Virginia DSS · Assisted Living Facility

Magnolia Ridge ALF

📍 1007 Amherst Street, SW, Roanoke, VA, 24015

ID 32180Two Year licenseActive
8
Inspections
On record
6
With violations
Visits that cited something
2
Clean visits
Nothing cited
35
Violations cited
Individual findings
26
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Magnolia Ridge ALF was inspected 8 times between April 21, 2021 and May 18, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 35 violations under 26 distinct standards. 1 inspection was 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. 7 of these 8 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
Two Year
License expires
05/31/2028
Administrator
Sherone Cephas
Licensing inspector
Cynthia Ball
Inspector phone
(540) 309-2968
Approved for
Non-Ambulatory · Assisted Living

Inspection History

8

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

May 18, 2026Inspection6 violations
Inspection dates
05/18/2026
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 PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 05/18/2026 8:15am until 1:30pm 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: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) were updated for changes in resident condition.
Evidence
  1. The record for resident 4 has documentation that the resident receives services from a mental health provider. In an interview with staff persons 1 and 4, it was reported that this was accurate. The ISP dated 07/31/2025 in the record for resident 4 does not include the identified need for mental health services.
Plan of correction
Resident 4 record was reviewed and the documentation from the Mental Health Service provider was contacted and the services are recorded and current.
22VAC40-73-120-A
Based on staff record review and staff interview, the facility failed to ensure that facility orientation and training for employees occurred within the first seven working days.
Evidence
  1. The record for staff persons 1 and 2, who were transfer employees from another facility in 2025, did not contain documentation that these employees had received orientation and training specific to this facility. In an interview with staff persons 1 and 4 it was reported that this was correct.
Plan of correction
Staff persons 1 and 2 have been reviewed by the Administrator and ensured both 1 and 2 received the necessary on boarding training for this specific facility.
22VAC40-73-320-B
Based on resident record review, the facility failed to ensure that a risk assessment for tuberculosis was completed annually for each resident.
Evidence
  1. The record for resident 1 has documentation that the last risk assessment for tuberculosis for this resident was completed on 02/28/2025.
  2. The record for resident 4 has documentation that the last risk assessment for tuberculosis for this resident was completed on 03/24/2025.
Plan of correction
Resident 1 records have been reviewed by the Administrator and corrected by the Home Healthcare nurse. The Administer will ensure all TB screening are completed annually. Resident 2 records have been reviewed by the Administrator and corrected by the Home Healthcare nurse. The Administer will ensure all TB screening are completed annually.
22VAC40-73-350-B
Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. The record for resident 3, admitted to the facility on 12/12/2025, did not contain documentation that the facility completed a sex offender screening prior to the residents admission to the facility.
Plan of correction
Resident 3 records have been reviewed by the Administrator and corrected by online screening through the VA State Police Sex Offenders website. Resident 3 ISP has be reviewed and updated to ensure all changes in the resident condition was identified and services are met.
22VAC40-73-640-A
Based on resident record and the facility medication management plan (MMP) review, the facility failed to implement their MMP regarding methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs).
Evidence
  1. The facility MMP has documentation that “verification of accurate transcription of medication orders to the MAR within 24 hours of receipt of a new order or change in an order shall be verified by the arriving med aide and the administrator”.
  2. The record for resident 4 has a physician order dated 01/21/2026 for Urea 40% cream apply a sufficient amount daily to rough skin areas on both heels. The medication observed in the cart for resident 4 was Urea 40% cream but the May 2026 MAR for resident 4 has documentation of Urea 20% cream.
Plan of correction
The Administrator reviewed the MMP with staff medication technicians. We will continue to follow the current MMP to ensure documentation is correct. The Administrator reviewed the MMP with staff medication technicians. We will continue to follow the current MMP to ensure documentation is correct.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure all required documentation was included on medication administration records (MARs).
