Virginia DSS · Assisted Living Facility

Emilia Assisted Living Of Ashlawn Court

📍 6533 Ashlawn Court, Springfield, VA, 22150

ID 34785Two Year licenseActive
7
Inspections
On record
4
With violations
Visits that cited something
3
Clean visits
Nothing cited
28
Violations cited
Individual findings
27
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Emilia Assisted Living Of Ashlawn Court was inspected 7 times between April 7, 2021 and August 20, 2025 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 28 violations under 27 distinct standards. 1 inspection was prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 6 of these 7 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
10/17/2027
Administrator
Rionario Porneso
Licensing inspector
Alexandra Roberts
Inspector phone
(804) 845-6956
Approved for
Assisted Living · Non-Ambulatory

Inspection History

7

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

August 20, 2025Inspection6 violations
Inspection dates
08/20/2025
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 PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 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
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: 8/21/2024 9am - 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 7 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed the residents eating lunch. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-925-B
Based on observation, the facility failed to ensure that common face/hand washing sinks have paper towels or an air dryer and liquid soap for hand washing.
Evidence
  1. During the inspection tour on 08/20/2025, the common bathroom on the first floor did not have paper towels.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that medication administration record (MAR) includes a diagnosis, dates the medication is discontinued or changed, date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident 1’s 07/29/2025 – 08/28/2025 MAR did not include diagnosis, dates the medication is discontinued or changed and the date and time given and initials of direct care staff administering all of the medications on the MAR.
  2. Resident 2’s 07/29/2025 – 08/28/2025 MAR did not include diagnosis and the date and time given and initials of direct care staff administering all of the medications on the MAR.
Plan of correction
Not published by VDSS.
22VAC40-73-870-E
Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, be kept clean and in good repair and condition.
Evidence
  1. During the inspection tour on 08/20/2025, licensing staff observed all HVAC vents to be covered in thick brown dust.
  2. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) includes a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. Resident 1’s (admitted 10-10-2024) comprehensive ISP dated 10-18-2024 did not include cameras are in their bedroom or that the resident has wound care services.
Plan of correction
Not published by VDSS.
22VAC40-73-960-C
Based on observation, the facility failed to ensure that the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center be posted by each telephone shown on the fire and emergency evacuation plan.
Evidence
  1. During the inspection tour on 08/20/2025, the telephone in the common area on the main floor did not have the required telephone numbers.
Plan of correction
Not published by VDSS.
22VAC40-73-960-B
Based on observation, the facility failed to ensure that the fire and emergency evacuation drawing show primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate.
Evidence
  1. During the inspection tour on 08/20/2025, the posted evacuation plans on the 1st and 2nd floor in the facility did not include secondary escape routes, area of refuge, and fire alarm boxes.
Plan of correction
Not published by VDSS.
August 21, 2024Inspection15 violations
Inspection dates
08/21/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 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
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: 8/21/2024 9am - 5pm 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: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed the residents sitting outside, doing puzzles and later eating lunch. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on record review and staff interview, facility failed to ensure annual tuberculosis evaluations for staff.
Evidence
  1. Staff 1’s (hired 04/07/2022) record did not contain a TB test.
  2. LI interviewed and asked Staff 1 when last TB test was. Staff 1 stated that he has not had a TB test in “2years and it was in Arizona”.
  3. Staff 3’s record did not contain a TB test.
  4. LI interviewed Staff 4 who confirmed that there is not an updated TB test for staff 1 or staff
Plan of correction
Not published by VDSS.
22VAC40-73-410-A
Based on record review and staff interview, facility failed to ensure that upon admission each resident is provided an orientation to new residents and/or their legal representatives, including emergency response procedures, mealtimes, and use of the call system.
Evidence
  1. Resident 1 admitted on 8/15/2024 record did not contain documentation or acknowledgment of an orientation being completed.
  2. LI requested acknowledgement from Staff 1 and staff 4.
  3. Staff 4 informed that it was not completed for resident 1 at time of his admission.
Plan of correction
Not published by VDSS.
22VAC40-73-490-D
Based on record review, facility failed to ensure that the licensed health care professional who provided the health care oversight shall identify the specific residents for whom the oversight was provided.
Evidence
  1. LI reviewed health care oversight completed on 03/06/2024 and prior records.
  2. No residents were identified. Staff 1 did not know the residents that were reviewed.
  3. Staff 4 stated that he did not know that the residents’ names should be included or identified in the review and does not have that information
