Virginia DSS · Assisted Living Facility

Chesterbrook Residences, Inc.

📍 2030 Westmoreland Street, Falls Church, VA, 22043

ID 34312One Year licenseActive
13
Inspections
On record
11
With violations
Visits that cited something
2
Clean visits
Nothing cited
29
Violations cited
Individual findings
25
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Chesterbrook Residences, Inc. was inspected 13 times between March 15, 2021 and February 17, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 29 violations under 25 distinct standards. 3 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. 12 of these 13 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
04/30/2027
Administrator
Rebekah Pearson
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Assisted Living · Non-Ambulatory

Inspection History

13

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

February 17, 2026Complaint survey1 violation
Inspection dates
02/17/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/17/2026 10:00 AM to 11:15 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/29/2026 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Admissions, Retention and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 96 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: Resident Record Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-220-B
Based on resident record review and staff interview, the facility failed to ensure the facility obtained the required information when private duty personnel, who are not employees of a licensed home care organization, provide direct care and companion services.
Evidence
  1. In an interview with the LI on 02/17/2026, Staff 1 stated that Resident 1 received 6-8 hours of private duty aide services from Collateral Contact 1, who was not employed with a licensed health care agency. Staff 1 confirmed that the required information, including qualifications, original criminal history record report, orientation and training, and tuberculosis screening, were not obtained for Collateral Contact 1.
  2. In a phone interview with the LI on 02/23/2026, Collateral Contact 1 confirmed that Collateral Contact 1 provided private duty aide services three times a week, for two hours a day to Resident 1.
Plan of correction
The Administrator, or designee will conduct an audit of the Direct Care / Companion Services documentation. Any files that are incomplete will be updated, per the standard.
February 17, 2026Inspection2 violations
Inspection dates
02/17/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 02/17/2026 9:10 AM to 10:00 AM 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 02/03/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 96 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: Resident Record Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-460-A
Based on resident record review and staff interview, the facility failed to ensure assume responsibility for the general health, safety, and well-being of the residents.
Evidence
  1. On 02/03/2026, the facility submitted an incident report regarding a potential medication error involving Resident 1. The report states that on 02/02/2026, Resident 1 self-administered 32 units of Humalog, instead of 32 units of Lantis that had been stored in Resident 1’s room, despite being discontinued at the time of error and change to staff administration of medications.
  2. Resident 1’s record contained discontinued orders of Humalog and Lantis dated after the hospice admission due to a hospice admission on 01/23/2026. The Humalog order contained a sliding scale, while the Lantis had a scheduled dose of 35 units in the morning, and 32 units in the evening.
  3. Resident 1’s record contained hospice notes dated 01/26/2026 that stated Resident 1 requested to be put back on Resident 1’s previous medication orders including Humalog and Lantis, and that Resident 1 wanted to continue to self-administer medication.
  4. In an interview with two LI’s on 03/09/2026, Staff 1 confirmed Resident 1’s medication orders including Humalog and Lantis were discontinued. Staff 1 also acknowledged Resident 1 maintained possession of the medication in Resident 1’s room following the order to discontinue this medication which resulted in Resident 1 self-administering the incorrect dose of medication.
Plan of correction
Upon discovery, all medications in the resident’s unit were immediately removed, and medications were reconciled with current physician orders. A full audit of resident units, who are approved for self-medication, will be completed by April 12, 2026. All residents on the self-medication management program will be re-educated on the requirements of being able to self-medicate. The nursing staff will be re-trained on the procedures when a self-medication resident transitions over to the facility run medication management program.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components.
Evidence
  1. On 02/03/2026, the facility submitted an incident report regarding a potential medication error involving Resident 1. The report states that Resident 1 previously self-administered medication; however, after a recent hospice admission (01/23/2026), the facility began to administer medication and Resident 1’s insulin was discontinued. However, the medication was within the resident’s possession and led Resident 1 self-administering 32 units of Humalog.
  2. The facility’s medication management plan was provided for review. In the section titled “Assisted Living Medication Self-Administration and Quarterly Review”, it states that the facility nurses will review proper storage and maintenance of medication, including ensure that each resident received specifically prescribed medication. In the section titled “Destruction – Return of Medications,” it states the facility nursing staff will account for all medications used by the resident for whom the medication is prescribed. The policy states that nursing staff will return medication when it is no longer used due to discontinuation.
  3. In an interview with the LI on 02/17/2026, Staff 1 acknowledged medication stored in Resident 1’s room was not removed upon hospice admission and change from self-administration to staff administering the resident’s medication. Staff 1 confirmed that the facility’s medication management plan was not followed.
Plan of correction
The Director of Nursing, or designee will conduct weekly audits of resident Medication Administration Records, and Pharmacy Communications for three months to ensure follow up is being completed as required by the facility medication management plan. Audit results will be documented and reviewed as part of the Quality Assurance and Performance Improvement (QAPI) process. All licensed and certified staff involved in medication management will receive training on medication management plan requirements, proper implementation, and documentation standards. Training will be provided by the Director of Nursing or designee and reinforced during orientation and annual in-service education.
February 17, 2026Inspection8 violations
Inspection dates
02/17/2026
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 PREPAREDNESS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-550: Updated LA contact information provided. Renewal Application Submission Reminder: Please submit through mail by expiration date of 04/15/2026.