Evidence
  1. The record for resident 1 has documentation of a physician order for Invega Sustenna 234mg injection to be administered every 4 weeks. The April and May 2026 MARs for resident 1 do not have documentation of this medication being administered. In an interview with staff person 1, it was report that this injection is administered monthly at resident 1’s physicians office but the record for resident 1 does not have documentation of the administration of the medication.
Plan of correction
The Administrator reviewed the MMP with staff medication technicians. We will continue to follow the current MMP, and ensure resident's return all documentation they receive from all physician visits.
April 29, 2025Inspection8 violations
Inspection dates
04/29/2025
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 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/29/2025 8:40am until 2:00pm 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: 21 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 1 has documentation of a mental health progress report dated 03/07/2025 that the resident needs continued mental health services. The ISP dated 11/03/2024 in the record for resident 1 does not address the identified need for mental health services.
  2. The record for resident 3 has documentation of a mental health progress report dated 04/23/2025 that the resident needs continued mental health services. The uniform assessment instrument (UAI) dated 02/10/2025 has documentation that resident 3 uses bed rails for mobility. The ISP dated 02/10/2025 in the record for resident 3 does not address the identified need for mental health services or bed rails for mobility.
Plan of correction
1. Resident 1 documentation of for continue mental health services have been reviewed and documented on the ISP. 2. Resident 3 documentation for continue mental health services have been reviewed and documented on the ISP.
22VAC40-73-970-A
Based on facility documentation review, the facility failed to ensure that the facility fire and emergency evacuation drill frequency and participation were in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. The facility fire drill log made available for review on 04/29/2025, the day of on-site inspection, did not include documentation of a drill being conducted for any shift for March 2025.
Plan of correction
The facility fire drill assessment was conducted and documented in accordance to Virginia Statewide Fire Prevention Code (13VAC5-51)
22VAC40-73-680-B
Based on observations of the facility medication cart, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. A opened Novolog Flex Pen and a opened Insulin Glargine-yfgn Pen were observed sitting out on the top of the medication cart at 9:21am on the day of on-site inspection. The pens did not contain a pharmacy issued label or the name of the resident that the medication is for.
Plan of correction
1. The Novolog Flex Pens that are “in use” will be placed in another container with required label/documentation.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair.
Evidence
  1. The 3 light fixtures in the hallway between rooms 9 through 12 were inoperable on the day of on-site inspection.
Plan of correction
. The 3 light fixtures light bulbs have been replaced. Also an additional light fixture will be installed within 30 days
22VAC40-73-490-A-2
Based on facility documentation review, the facility failed to ensure that for residents who meet the criteria for assisted living care a licensed health care professional, practicing within the scope of their profession, provided health care oversight at least every three months, or more often if indicated.
Evidence
  1. The most recent health care over sight provided for review on 04/29/2025, the day of on-site inspection, was dated 12/14/2024, which is past the three-month requirement for residents residing in the facility who are assessed for assisted living level of care.
Plan of correction
1. Health care over sight will be reviewed and documented quarterly.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The record for resident 1 has documentation of a physician order dated 04/23/2025 for Potassium Chl 20meq daily and Furosemide 20mg daily. The April 2025 medication administration record (MAR) for resident 1 has documentation that the Furomeside 20mg was not started until 04/28/2025 and the Potassium 20meq was not documented on the MAR. The Potassium was noted to not be available in the facility for resident 1 on the day of on-site inspection. An interview with staff person 4 on the day of on-site inspection expressed that the Furosemide 20mg was not started until 04/28/2025 because that is when it was received from the pharmacy and the Potassium medication has not been administered because it has not been received from the pharmacy.
  2. The record for resident 1 has a physician order dated 01/17/2025 for Ferrous Sulfate 325mg daily for 90 days then stop. The April 2025 MAR for resident 1 has staff initials for the administration of this medication from 04/18/2025 through 04/29/2025 even though the 90-day time frame ended on 04/17/2025.
