 4 record, admission date into safe secure environment 3/24/2026, contained an Assessment of Serious Cognitive Impairment, dated 3/20/2026, with documentation that the Resident does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia.
Interview with Staff 6 confirmed Resident 4 record to be current.

Plan of correction

Not published by VDSS.

22VAC40-73-640-A

Based on resident record review and staff interview, the facility failed to have a medication management plan with all the required elements. The plan failed to include a plan for medication management to ensure that each resident’s prescriptions are refilled in a timely manner to avoid missed dosages.

Evidence

On the date of on-site inspection, a review of the facility’s medication plan, showed that the plan did not include a policy and/or procedure to ensure that each resident’s prescriptions are filled and refilled in a timely manner to avoid missed dosages.
On the date of on-site inspection, an interview with staff person 5, confirmed a refill policy or procedure is not contained in the current medication management plan (MMP).
The record for resident 5 has a physician order signed on 02/18/2026 for Cephalix 250mg at night for UTI prophylaxis. On the date of on-site inspection, the April medication administration record (MAR) for resident 5 had documentation on 4/19/2026 that the medication was not available to be given to the resident.
Interview with staff person 3, confirmed that on the night of 4/19/2026, the medication was not on the cart and unavailable to be given to the resident as the refill was not available.

Plan of correction

1. The attending physician and the resident’s responsible party was immediately notified on 4/21/26 of the missed medication “Cephalix 250 mg at night for prophylaxis” for resident 5 on 4/19/26. No new orders were received. 2. All residents who have orders for medication are at risk. A review of the past 7 days of all resident medical records was completed by the Administrator on 4/28/26 to ensure that all residents had physician prescribed medications available for administration. No other issues were noted. 3. The Medication Management plan was updated on 4/28/26 by the Administrator and Assisted Living Director of Nursing (ADON) to include a process for refill policy and procedure as well as notifying the physician if medication is not available to obtain additional physician orders. Nurses and Registered Medication Aides will educated by the Clinical Educator on the updated Medication Management Plan on or before 5/10/26. 4. The ADON/designee will audit medications for all assisted living residents two times per week for 6 weeks to ensure that the updated Medication Management Plan is followed. Any issues of low supply of medication will be immediately addressed per the Medication Management Plan. 5. Compliance will be attained on or before 5/10/26.

January 20, 2026Inspection0 violations

Inspection dates

01/20/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 PERSONNEL

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: 01/20/2026 12:15 to 13:30 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 1/10/2026 regarding allegations in the area(s) of: Resident Care and Related Services, Personnel 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: 2 Number of staff records reviewed: 2 Number of interviews conducted with staff: 2 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 8, 2025Inspection0 violations

Inspection dates

05/08/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 05/08/2025 from 11:00 AM to 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/03/2025 regarding allegations in the area(s) of: Resident care and related services; Additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 51 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: 1 Observations by licensing inspector: N/A 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 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 21, 2025Inspection0 violations

Inspection dates

03/21/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 3/21/2025 11:15 to 12:30 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 3/17/2025 regarding allegations in the area(s) of: Safe, Secure Environment and Personnel The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 11, 2025Inspection2 violations

Inspection dates

03/11/2025

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 IMPAIRMENTS22VAC40-90 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: 3/11/2025 08:40 to 15:00 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: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Lunch Meal, Morning activities, Medication Cart Audits, Medication Pass Observations An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations

22VAC40-73-1110-A

Based on resident record review and staff interview, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.

Evidence

Resident 1 record, admission date 6/7/2024, contained an Approval for Placement in Special Care Neighborhood with documentation that the designee (director of health services) signed the document on 6/24/2024, which is after the admission date.
During an interview with the licensing inspector and staff 2, staff 2 confirmed the resident’s record to be current.