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: Date: 02/17/2026 Time in: 11:15 Time Out: 6:20pm 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: 96 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: 9 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed Policies and Procedures, Resident Records, Staff Records, Lunch, Medication Pass and Group Activity Additional Comments/Discussion: N/A 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 AJ Velasco, Licensing Inspector at 703-397-4587or by email at amanda.velasco@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on record review and staff interview, the facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. During onsite inspection on 2/17/2026, LI reviewed the criminal background of all staff hired after May 2025.
  2. The following staff members had background checks that were completed after the 30th day of employment: a. Staff 4, hired on 07/29/2025, Criminal Record Report completed on 11/20/2025 b. Staff 6, hired on 09/07/2025, Criminal Record Report completed on 11/20/2025 c. Staff 7, hired on 07/31/2025, Criminal Record Report completed on 11/20/2025 d. Staff 8, hired on 09/07/2025, Criminal Record Report completed on 11/20/2025 e. Staff 9, hired on 09/29/2025, Criminal Record Report completed on 11/20/2025
  3. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged that the identified staff members had background checks that were obtained after the 30th day of employment.
Plan of correction
The Executive Director and business office personnel have been retrained on state regulations regarding criminal background checks and required timelines. Ongoing training will be provided to any staff involved in the hiring process. The Administrator or designee will conduct monthly audits of all new hire files for a period of 90 days to ensure compliance. After 90 days, quarterly audits will be conducted. Any discrepancies will be addressed immediately and reported to administration.
22VAC40-73-640-D
Based on record review and staff interview, the facility failed to ensure a pharmacy reference book, drug guide, or medication handbook that is no more than two years old was readily accessible in addition to the facility’s written medication management plan.
Evidence
  1. During a medication pass observation between Resident 2 and Staff 10, two LI’s observed a copy of the facilities pharmacy reference book dated 2022.
  2. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged that the facilities’ current pharmacy reference book that is accessible to staff members is more than two years old.
  3. Photo evidence obtained.
Plan of correction
The updated inspection drug guide was immediately requested, and received within 72 hours. The administrator or designee will do monthly audits of each med cart to ensure that the correct information is always available.
22VAC40-73-860-I
Based on observation, the facility failed to ensure that the facility shall store cleaning supplies and other hazardous materials in a locked area, except as noted in subsection J of this section.
Evidence
  1. During inspection that took place on 2/17/2026, LI observed the laundry room to have 3 containers of laundry pods in an unlocked closet.
  2. Staff 1 acknowledged that all cleaning supplies and other hazardous materials are always locked away, expect noted in subsection J.
  3. Photo evidence obtained.
Plan of correction
Not published by VDSS.
22VAC40-73-240-F
Based on record review and staff interview, the facility failed to ensure volunteers attended an orientation prior to beginning volunteer service and signed and dated a statement that they received and understood orientation information.
Evidence
  1. During inspection on 2/17/2026, LI reviewed the facilities “Volunteer Polices and Regulations,” which did not include a procedure for the orientation process; however, included that emergency procedures were required to be reviewed during orientation.
  2. The following records did not contain the required volunteer orientation: a. Collateral Contact 1, service began 09/2024 b. Collateral Contact 4, service start date unknown, contained a blank orientation form (not completed, dated, or signed.)
  3. Collateral Contact 3, service began 01/2025, contained a completed orientation checklist dated 01/20/2025; however, the form did not contain a supervisor’s signature.
  4. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged the orientation for Collateral Contact 1 and Collateral Contact 4 were not completed, and Collateral Contact 3 did not contain documentation of review by the supervisors.
Plan of correction
An audit will be completed of all volunteer files by the administrator or designee. Any files for people who have not volunteered in over 12 months will be securely filed in a separate location. Any volunteers who are found to not have an orientation form will attend an orientation training with Chesterbrook team.
22VAC40-80-120-E-1
Based on observation, the facility failed to ensure the following items were posted on the premises: the most recently issued license, the most recent inspection findings, and any other documents required by the commissioner.
Evidence
  1. During onsite inspection on 02/17/2026, two LI’s observed the facility to have the monitoring inspection on 05/09/2025 posted as the most recent inspection findings; however, their most recent inspection took place on 12/22/2025.
  2. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged that the most recent inspection findings were not posted in the facility.
  3. Photo evidence obtained.
Plan of correction
The updated inspection information was immediately posted in the lobby. The administrator will ensure that the correct information is always posted and available for visitors to the community.
22VAC40-73-840-B
Based on record review and staff interview, the facility failed to ensure that documentation of examinations and immunizations shall be maintained at the facility, if pets are allowed to live on the premises.
Evidence
  1. During onsite inspection on 2/17/2026, LI reviewed pet policy, that stated, “All animals residing on the community premises shall receive regular examinations and species-appropriate immunizations from a licensed veterinarian, at a minimum of once per year.”
  2. The facility currently has only 3 pets that reside in community and during inspection on 2/17/2026, LI observed all three of the pet records. The following pet records did not include the updated vaccinations to reflect the minimum yearly examination requirement from the facility’s own policy: a. Resident 2’s pet, pet admission 03/13/2024 – last documented examination and vaccinations completed on 03/13/2024. b. Resident 3’s pet, pet admission 07/01/2023 – last documented examination and vaccinations completed 06/07/2023. c. Resident 4’s pet, pet admission 04/19/2024 – last documented examination and vaccinations completed 03/13/2024.
