Virginia DSS · Assisted Living Facility

Spring Hills Mt. Vernon (Fairfax Co)

📍 3709 Shannons Green Way, Alexandria, VA, 22309

ID 34036One Year licenseActive
20
Inspections
On record
16
With violations
Visits that cited something
4
Clean visits
Nothing cited
54
Violations cited
Individual findings
46
Standards cited
Distinct rules
12
Complaint visits
Prompted by a complaint

Spring Hills Mt. Vernon (Fairfax Co) was inspected 20 times between February 26, 2021 and February 2, 2026 by the Virginia Department of Social Services. 16 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 54 violations under 46 distinct standards. 12 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 17 of these 20 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
03/09/2027
Administrator
Bora Bisimwa
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

20

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

February 2, 2026Inspection15 violations
Inspection dates
02/02/2026
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 IMPAIRMENTS
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-45, 22VAC40-73-240, 22VAC40-73-310, and 22VAC40-73-490.
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: 02/02/2026 Time in: 10:22 AM Time out: 6:48 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: 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: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: Licensing inspector (LI) observed residents entering and exiting the facility for community outings, residents moving out of the facility, residents moving in the facility, residents dining for lunch and dinner, residents engaged in physical therapy, and residents participating in scheduled activities. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-950-F
Based on record review and staff interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documented the review by signing and dating the plan, and made necessary plan revisions.
Evidence
  1. Upon request 02/02/2026, the facility did not provide documentation of an annual review of the emergency preparedness and response plan.
  2. During the onsite inspection, 02/02/2026, staff 8 confirmed that an annual review of the emergency preparedness plan was not provided to licensing upon request.
Plan of correction
The emergency preparedness plan was signed and dated by the Executive Director to provide proof of the current year review
22VAC40-73-650-E
Based on resident record review and staff interview, the facility failed to ensure that the resident’s record should contain the physician’s or other prescriber’s signed written order or a dated notation of the physician’s or other prescriber’s oral order.
Evidence
  1. Resident 1’s January 2025 Medication Administration Record included PRN medications, Loperamide 2 MG and Baza Protect Cream 12%; however, resident 1’s records did not include these medications on the physician order sheet.
  2. During the onsite inspection, 02/02/2026, licensing inspector reviewed resident 1’s medication cart with staff 12, who provided Loperamide 2 MG and Baza Protect Cream 12%. Staff 12 stated that the medications were discontinued and not on the physician order sheet.
Plan of correction
The community updated resident #1 record to include missing order. Community will conduct a house-wide audit of all residents’ records to ensure no other files have missing orders. Any discrepancies found during this audit must be correct immediately.
22VAC40-73-290-A
Based on record review and staff interview, the facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. April 2025, October 2025, and January 2026’s written work schedule did not include the job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
  2. During the onsite inspection, 02/02/2026, staff 10 confirmed that the written work schedule did not include the job classifications of the care managers (CM) and registered medication aids (RMAs).
Plan of correction
Director of Resident care updated the schedule to include the staff names, job classification (CNA, RMA, LPN) Task completed 2/07/2026
22VAC40-73-280-A
Based on record review and staff interview, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychological well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.
Evidence
  1. During the onsite inspection, 02/02/2026, licensing inspector (LI) interviewed staff 10, who provided support with developing the written work schedule. Staff 10 stated that there are 4 CMs (2, assisted living and 2, safe, secure environment), 1 RMA, and 1 RN were scheduled on first shift; 4 CMs, 1 RMA, and 1 RN were scheduled on second shift; and 3 CMs (1 CM, assisted living and 2 CMs, safe, secure environment). Staff 10 stated that there are only 1 RMA and 1 RN scheduled per shift that covered both assisted living and safe, secure environment floors.
  2. April and October 2025’s work schedule indicated that on 04/07/2025 there was 1 CM scheduled in AL; on 04/19/2025 and 10/03/2025 there was 1 CM scheduled in the safe, secure unit, on first shift.
  3. April and October 2025’s work schedule indicated that on 04/07/2025 and 10/17/2025 there was 1 CM scheduled in the safe, secure unit; on 04/15/2025 there was no staff scheduled in the safe, secure unit; and on 04/19/2024 there was 1 CM scheduled in AL, on the second shift.
  4. January 2026’s work schedule indicated that on 01/25/2026 indicated that on 01/25/2026 there was 1 CM scheduled in the safe, secure unit on the second shift
Plan of correction
New compliant staffing plan has been developed to include specific shift hours, positions, titles, and direct care roles A schedule for ongoing monthly audits was developed for three months to ensure the staffing plan matches actual daily schedules and meets residents’ acuity levels. The Executive Director will ensure the written staffing plan remains current, reviewed and updated at least annually
22VAC40-73-680-M
Based on resident record review and staff interview, the facility failed to ensure that medications ordered for PRN administration should be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Resident 3 was prescribed Oxybutynin (start date, 09/16/2025) 5 MG (give 1 tablet orally as needed for bladder spasm).
  2. During the onsite inspection, 02/02/2026, licensing inspector (LI) requested to review resident 1’s medication cart with staff 12.
  3. During the review, staff 12 confirmed that the medication, Oxybutynin 5 MG, was not available for administration.
Plan of correction
Resident #3’s PRN missing medication was immediately ordered from the pharmacy. Community will conduct a full audit of medication carts to verify every PRN listed on the Medication Administration Records (MAR) is physically present. Community will provide a mandatory in-service for RMAs and LPNs on the medication management plan, focusing specially on checking PRN availability during shift change. The Director of Resident care will conduct a biweekly MAR- to Cart audit for 4 weeks comparing the MAR to the physical inventory to ensure PRN medications are available.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual’s respective responsibilities. The review should be documented by signing and dating.