Plan of correction
Not published by VDSS.
22VAC40-73-980-C
Based on record review and staff interview, facility failed to ensure first aid kits are checked at least monthly to ensure all items are present.
Evidence
  1. LI requested evidence of monthly check of first aid kit. Staff 4 stated that facility does not have a monthly check or documentation, and that facility has not been completing a monthly check.
Plan of correction
Not published by VDSS.
22VAC40-73-550-G
Based on record review and staff interview, facility failed to ensure that the rights and responsibilities of residents in assisted living facilities is reviewed annually with each resident or his legal representative or responsible individual.
Evidence
  1. Resident 1, resident 2 and resident 3 record had no written acknowledgement of having been informed of resident rights and responsibilities.
  2. Staff 1 provided LI with the resident agreement for resident 1, resident 2 and resident 3, 3 times before Staff 4 arrived and confirmed that resident 1 and resident 2 do not have any written acknowledgement of providing the resident rights and responsibilities.
  3. Staff 4 provided documentation that resident 3 has a resident rights and responsibilities dated 7/14/2021 and 6/03/2019.
  4. Records contained general copy and unsigned rights and responsibilities of residents.
  5. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-950-E
Based on record review and staff interview, facility failed to ensure semi-annual review on the emergency preparedness and response plan for all staff and residents.
Evidence
  1. LI requested Emergency preparedness policy with supporting documentation that a review was conducted with staff and residents over the past year.
  2. First page of the Emergency preparedness policy states facility will complete ‘semi-annual training and updates as contingency of employment’.
  3. Staff 1 provided policy and a training log that had no dates just names of staff that are no longer employed when compared to the staff list provided to LI during inspection. None of the present staff names were on list.
  4. The only dated documentation for the semi-annual review was dated as 07/29/2016 & 02/17/2016.
  5. Staff 4 confirmed that facility does not have an updated semi-annual review with staff and did not have a date from when the provided training log would have taken place.
  6. Staff 4 confirmed facility has not completed a semi-annual review with residents.
  7. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-80-120-E-1
Based on observation and interview, facility failed to post on premises the most recently issued license.
Evidence
  1. During facility tour LI observed license that expired on Oct. 17th, 2023, posted at the front door entrance hallway.
  2. Facility had renewal inspection on Sept. 19th, 2023, with a new license & expiration date of October 17th, 2024.
  3. Staff 4 confirmed that he did not update that prior license that was posted.
  4. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-980-A
Based on observation and staff interview, facility failed to ensure that a complete first aid kit shall be on hand in each building at the facility, located in a designated place that is easily accessible to staff but not to residents. Items with expiration dates must not have dates that have already passed. the facility failed to ensure a complete first aid kit is on hand.
Evidence
  1. First aid kit on hand did not include: Adhesive tape, blankets, CPR masks, roller gauze or pads, hand cleaner, plastic bags, flashlights, batteries, thermometer, triangular bandages or tweezer.
  2. The first aid kit had the following expired items: antiseptic wipes (expired 02/2022), gauze pads (expired 03/2019) and bandages (expired 01/2021).
  3. Staff 1 stated he did not know that there were items missing and expired.
  4. Staff 4 confirmed that he did not know of the missing items and expired items.
  5. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-970-A
Based on record review and staff interview, facility failed to ensure fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. Last documented fire drill that was conducted was on 5/5/2024.
  2. Staff 1 confirmed that the facility has 2 shifts - 7am to 7pm the other being 7pm to 7am.
  3. Staff 4 confirmed that they did not complete a June, July or August fire and emergency evacuation drill for both shifts.
  4. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-100-A
Based on record review and staff interview, facility failed to ensure that the administrator completes an annual review of the infection prevention policies and procedures for any updates.
Evidence
  1. LI reviewed infection control and prevention policy. LI requested annual review documentation completed by administrator and another health care professional.
  2. Staff 4 confirmed that he was not aware that an annual review was required and does not have any supporting documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-350-C
Based on record review and staff interview, facility failed to ensure that each resident or his legal representative is fully informed, prior to or at the time of admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 (§ 9.1-900 et. seq.) of Title 9.1 of the Code of Virginia, including how to obtain such information with written acknowledgement maintained in the resident record.
Evidence
  1. Resident 1, Resident 2 and resident 3’s record did not have any acknowledgement or documentation of sex offender notification.
  2. LI requested annual notification from Staff 1 who provided LI with the sex offender search 2 times.
  3. Staff 4 confirmed that they have not been providing the annual sex offender notification to residents or family at admission or annually.
Plan of correction
Not published by VDSS.
22VAC40-73-310-M