  3. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged that the current files of Resident 2, Resident 3, and Resident 4’s pets did not include updated examination and immunization records.
Plan of correction
The facility immediately conducted a review of all pets residing in the community. Pet records were updated, and all animals in the community are currently in compliance with their examinations and vaccinations.
22VAC40-73-870-G
Based on observation, the facility failed to ensure that grounds shall be properly maintained to include mowing of grass and removal of snow and ice.
Evidence
  1. During onsite inspection on 2/17/2026, two LI’s observed the facilities unlocked courtyard on the 2nd floor with noted snow and ice.
  2. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged that the grounds were not properly maintained.
  3. Photo evidence obtained.
Plan of correction
All cleaning supplies and hazardous materials identified during the inspection were immediately secured in designated locked storage areas upon discovery. Any items found unsecured were removed from open access areas without delay. The Executive Director or designee will conduct weekly audits for four weeks, followed by monthly audits thereafter, to ensure ongoing compliance..
22VAC40-73-560-E
Based on record review, direct observation, and staff interview, the facility failed to ensure resident records were kept current, retained at the facility, and kept in a locked area.
Evidence
  1. During a tour of the facility on 2/17/2026, two LI’s observed the nursing station on the 1st floor having an unlocked computer and exposed resident records on the desk. There were no staff in the area, and one resident observed sitting in the hallway adjacent to the station.
  2. After approximately 3-4 minutes, two staff arrived and the LI notified nearby staff to lock the computer and place the resident files in a locked area.
  3. During onsite inspection on 02/17/2026, the following resident records contained admission date discrepancies between the business chart, medical chart, and electronic health record: a. Resident 1, admission dates of 05/01/2025, 05/14/2025, and 06/04/2025 b. Resident 8, admission dates of 06/17/2021 and 07/20/2022 c. Resident 9, admission dates of 07/26/2019 and 12/31/2018
  4. In an interview with two LI’s on 02/17/2026, Staff 1 acknowledged that Resident 1, Resident 8 and Resident 9 were not being kept current or in a locked area.
Plan of correction
On 02/17/2026, immediately upon notification by the Licensing Inspectors (LIs), staff secured all exposed resident records and locked the unattended computer at the 1st floor nursing station. A 100% audit of all resident records will be conducted by the Executive Director or designee to verify: Admission dates are consistent across all documentation systems (business file, medical record, and EHR), and records are complete, current, and properly filed. Any discrepancies identified during the audit will be corrected immediately. All staff will been re-educated on HIPAA compliance requiring that resident records and computers must be secured at all times when unattended. Automatic screen-lock settings will been enabled on all facility computers after 2 minutes of inactivity.
December 22, 2025Inspection1 violation
Inspection dates
12/22/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/21/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Provisions. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/22/2025 10:00 AM to 11:00 AM 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: 90 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: Activities Additional Comments/Discussion: Resident declined to be interviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident was reported to the regional licensing office within 24 hours.
Evidence
  1. On 11/21/2025, the facility submitted a written report regarding an elopement/ wandering incident that occurred on 11/16/2025. The report stated that Resident 1 was located by police at 2:43 PM near 1836 Westmoreland St. The report stated that the facility determined Resident 1 left the building at 12:22 PM.
  2. In an interview with the LI on 12/22/2025, Staff 3 acknowledged that a report was submitted on 11/21/2025, 5 days after the incident occurred.
Plan of correction
The Director of Nursing or designee will review all incident reports weekly for three months to ensure reportable incidents are identified and reported within the required timeframe. Thereafter, monitoring will occur monthly. Findings will be documented and reviewed during Quality Assurance and Performance Improvement (QAPI) meetings. All staff will receive training on identifying major incidents, reporting timelines, and documentation requirements. Training will be provided by the Administrator or designee and reinforced during orientation, annual training, and staff meetings.
November 20, 2025Inspection3 violations
Inspection dates
11/20/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
440-A: Ensure UAI is updated with change in condition.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/27/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2025 9:35 AM to 11:30 AM 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: 97 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: Area in which resident was found via google maps, video footage of front entrance at time of elopement. Additional Comments/Discussion: Resident no longer resides in facility and was unable to be interviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of the resident was reported to the regional licensing office within 24 hours.
Evidence
  1. On 10/27/2025, the facility submitted an incident report regarding Resident 1 eloping from the building.
  2. During a review of Resident 1’s record, a progress note was found dated 09/01/2025. The progress note stated that Resident 1 was found locked out of the building at around 9:15 PM in Resident 1’s night clothes with no shoes on. The note indicates that they spoke to Resident 1 around dinnertime. The progress note did not include the last time Resident 1 was seen prior to being found outside, or if it was determined Resident 1 had eloped and then returned.
  3. In an interview with the LI on 11/18/2025, Staff 1 stated no additional information was available, and confirmed an incident report was not submitted regarding the 09/01/2025 incident.
Plan of correction
The Director of Nursing or designee will review all incident reports weekly for three months to ensure reportable incidents are identified and reported within the required timeframe. Thereafter, monitoring will occur monthly. Findings will be documented and reviewed during Quality Assurance and Performance Improvement (QAPI) meetings. All staff will receive training on identifying major incidents, reporting timelines, and documentation requirements. Training will be provided by the Administrator or designee and reinforced during orientation, annual training, and staff meetings.