Evidence
  1. The emergency preparedness and response plan (EPR) review was documented and signed by staff on 12/29/2025 and 12/30/2025. The EPR was sent to residents and legal representatives in January 2026; however, the documentation did not include signatures and dates. The EPR did not include documentation of a review with volunteers.
  2. During the onsite inspection, 02/02/2026, staff 8 confirmed that the EPR was not documented and signed as reviewed semi-annually with staff, residents, and volunteers.
Plan of correction
The community will complete reviewing the Emergency Preparedness and Response plan with the residents’ representatives, residents, volunteers, staff members and documentation for completion will include all parties’ signatures and dates. Community will update a master training calendar to include fixed days for the semi-annual emergency plan reviews (Jan-July)
22VAC40-73-970-A
Based on record review, the facility failed to ensure that fire and emergency evacuation drill frequency and participation should be in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills for each shift in a quarter should not be conducted in the same month.
Evidence
  1. The documentation for fire and emergency evacuation drills indicated that the drills were conducted for first (7 am – 3 pm) and second shift (3 pm – 11 pm) on 06/19/2025 (time, 3:40 pm), 07/10/2025 (time, 3:30 pm), 08/13/2025 (time, 2:45 pm), and 10/15/2025 (time, 3:10 pm).
  2. The documentation for fire drills conducted on 09/16/2025 (time: 4:30 pm and 9:00 pm) included all three shifts, first, second, and third (11 pm – 7 am).
  3. The documentation for fire drills conducted on 12/29/2025 included first shift; and 12/30/2025 included second shift.
  4. During the onsite inspection, 02/02/2026, the documentation provided by staff 11 did not indicate that the drills for each shift in a quarter were conducted in the same month.
Plan of correction
Community has implemented a quarterly drill calendar that pre-assigns drills to different months for each shift (e.g. Day shift in Jan, Evening in Feb, Night shift in March) to ensure compliance. The Maintenance Director will be re-educated on the drill frequency, unannounced status, and the ban on conducting drills same shift drills in the same month. The Executive Director or designee will review the drill log at end of every month to verify that the required drills were conducted, evaluated and documented correctly.
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure that medications should be removed from the pharmacy container, or the container should be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. Medications should remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During the onsite inspection, 02/02/2026, licensing inspector (LI) observed staff 3 complete a medication pass with resident 6 during the 1:00 pm administration time.
  2. The facility’s Medication Management Plan stated, “the person administering will review each resident’s Medication Administration Record to determine which medications need to be administered at the given time. The person will observe the 9 rights in administering each medication: the right resident, the right time, the right medication, the right dose, the right method of administration, the right documentation, the right reason, the right response, and the right to refuse.”
  3. During the observation, staff 12 placed a cup with medication and a cup of water next to resident 6 on their end table. Staff 12 walked out of the room and did not administer the medication; the medication was still in the cup. LI asked staff 12 if they were finished with administration; and staff 12 confirmed that they had completed administration with resident 6, despite not observing resident 6 physically taking the medication.
Plan of correction
Community will provide a mandatory in-service for all Registered Medication Aides (RMA) and License nursing staff, emphasizing that they must observe residents physically taking the medication. The DRC will perform live medication administration observation for the team members involved and all the other nursing staff.
22VAC40-73-280-B
Based on record review and staff interview, the facility failed to maintain a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. The plan should be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. Upon request, 02/02/2026, the facility did not provide a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care.
  2. During the onsite inspection, 02/02/2026, staff 8 confirmed that a written plan was not provided to licensing inspector upon request
Plan of correction
New compliant staffing plan has been developed to include specific shift hours, positions, titles, and direct care roles A schedule for ongoing monthly audits was developed for three months to ensure the staffing plan matches actual daily schedules and meets residents’ acuity levels. The Executive Director will ensure the written staffing plan remains current, reviewed and updated at least annually
22VAC40-73-640-A
Based on resident records and staff interview, the facility failed to ensure that the facility should have, keep current, and implement a written plan for medication management. The facility’s medication plan should address procedures for administering medication and should include: methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order; and a plan for proper disposal of medication.
Evidence
  1. Resident 1 was prescribed Clopidogrel 75 MG (give 1 tablet orally one time a day for hematological for 21 days) on 10/20/2025, with instructions of a start date, 10/21/2025.
  2. Resident 1’s October 2025 MAR indicated that Clopidogrel 75 MG was administered on 10/23/2025.
  3. Resident 3 was prescribed Sulfamethoxazole-Trimethoprim 800-160 MG (take 1 tablet by mouth two times daily for 7 days) on 08/16/2025. Resident 1 started this medication on 08/18/2025.
  4. During the onsite inspection, 02/02/2026, staff 10 confirmed that resident 1 and resident 2’s medications were not transcribed onto the MAR within 24 hours of receipt of a new order or change in an order.
  5. During the onsite inspection, 02/02/2026, licensing inspector (LI) requested to review resident 1’s medication cart with staff 12. During the review, staff 12 provided 2 medications that were not on resident 1’s physician order sheet: Hydrocort Cream 1% ALOE and Glipizide ER 5 MG.
  6. During the onsite inspection, 02/02/2026, staff 12 confirmed that Hydrocort Cream 1% ALOE and Glipizide ER 5 MG were not properly disposed of after each medication was discontinued
Plan of correction
Community will update and review with the nursing team the current medication management plan to include how to handle medications, from ordering to disposal. The Director of Resident Care will schedule monthly direct observation of staff administering medication. The DRC will conduct in-services for staff to ensure medication orders are properly transcribed to medication administration record within 24 hrs. The DRC will implement a quarterly audit of the Medication Administration Records.
22VAC40-73-650-C
Based on resident record review, the facility failed to ensure that physician’s or other prescriber’s oral orders should be reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. Resident 1 received a telephone order of Hydrocortisone 1% (7 days for rash on abdomen) on 10/09/2025. The prescription was reviewed and signed by a physician on 12/29/2025.