Plan of correction

22VAC40-73-1110 This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. In respect to the specific resident/situation cited: The cited deficiency has been noted and the resident it pertains to has been verified as meeting the requirements under this subsection. In respect to how the facility will identify resident/situations with the potential for the identified concerns: The facility has completed a community wide audit of this document to ensure no other potential deficiencies are noted. In respect to what systemic measures have been put into place to address the stated concern: The admissions team has completed education on the regulatory requirements outlined in 22VAC40-73-1110. As an additional safeguard, the Director of Health Services or their designated representative will review and sign all documents pertaining to 22VAC40-73-1110 to ensure continued compliance. Date to be Corrected: 5/31/2025

22VAC40-73-1100-A

Based on resident record review and staff interview, the facility failed to obtain written approval of one the required persons prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.

Evidence

Resident 1 record, admission date 6/7/2024, contained an Approval for Placement in Special Care Neighborhood with documentation that the guardian or legal representative for the resident signed the document on 6/19/2024, which is after the admission date.
During an interview with the licensing inspector and staff 2, staff 2 confirmed the resident’s record to be current.

Plan of correction

This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. In respect to the specific resident/situation cited: The cited deficiency has been noted and the resident it pertains to has been verified as meeting the requirements under this subsection. In respect to how the facility will identify resident/situations with the potential for the identified concerns: The facility has completed a community wide audit of this document to ensure no other potential deficiencies are noted. In respect to what systemic measures have been put into place to address the stated concern: The admissions team has completed education on the regulatory requirements outlined in 22VAC40-73-1100. As an additional safeguard, the Director of Health Services or their designated representative will review all documents pertaining to 22VAC40-73-1100 to ensure continued compliance. Date to be Corrected: 5/31/2025

November 20, 2024Complaint survey0 violations

Inspection dates

11/20/2024

Areas reviewed

22VAC40-73 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: 11/20/2024 09:40 to 11:40 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 11/9/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 3, 2024Inspection0 violations

Inspection dates

09/03/2024

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/03/2024 10:15am to 10:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 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 within five (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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 10, 2024Inspection1 violation

Inspection dates

04/10/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 4/10/2024 08:00am to 03:00pm 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 3/21/2024 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 45 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations

22VAC40-73-130-A

Based on document review and staff interview, the facility failed to ensure that all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia report suspected abuse or neglect of residents in accordance with that section.

Evidence

The licensing inspector (LI) received a self-report, from the facility, of verbal abuse allegations on resident 1 on 3/21/2024 by a staff member. The final report was received on 3/26/2024 however neither report had documentation on the local Adult Protective Services agency being notified.
During an interview conducted with one LI and staff person 1 on 4/10/2024, it was confirmed that these allegations of suspected abuse were brought to their attention on 3/21/2024, however, staff 1, who completed the self – report, did not report these allegations of suspected abuse to their local Adult Protective Services Agency as required by §63.2-1606 of the Code of Virginia.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/10/2024 it was determined that the Department of Social Services was notified on 3/21/2024 of an allegation of verbal abuse. A final report was sent to the Department of Social Services on 3/26/2024. The Director of Health Services was unable to provide documentation that Adult Protective Services had received notification. On 4/10/2024 The Director of Health Services faxed a copy of the final report to Adult Protective services and the local ombudsman for review. Confirmation not received. Re-faxed copy of final report on 4/11/2024. Confirmation received. On 4/10/2024 the Director of Health Servies was re-educated on the importance of notification to the Adult Protective Services for any allegations involving Abuse and/or Neglect by A Marie Swink Licensing Inspector, Division of Licensing Programs. The community will ensure compliance by 4/12/2024 through audits weekly by reviewing the confirmation reports to ensure all regulatory entities have been notified Weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.

April 10, 2024Inspection1 violation

Inspection dates

04/10/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE 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

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: 4/10/2024 08:00am to 3:00pm 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: 45 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations

22VAC40-73-1180-B

Based on observations of the physical plant, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident.