22VAC40-73-460-D
Based on resident record review, facility video footage review, and staff interview, the facility failed to ensure supervision of specialized needs such as wandering from the premises.
Evidence
  1. On 10/27/2025, the facility submitted an incident report regarding Resident 1 eloping from the building on 10/26/2025 resulting in the need for police intervention to locate the resident.
  2. An update to the incident report, received via email on 10/28/2025, stated that Resident 1 was determined to be missing at 7:47 PM on 10/26/2025 and was later located at 9:09 PM on 10/26/2025.
  3. Resident 1 Report of Physical Examination, dated 05/19/2025, included mild cognitive impairment and memory loss under diagnosis.
  4. During the on-site inspection on 11/18/2025, Staff 1 reviewed video footage of the entrance of the facility with the LI. The video footage showed Resident 1 exiting the building around 5:33 PM on 10/26/2025 in a heavy jacket, day clothes, and sneakers.
  5. On 10/26/2025, the National Weather Service indicated that the maximum recorded temperature for the day was 56 degrees, while the lowest recorded temperature was 34 degrees.
  6. In an interview with the LI on 11/20/2025, Staff 1 and the LI reviewed the property on Google Maps. Staff 1 indicated an area on the map, approximately 0.1 miles away, where Resident 1 was found by Resident 1’s son on 10/26/2025. Staff 1 acknowledged that supervision was not provided for specialized needs such as wandering from the premises.
Plan of correction
A standardized elopement risk assessment will be completed with any significant change in cognition. Residents with a high risk for elopement will be discharged to a Secured Memory Care Community. The Director of Nursing or designee will conduct weekly audits for 4 weeks, then monthly audits for 3 months, to ensure residents identified as elopement risks have appropriate interventions in place and are being supervised according to their care plans. Audit results will be documented and reviewed during Quality Assurance and Performance Improvement (QAPI) meetings.
22VAC40-73-450-F
Based on resident record review, staff interview, the facility failed to ensure individualized service plans (ISP) were reviewed and updated as needed for a significant change in a resident’s condition.
Evidence
  1. On 10/27/2025, the facility submitted an incident report regarding Resident 1 eloping from the building. On 10/28/2025, Staff 3 submitted an email that stated Resident 1 had demonstrated increasing confusion and memory decline over the past few weeks, resulting in a need for intermittent redirection and reminders for safety.
  2. Staff 2 provided nighttime rounding logs for Resident 1 for scattered dates throughout October 2025.
  3. In an interview with the LI on 11/20/2025, Staff 2 stated that Resident 1 experienced sundowning which resulted in getting lost or agitated after dinner. Staff 2 stated that staff were encouraged to complete rounds frequently but did not have a specific time that was assigned to Resident 1.
  4. Resident 1’s ISP, dated 05/01/2025, did not include Resident 1’s service of rounding or the changed care need of frequent supervision and monitoring for safety.
  5. In an interview with the LI on 11/20/2025, Staff 1 confirmed that Resident 1’s ISP was not updated to reflect the change in condition.
Plan of correction
The Director of Nursing or designee will conduct monthly audits of a sample of resident ISPs for three months to ensure timely updates following significant changes in condition. Audit findings will be documented and reviewed during Quality Assurance and Performance Improvement (QAPI) meetings. Corrective action will be taken as needed. All relevant staff will receive education on identifying significant changes in condition, ISP requirements, and documentation expectations. Training will be conducted by the Director of Nursing or designee and included in new hire orientation and annual in-services.
November 20, 2025Inspection1 violation
Inspection dates
11/20/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
Facility’s medication management plan will be reviewed by the VDSS clinical training team and guidance provided.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/11/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2025 11:30 AM to 1:15 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: 97 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: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure that the medication management plan contained required components and was implemented.
Evidence
  1. On 11/11/2025, the facility received an incident report regarding a potential medication error with Resident 1.
  2. Resident 1’s record contained an order, dated 02/20/2025, for Galantamine 8MG that states “Take one capsule every day with breakfast…”. This order was discontinued by 05/20/2025.
  3. In an interview with the LI on 11/20/2025, Staff 1 stated that Resident 1’s daughter brings in medication for repackaging and transports Resident 1 to and from the facility to their outside physician.
  4. Resident 1’s record contains re-packaging requests for Galantamine16 MG on 07/22/2025, and 10/19/2025. On 08/12/2025, the pharmacy faxed a request for clarification stating “Need Directions” and the facility responded with a fax stating to not send the medication.
  5. The facility’s medication management plan states “Medications should be reordered according to pharmacy procedures” but does not list the specific methods to ensure that each resident’s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed doses.
  6. In an interview with the LI on 11/20/2025, Staff 1 reported although they believe the Galantamine 8 MG was supposed to be discontinued and increased to 16 MG on 05/20/2025, no corresponding order was ever received which was verified via the resident record. Despite this, Staff 1 acknowledged the facility failed to follow its medication management procedures by not seeking clarification from the provider after the pharmacy’s follow up request upon repackaging the medication on 08/12/2025, resulting in a potential medication error.