  3. The record for resident 2 has a physician order dated 02/27/2025 for Fluticas 250/ Salmeterol 50 Inhl Disk, inhale 1 inhalation by mouth twice a day. Rinse mouth after each use to prevent oral thrush. The April 2025 MAR for resident 2 does not have documentation of the mouth rinse after each use of this medication.
  4. The record for resident 3 has a physician order dated 12/18/2024 for Ferrous Sulfate 325mg daily for 90. The April 2025 MAR for resident 3 has staff initials for the administration of this medication from 04/01/2025 through 04/29/2025 even though the 90-day time frame ended on 03/18/2025.
Plan of correction
1-2. Reviewed Doctor orders with physician and the following will be included: “RX start date when facility receives medication”. All Med. Tech. have reviewed and will continue to follow the MMP. 3. The Administrator reviewed MMP with all Med. Tech. Will continue to adhere and following physician orders thoroughly and document accurately. 4. The Administrator reviewed MMP with all Med. Tech. Will continue to adhere and follow physician orders thoroughly and document accurately.
22VAC40-73-640-A
Based on observations of the facility medication cart, the facility failed to implement their medication management plan (MMP) in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility MMP has documentation on page 5 that “Controlled substances must be kept under double locks; controlled substances must be counted at the end of each shift and documented by two med-aides”.
  2. The February and March 2025 12-Hour Controlled Drugs-Count Record has multiple days/shifts that do not have documentation of staff signatures for the counting of controlled substances.
Plan of correction
1. The facility MMP was reviewed by the Administrator with all Med. Techs. We will continue to follow the current MMP to ensure documentation is correct. 2. The facility MMP was reviewed by the Administrator with all Med. Techs. We will continue to follow the current MMP to ensure documentation is correct.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that medical procedures ordered by a physician were documented.
Evidence
  1. The record for resident 4 has a physician order for blood sugars 4 times a day before meals and at bedtime before giving insulin. The Blood glucose monitoring form for April 2025 does not have documentation of resident 4’s blood sugar results at pre-dinner on 04/01/2025.
Plan of correction
1. Sliding scale is attached to the resident MAR to ensure all blood sugars are documented
February 4, 2025Complaint survey0 violations
Inspection dates
02/04/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/04/2025 10:50am until 1:00pm 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 regarding allegations in the area(s) of: Administration and administrative services and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 21 Number of resident records reviewed: 1 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 investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 3, 2024Inspection5 violations
Inspection dates
05/03/2024
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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 05/03/2024 8:30am until 12:30pm 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: 24 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that all required information was documented on resident medication administration records (MARs).
Evidence
  1. The April 2024 MAR for resident 3 has documentation of the PRN medication Lorazepam 0.25ml every 4 hours as needed for anxiety being administered on 04/07/2024 and 04/12/2024 and the PRN medication Morphine Sulf 0.25ml every 4 hours as needed for pain being administered on 04/06/2024 and 04/07/2024. The MAR does not have documentation of the effectiveness of these medications for the doses that were administered.
Plan of correction
The Medication Technicians have been instructed to continue to follow our medication plan and procedures for the documentation of administering PRNs.
22VAC40-73-1040-A
Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was in place on doors leading to the outside for residents with serious cognitive impairments.
Evidence
  1. The alarms on the doors leading to the outside next to rooms 12 and 27 were not operable on the day of inspection. The facility houses a mixed population of residents such as resident 2 who has a diagnosis of Dementia, is assessed as non-ambulatory on a history and physical dated 03/21/2023 and is marked as disoriented to some spheres some of the time with time and place being the spheres affected on a uniform assessment instrument (UAI) dated 02/08/2024.
Plan of correction
Door alarms were purchased and will be install.
22VAC40-73-690-B
Based on resident record review, the facility failed to ensure that a medication review was completed every 6 months for resident assessed as assisted living level of care.
Evidence
  1. The records for residents 2, 3 and 5 have documentation that the last review of medications for these residents was completed on 10/05/2023. All 3 of these residents are assessed as assisted living level of care on their uniform assessment instruments (UAI).
