Virginia DSS · Assisted Living Facility

Commonwealth Senior Living at Georgian Manor

📍 651 River Walk Parkway, Chesapeake, VA, 23320

ID 35095Two Year licenseActive
17
Inspections
On record
10
With violations
Visits that cited something
7
Clean visits
Nothing cited
31
Violations cited
Individual findings
27
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Commonwealth Senior Living at Georgian Manor was inspected 17 times between November 30, 2020 and April 29, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 31 violations under 27 distinct standards. 9 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. 13 of these 17 are still on the state's site; the other 4 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
06/29/2027
Administrator
Jasmine Montgomery
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

17

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

April 29, 2026Complaint survey0 violations
Inspection dates
04/29/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/29/2026 10:30am-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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 3 A complaint was received by VDSS Division of Licensing on 1/26/2026 regarding allegations in the area(s) of: Resident Care And Related Services. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2026Inspection0 violations
Inspection dates
04/28/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (1) GENERAL PROVISIONS
Technical assistance
22VAC40-73-70
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/28/2026 8:30am-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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:3 Number of interviews conducted with residents:9 Number of interviews conducted with staff: 4 Observations by licensing inspector: breakfast, lunch and activity were observed. Call bell, Emergency Preparedness and Medication passes were completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 13, 2025Complaint survey0 violations
Inspection dates
11/13/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2025 2:30pm to 3:45pm. A complaint was received by VDSS Division of Licensing on 10/20/2025 regarding allegations in the area(s) of: Staffing And Supervision, Resident Care And Related Services 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: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity and tour of the Buildings and Grounds were observed. Resident records, resident interviews and staff interviews were conducted. Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 13, 2025Complaint survey0 violations
Inspection dates
11/13/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2025 3:45pm to 4:45pm. A complaint was received by VDSS Division of Licensing on 9/19/2025 regarding allegations in the area(s) of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 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: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity and tour of the Buildings and Grounds were observed. Resident records, resident interviews and staff interviews were conducted. Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 13, 2025Complaint survey0 violations
Inspection dates
11/13/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2025 2:30pm to 3:45pm. A complaint was received by VDSS Division of Licensing on 10/20/2025 regarding allegations in the area(s) of: Staffing And Supervision, Resident Care And Related Services 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: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity and tour of the Buildings and Grounds were observed. Resident records, resident interviews and staff interviews were conducted. Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 21, 2025Inspection2 violations
Inspection dates
04/21/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/21/2025 09:40 am to 4:00pm. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed:3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch, activity and medication pass were observed by licensing inspector. Tour of the facility interior/ exterior and first aid kits reviewed. Water Temperature checked. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on the record review the facility did not ensure to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident #1, admission date of 7/05/2022, contains a risk assessment for TB dated 03/19/2024. The resident’s record does not contain an annual risk assessment for TB completed after 03/19/2024.
  3. Staff #1 confirmed the record for resident #1 did not contain an annual risk assessment for TB completed after the date of 03/19/2024.
Plan of correction
Resident #1 – TB was completed by Sean Regan, NP and filed in residents chart. Monthly evaluations of residents chart will be completed to ensure we are staying within the guidelines. The RCD and ED will complete chart audits and provide training to the RCC on how to audit resident charts effectively. Person Responsible: RCD, ED
22VAC40-73-640-A
Based on observation and a review of the facility’s medication plan, it was determined that the facility shall have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include A plan for proper disposal of medication.
Evidence
  1. During the medication cart inspection, medication for resident #9, Furosemide 20mg was found and it expired on 12/19/2024.
  2. Staff #5 confirmed the medication for resident #9 was expired.
Plan of correction
Resident #9 – expired medication was removed from med cart. New medication order was completed, and new current medication was put on the cart for resident. Continuing monthly evaluations of med cart will be completed to ensure we are staying within the guidelines. Within the med cart audit RCD will notate if there is a medication that is coming up for expiration and then will notify the NP that a new order is needed to ensure that it is replaced prior to expiration date. The RCD and RCC go on step further when auditing the med carts. They will notate the medication that is expiring and submit a request for updated order to NP. Will replace expired medication with new when it comes in. Person Responsible: RCD, ED
February 25, 2025Complaint survey0 violations
Inspection dates
02/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/25/2025 12:50pm to 1:30pm. A complaint was received by VDSS Division of Licensing on 1/23/2025 regarding allegations in the area(s) of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 70 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: none Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 13, 2024Complaint survey1 violation
Inspection dates
11/13/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/24 2:12pm to 3:00pm. A self-reported incident was received by VDSS Division of Licensing on 10/18/2024 regarding allegations in the area(s) of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on review of records, the facility did not ensure that All staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities.