Plan of correction
The Director of Nursing, or designee will conduct weekly audits of resident Medication Administration Records, and Pharmacy Communications for three months to ensure follow up is being completed as required by the facility medication management plan. Audit results will be documented and reviewed as part of the Quality Assurance and Performance Improvement (QAPI) process. All licensed and unlicensed staff involved in medication management will receive training on medication management plan requirements, proper implementation, and documentation standards. Training will be provided by the Director of Nursing or designee and reinforced during orientation and annual in-service education.
August 28, 2025Complaint survey5 violations
Inspection dates
08/28/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Renovation (Gen Procedures 150) 880-A
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 08/28/2025 regarding allegations in the area(s) of: 1. Buildings and Grounds Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/28/2025 8:10 AM to 9:41 AM 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: 88 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Resident Rooms, Dining Area, Common Areas Additional Comments/Discussion: Administrator was off-site during inspection. Phone call completed regarding upcoming renovation. The administrator is aware that a renovation needs to be submitted to the licensing department prior to initiation. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure that all cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. During a tour of the facility with Staff 2 on 08/28/2025, the LI observed a bottle of Lysol disinfectant spray sitting on the table in the physical therapy space with the door propped open. There was nobody in the room. Staff 2 confirmed the cleaning supplies were not stored in a locked area.
Plan of correction
I. Corrective Action: The disinfectant spray observed on 08/28/2025 was immediately removed and placed in a locked housekeeping closet. The physical therapy room door was secured. II. Identification of Others: A facility-wide environmental sweep was completed on 08/29/2025 to confirm all hazardous materials were secured. No additional concerns were found. III. Systemic Changes: On 08/29/2025, all staff were re-educated on hazardous material storage. A sign-off log was introduced for therapy, housekeeping, and nursing staff to ensure cleaning products are returned to locked storage after each use. IV. Monitoring Process: The Maintenance Director or designee will conduct daily checks for 2 weeks, then weekly for 4 weeks, then monthly for 3 months, to ensure all hazardous materials remain secured. Findings will be logged and reviewed in QA meetings. V. Completion Date: 09/12/2025
22VAC40-73-150-C
Based on direct observation, facility document review, and staff interview, the facility failed to ensure responsibility for the general administration, management, and day-to-day operation of the facility including maintaining the building and grounds.
Evidence
  1. In an interview with the LI on 08/28/2025, Staff 1 confirmed that mold was found in Resident 1’s room and provided a service report completed by Collateral Contact 1, a home inspection service.
  2. A “Mold Tape and Fungi Identification Report,” dated 07/29/025, and reviewed by the LI on 08/28/2025, identified aspergillus, Cladosporium, and penicillium mold on the furniture, the HVAC unit, and the refrigerator in Resident 1’s room. The report recommended servicing the HVAC system and deep cleaning of the walls and carpets.
  3. During a tour of Resident 1’s room on 08/28/2025 with Staff 2, black spores were observed on the A/C unit of Resident 1. A pale green spore was observed on the kitchen cabinets. Staff 2 stated that the HVAC unit was likely going to be replaced.
  4. In an interview with the LI on 08/28/2025, Staff 2 confirmed that the HVAC units had not been serviced or cleaned after receiving the report, despite the presence of mold still on the A/C unit in Resident 1’s room.
Plan of correction
I. Corrective Action: Resident 1’s room was professionally cleaned by the environmental services team. The HVAC unit was replaced, affected furniture was removed, and the walls and carpets were deep cleaned. II. Identification of Others: The Maintenance Director began room inspections on 09/01/2025, starting on the second floor and proceeding throughout the community, including all common areas. III. Systemic Changes: The facility has implemented a Preventive Maintenance Program requiring quarterly HVAC servicing, humidity monitoring in resident rooms, and immediate remediation when concerns are identified. Staff were in-serviced on 09/05/2025 regarding reporting environmental concerns. IV. Monitoring Process: The Administrator or designee will conduct weekly environmental inspections for 4 weeks, then monthly for 3 months, to verify that HVAC systems are clean. Findings will be logged and reviewed during QA meetings, and any issues will be addressed immediately. V. Completion Date: 09/30/2025
22VAC40-73-870-A
Based on direct observation and staff interview, the facility failed to ensure that the interior of all buildings was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of Resident 1’s room on 08/28/2025 with Staff 2, black spores were observed on the A/C unit. Staff 1 confirmed that mold was found in Resident 1’s room by Collateral Contact 1, a home inspection service.
  2. During a tour of Resident 2’s room with Staff 2, the LI observed brown substance with black spots on the A/C unit tray.
  3. During a tour of Resident 3’s room with Staff 2, black spots were observed on the A/C unit, visually similar to the spots seen on the A/C unit in Resident 1’s room.
  4. During a tour of Resident 4’s room with Staff 2, Resident 4’s room had a large amount of fruit flies on the cabinet. Staff 2 told Resident 4 that they would come up to spray the room.
  5. The LI toured an unoccupied room, Room 255, with Staff 2. The LI observed a smaller number of black spots, visually similar to the spots seen on the A/C unit in Resident 1’s room, were on the A/C unit.
  6. The LI toured the dining area with Staff 2. Black dirt and spotting were observed on multiple vents in the room, with other debris that could be seen in the vents.