Plan of correction
Community will ensure the nursing staff immediately records any oral orders received and ensure the oral order is reviewed and signed by the prescriber or physician within 14 days of the order being given. The DRC will implement a monthly audit of the Medication Administration Records for three months to ensure all oral orders are recorded and signed timely.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to provide a statement to the prospective resident and the prospective resident’s legal representative, if any, that disclosed information about the facility. The statement should be on a form developed by the department.
Evidence
  1. Upon request 02/02/2026, the facility did not provide the disclosure statement on a form developed by the department.
  2. During the onsite inspection, 02/02/2026, staff 8 confirmed that the disclosure statement provide was not on a form that was developed by the department.
Plan of correction
The community updated the Disclosure statement on a form developed by the department
22VAC40-73-830-E
Based on record review, the facility failed to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. April 2025 through May 2025, July 2025, and January 2026’s resident council meeting documentation did not include a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Plan of correction
The Activity Director and the Executive Director will review the resident council recommendations monthly to ensure all recommendations receive a timely written response. Community will review the last 3 months of resident council meeting minutes to ensure no other recommendations were overlooked.
22VAC40-73-980-H
Based on record review and staff interview, the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility’s rotating stock may be used.
Evidence
  1. During the onsite inspection, 02/02/2026, licensing inspector toured the kitchen and emergency supply storage area with staff 9.
  2. During the review, licensing inspector observed that the facility’s emergency drinking water expired; and staff 8 and staff 9 confirmed that the emergency drinking water expired on 02/28/2019.
Plan of correction
The community purchased and stored enough unexpired drinking water to meet the 96-hourrequirement for the current residents and staff census. The community removed all existing emergency supplies that have passed their expiration and implemented a rotating stock, where emergency water is rotated into the community 3-6 months before it expires and is immediately replaced with fresh stock. The Dining Director will add a digital calendar (e.g. 30days before the current stocks expiration date
22VAC40-73-220-A
Based on private duty records and staff interview, the facility failed to ensure when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: before direct care or companion services are initiated, the facility should obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to the home care organization regarding any needed changes.
Evidence
  1. Private duty 6 (start date, 12/03/2025) and private duty 7 (start date, 01/10/2026) records did not include information on the type and frequency of the services to be delivered to the residents.
  2. During the onsite inspection, 02/06/2026, staff 8 confirmed that private duty 6 and private duty 7’s records did not include, in writing, information on the type and frequency of the services to be delivered to the residents.
Plan of correction
Community conducted an audit of all plans of care records to ensure all private duty services are accurately documented including information on the type of service and frequency of the services to be delivered to the residents. Completion date: 2/7/2026 The Director of Resident care and executive Director are responsible for continued monitoring
November 21, 2025Complaint survey2 violations
Inspection dates
11/21/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/21/2025 Time in: 1:47 PM Time out: 3:52 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/12/2025 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents engaged in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Admission, Retention and Discharge of Residents and Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating should be reviewed and updated after a fall.
Evidence
  1. Resident 1’progress note indicated that they had a fall on 10/17/2025 and 10/29/2025.
  2. Upon request the facility did not provide a post fall risk rating for 10/17/2025 and 10/29/2025.
  3. During the onsite inspection, 11/21/2025 staff 1 and staff 2 confirmed that a post fall risk rating was not included in resident 1’s records on 10/17/2025 and 10/29/2025.
Plan of correction
• Resident #1: Post fall risk assessment was completed for the fall on 10/29/25 however, there was no post fall risk rating for the fall on 10/17/25. • The community will conduct an audit of all resident records to identify any other individuals who have had a fall within a year and confirm that every resident identified in the audit has a fall risk rating that was updated following their most recent incident. • The nursing staff (LPN, RMAs) will be reeducated on the importance and requirement of updating a fall risk rating after any falls. • The DRC or designee will audit all incident reports weekly for the next 90 days to ensure fall risk ratings are updated
22VAC40-73-450-F
Based on resident record and staff interview, the facility failed to ensure that the individualized service plans should be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update should be performed by a staff person with the qualification specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident’s family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident 1’s Progress Notes indicated that they had a fall on 10/15/2025. The fall resulted in a laceration with stitches to the right side of the forehead.
  2. Resident 1’s Progress Notes indicated that resident had a fall by “sliding” out of recliner on 10/17/2025, 10/24/2025, and 10/29/2025 (twice).
  3. On 10/30/2025, resident 1’s progress notes stated, “resident put on the bed for comfort due to the recliner being adjusted in a wrong manner by resident increasing falls.”
  4. Resident 1’s individualized service plan did not include a preference to remain in recliner for comfort.
Plan of correction
• Community will conduct an audit of all current residents’ ISPs to ensure they are updated yearly, or as needed for a change of resident’s condition and include preferences from resident’s interview, and in conjunction with the resident’s family, legal representative, direct care staff, professional health care providers, or other persons, as appropriate. • Community will implement a monthly quality assurance check where the Administrator, the Director of Resident Care or designee will review residents’ ISPs to verify that residents’ preferences are documented.
November 10, 2025Complaint survey0 violations
Inspection dates
11/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Licensing inspector reviewed the following standards with the facility: 22VAC40-73-310 and 22VAC40-73-870.
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: 11/10/2025 Time in: 12:58 PM Time out: 2:16 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/17/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Buildings and Ground, and Complaint Investigation 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents interacting with peers and staff during scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 6, 2025Complaint survey4 violations
Inspection dates
10/06/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 10/06/2025 Time in: 12:23 PM Time out: 1:46 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/02/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Resident Care and Related Services, and Complaint Investigation. 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities and interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medication was administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Per the telephone order (prescribed date, 08/15/2025) and the medication label, resident 1 was prescribed Amox-Clav 500-125 MG (take 1 tablet by mouth every 12 hours).