Plan of correction
Resident 2, 3, and 5 medication reviews have been received and placed in their charts. We will continue to work with our pharmacy to ensure timely compliance of our medication reviews.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that a statement that the individual does not have any prohibited conditions was included in the physical examination.
Evidence
  1. The record for resident 4, admitted on 03/22/2024, has documentation on the physical examination dated 03/20/2024 that resident 4 has the prohibited conditions, psychotropic medications without appropriate diagnosis and treatment plans and requires continuous licensed nursing care., making it unclear if this resident is appropriate for placement in an assisted living facility.
Plan of correction
The resident 4 placement in an assisted living facility is accurate. The documentation has been reviewed and corrected by the physician.
22VAC40-73-660-A-1
Based on observations of the facility physical plant, the facility failed to ensure that all medications were stored in a locked area.
Evidence
  1. The storage closet next to room 18 was observed to be unlocked on the day of inspection and contained 2 boxes of Lidocaine 5% patches sitting out on a shelf in the closet.
Plan of correction
The staff were instructed to ensure the storage room always remain locked according to company policies and procedures. The 2 boxes of Lidocaine 5% patches were immediately removed.
April 19, 2023Inspection7 violations
Inspection dates
04/19/2023
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
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/19/2023 8:40am until 1:30pm 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: 25 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: 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. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-880-B
Based on observations of the facility physical plant, the facility failed to ensure that electric space heaters were only used in an emergency provided their installation or operation has been approved by the state or local building or fire authorities.
Evidence
  1. At 9:22am on the day of inspection a electric space heater was observed on and in use in room 17.
Plan of correction
The electric space heater was removed out of the room. Policy regarding use of space heaters for emergency use reviewed with staff by the administrator.
22VAC40-73-660-B
Based on observations and resident record review, the facility failed to ensure that only residents whose uniform assessment instrument (UAI) indicate they are capable of self-administering medications stored medications in their rooms.
Evidence
  1. On the day of inspection a bottle of Advil PM and a bottle of Excedrin Migraine were observed sitting out on the top of a dresser in the room for resident 6. A review of the UAI dated 10/10/2022 in the record for resident 6 has documentation that the facility administers medications to resident 6. There was no documentation of a physician order for these medications in resident 6’s record.
Plan of correction
Both bottles of Advil PM and Excedrin Migraine were removed from resident’s room day of inspection. Medication policy was reviewed with the resident to notify the facility if there’s any complaints of pain or discomfort. Do not purchase over-the-counter medications.
22VAC40-73-325-B
Based on resident record reviews, the facility failed to ensure that a fall risk rating was completed annually for resident assessed as assisted living level of care.
Evidence
  1. The record for resident 4 has documentation that the last fall risk rating completed for this resident was dated 01/07/2022. The uniform assessment instrument (UAI) dated 01/05/2023 in the record for resident 4 has documentation that the resident is assessed as assisted living level of care.
Plan of correction
Fall risk rating was completed. The administrator will ensure that all fall risk ratings will be accessed annually.
22VAC40-73-450-C
Based on resident record reviews, the facility failed to ensure that identified needs were addressed on individualized service plans (ISP).
Evidence
  1. The record for resident 6 has documentation that the resident receives mental health services. The ISP dated 11/06/2022 does not address this identified need.
Plan of correction
The need for mental heath services was identified on the ISP
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that all employees completed a screening for tuberculosis annually.
Evidence
  1. The record for staff person 1, hired on 10/30/2006, has documentation that the last screening for tuberculosis was completed on 10/07/2021.
Plan of correction
The TB screening was completed by Nurse on day of inspection. Administrator will ensure that all TB screening are performed annually.
22VAC40-73-870-E
Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment shall be kept clean and in good repair and condition.
Evidence
  1. The light fixture above the medication room was noted to be hanging loose from the ceiling on one side.
  2. The light fixture above the sink in room 17 was missing and the light was inoperable after flipping on the corresponding light switch.