Evidence

One Licensing Inspector and staff person 2 observed the laundry room, in the safe, secure unit that provides care to residents that have a serious cognitive impairment, near the back hallway near the second nurses’ station to be unlocked and accessible to enter by residents. A 30 FL OZ bottle containing Shout Triple Acting Laundry Stain Remover was observed in the top right unlocked cabinet in this laundry room which was accessible to residents. The bottle had language on its label that stated KEEP OUT OF REACH OF CHILDREN AND PETS.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/10/2024 the laundry room door with the keyless entry mechanism did not engage and lock in the Chaplick Center Memory Care neighborhood. The door was easily opened and accessible for entry. Upon entry, behind a closed cabinet door was a bottle of Shout Triple Acting Stain Remover used for laundering purposes. On 4/10/2024 The Director of Facilities Services was immediately notified and determined no reason why the door did not engage. There was no issue with the keyless entry mechanism and the laundry room door has been functioning properly and locking since the initial occurrence. Team members will be re-educated on the importance of checking doors to ensure engagement of the keyless entry mechanism to prevent accidental injury from chemicals and/or cleaning products that require a secure and locked storage location. Re-education with team members will be completed by 5/1/2024. The community will ensure compliance by 4/12/2024 through random environmental audits to ensure doors with keyless entry devices are engaging properly and verify the doors are locked. Weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.

February 12, 2024Complaint survey0 violations

Inspection dates

02/12/2024

Areas reviewed

22VAC40-73 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: 2.12.2024 9:15am to 10:46am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 2.9.2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 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 A Marie Swink, Licensing Inspector at 276.623.6575 or by email at angela.swink@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 11, 2024Inspection0 violations

Inspection dates

01/11/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 01/11/2024 9:59AM until 10:31AM 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 12/13/2023 regarding allegations in the areas of: personnel and resident care and related services 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 within five (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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 25, 2023Inspection0 violations

Inspection dates

05/25/2023

Areas reviewed

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

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/25/2023 9:00AM until 10:10AM 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 no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 18, 2023Inspection6 violations

Inspection dates

04/18/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND 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

Technical assistance

To ensure that the facility had a thorough understanding of the standards, the licensing inspectors had a discussion with facility staff during the inspection regarding standard 1150-B.

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 04/18/2023 9:20AM until 4:45PM. 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: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: activities, noon-time meal, audit of medication carts 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations

22VAC40-73-930-D

Based on resident record review and staff interview, the facility failed to ensure that for each resident with an inability to use the signaling device that once a resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and the facility, and the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds and the documentation shall be retained for two years.

Evidence

Residents 2 and 4 reside in the facility’s safe, secure unit. It was verified through an interview with staff 5 that residents 2 and 4 have an inability to use the signing device.
Interview with staff 5 revealed that staff do not document the date and time of rounds that have been made and the name of the staff member who made the rounds.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. The Physician was notified and orders were entered in the electronic medical record on 4/23/2023. The ISP will be updated to reflect every two-hour monitoring of residents residing on the Chaplick Center who have the inability to utilize the signaling call system device. The alleged deficient practice has the potential to affect all residents in the Chaplick Center Memory Care neighborhood. On 4/23/2023 orders were entered in the electronic medical record and the ISP was updated to reflect every two-hour monitoring of residents residing on the Chaplick Center who have the inability to utilize the signaling call system device The Chaplick Center manager and/or designee will ensure all new admissions who have the inability to utilize the signaling call system device for assistance has an order for every two-hour rounding for documentation to monitor emergencies or other anticipated resident needs. Nursing team members will be educated on the importance of documentation for two-hour monitoring for residents residing in a safe, secure neighborhood. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023

22VAC40-73-100-C-2

Based on observation during an audit of medication carts and policy review, the facility failed to implement its infection control policy regarding blood glucose monitoring practices that are consistent with CDC recommendation.

Evidence

Regarding blood glucose staff monitoring, the facility’s infection control policy states, “Blood glucose monitoring will be obtained using a facility approved and individualized blood glucose monitor and in accordance to manufacturer’s instructions”.
At approximately 9:44 AM, one licensing inspector observed two blood glucose monitors within the facility’s memory care unit medication cart. Blood glucose monitor #1 was not labeled with a resident’s name and was inside of a bag labeled with resident 10’s name. Blood glucose monitor #2 was labeled with resident 10’s name and was found inside of a bag labeled with resident 11’s name.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/18/2023 the Director of Nursing immediately obtained two new accu-check machines. The Director of Nursing ensured both storage bags and glucometers were labeled with each resident name. The alleged deficient practice had the potential to affect all residents in the Chaplick Center neighborhood who receive blood sugar monitoring. A 100% physician order audit was completed on 4/20/2023 to review all residents receiving blood sugar monitoring. A medication cart audit was conducted to ensure glucometers and storage bags were labeled and stored accurately. No additional residents were affected. The Chaplick Center manager and/or designee will review all new physician orders for blood sugar monitoring and ensure each resident has an individualized storage bag and glucometer that is appropriately labeled in the medication cart. Nursing team members will be re-educated on the importance of ensuring glucometers and storage bags are labeled and appropriately stored for each resident receiving blood sugar monitoring. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023