Evidence
  1. Staff #1 and staff #2 went to the Resident #1`s apartment to assist with changing her. Resident #1 proceeded to spit on Staff #2. When Resident #1 spat on Staff #2, Staff #2 cupped her hand and put it over Resident #1’s mouth with her fingers on Resident #1`s cheek. Resident #1 was able to get air; however, Staff #2 did put her hands on the client`s face. Staff #2 was terminated from employment with the facility.
Plan of correction
Employee #2 was terminated Lead RMA completed CDP training, to better assist staff PPE was placed in residents apartment for staff to use when providing care. All staff that work on Sweet Memories will complete dementia training to re-educate steps to assist residents who have diagnosis of dementia Re-education on the process for proper reporting of any rights, dignity, and sensitivities of person who are aged or infirm or who have disabilities to direct supervisor immediately ED will provide training on residents rights x 3 months and as needed to ensure compliance. RCD and ED will ensure that training is completed, and PPE supplies are available for staff
May 21, 2024Inspection3 violations
Inspection dates
05/21/2024
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/21/2024 at 08:21 am until 02:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-H
Based on the onsite observation and record review the facility failed to ensure the facility shall ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. Resident’s # 3 ISP dated 12/31/23 includes the following: “resident must be fed by mouth by another person.” Resident’s # 3 UAI dated 12/31/23 identifies the resident’s eating/feeding needs as performed by others, “spoon fed.” During observation of breakfast in the safe, secure environment, resident #3 was observed to be eating independently without the assistance of another person.
Plan of correction
What Has Been Done to Correct? ISP has been updated to indicate that resident is now able to feed himself. How Will Recurrence Be Prevented? Changes will be made to care plan as significant changes occur with resident as report to RCD/ARCD by staff. Person Responsible: RCD and ARCD Due Date: Update to resident #3’s ISP was completed on 5/21/24 and POA was made aware of the change. POA was in on 5/30/24 and reviewed and signed off on the ISP. RCD and ED have also signed off.
22VAC40-73-640-A
Based on the record review, the facility failed to implement a written plan for medication management to include: a plan for proper disposal of medication.
Evidence
  1. The facility’s medication management plan includes the following: “all discontinued medication will be returned to the pharmacy or destroyed within 72 hours of discontinuance.”
  2. The record for resident #2 contains a physician order dated 04/30/24 to discontinue the use of “Trospium CL tab 20mg.” During the medication pass observation completed on 05/21/24, with staff #1, “ Trospium CL tab 20mg” for resident #2 was observed on the medication cart. Staff #6 confirmed Trospium for resident #2 was discontinued on 4/30/24 according to the resident’s physician order.
Plan of correction
What Has Been Done to Correct? The medication, Trospium CL 20mg, has been removed from the medication cart and destroyed by RCD on 5/21/24. How Will Recurrence Be Prevented? RCD/ARCD will conduct monthly med cart audits to ensure compliance with this standard. Person Responsible: RCD/ARCD
22VAC40-73-940-A
Based on the facility record review, the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. The most recent fire inspection completed at the facility was dated 3/27/23.
Plan of correction
What Has Been Done to Correct? The Fire Marshall conducted the on-site fire inspection of the facility on 5/23/24. See attached Operational Fire Code Permit How Will Recurrence Be Prevented? Maintenance Director (MD) will ensure that the on-site fire inspection will occur prior to the expiration date of this license which is 5/22/25 by placing on his calendar as a reminder of this annual inspection. Person Responsible: Maintenance Director (MD)
February 15, 2024Inspection1 violation
Inspection dates
02/15/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 02/15/24 at 10:42 am to 12:10. 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 01/11/2024 regarding allegations in the area of: Personnel Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of residents, and lunch was completed in the safe, secure environment. Additional Comments/Discussion: None 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. 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 (Donesia Peoples) Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on the onsite record review the facility failed to ensure all staff be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirmed, or disabled.