Based on record review and staff interview, the facility failed to have a written agreement between the assisted living facility and the hospice program that provides care in the facility.
Evidence
  1. Resident 2 began hospice services on 7/31/2024.
  2. LI requested hospice contract or agreement with the hospice provider. Staff 1 provided the plan of care.
  3. LI explained written agreement and what it is. Staff 4 confirmed that they do not have a written agreement with the hospice provider and did not know that they needed to obtain an agreement.
Plan of correction
Not published by VDSS.
22VAC40-73-350-B
Based on record review and staff interview, facility failed to ensure that they shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident to stay longer than three days and shall be documented in the resident record.
Evidence
  1. Resident 1 admitted on 8/15/2024 and the sex offender search was completed on 8/20/2024 – 5 days after admission to the facility.
  2. Staff 4 confirmed that the search was completed 5 days late.
  3. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-550-F
Based on observation and staff interview, facility failed to ensure rights and responsibilities of residents is posted with the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services' toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate (i.e., local) ombudsman program serving the area, and the toll-free telephone number of the Disability Law Center of Virginia.
Evidence
  1. Resident Rights and responsibilities posted on the entryway hallway with outdated contact information for required contacts.
  2. Staff 4 confirmed that the posting was out of date and needed to be updated with correct information. LI provided correct information.
  3. LI obtained photo evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-950-F
Based on record review and staff interview, the facility failed to ensure that the annual emergency preparedness plan review was documented by signing and dating the plan.
Evidence
  1. Staff 1 provided Emergency preparedness policy for review.
  2. LI requested documentation or evidence of annual plan review. Staff 4 confirmed that he did not know that the plan should be reviewed annually.
Plan of correction
Not published by VDSS.
August 21, 2024Complaint survey0 violations
Inspection dates
08/21/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/21/2024 9:30am - 10:30am 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 7/22/2024 regarding allegations in the area(s) of: Physical grounds & resident supervision. Number of residents present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents socializing and participating in therapy services. 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 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 19, 2023Inspection5 violations
Inspection dates
09/19/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESSSubjectivity63.2 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: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/19/23 (8:20 AM - 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with residents: Three Number of interviews conducted with staff: Two Observations by licensing inspector: Meal, Medications An exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-H
Based on observation and documentation, the facility failed to ensure that information is documented on the medication administration record (MAR), at the time medication is administered.
Evidence
  1. Facility staff reported that Staff #1 and Staff #2 administered medications, on the date of the inspection. Only Staff #1's initials appeared on the MAR. Facility staff reported that resident medications are punched out of their medication cards in accordance with the day of the month. Resident #3's Levothyroxine was documented on the MAR as being given by Staff #1 on 9/19/23. Resident #3's Levothyroxine was still in her medication card for the 19th day of the month. Resident #4's Primidone (7AM and 11 AM administrations) were documented as being given by Staff #1 on 9/19/23. Resident #4's Primidone medication cards still contained the 7AM and 11 AM doses.
Plan of correction
RMAs will be educated to properly document medication administration and to ensure that medication is given at the right time and date. RMA's will also be reminded to double check the MAR before leaving their shift to ensure proper documentation. RMA's will receive a retraining on how to retrieve medications properly from the med cards, and to constantly document at the back of the resident’s MAR, if a medication was pulled from a different date, and the reason why this happened.
22VAC40-73-40-B-3
Based on documentation and interview, thefacility failed to ensure the criminal history record report is obtained, on or prior to the 30th day of employment for each staff member.
Evidence
  1. Staff #3 was hired on 4/30/23. Staff #3's record contained a letter from the Virginia State Police, dated 5/5/23, that indicated that a different search form would need to be completed in order to receive the criminal history record for Staff #3. No documentation was provided, during the inspection, to indicate that the facility attempted to obtain Staff #3's criminal history report after receiving the 5/5/23 letter from the Virginia State Police.
Plan of correction
Staff 3's criminal background check will be re-submitted by first week of October. The letter from VSP will be followed and requirements will be submitted if needed. An update will be given to the licensing inspector if report has been finally received OR if other situations arise.
22VAC40-73-520-I
Based on observation and documentation, the facility failed to ensure that the activity calendar is updated if one activity is substituted for another.
Evidence