22VAC40-73-860-I

Based on observation during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area.

Evidence

At approximately 9:52AM during on-site inspection, one licensing inspector (LI) noted that the door to room G204 (laundry room on second floor) was unlocked. The cabinets located on the wall were also unlocked and contained a bottle of Tide laundry detergent and a spray bottle of Downy wrinkle releaser. This was also noted by staff 1.
Also at approximately 10:14AM, one LI noted that the door to room G303 (laundry room on third floor) was unlocked. The cabinets located on the wall were also unlocked and contained the following: two spray bottles of Shout laundry stain remover, a spray bottle of Oxi Clean laundry stain remover, a spray bottle of Dreft laundry stain remover, a spray bottle of Spray & Wash and a bottle of Windex. This was also noted by staff 2.
At approximately 10:57 AM, one LI observed a can of New Image hairspray under the bathroom sink of memory care room 148. The can contained a warning to “Keep out of reach of children”.
At approximately 11:01 AM, one LI observed a medication cup that contained an unidentified white cream inside of the cabinet in the bathroom of memory care room 138.
At approximately 11:22 AM, one LI observed an oval white pill stamped with “L612” laying in the hallway outside of room 2201.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/20/2023 new keyless entry locks were placed on the laundry room doors for Assisted Living 2 and Assisted Living 3. Team members were issued a key code to enter the laundry rooms. The alleged deficient practice has the potential to affect other residents residing in the Assisted Living neighborhood. On 4/20/2023 new keyless locks were placed on the laundry room doors for Assisted Living 2 and Assisted Living 3. The Assisted Living manager and/or designee will provide environmental rounds to ensure laundry room doors are locked and secure. Nursing team members will be re-educated on the importance of laundry room doors remaining closed and secured when not in use to prevent accidental injury from chemicals and/or cleaning products. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Assisted Living manager and/or designee by May 15, 2023On 4/18/2023 the can of hairspray was immediately removed from room 148 by the Chaplick Center Memory Care manager. The alleged deficient practice has the potential to affect other residents residing in the Chaplick Center neighborhood. A 100% environmental room audit was completed to ensure all items with specific instructions to “Keep out of reach of children.” were either removed or placed in a secure, locked cabinet. No additional items were observed. No additional residents were affected. The Chaplick Center manager and/or designee will provide environmental rounds to ensure items containing the label to “Keep out of reach of children.”, cleaning supplies or other hazardous materials are stored in a secure, locked cabinet. Nursing team members will be re-educated to ensure cleaning items and other hazardous materials are stored in a secure, locked area when not in use to prevent accidental injury from chemicals and/or cleaning products. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023On 4/18/2023 the medication cup containing white cream was immediately removed from room 138 by the Chaplick Center Memory Care manager. The alleged deficient practice has the potential to affect other residents residing in the Chaplick Center neighborhood. A 100% environmental room audit was completed to ensure there were no unidentified treatment modalities left un-attended in resident rooms. No additional residents were affected. The Chaplick Center manager and/or designee will provide environmental rounds to ensure no unidentified treatment modalities are left un-attended in resident rooms to prevent accidental injury from chemicals, cleaning products and/or other items that could be ingested and potentially harmful to the resident. Nursing team members will be re-educated on the importance of not leaving treatment modalities in residents’ rooms unattended. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023 On 4/18/2023 the white oval pill observed in the hallway of Assisted Living 2 was immediately discarded by the Assisted Living Licensed Practical nurse.