Evidence
  1. Resident’s #1 incident report dated 01/11/24 includes the following statement written by staff #1, “resident #1 spit in staff #1’s face, staff #1 wiped the spit with resident’s #1 hand and mushed it back into resident’s #1 face”. Resident #1’s incident report includes “resident #1 was assessed by staff #4 upon staff #4 arrival to the community, resident #1 had bruising to the left side of resident #1’s face. Staff #1 was terminated from employment with the facility.”
  2. Staff #2’s written statement dated 01/11/24 includes the following: “Staff #1 reported to staff #2 that staff #1 grabbed resident #1’s hands wiped the spit back on resident #1’s face, mushed resident #1’s own hand in resident #1’s face. Staff #2 went to go check resident #1 and noticed the whole left side of resident #1’s face was red.”
  3. During an interview on 02/09/24 with collateral contact (CC) #1, CC#1 observed resident #1 on 01/17/24 and observed the resident’s left cheek to be red.
Plan of correction
What Has Been Done to Correct? Staff #1 was immediately terminated. ED/RCD/BOM conducted re-education to associates on Resident Abuse and Neglect beginning on 1/11/24 at our All-Staff Meeting. Additionally, 1:1 re-education was completed with associates who were not able to attend that all staff training on 1/11/24. ED/RCD/BOM will continue to re-educate associates on Abuse and Neglect at our monthly all staff meetings through December 2024. How Will Recurrence Be Prevented? 1. Re-education by management of Resident Abuse and Neglect of Residents. 2. Ensuring background checks do not contain barrier crimes for any associates. 3. Management to follow up with any Abuse and Neglect allegations immediately as mandated reporters and report to DSS and APS. 5. Signs of Abuse is reviewed in Jump Start by RCD/ARCD. 6. Resident Abuse and neglect is taught in 6 hour dementia training as well. PersonResponsible: ED and all management
August 1, 2023Inspection0 violations
Inspection dates
08/01/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 08/01/23 from 1:09 pm to 4:15 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: 65 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: The facility’s medication management plan was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 18, 2023Inspection4 violations
Inspection dates
05/18/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Ensure Criminal Record Checks include the correct spelling of the first and last name.
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: An announced renewal inspection took place on 05/18/2023 from 8:18 am to 4:00 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: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for five residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on the record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident #6, contains a progress note dated 02/23/23 that documents “resident came out of room with a raised bruise noted to her left eye.” The facility did not provide a report to the regional licensing office reporting the observation of the resident’s bruised eye on 02/23/23.
  2. The record for resident #2, contains a progress noted dated 04/25/23 that documents “resident sent out to ER due to shortness of breath.” A progress note dated 04/29/23 documents “resident returned from hospital on hospice.” The facility did not provide a report to the regional licensing office reporting the resident’s hospital admission from 04/25/23-04/29/23.
  3. The record for resident # 1 contains a medical note dated 05/05/23 that documents “patient seen for follow-up due to recent hospitalization 04/27-05/01 due to pneumonia due to COVID 19.” The facility did not provide a report to the regional licensing office reporting the resident’s hospital admission from 04/27/23-05/01/23.
Plan of correction
Executive Director has informed management team as well as educated front line associates to inform management when any resident is sent out 911 whether for a fall or medical emergency. Executive Director or designee will submit within 24 hours to the LI a report of any resident leaving the community due to a fall or medical emergency.
22VAC40-73-320-B
Based on the record review the facility failed to ensure a risk assessment for (TB) shall be completed annually on each resident as
Evidence
  1. d by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence:
  2. The record for resident #2 contains a risk assessment for TB dated 09/22/21. The resident’s record does not contain an annual risk assessment for TB completed after 09/22/21.
Plan of correction
Risk assessment for Resident #1 has been completed and chart updated. (see attached). An audit of current residents will be conducted to assure updated TB risk assessment has been completed annually. This audit will be completed by 6/30/2023. Moving forward TB Risk assessments will be tracked by the RCD/designee and annual risk assessment will be completed per regulatory standards RCD or Designee
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs based upon the uniform assessment instrument (UAI).
Evidence
  1. The record for resident # 3, admission date 02/21/23, contains an ISP dated 04/10/23. The ISP in the record is dated more than 30 days after the resident’s admission date. 2.Resident # 1’s UAI dated 04/30/23 documents mechanical and human help needed for transferring. The resident’s ISP dated 05/04/23 does not include documentation of the mechanical help needed for transferring.