  2. Resident 1’s August 2025 medication administration record (MAR) stated the following order: Amoxicillin Oral tablet 500 MG (Give 1 tablet by mouth every Mon, Fri, Sat, Sun for suspected UTI).
  3. August 2025 MAR indicated that resident 1 received Amoxicillin Oral tablet 500 MG 08/15-18/2025 and 08/22-24/2025.
  4. During the onsite inspection, 10/06/2025, staff 1 confirmed that resident 1’s Amox-Clav 500-125 MG was not administered in accordance with the physician’s instructions.
Plan of correction
Not published by VDSS.
22VAC40-73-650-C
Based on resident record review and staff interview, the facility failed to ensure that physician’s or other prescriber’s oral orders were reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. Resident 1 had an oral order for Amox-Clav 500-125 MG tablet (prescribed, 08/15/2025).
  2. During the onsite inspection, 10/06/2025, licensing inspector (LI) observed that resident 1’s oral order for Amox-Clav 500-125 MG was not signed by a physician.
  3. During the onsite inspection, 10/06/2025, staff 1 confirmed that resident 1’s oral order for Amox-Clav 500-125 MG was not signed by a physician within 14 days of receiving the order.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident.
Evidence
  1. Licensing inspector received an incident report on 09/19/2025 regarding an injury of unknown origin for resident 1. Per the incident report, the power of attorney (POA), physician, and APS were notified on 09/09/2025.
  2. August 2025’s progress notes for resident 1 indicated that the injury presented on 08/19/2025 and the POA was notified on 08/20/2025.
  3. During the onsite inspection, 10/06/2025, staff 1 confirmed that resident 1’s injury of unknown origin was not reported to the regional licensing office within 24 hours.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure to implement a written plan for medication management. The facility’s medication plan should address procedures for administering medication and should include: methods for verifying that medication orders have been accurately transcribed to medication administration records (MAR) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. Resident 1 had an oral order for Amox-Clav 500-125 MG tablet (prescribed, 08/15/2025) 2. Resident 1’s telephone order for Amox-Clav 500-125 MG stated, “take 1 tablet by mouth every 12 hours.”
  2. During the onsite inspection,10/06/2025, LI reviewed resident 1’s August 2025’s MAR, which stated, “give 1 tablet by mouth every Mon, Fri, Sat, Sun for suspected UTI.”
  3. During the onsite inspection, 10/06/2025, staff 1 confirmed that resident 1’s Amox-Clav 500-125 MG order was not accurately transcribed to August 2025’s MAR.
Plan of correction
Not published by VDSS.
October 6, 2025Complaint survey1 violation
Inspection dates
10/06/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 10/06/2025 Time in: 1:48 PM Time out: 2:44 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/19/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Resident Care and Related Services, and Complaint Investigation. 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities and interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaints 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-680-C
Based on resident record review and staff interview, the facility failed to ensure that medications should be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Resident 1 was prescribed Levothyroxin 150 MG (give 1 tablet orally one time a day for thyroidism) that was scheduled to be administered daily at 6:30 PM.
  2. On 08/30/2025, the medication administration audit reflected that resident 1’s Levothyroxin was documented as administered at 12:24 AM on 09/03/2025.
  3. During the onsite inspection, 10/06/2025, staff 1 confirmed that at the time of administration, resident 1’s medication was not documented as administered not earlier than one hour before and not later than one hour after the dosing schedule.
Plan of correction
Not published by VDSS.
June 18, 2025Complaint survey1 violation
Inspection dates
06/18/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 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: 06/18/2025 Time in: 4:07 PM Time out: 4:54 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/04/2025 regarding allegations in the area(s) of: Buildings and Grounds, Emergency Preparedness, and Complaint Investigation 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents entering and exiting the facility for community outings and dining for dinner. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Buildings and Grounds A violation notice was issued; any violation(s) not related to the complaints 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-880-C
Based on licensing inspector’s (LI) observation, the facility failed to provide an air conditioning system for all areas used by residents, including residents’ bedrooms and common areas. Temperatures in all areas used by residents would not exceed 80 F.
Evidence
  1. During LIs tour of the facility on 06/18/2025, staff 2 utilized a movable thermometer that displayed 91 degrees in the second-floor hallway, 81.5 in the front lobby, and 102 in resident 1’s room.
Plan of correction
Not published by VDSS.
June 5, 2025Inspection1 violation
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 01/17/2025 Time In: 3:15 PM Time Out: 5:18 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 10/3/2024 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents, Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed residents entering and exiting the facility for community outings, celebrating a birthday party with peers, and listening to music in the lobby. Additional Comments/Discussion: 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: Admission, Retention and Discharge of Residents, Resident Care and Related Services 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 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-130-A
Based on facility review, the facility failed to ensure all staff who were mandated reporters reported suspected abuse, neglect, or exploitation of residents.
Evidence
  1. Staff 3 (hire date, 12/7/2023) failed to report an injury of unknown origin to the executive director and director of nursing due to Resident 2 being at moderate risk for falls due to confusion and unsteady gait.
  2. On 01/17/2025, LI interviewed staff 2 who confirmed that staff 3 did not report resident 2’s injury of unknown injury to nurse in charge on 09/23/2024. Staff 3 confirmed that resident 2’s injury was reported on 10/03/2024.
Plan of correction
Not published by VDSS.
May 27, 2025Inspection4 violations
Inspection dates
05/27/2025
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 PREPAREDNESS
Technical assistance
Licensing inspector reviewed the following standards with the facility: 22VAC-40-73-1110-A, 22VAC-40-73-950-E, and 22VAC-40-73-970-E.
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: 05/27/2025 Time in: 11:49 am Time out: 6:10 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed residents participating in scheduled activities and dining for lunch and dinner. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-240-F
Based on volunteer records and staff interview, the facility failed to ensure that all volunteers attended an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Volunteers should sign and date a statement that they have received and understand this information.