Plan of correction
1. Light fixture repaired 2. Light bulb was replaced and now in working condition
22VAC40-73-930-B
Based on observations of the physical plant and staff and resident interviews, the facility failed to ensure that a signaling device was easily accessible to residents in their rooms that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During the day of inspection both LI’s were unable to locate the pendant device for the facility signaling system for room 9, 12, 14, 17, 21, and 22. A signaling device pendant located in room 31 was pushed by the LI but it alerted to the signaling box that it was room 12. Interview with residents expressed that they do not have signaling devices in their rooms. Interview with staff 3 expressed that residents frequently remove the signaling pendant devices from their rooms and then lose them.
Plan of correction
The new signaling system is in review and will be upgraded. Increased monitoring by staff is in place until the upgrade is completed.
August 4, 2022Inspection0 violations
Inspection dates
08/04/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date 8/4/2022 of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9:00am until 11:00am 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: 25 The licensing inspector completed a tour of the physical plant. Number of resident records reviewed: 2 Number of interviews conducted with residents: 2 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 10, 2022Inspection8 violations
Inspection dates
05/10/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2022 9:20am until 2:30pm 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: 24 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on observations made of the facility medication refrigerator, the facility failed to follow their medication management policy in regards to destruction of discontinued medications and medications with expirations dates.
Evidence
  1. On the day of inspection 3 Lantus Solostar pens and 1 Novolog Flexpen was observed in the medication refrigerator for resident 3, who had passed away on 02/26/2022. The facility medication management plan has documentation that it is the facility’s best practice to return all expired and discontinued medications to the pharmacy.
  2. An open bottle of Lantus insulin was observed in the medication refrigerator for resident 1 on the day of inspection. The bottle did not contain a date that the insulin was opened to ensure that it is discarded within 28 days of opening per manufacturer’s instructions. The facility medication management plan has documentation to check expiration dates before administering monthly and before each med pass.
Plan of correction
The medications were discarded according to facility’s medication management plan. Undated medications were discarded according to facility medication management plan. The administrator reviewed/reinforced facility medication management plan with the medication aides.
22VAC40-73-490-A
Based on a review of facility documentation, the facility failed to ensure that a health care oversight was completed at least every 3 months for resident who are assessed as assisted living level of care.
Evidence
  1. The most recent health care oversight available for review was dated 01/09/2022. The facility houses residents who are assessed at an assisted living level of care which require a healthcare oversight every 3 months.
Plan of correction
The healthcare oversight was completed.
22VAC40-73-610-D
Based on a review of resident records, observations of the mid-day meal and interviews with staff, the facility failed to ensure that diets prescribed for residents by their physician was prepared and served according to physician’s orders.
Evidence
  1. The record for resident 2 has documentation of a physician order dated 05/23/2019 for a No Added Sweets diet.
  2. The record for resident 3 has documentation of a physician order dated 10/20/2021 for a No Concentrated Sweets diet.
  3. The mid-day meal was observed at 12:11pm on the day of inspection in the presence of staff person 5. It was noted that a hamburger with lettuce, tomato and onion, tator tots, and white cake with icing was served to all resident in the dining room including residents 1 and 2. An interview was conducted with staff person 4 on the day of inspection in which it was expressed that the cake that was served during the mid-day meal was a regular cake with icing. The LI asked staff person 4 if a reduced or sugar free desert option was available for residents who have diets requiring No Added Sweets or No Concentrated Sweets. Staff person 4 expressed that there are sugar free deserts available but that they had not been served to residents 2 or 3 at the mid-day meal on the day of inspection.
Plan of correction
The facility has clarified residents diets and dietary staff will serve prescribed diets.
22VAC40-73-680-B
Based on observations made of the facility medication room and medication cart, the facility failed to ensure that all medications remained in the pharmacy issued container with the prescription label until administered to residents.
Evidence
  1. A paper soufflé cup with 1 whole and 1 half white pill was observed to be sitting out on the shelf in the medication room.