22VAC40-73-680-D

Based on resident record review and staff interview, the facility failed to ensure medications are administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 9 contained a verbal order from the physician on 04/12/2023 to change the resident’s scheduled Novolog to three units before meals and continue with sliding scale insulin and hold if the resident’s blood sugar is less than 150.
The April 2023 medication administration record (MAR) reflected this order effective 04/13/2023 for the resident’s scheduled Novolog.
The April 2023 MAR indicated that the resident’s blood sugar was 133 on 04/13/2023 at noon and 116 on 04/15/2023 at noon; therefore, Novolog should not have been administered to the resident; however, the MAR includes documentation that Novolog was administered to the resident both dates/times. Also, the April 2023 MAR indicated that the resident’s blood sugar was 121 on 04/14/2023 at 16:30PM; however, the MAR includes documentation that Novolog was administered to the resident.
The aforementioned information and documentation was also noted by staff 5 and staff 5 confirmed this was accurate.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. The insulin order for residents # 9 was verified to be correctly transcribed. The hold parameters were transcribed but were not clearly visible to nursing team members administering medications. The Assisted Living nurse manager updated the order to reflect the hold parameters at the beginning of the instruction section for greater visibility during the medication pass. The attending was notified. Medication error reports were completed with each nursing team member and re-education was provided on the importance of following physician ordered parameters. The alleged deficient practice has the potential to affect other residents residing in the Assisted Living neighborhood who receive insulin with physician ordered parameters. An audit was completed on 4/20/2022 to review compliance with physician orders for insulin management. No additional residents were affected. The Assisted Living manager and/or designee will review all new physician orders to ensure transcription is clear and visible for orders requiring parameter monitoring. Nursing team members will be re-educated on the importance of following physician ordered parameters and transcribing physician ordered parameters at the beginning of the instruction section for greater visibility during medication administration. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Assisted Living manager and/or designee by May 15, 2023

22VAC40-73-680-E

Based on resident record review and staff interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber are provided according to his instructions and documented and the documentation is to be maintained in the resident’s record.

Evidence

The record for resident 5 contained a physician’s order, dated 03/31/2023, for Ted hose to bilateral lower extremities as tolerated by the resident, on in the morning and off at night for edema management.
The April 2023 treatment administration record (TAR) for the resident provided during on-site inspection did not contain documentation of whether staff applied the resident’s Ted hose or not during the month of April 2023. This was also noted by staff 5 and staff 5 confirmed that there was no additional documentation.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/18/2023 the Director of Health Services reviewed the TED hose order for resident # 5. It was determined that the order was transcribed correctly. The order type selected was a Treatment FYI which does not provide the means for the nurse to sign that the treatment was refused and/or completed. The Director of Health Services immediately corrected the order on 4/18/2023 to allow for team member documentation. On 4/23/2023 received new orders from in-house attending to discontinue the order for TED hose application. The alleged deficient practice has the potential to affect other residents residing in the Chaplick Center neighborhood who have physician orders for TED hose management. A 100% physician order audit was completed on 4/20/2023 to ensure all orders for TED hose had the correct order type selected to allow team members signature. No additional residents were affected. The Chaplick Center manager and/or designee will review all new physician orders for TED hose to ensure the time code is accurate to allow for a team member signature. Nursing team members will be re-educated on the importance of selecting the correct time code when entering physician orders to ensure a signature block for treatments performed. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023

22VAC40-73-680-B

Based on observation during an audit of medication carts, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

Evidence

At approximately 9:46 AM, one licensing inspector observed a small bottle of Haloperidol injection, USP 5 MG/ML sitting in the top drawer of the memory care medication cart that did not contain a prescription label or a resident’s name.