Evidence
  1. Upon request the facility did not provide volunteer records for staff 4.
  2. On 05/27/2025, LI interviewed staff 1 who confirmed that there was not a volunteer record on site for staff 4.
Plan of correction
Not published by VDSS.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to provide a statement that disclosed information about the facility on a form developed by the department.
Evidence
  1. Upon request the facility did not provide a statement that disclosed information about the facility on a form developed by the department.
  2. On 05/27/2025, LI interviewed staff 1 who confirmed that the statement that disclosed information about the facility was not on a form developed the department.
Plan of correction
Not published by VDSS.
22VAC40-73-430-H-1
Based on resident record review and staff interview, the facility did not ensure that at the time of discharge, a dated statement was signed by the licensee or administrator.
Evidence
  1. Resident 1’s (discharge, 02/01/2025) discharge statement was not signed by the licensee or administrator.
  2. On 05/27/2025, LI interviewed staff 1 who confirmed that resident 1’s discharge statement was not signed by the licensee or administrator.
Plan of correction
Not published by VDSS.
22VAC40-73-390-A
Based on resident record review and staff interview, the facility failed to ensure there was a written agreement dated and signed by the licensee or administrator.
Evidence
  1. Resident 5’s resident agreement was not signed by the licensee or administrator.
  2. On 05/27/2025, LI interviewed staff 1 who confirmed that resident 5’s resident agreement was not signed by the licensee or administrator.
Plan of correction
Not published by VDSS.
January 17, 2025Complaint survey2 violations
Inspection dates
01/17/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICESARTICLE 1 – SUBJECTIVITY22VAC40-80 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: 01/17/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/09/2024 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Article 1 - Subjectivity. 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents entering and exiting the facility, participating in a birthday party for a peer, and listening to music in the lobby. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-1110-B
Based on resident record review and staff interview, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee performed a review of the appropriateness of the resident’s continued residence in the special care unit.
Evidence
  1. Resident 1’s (admit date, 12/8/2023) records did not include a 6-month review of appropriateness in a special care unit.
  2. On 1/17/2025, licensing inspector (LI) interviewed staff 2, who confirmed that the 6-month review was not completed.
Plan of correction
a. What did you do to fix this specific violation? Resident 1’s, 6 months appropriateness assessment reviewed and completed. b. What steps are you going to implement to ensure future compliance? DRC or Designee conducted an audit for current residents of semi-annual reviews of Approval for Placement in the Special Care Unit. Issues identified were resolved. c. What measures will be put into place to monitor compliance? For the next 3 months, the DRC or Designee will audit resident records to confirm the records contain the semi-annual Approval for Placement in Special Care Unit. Issues that may be identified will be addressed and resolved. The QAPI committee will evaluate the results of the audit during and after three months and determine if additional action is warranted or if the review period needs to be extended. d. What date will this be completed by? 8/31/2025
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls.
Evidence
  1. Resident 1’s records indicated that a fall occurred on 03/06/2024, 10/02/2024, 11/14/2024, and 12/05/2024.
  2. Resident 1’s Fall Intervention Plan (effective date, 12/8/2024) stated, “The resident has had a history of falls R/T, dementia. Follow community fall. Protocol: Morse fall evaluation after each fall, frequent safety check at least every 2 hours and PRN.”
  3. During the onsite inspection, staff 2 was unable to provide documentation of 2-hour safety checks for resident 1 and confirmed they do not occur.
Plan of correction
a. What did you do to fix this specific violation? POC Q-shifts have been changed to "every 2 hours" b. What steps are you going to implement to ensure future compliance? DRC or designee will do an audit of all ISPs to make sure we monitor residents and documenting based on their ISPs c. What measures will be put into place to monitor compliance? Monthly audit of all ISPs by DRC or designee for the next 3 months to ensure staff are monitoring residents and documenting based on their ISPs. All findings will be submitted to the QAPI committee for review. d. What date will this be completed by? 8/31/2025
March 1, 2024Inspection4 violations
Inspection dates
03/01/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: March 1, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 60 Number of records reviewed and interviews conducted- 8 records(staff and residents), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: pharmacy review, dietician report, emergency preparedness drills, fire drills, resident emergency drills, and healthcare oversight..The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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 m
Violations
22VAC40-73-880-B
Based on direct observation by the Licensing Inspector, it was determined that the facility staff was using a portable heating unit that was not approved by the state fire authorities.
Evidence
  1. The staff breakroom had an operating portable heater in use at the time of inspection.
Plan of correction
The portable heater was removed immediately from the premises. DES will ensure portable heaters are not in use during daily rounds.
22VAC40-73-490-A-2
Based on facility record review and staff interview, it was determined that the facility failed to have documentation of a healthcare oversight every three months as required.
Evidence
  1. The last healthcare oversight was dated January 2023 for the facility.
Plan of correction
Healthcare Oversight will be completed by Corporate Registered Nurse quarterly.
22VAC40-73-860-I
Based on direct observation by the Licensing Inspector, It was determined that the facility failed to store cleaning supplies in a locked area.
Evidence
  1. The cleaning carts were not locked as required and the cleaning supplies were loose and unattended while staff completed the assignments for the day.
Plan of correction
Cabinets and locks will be installed on all housekeeping carts cabinets. Staff will be in-serviced on appropriate storage of cleaning supplies and carts.
22VAC40-73-870-A
Based on direct observation by the Licensing Inspector, it was determined that the interior and the exterior of the building was not in good repair.
Evidence
  1. There were windows that were broken in the safe, secure unit as well as the staff breakroom. The fencing on the side of the building was down on the ground. The fencing in the secure courtyard was broken along the top. The cleaning carts had broken compartment doors.
Plan of correction
Replacement windows ordered and will be installed. Fencing on side of building will be repaired or removed. Lattice on memory care courtyard will be repaired. Cleaning carts compartment doors will be repaired or replaced.