  2. 3 white pills were observed to be lying loose in the bottom of the third drawer of the medication cart.
Plan of correction
The medications were discarded according to facility management of medication plan. Plan reviewed with staff.
22VAC40-73-100-C-1
Based on observations made of the facility medication cart and interviews with staff, the facility failed to ensure that blood glucose monitoring practices that are consistent with CDC recommendations were followed when assisted blood glucose monitoring is required.
Evidence
  1. An unlabeled glucometer was observed lying on top of the medication cart on the day of inspection.
  2. An unlabeled glucometer was observed in the right top drawer on the medication cart.
  3. A bag labeled with resident 8’s name was noted in the medication cart. The glucometer inside of the bag was unlabeled.
  4. A multi-stick penlet device was observed lying on top of the medication cart on the day of inspection. An interview conducted with staff person 2 on the day of inspection expressed that the facility currently did not have any single use safety lancets for assisted blood glucose monitoring and that the multi-stick penlet lying on top of the medication cart had been used to check blood glucoses for both residents 1 and 2 that morning.
Plan of correction
All glucometers were immediately labeled. Separate lancets were used for each of the two residents in the multi-stick penlet. However, staff was re-instructed to use the single use lancets and must obtain or notify facility administrator no less than 1 week of supplies on hand.
22VAC40-73-660-A-1
Based on observations made of the facility medication room and cart. The facility failed to ensure that medication cabinets, containers or compartments were locked.
Evidence
  1. At 9:20am on the day of inspections it was observed that the sliding glass window in the door to the facility medication room was unlocked. The LI was able to reach their hand through the window and open the door to the medication room. The room was unoccupied and contained a shelf with numerous medications for multiple residents sitting on the shelf. The facility medication cart, which contained various medications for multiple residents was also stored in this room and was observed to be unlocked.
Plan of correction
The importance of locking the med room/cart was strongly reviewed and reinforced by the administrator with staff.
22VAC40-73-890-B
Based on observations made of the facility physical plant, the facility failed to ensure that the interior of the building was adequately lighted for the safety and comfort of residents and staff.
Evidence
  1. The ceiling lights in the hallway outside of rooms 10, 20, 27, the visitor/employee bathroom and the Administrators office were noted to be inoperable on the day of inspection.
Plan of correction
All lights were replaced. Will replace lighting immediately when needed
22VAC40-73-660-B
Based on observations made of the facility’s physical plant and resident record review, the facility failed to ensure that medications kept in residents’ rooms were stored in an out of sight place in the residents’ rooms and for only residents who have been assessed as capable of self-administering their own medications.
Evidence
  1. A bottle of Chlorhexidine Gluconate Mouth Wash was observed sitting out on a dresser in the room for resident 3 on the day of inspection. An interview with resident 3 expressed that he uses this mouth wash himself twice a day.
  2. The uniform assessment instrument (UAI) dated 01/09/2022 in the record for resident 3 has documentation that the resident requires medication administration from a layperson. The physician order in resident 3’s record for the Chlorhexidine Gluconate Mouth Wash dated 04/18/2022 does not have instructions that the resident can self-administer this prescribed medication.
Plan of correction
The mouthwash was removed from the resident’s room. Staff was instructed that all self-administering medications must have a doctor’s order and meds must be securely kept in resident’s room.
April 21, 2021Inspection1 violation
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 PREPAREDNESS32.1 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. A renewal inspection was initiated on 4/21/21 and concluded on 4/21/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 27. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, health care oversight, fire and health inspections, fire drill logs, dietician oversight, medication management plan, infection control policy submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-640-A
Based on a review of the facility medication management plan, the facility failed to address all required procedures in their plan.
Evidence
  1. The facility medication management plan did not include procedures for the facility standard dosing times, ensure that residents do not receive medications or dietary supplements to which they have known allergies, or procedures for identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber;
Plan of correction
The Administrator will review the regulations and will update the facility medication management plan to include all required procedures. The Administrator will submit the revised plan to the LI for review.