  7. Photo evidence obtained.
Plan of correction
I. Corrective Action: On 08/30/2025, HVAC units were cleaned, and vents were inspected by Integrity Air, a third-party service. Dining area vents were also cleaned. Pest control treated Resident 4’s room on 08/31/2025 to eliminate fruit flies. II. Identification of Others: A building-wide environmental inspection was conducted on 09/08/2025. No additional pest concerns were identified. III. Systemic Changes: The preventive maintenance schedule was updated to include monthly HVAC cleaning, quarterly deep cleaning, and pest control service every 30 days. Housekeeping staff were in-serviced on 09/02/2025 regarding prompt reporting of cleanliness concerns. IV. Monitoring Process: The Administrator or designee will conduct weekly environmental rounds for 4 weeks, then monthly for 3 months, to ensure HVAC units, vents, and resident rooms remain clean and in good repair. Logs will be maintained and reviewed in QA meetings. V. Completion Date: 09/22/2025
22VAC40-73-870-B
Based on direct observation, facility document review, and staff interview, the facility failed to ensure that the building was well ventilated and free from foul, stale, and musty odors.
Evidence
  1. A “Mold Tape and Fungi Identification Report,” dated 07/29/025, was reviewed by the LI on 08/28/2025. The report confirmed that the humidity was higher than 70% relative humidity in Resident 1’s room and confirmed the presence of mold.
  2. During a tour of Resident 4’s and Resident 5’s room with Staff 2, the LI observed a musty smell. Room 5’s temperature was set to 88 degrees.
  3. In an interview with the LI on 08/28/2025, Staff 2 confirmed the building was not well-ventilated.
Plan of correction
I. Corrective Action: HVAC units in Residents 4 and 5’s rooms were serviced on 08/29/2025. Resident 5’s thermostat was adjusted to maintain the recommended temperature range, and dehumidifiers were placed in both rooms on 09/08/2025. II. Identification of Others: All occupied rooms were assessed on 08/29/2025 for ventilation and odors. Two rooms with humidity greater than 70% were provided with portable dehumidifiers. III. Systemic Changes: A ventilation and humidity monitoring form was implemented on 09/05/2025, requiring daily thermostat checks by housekeeping and weekly humidity checks by maintenance. Staff were in-serviced on 09/05/2025. IV. Monitoring Process: The Maintenance Director or designee will perform weekly checks for 4 weeks, then monthly for 3 months, to ensure all resident rooms remain well-ventilated and odor-free. Logs will be reviewed during QA meetings. V. Completion Date: 09/25/2025
22VAC40-73-290-B
Based on direct observation staff interview, the facility failed to ensure the name of the current on-site person in charge was posted in the facility.
Evidence
  1. The LI observed a sign in the lobby area that designates the “Manager on Duty” as the charge nurse, without specifying a name.
  2. In an interview with the LI on 09/02/2025, Staff 1 stated that the person in charge is typically Staff 5, who was not on site at the time of inspection. When the LI referenced the sign, Staff 1 confirmed the charge nurse was the person in charge and called the nurses’ station to identify them as Staff 3.
Plan of correction
I. Corrective Action: On 09/02/2025, the “Manager on Duty” board in the lobby was updated to include not only the role (“Charge Nurse”) but also the specific name of the person serving in that role at the time. II. Identification of Others: A facility-wide review confirmed that the signage was already present; the only correction needed was to ensure the individual’s name is displayed along with the role. III. Systemic Changes: Charge nurses were in-serviced on 09/04/2025 regarding the requirement to update the board with both the role and the individual’s name at each shift change. IV. Monitoring Process: The Administrator or designee will verify that the “Manager on Duty” board displays the correct name daily for 2 weeks, weekly for 4 weeks, and then monthly for 3 months. Findings will be logged and reviewed during QA meetings. V. Completion Date: 09/10/2025
May 9, 2025Inspection1 violation
Inspection dates
05/09/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
70-C: Comprehensive Incident Reports
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/09/2025 9:15 AM to 2:10 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: 87 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:2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meals (Lunch), Activities (Exercise), Medication Pass Additional Comments/Discussion: N/A 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on direct observation and staff interview, the facility failed to ensure that the posted weekly menu contained all meals and snacks.
Evidence
  1. On 05/09/2025, the LI observed the posted menu in two elevators. The posted menu did not include snacks. The posted menu included the following statement, “The Bistro is open outside of Dining Hours for Snacks & Light Fare.”
  2. In an interview with the LI on 05/09/2025, Staff 2 stated that snacks could be found at the nurse’s station.
  3. In an interview with the LI on 05/09/2025, Staff 1 confirmed that the menu did not include the snacks provided by the facility.
  4. In a follow-up email sent to the LI on 05/12/2025, Staff 1 stated “While we don’t have a designated ‘bistro’ space, our nursing station area functions as the location where snacks are made available to residents during off-hours.”