March 30, 2023Inspection1 violation
Inspection dates
03/30/2023
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 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
Please refer to the DSS website for the most recent Health & Physical Report, TB Screening and Fire Drill Report model forms. Encourage the Maintenance Director, Administrator and corporate office to complete a formal walkthrough of the facility and note furniture that is showing wear, walls that require painting and carpet that requires cleaning or replacement. Please update the posted resident rights to reflect the current Licensing Administrator — Sharae Henderson, 804-629-3479
Comments
Type of inspection: Renewal An unannounced renewal inspection was conducted on 3/30/2023. At the time of entrance 74 residents were in care. The sample size consisted of ten resident records, five staff records and three individual interviews. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection conducted on 3/8/2022. Residents were observed eating breakfast and lunch and engaging in activities including current events, exercise and sing-along. Medication administration was observed. An exit meeting was 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. Wthin 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at Iynette.storr@dss.virginia.gov
Violations
22VAC40-73-280-A
Facility failed to ensure that there are staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident.
Evidence
  1. Upon Licensing Inspector’s arrival in the memory care environment six residents were observed in the dining room having breakfast. One staff was present with his back turned to the residents. The residents were not attended to while eating or provided any social interaction for 10 minutes. During the observed lunch in the memory care environment, 12 residents were in the dining room being seated for lunch with one staff person providing care. The residents that were seated in the dining room required a higher level of supervision due to wandering behaviors, assistance with eating and socialization needs.
Plan of correction
All associates are required to complete training upon hire and ongoing to ensure person centered care is provided to our residents. In response to the inspector’s observations, a mandatory in-service for all associates will occur no later than April 19, 2023.
March 13, 2023Complaint survey7 violations
Inspection dates
03/13/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING
Comments
A complaint was received by VDSS Division of Licensing on 1/10/2023 regarding allegations in the areas of documentation and service plan delivery. Licensing Inspector (LI) conducted unannounced complaint investigation on 3/13/2023. LI reviewed resident records and conducted staff interviews. 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. The department's inspection findings are subject to public disclosure. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
22VAC40-73-310-H
Based on documentation facility failed to ensure that in accordance with § 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: individuals requiring continuous licensed nursing care.
Evidence
  1. Resident #1’s admission health and physical dated 9/30/2022 indicates that the resident requires continuous licensed nursing care.
Plan of correction
The community has twenty four hour LPN oversight. In the absence of an Executive Director and Director of Resident Care- the H&P was not revised by the physician to not reflect 24 hour care. The resident physician will be contacted for revision to accurately reflect ALF services per standards. The newly pointed Director of Resident Care will audit resident admission files in order to identify any discrepancies on admission paperwork
22VAC40-73-460-D
Based on documentation and interview facility failed to ensure that it shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident #1’s incident notes indicate that the resident experienced unwitnessed falls on 10/5/2022, 10/27/2022, 12/24/2022,1/11/2023,1/15/2023. 1/26/2023,2/9/2023 and 2/15/2023. Staff did not attend to the resident’s specialized needs.
Plan of correction
Documentation of appropriate interventions will occur to ensure resident’s needs are appropriately met. Hospice was notified and care coordination meetings occurred in response to the resident’s risk of falls. The newly appointed Director of Resident Care will educate wellness nurses to ensure care coordination is appropriately documented
22VAC40-73-325-C
Based on documentation and interview facility failed to ensure that the facility must document an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. The current facility fall risk rating does not include documentation of interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of correction
The community will ensure the fall risk rating is accurately updated for the identified resident. Despite documentation failure- several in person care coordination meetings were held with hospice provider and resident Power of Attorney to discuss resident’s risk of falls. The newly appointed Director of Resident Care will audit fall risk plans for appropriate residents
22VAC40-73-470-F
Based on documentation and interview facility failed to ensure that when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately.
Evidence
  1. As documented in the Resident #1’s incident notes, on 1/26/2023 the resident experienced a fall that resulted in a laceration, bruising and swelling around the resident’s eye and face. Medical attention was not sought out until 1/31/2023.
Plan of correction
The resident is on hospice services. Both the medical POA and hospice were notified of all incidents that occurred and appropriate treatment at the time of the incidents was agreed upon and discussed. The newly appointed DRC will conduct education to ensure that appropriate documentation occurs in the resident’s record to ensure the appropriate treatment plan that was agreed to
22VAC40-73-480-E
Based on documentation and interview the facility failed to ensure that the physician's or other prescriber's orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident's record.
Evidence
  1. Resident #1 receives hospice services. There is no documentation in the resident record to indicate that hospice visits have been conducted.
Plan of correction
The resident is on hospice services. Both the medical POA and hospice were notified of all incidents that occurred and appropriate treatment at the time of the incidents was agreed upon and discussed. The newly appointed DRC will conduct education to ensure that appropriate documentation occurs in the resident’s record to ensure the appropriate treatment plan that was agreed to
22VAC40-73-450-C
Based on documentation and interview facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. Resident #1 admitted 9/30/2022 did not have documentation that a comprehensive ISP was completed within 30 days.
Plan of correction
The community had a lapse in Director of Resident Care at the time of admission. A service plan was completed and coordinated with hospice and Power of Attorney. The care plan will be updated immediately to reflect comprehensive care. The newly appointed Director of Resident Care will audit service plans on or before 4/13/23 to identify any discrepancies in comprehensive ISP documentation.
22VAC40-73-450-D
Based on documentation and interview facility failed to ensure that when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan.