Plan of correction

Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/18/2023 the bottle of unlabeled Haldol was immediately removed from the medication cart and discarded by the Chaplick Center Memory Care manager. The alleged deficient practice had the potential to affect all residents in the Chaplick Center neighborhood who receive medications administered from the STAT box. A 100% medication cart audit was conducted on 4/18/2023 to ensure all medications had appropriate labeling. No additional medications were identified. No additional residents were affected. The Chaplick Center manager and/or designee will audit the medication carts to ensure all medications are labeled appropriately. Nursing team members will be re-educated on the importance of ensuring medications are labeled with resident’s name and directions for medication use. Nursing team members will be educated to label the medication based upon the physician order if retrieved from the in-house STAT box with the resident name and directions for use. The community will ensure compliance through weekly audits x4 weeks then monthly audits x3 months. Progress of audits and new processes will be reported during the quarterly QA meeting. Person responsible for completion: Chaplick Center manager and/or designee by May 15, 2023

June 20, 2022Inspection0 violations

Inspection dates

06/20/2022

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

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: 6/2/2022, 2:30 pm to 2:50 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Observations by licensing inspector: The prior violation has been corrected. 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 within five (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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 27, 2022Inspection3 violations

Inspection dates

04/27/2022

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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

UAIs were discussed and the components of wheeling and self care with continence were clarified. The use of oxygen was discussed.

Comments

On 4/27/2022 two inspectors conducted a renewal study )8:30 am to 1:10 pm. 46 residents were in care. Eight resident records, four staff records, and other documents were reviewed. A medication pass was observed and a physical plant tour was done. An exit interview was held on-site the day of the inspection and the facility was given an opportunity to resent additional evidence. A telephone exit interview was done on 4/28/2022.

Violations

22VAC40-73-860-I

Based on observations made of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.

Evidence

The door to the soiled utility room on the AL3 Unit was noted to not lock properly as there was tape and an Oxygen in Use magnet over the latch on the door trim. A bottle of Terro Ant Killer, Proteus Solution, Eco-88 Pet Stain Remover and a can of Heritage Furniture Polish was observed in an unlocked cabinet above the sink.
A Micro-Kill One Germicidal wipes was observed sitting out on the counter above a small refrigerator in the facility memory care unit.
The door to the food pantry in the facility memory care unit was noted to be propped open on the day of inspection and dietary staff were observed coming and going from this room. A bottle of Clorox Bleach, a container of Micro-Kill One Germicidal wipes, a bottle of Granite Gold Cleaner and several spray bottle containing liquid substances were observed sitting out unlocked in the room.

Plan of correction

This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/27/2022 the coverings on the door strike plate were removed to allow the door to close properly. The Director of Facilities Services was notified to order and place keyless locks to the Soiled utility rooms and clean linen rooms on Assisted Living 2 and Assisted Living 3. The new keyless entry locks will be installed no later than May 3, 2022. Team members will be issued a key code to enter the soiled utility room for easier access. On 4/27/2022 Director of Environmental Services removed the cleaning products and other products that were identified in the soiled utility room, the Food and Beverage Manager removed the cleaning supplies observed in the Memory Care Pantry and the Memory Care manager removed the Micro-Kill Wipes from the nursing station of the Memory Care neighborhood. Team members will be re-educated on the importance of keeping doors shut and not propping doors open on the neighborhood to prevent accidental injury from chemicals and/or cleaning products that require a secure and locked storage location. Re-education with team members will be completed by 5/15/2022. The community will ensure compliance through random environmental audits weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.

22VAC40-73-990-C

Based on staff interview, the facility failed to hold, at least once every six months, an exercise in which the procedures for resident emergencies are practiced.

Evidence

There is no documentation to support that the practice exercises are being done, and this was confirmed by interview with staff 5.

Plan of correction

This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/28/2022 it was identified that the medical emergency education was not conducted every (6) six months as required by regulatory guidance. Team members will be provided the medical emergency education by 5/15/2022 and every 6 months thereafter to ensure regulatory compliance. The community will ensure compliance in the mandatory education and report findings during the quarterly QA meeting.

22VAC40-73-660-B

Based on observations made of the facility physical plant and resident record reviews, the facility failed to ensure that medications kept in resident rooms were stored in an out of sight place in the residents rooms and only for residents who have been assessed as capable of self-administering their own medications.