Plan of correction
I. Corrective Action: The Dining Services Director and Nursing staff were re-educated on 5/17/2025 by the Administrator regarding the regulatory requirement for clearly posted menus that accurately list all meals and snacks. As of 5/17/2025, the snack information has been added directly to the weekly menu posted in resident-accessible areas. II. How to Identify Other Residents/Staff Affected: An audit was completed by the Dining Services Director and Administrator on 5/17/2025 to verify that all required meal and snack information is clearly posted in all appropriate resident-facing locations. No other missing or misposted content was identified. III. Systemic Changes: A new process has been implemented where the Dining Services Director, prior to weekly menu posting, will ensure that all meals—including snacks—are clearly listed on the menu in areas designated for resident viewing. IV. Monitoring Process: The Administrator or designee will conduct weekly checks × 4 weeks, then monthly × 3 months, to verify that menus posted in all resident-accessible areas include complete and accurate information on meals and snacks. Findings will be logged and reviewed at the next scheduled QA meeting. Any issues will be addressed immediately. V. Completion Date: 5/17/2025
April 25, 2024Inspection3 violations
Inspection dates
04/25/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/25/2024 Begin: 8:49am End: 2:10pm 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: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: 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 Crystal B .Henson, Licensing Inspector at276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on staff record review, the facility failed to obtain the criminal history report on or prior to the 30th day of employment for six employees
Evidence
  1. Staff #10 was hired on 11/24/2023; a criminal history report was not obtained until 03/09/2024.
  2. Staff #11 was hired on 10/10/2024; a criminal history report was not obtained until 03/09/2024.
  3. Staff #12 was hired on 11/20/2023; a criminal history report was not obtained until 03/09/2024.
  4. Staff #15 was hired on 09/28/2023; a criminal history report was not obtained until 03/09/2024.
  5. Staff #17 was hired on 10/20/2023; a criminal history report was not obtained until 03/11/2024.
  6. Staff #18 was hired on 11/10/2023; a criminal history report was not obtained until 03/11/2024. .
Plan of correction
Corrective Action: Employee was retrained on 04/26 by Administrator on timeliness of criminal background check. How to identify other staff/residents: BOM or designee reviewed all active employees’ files as of 4/25 to ensure current employees have a criminal background check that are within 30 days of hire on file. Systemic Changes: BOM completed a review of all current employee files as of 4/25. Administrator held an in-service with BOM regarding said regulatory standard and compliance. Monitoring Process: QA meeting was held with administrative team to ensure criminal background check of new hire are in compliance with mandatory standards. Newly hired employee files weekly x 4 weeks then monthly thereafter. All findings will be addressed immediately and reviewed/reported during the next scheduled QA meeting. [sic]
22VAC40-73-100-C-1
Based on an audit of the Terrace medication cart, the facility failed to implement and follow their infection control plan.
Evidence
  1. Per the facility’s Blood Glucose Monitoring policy, last revised Nov 29, 2023, #3 states, “….the meter will be labeled for the specific resident and stored in a bag labeled with the resident’s name.
  2. LI observed an unlabeled glucometer in a labeled bag. The bag holding the glucometer had resident #7’s first initial and last name along with his/her room number indicated on the bag
Plan of correction
The sanitation of equipment, including medical equipment that may be used on more than one resident (e.g., blood glucose meters and blood pressure cuffs, including cleaning and disinfecting procedures, agents, and schedules) Corrective Action: Medication Aide was retrained on 4/26 by DON on labeling blood glucose meter and bag. How to identify other staff/residents: DON held an in-service training with current charge nurses and medication aides on labeling blood glucose meter and bag. Systemic Changes: Administrator, Director of Nursing or designee will audit medication cart to ensure proper labeling compliance of medical equipment. A medication cart audit will be completed for each person passing medications (licensed nurses and medication aides) by 6/9. Monitoring Process: Will monitor by conducting random audits by DON or Administrator weekly x4 weeks then monthly. All findings will be addressed immediately and reviewed/reported) during the next scheduled QA meeting. [sic]
22VAC40-73-210-D
Based on staff record review and staff interview, the facility failed to ensure training for a medication aide was completed as required by the Virginia Board of Nursing.
Evidence
  1. Staff #1 was hired on 7/25/2011, staff #1’s file contained documentation of the Registered Medication Aide (RMA) 4 Hour Refresher Training completed on 8/23/2021 however there was no documentation for the years of 2022 and 2023.
  2. During an interview with two licensing inspectors and Staff #4 on 4/25/2024, staff #4 confirmed there were no training certificates available in the facility filed for the years 2022 and 2023 for staff #’s record for the RMA 4 hour Refresher Training.
Plan of correction
In addition to the training curriculum, the program may provide one or more four-hour modules that can be used by facilities as refresher courses or by medication aides to satisfy requirements for continuing education. Corrective Action: Office Manager and DON was retrained on 4/26 by administrator on continuing education for medication aides. How to identify other staff/residents: An audit was conducted by the Office Manager of the medication aides as of 4/25. A medication refresher course is scheduled for May 15th and May 22nd . Systemic Changes: Administrator, Director of Nursing or designee will review the medication aide files annually. Monitoring Process: Administrator or designee will audit staff records weekly x4 weeks then monthly by Office Manager or designee to continue education compliance. All findings will be addressed immediately and reviewed during the next scheduled QA meeting. [sic]
May 8, 2023Inspection3 violations
Inspection dates
05/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
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: LI entered the facility at 8:45 am on 5/8/2023 and exited oat 4:15 pm on 5/8/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents engaging in 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. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-680-H
Based upon a review of records and observation, the facility failed to ensure that at the time medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.