Evidence
  1. Resident #1 receives hospice services. These services are not documented on the resident’s most recent ISP.
Plan of correction
Coordination of care did occur with the resident’s hospice provider. In the absence of a Director of Resident Care there was a lapse of documentation on the resident ISP. The newly appointed Director of Resident Care will audit ISP’s with outside services to ensure coordination of care is accurately reflected on the ISP
January 5, 2023Complaint survey0 violations
Inspection dates
01/05/2023, 03/13/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 Protection of adults and reporting
Comments
A complaint was received by VDSS Division of Licensing on 1/10/2023 regarding allegations in the areas of documentation and service plan delivery. Licensing Inspector (LI) accompanied by Licensing Consultant conducted unannounced complaint investigation on 3/13/2023. LI reviewed resident records and conducted staff interviews. 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. The department's inspection findings are subject to public disclosure. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 5, 2023Complaint survey3 violations
Inspection dates
01/05/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 Protection of adults and reporting
Technical assistance
Please note: The facility will review their policy regarding secondary notifications when the primary notification cannot be made. Also, it should be indicated in the resident record when multiple notifications have been requested for a resident. Please ensure that internal facility investigatory notes and reports are complete and kept on file. Discussed upcoming renewal inspection. Please ensure that a renewal application is submitted prior to the current license expiring.
Comments
A complaint was received by VDSS Division of Licensing on 12/16/2022 regarding allegations in the areas of notifications, documentation and resident injury. Licensing Inspector (LI) conducted unannounced complaint investigation on 1/5/2023. LI reviewed resident records and conducted staff interviews. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violation not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
22VAC40-73-560-E
Based on documentation and interview the facility failed to ensure that all resident records shall be kept current.
Evidence
  1. On 11/20/2022 Resident #1 was observed by direct care staff as having discoloration on the upper left eye and a bruise on the roof of his nose. The origin of this injury is unknown. This incident was not recorded in the resident until 11/22/2022. The progress note did not indicate the care giver that reported the injury.
Plan of correction
All documentation will occur timely and accurately in the resident record. Progress notes will be reviewed to ensure documentation is completed and up to date. Education will be provided on documentation and incident reporting requirements on 1/10/23. Training will occur bi-annually and on an ongoing basis.
22VAC40-73-70-A
Based on interview and documentation review the facility failed to ensure that a report was made to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 11/20/2022 Resident #1 was observed by direct care staff as having discoloration on the upper left eye and a bruise on the roof of his nose. The origin of this injury is unknown. This incident was not reported to the regional licensing office.
Plan of correction
All incidents will be reported to the regional licensing office as required. Education will be provided on Incident Reporting and Mandated Reporting requirements on 1/10/23. Training will occur bi-annually and on an ongoing basis.
22VAC40-73-130-A
Based on interview and documentation the facility failed to ensure that all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. On 11/20/2022 Resident #1 was observed by direct care staff as having discoloration on the upper left eye and a bruise on the roof of his nose. The origin of this injury is unknown. This incident was not reported to Adult Protective Services
Plan of correction
All applicable incidents will be reported to APS as required. Education will be provided on Incident and Mandated Reporting Requirements on 1/10/23. Training will occur bi-annually and on an ongoing basis.
May 6, 2022Complaint survey1 violation
Inspection dates
05/06/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced complaint inspection was conducted on 5/6/22, in response to a complaint that was received by the licensing office on 4/22/22 regarding: Resident Care and Related Services. Facility documents and resident information were reviewed. Additional facility documentation was observed after the on-site visit. The allegation was determined to be valid, as a preponderance of evidence supported the allegation. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on documentation, the facility failed to administer medication in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1’s record contained an order for Keflex, dated 2/8/22. Medication Administration Records (MARs), for Resident #1, were reviewed during the inspection. The order called for Resident #1 to receive one Keflex 500mg capsule, twice per day for 10 days. Facility records indicated that 20 Keflex capsules were sent to the facility for Resident #1. Resident notes indicate that the medication was first administered at 11:04 PM on 2/9/22. Resident #1’s MAR documented the administration of another 18 Keflex capsules. No documentation was provided, during the inspection, to indicate that Resident #1 received the last Keflex capsule that was ordered for her.
Plan of correction
Nurses were re-educated by the Director of Resident Care on medication transcription and administration protocol. An audit of residents MARs was conducted to ensure residents currently receiving ABT were not affected. Director of Resident Care will audit for new ABT orders 3 times per week for 8 weeks to ensure meds are transcribed and administered according to PCP order.
March 8, 2022Inspection0 violations
Inspection dates
03/08/2022
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
Comments
Type of Inspection: Renewal An unannounced renewal inspection was conducted on 3/8/2022. At the time of entrance 79 residents were in care. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. The sample size consisted of nine resident records, five staff records and four individual interviews. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection. Residents were observed eating breakfast and engaging in activities including current events, trivia and music appreciation. Medication administration was reviewed. Exit interview held with Administrator. 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 Lynette Storr, Licensing Inspector at 703-479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 18, 2021Inspection1 violation
Inspection dates
10/18/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
On 11/19/2021 through 11/26/2021, Licensing Inspector conducted an inspection in response to a self-reported incident. Reviewed incident reports and other communications with staff. Violation notice issued and assessed risk assigned to violations reviewed during the exit interview. Exit interview conducted on 11/29/2021 with the Regional Executive Director and the violation notice regarding the standards deemed valid was emailed for correction. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-70-C
Based on documentation, facility failed to submit a written report of each incident within seven days from the date of the incident and the report shall be signed and dated by the administrator and include the following information: Name and address of the facility; Name of the resident or residents involved in the incident; Date and time of the incident; Description of the incident, the circumstances under which it happened, and when applicable, extent of injury or damage; Location of the incident; Actions taken in response to the incident; Actions to prevent recurrence of the incident, if applicable; Name of staff person in charge at the time of the incident; Names, telephone numbers, and addresses of witnesses to the incident, if any; and Name, title, and signature of the person making the report, if other than the administrator, and date of the completion of the report.
Evidence
  1. Facility Executive Director emailed an initial report to the Licensing Inspector on 10/17/2021 that stated "issues with the boiler and hot water goes on and off" and did not issue a complete report within seven days from the date of the incident. Emails from the Regional Executive Director were received on 11/19/2021, 11/24/2021 and 11/26/2021 regarding steps taken at the facility to repair the issues.