  1. Residents were observed in their rooms at 10 AM. Residents were observed completing a puzzle, watching television, and resting. The activity calendar indicated that a Calisthenics activity was going to be conducted at 10 AM. No change was made to the activity calendar, to reflect the change in the activities that were going to be offered.
Plan of correction
This director will ensure that scheduled activities will be followed throughout the day. An alternative activity book will be created which will list the options of alternative activities per day if residents does not want to join the scheduled activity. The Ashlawn home manager is tasked to complete the project by the end of October, 2023 and activities, with alternative option will be ready by the first week of November of this year.
22VAC40-73-950-E
Based on documentation, the facility failed to ensure that a semi-annual review on the emergency preparedness and response plan was conducted with all staff, residents, and volunteers.
Evidence
  1. No documentation was provided, during the inspection, to indicate that a semiannual review of the facility's emergency preparedness plan was conducted with all staff, residents, and volunteers.
Plan of correction
This director will review the policy on emergency preparedness and response plan semi-annual review requirement and will initiate a meeting with the home managers. A form will be created for documentation. The facility will have a semi annual review by the end of October, 2023.
22VAC40-73-670-2
Based on record review and interview, the facility failed to ensure that an applicant, for registration as a medication aide, does not act as a medication aide on a provisional basis for longer than 120 days.
Evidence
  1. Facility staff reported that Staff #2 administered medication for several residents on the date of the inspection. Staff #2's record contained documentation that indicated that her provisional medication aide status began in June 2022. Staff #2's record contained documentation that the staff member is medication technician in Maryland. No documentation was provided, during the inspection, to confirm that Staff #2 is a registered medication aide in Virginia.
Plan of correction
Per Inspector’s recommendation, all medications will ONLY be given by RMA or RN, or staff on RMA training without license but within the 120 provisional days. Employees with certification will be retrained by the director (who's also an RN) to ensure that this regulation will be met.
May 17, 2023Inspection2 violations
Inspection dates
05/17/2023
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 PREPAREDNESSArticle 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
Discussed ISP requirements and bed check documentation requirements. Please update the posted resident rights to reflect the current Licensing Administrator – Sharae Henderson, 804-629-3479
Comments
An unannounced mandated monitoring inspection was conducted on 5/17/2023. At the time of entrance six residents were in care with two staff providing care. The sample size consisted of three resident records, three staff records and one individual interview. 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 9/13/2021. Residents were observed eating breakfast and engaging in activities including current events. Medication administration was reviewed. 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. 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
22VAC40-73-450-A
Facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. Resident #2 was admitted on 4/21/2023. There is no documentation that a preliminary plan of care was developed
Plan of correction
Administrator to ensure that all new residents have an ISP completed by the day of admission
22VAC40-73-450-D
Facility failed to ensure that the comprehensive individualized service plan shall be completed within 30 days after admission and shall include a description of identified needs.
Evidence
  1. Resident #1’s ISP dated 3/30/2023 did not include the resident’s assessed need for a mechanical soft diet.
Plan of correction
Administrator to update all ISPs to reflect each assessed need.
September 13, 2021Inspection0 violations
Inspection dates
09/13/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Provider indicated that the renewal application was mailed to the Valley Office in August to the new mailing address.
Comments
A renewal inspection was initiated on 9/12/2021 and concluded on 9/13/2021. The Manager was contacted by telephone to initiate the inspection and reported that the current census was seven. The Licensing Inspector (LI) emailed the Manager a list of items required to complete the remote documentation review portion of the inspection. The LI reviewed two resident records, two staff records, staff schedules, health care oversight, fire and emergency drills, Fire Inspection, Health Inspection, activity calendar, menu and the most recent dietary oversight submitted by the facility to ensure documentation was complete. Background Checks of all staff hired since the previous inspection were reviewed. The LI conducted the on-site portion of the inspection on 9/13/2021. An exit interview was conducted with the Manager on the date of inspection, where findings were reviewed and an opportunity was given for questions. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 7, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A mandated monitoring inspection was initiated on 4/5/2021 and concluded on 4/7/2021. The Administrator was contacted by email to initiate the inspection. The Administrator reported that the current census is eight. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, medication administration records, local fire and health inspection and other documentation submitted by the facility to ensure documentation was complete. All background checks of staff hired after the most recent inspection were reviewed. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.