Evidence
  1. On 5/8/2023 at approximately 10:05 am, LI observed Staff #5 administer the following medications to Resident #3: a. Eliquis b. Escitalopram c. Furosemide d. Valacyclovir HCl e. Hydrocod/APAP
  2. On 5/8/2023 LI reviewed the May 2023 medication administration record (MAR). According to the May 2023 MAR, Staff #5 failed to document the medications administered to Resident #3 at approximately 10:05 am on 5/8/2023.
Plan of correction
1. Employee was retrained on 5/10/2023 by Director of Nursing (DON) on medication administration record (MAR) documentation. 2. DON held an in-service training with current charge nurses and medication aides on the MAR documentation. Pharmacy will provide an in-service training on med pass for the licensed practical nurses and medication aides by 6/20/2023. 3. Administrator, DON, or designee will review resident MAR records weekly. A medication pass review will be completed for each person passing medications (licensed practical nurses and medication aides) by 6/8/2023. 4. DON or designee will monitor by conducting random MAR record audits weekly x4 weeks and then monthly. All findings will be addressed immediately and reviewed/ reported during the next scheduled QA meeting.
22VAC40-90-60-C
Based upon a review of records, the facility failed to make available to the licensing representative criminal history record reports.
Evidence
  1. During a review of criminal history record reports by LI on 5/8/2023,the facility could not make available the criminal history record reports for the following staff members: #18, #19, #20, #21, #22, #23, #24, #25, and #26.
Plan of correction
1. A criminal background check was completed on the following staff: #18, #19, #20, #21, #22, #23, #24,#25, and #26 on 5/8/2023. 2. Business Office Manager (BOM) or designee reviewed all active employees files as of 5/8/2023 to ensure current employees have a criminal background check on file. 3. BOM completed a review of all current employees files as of 5/8/2023. Administrator held an in-service with BOM regarding said regulatory standard and compliance. 4. Quality Assurance (QA) meeting was held on 5/18/2023 with Administrative team. Executive Director will monitor compliance by conducting random audits of newly hired employee files weekly x4 weeks and then monthly thereafter. All findings will be addressed immediately and reviewed/reported during the next scheduled QA meeting.
22VAC40-73-680-B
Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 5/8/2023 at approximately 9:30 am LI observed staff #5 pour medications for Resident #3 into a cup for administration and take the medications to the room of the resident. LI observed Staff #3 not administering the poured medications to Resident #3 as Resident #3 was in the bathroom. LI observed Staff #3 put the poured medications into the top right drawer of the medication cart.
  2. At approximately 10:05 am on 5/8/2023, LI observed Staff #5 administer pre-poured medications to Resident #3. Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Plan of correction
1. Employee was retrained on 5/10/2023 by Director of Nursing (DON) in ensuring that medications shall remain in the pharmacy issued container until administered to the resident. 2. DON or designee will provide an in-service to all current licensed practical nurse and medication aides by 6/8/2023 that medications shall be removed from the pharmacy packaging and administered immediately (pre-pouring is not permitted) by the same authorized person. A medication pass review will be completed for each person passing medications (licensed nurse/medication aide) by 6/8/2023. 3. Administrator, DON, or designee will observe at least one medication pass monthly. 4. DON or designee will monitor weekly x4 weeks then monthly. All findings will be addressed immediately and reviewed/reported during next scheduled Quality Assurance meeting.
February 23, 2022Inspection0 violations
Inspection dates
02/23/2022,02/28/2022
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 PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
Comments
An unannounced renewal study was initiated on 2/23/2022 and concluded on 2/28/2022. At the time of entrance 97 residents were in care. The sample size consisted of 10 resident records, five staff records, two volunteer records and three pet records. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 3/15/2021 were reviewed. Residents were observed engaging in physical exercise. Medication administration was observed. No violations were cited and exit interview was conducted.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 27, 2021Complaint survey0 violations
Inspection dates
12/27/2021,02/23/2022
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Licensing Inspector (LI) conducted unannounced complaint investigation that began on 12/27/2021 and concluded on 2/23/2022 regarding concerns about the administrator. LI interviewed the Regional Director of Coordinated Services Management Company and the Regional Director for Chesterbrook Residences. LI also reviewed staff records. Complaint regarding qualifications of the administrator is deemed not valid as a preponderance of evidence gathered during the investigation did not support the allegations. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 15, 2021Inspection1 violation
Inspection dates
March 15, 2021 and March 17, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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 3/15/2021 and concluded on 3/17/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 87. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records, five staff records, staff work schedule, dietary and healthcare oversight reports, fire drill reports, and annual health and fire inspections, submitted by the facility to ensure compliance. LI completed the entrance and exit interview with the administrator. LI reviewed the Criminal Background Checks for all staff hired since the last mandated inspection conducted on 2/25/2020. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. LI completed the exit interview with the administrator via telephone on 3/17/2021. During the exit interview LI reviewed the violations with the administrator. 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; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-260-A
Based upon a review of records and interview with administration, the facility failed to ensure that each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment .
Evidence
  1. Neither Staff #3 (date of hire 11/19/2020) nor Staff #4 ( date of hire 9/29/2020) had verifications of current First Aid Certification in their records.
Plan of correction
A direct care file audit will be immediately conducted to ensure all direct care staff members have First Aid Training. Newly hired employees, who are not First Aid certified will be registered for First Aid training within their first 60 days of employment by the community's Executive Director (ED) or designee. Quarterly audits of direct care staff records will be conducted by the ED or designee to ensure continued compliance.