Plan of correction
Not published by VDSS.
April 2, 2021Complaint survey0 violations
Inspection dates
April 2, 2021 and April 6, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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 complaint inspection was initiated on 4/02/2021 and concluded on 4/06/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. 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 did not support the allegations of non-compliance with standards or law. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice. Exit interview with the administrator.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 2, 2021Inspection5 violations
Inspection dates
April 2, 2021 and April 6, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 4/02/2021 and concluded on 4/06/2021. The administrator was contacted by telephone for an entrance interview to initiate the inspection. The administrator reported that the current census was 62. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records and four staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. Exit interview conducted with administrator and management team on 4/14/2021. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s); and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-1090-A
Based on record review, 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.
Evidence
  1. Resident #1 was admitted to a safe, secure environment on 9/03/2020 with an assessment of serious cognitive impairment dated 9/07/2020, not prior to admission.
Plan of correction
The Director of Resident Care services (DRC) to conduct a 100% audit of all residents with primary diagnosis of serious cognitive impairment to ensure they were assessed prior to admission. The Director of Residential Care (DRC) will review documentation prior to move in using the “new admission checklist” to verify that required documentation is present prior to admission. The Executive Director will perform an audit on 25% of new move in files quarterly to verify compliance using the community quality assurance tool.
22VAC40-73-1110-A
Based on record review, facility failed to ensure that 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.
Evidence
  1. Resident #2 was admitted to a safe, secure environment on 1/06/2020 with an appropriateness documented on 2/25/2020, not prior to admission.
Plan of correction
The Director of Resident Care services (DRC) to conduct a 100% audit of all residents with primary diagnosis of serious cognitive impairment to ensure they were assessed prior to admission to determine placement. The Director of Residential Care (DRC) will review documentation prior to move in using the “new admission checklist” to verify that required documentation is present prior to admission. The Executive Director will perform an audit on 10% of new move in files quarterly to verify compliance using the community quality assurance tool.
22VAC40-73-250-A
Based on record review, facility failed to ensure that a record shall be established for each staff person and it shall not be destroyed until at least two years after employment is terminated.
Evidence
  1. Staff #4 was listed as a wellness nurse on staff roster provided by facility on 3/31/2021 with a date of hire on 6/04/2020 and Staff #4's termination date was on 4/02/2021 and a staff record of the verification of current professional license and tuberculosis report was not maintained for at least two years after employment is terminated.
Plan of correction
The Executive Director will in-service all managers on company’s policy and regulation pertaining to preserving and destruction of staff records.
22VAC40-90-30-B
Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. 1/16 records reviewed did not document a Sworn Statement (SS) completed as an applicant; Staff #2 was hired on 2/19/2021 with a SS signed as an employee on 2/23/2021.
Plan of correction
The Business Office Manager (BOM) to conduct a 100% audit on all current staff records to ensure a sworn statement or affirmation was obtained and filed. The Business Office Manager (BOM) will review documentation prior to employment by utilizing Excelforce credentialing process according to company policy to ensure that all associate credentials are completed in accordance to DSS and company standards. The Executive Director will perform an audit on 25% of new employee files quarterly to verify compliance using the community credentialing tool.
22VAC40-90-40-B
Based on record review, facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. 2/16 staff records did not document a Criminal History Record (CHR) prior to the 30th day of employment; Staff #14 was hired in dining on 8/05/2020 with a CHR dated 4/01/2021 and Staff #15 was hired in housekeeping on 4/19/2020 with a CHR dated 11/30/2020.
Plan of correction
The Business Office Manager (BOM) to conduct a 100% audit on all current staff records to ensure a criminal history record was obtained and filed prior to 30 days of employment. The Business Office Manager (BOM) will review documentation prior to employment by utilizing Excelforce credentialing process according to company policy to ensure that all associate credentials are completed in accordance with DSS and company standards. The Executive Director will perform an audit on 25% of new employee files quarterly to verify compliance using the community credentialing tool.
February 26, 2021Complaint survey2 violations
Inspection dates
Feb. 26, 2021 and March 3, 2021
Areas reviewed
22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
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 complaint inspection was initiated on 2/26/2021 and concluded on 3/03/2021. A complaint was received by the department regarding allegations in the areas of Resident Accommodations and Related Provisions. 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 allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-740-A
Based on interview and documentation, facility failed to ensure that each resident shall be permitted to keep reasonable personal property in his possession at a facility in order to maintain individuality and personal dignity.
Evidence
  1. Facility moved Resident #1 and a portion of her belongings from room #329 to room #320 on May 22, 2020 where resident resided until her death on October 1, 2020 with the remainder of her personal possessions stored elsewhere at the facility.
Plan of correction
Facility completed review of investigation and no other residents were affected. The Executive Director to re-educate all facility staff on policies and procedures in handling resident’s possessions during room changes and or discharge.
22VAC40-73-740-D
Based on documentation and interview, facility failed to ensure that each facility shall develop and implement a written policy regarding procedures to be followed when a resident's clothing or other personal possessions, such as jewelry, television, radio, or other durable property, are reported missing. Attempts shall be made to determine the reason for the loss and any reasonable actions shall be taken to recover the item and to prevent or discourage future losses. The results of the investigation shall be reported in writing to the resident. Documentation shall be maintained for at least two years regarding items that were reported missing and resulting actions that were taken.
Evidence
  1. Facility did not develop and implement policies and procedures to move residents and personal possessions and to prevent the loss of Resident #1's belongings between May 22, 2020 and October 1, 2020; and facility was unable to return all personal possessions to legal representatives.
Plan of correction
The facility has policies and procedures in place to address how to deal with resident missing belongings and their right to initiate a grievance. The Executive Director will re-educate all staff on facility policy and procedure for resident lost or missing belongings.