Evidence

During the morning medication pass conducted on 04/27/2022, the LI observed a bottle of Kroger Brand Tussin DM, a container of Preparation H, a bottle of Acetaminophen 325mg tablets and a bottle of Acetaminophen 500mg tablets sitting out on the bookshelf in the room for resident 4. The uniform assessment instrument (UAI) for resident 4, dated 03/27/2022, has documentation that the resident requires medications to be administered by facility staff. There was not a physician’s order for these medications in the record for resident 4.
During the morning medication pass conducted on 04/27/2022, the LI observed a container of Bio-Freeze sitting out on the bathroom sink in the room for resident 8. The UAI for resident 8, dated 10/11/2021, has documentation that the resident requires medications to be administered by facility staff. There was not a physician’s order for this medication in the record for resident 8.

Plan of correction

This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. Residents #4 and #8 were involved in the alleged deficient practice. An audit was completed on 4/28/2022 to ensure that there were no over the counter medications observed in residents’ apartments. No other residents were affected. On 4/27/2022 the medications were immediately removed from the residents’ apartments and the attending was notified regarding the continued use of the over-the-counter medications. Orders were not received from the attending physician to continue the use of the medications. The residents and their families were notified. There were no adverse effects from the alleged deficiency. Team members will be re-educated on the importance of neighborhood rounding and monitoring of the environment to ensure that over-the-counter medications that have not been prescribed by a physician are removed with prompt notification to the attending physician. Re-education with team members will be completed by 5/15/2022. On 4/28/2022 during the Assisted Living/Memory Care Family meeting, families and residents will be re-educated on the importance of notifying the primary nurse when medications are being brought into the neighborhood to ensure that an active physician order is present. The community will ensure compliance through random environmental audits weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.

June 10, 2021Inspection0 violations

Inspection dates

June 10, 2021 , June 11, 2021 and June 17, 2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

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. An annual monitoring inspection was initiated on 6/10/2021 and concluded on 6/17/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 47. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, staff schedules, fire drill records, background check review on new staff, health care oversight report, fire inspection report, health department report, medication management plan, and infection control plan 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.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 8, 2020Complaint survey1 violation

Inspection dates

Dec. 8, 2020 and Dec. 15, 2020

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity

Technical assistance

The LI explained a training deadline to a staff person responsible for some training.

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 monitoring inspection was initiated on 12/9/2020 and concluded on 12/16/2020. A complaint was received by the department regarding allegations in the areas of personnel, resident care and related services, and additional requirements for facilities that care for adults with serious cognitive impairments. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the monitoring inspection but identified during the course of the investigation can be found on the violation notice.

Violations

22VAC40-73-440-A

Based on resident record review, the facility failed to update the uniform assessment instrument (UAI) when there was a significant change in a resident's condition.

Evidence

D:
The UAI for resident 3 dated 10/7/2020 showed this resident shows a behavior pattern of Wandering/Passive - Weekly or more. The nurses notes showed this resident exhibited Abusive/Aggressive/Disruptive behavior, Weekly or more. The notes detail incidents of such behavior on 10/29/2020, 11/1, 4, 5, 6, and 7/2020. The UAI for resident 3 also shows this resident is continent of bowel and bladder. Nurses notes dated 10/30/2020, 11/1, 4, and 5/2020 indicate the resident is not continent of bowel and bladder.

Plan of correction

The facility continues to review and updated resident UAI and ISP as conditions change related to baseline behavior. Based on the violation notice 22VAC-73-(6)-440-A Complaint related, the facility noted there was inconsistency in the resident 3, behavior between 10/29-11/7. The resident had been admitted directly into the facilities MC neighborhood with ongoing adjustment to daily routine, ADL assistance, and medication management. The facility was working in conjunction with the family and the medical director to determine the baseline behavior in these first two week of admission. Due to the unknown nature and the inconsistency of behavior the facility documented the change in the medical record and nursing notes. The UAI was maintained during the initial admission period in order for the facility personnel to accurately understand what the residents baseline behavioral pattern would be. The facility feels it maintained nursing oversight and accurate record of fluctuating behavior on a daily basis to ensure the residents was supported in their daily living needs. The facility will continue to update resident UAI in relation to 22VAC40-73-(6)-440-A The facility would like to request a desk review and conference to further evaluate the violation notice as issued .

Provider Information

Inspection History