  2. Resident # 2’s UAI dated 04/29/23 documents mechanical help needed for toileting and transferring. The resident’s ISP dated 05/05/23 does not include documentation of the mechanical help needed for toileting and transferring.
  3. Resident #3’s UAI dated 03/25/23 documents mechanical help needed for dressing, toileting, and transferring. The resident’s ISP dated 04/10/23 does not include documentation of the mechanical help needed for dressing, toileting, and transferring.
Plan of correction
RCD has reviewed UAl's and ISP's for residents #1,#2 and #3. Corrections have been made to the ISP to more accurately reflect the UAI and the assistance these residents need. RCD or designee will conduct random audits comparing UAI and ISP's to ensure they match. These will be conducted quarterly. First audit to be conducted in June 2023 RCD or designee will also ensure that there is a comprehensive ISP completed within 30 days of admission for each resident. RCD or Designee
22VAC40-73-310-H
Based on the record review the facility failed to ensure in accordance with 63.2-1808 of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans.
Evidence
  1. The record for resident #3 contains a physician order dated 05/02/23 to include “Sertraline 25mg, take one tablet by mouth every day for depression.” The record does not contain documentation of a treatment plan for the psychotropic medication, Sertraline.
Plan of correction
Record for resident #3 has been updated to include Sertraline 25mg tablet daily for depression to residents current psychoactive medications and diagnosis sheet (see attached). An audit will be completed of current residents to assure psychotropic treatment plans are in place to address current psychoactive medications for each resident. This audit will be completed by 6/30/2023. The Pscyhotropic Treatment Plan for each psychoactive medication that a resident is currently prescribed will be obtained at move-in, with change in medication/dose, and reviewed for update at least every 6 months to assure medication is included with appropriate diagnosis and treatment plan. RCD or Designee
June 22, 2022Inspection14 violations
Inspection dates
06/22/2022, 06/23/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 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
An unannounced renewal inspection was initiated and completed on 6/30/22- from 9:00 a.m. until 4:11p.m. The Acknowledgement of Inspection form was signed and left at the facility for this date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 9 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass, dinning, water temperatures, bathrooms, resident’s apartments, kitchen, emergency food and water supply Additional Comments/Discussion: Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Violations
22VAC40-73-490-A-2
Based upon review the facility failed to employ a licensed health care professional who is onsite on full-time basis, a licensed health care professional, practicing within the scope of his profession to ensure that health care oversight is provided at least every six months, or often as indicated, based on his professional judgement of the seriousness of a resident’s needs or stability of a residents condition.
Evidence
  1. The facility’s last health care oversite was dated on 12/3/21.
Plan of correction
The Community completed their bi-annual Healthcare Oversight on July 21st. Going forward the RCD and/or Designee will ensure that it is competed bi-annually during the 7th month of the year (July) and the 1st month of the year (January).
22VAC40-90-30-B
Based on record review, the facility failed to ensure the sworn statement or affirmation be completed for all applicants for employment.
Evidence
  1. Staff #9 did not have a completed sworn statement in the record.
Plan of correction
The Sworn Disclosure was completed for this Employee. Going forward the Business Office Manager (BOM) and/or Designee will complete prior to any new Employee being hired at the community and/or when required for an existing Employee. Employee Records will be Audited by August 8th to ensure compliance.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of the facility on 6-22-2022, the vents in the halls had a black and grey substance on them.
Plan of correction
The HVAC vents have been dusted (Completed) and going forward the Maintenance Director and/or Designee will monitor vents on his weekly Interior/Exterior Preventative Maintenance & Housekeeping schedule, as well as maintain a schedule for vents to be cleaned.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, national Safety Council, American safety and Health Institute, community college, hospital volunteer rescue squad, or fire department.
Evidence
  1. Staff #4 and Staff #5 work as direct care staff and do not have a current certification in first aid
Plan of correction
The 2 staff members have completed their 1st Aid/CPR trainings and the community has documentation of as such in their employee file. Going forward the BOM and/or Designee will review All Employee Certifications on a Monthly basis to ensure compliance. Auditing of Employee files to be completed by August 8th to ensure compliance.
22VAC40-73-250-D
Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of health or a form consistent with it. Evidence:
  2. During onsite inspection on 6/23/22 and 6/23/22, there were no documentation of an initial tuberculosis examination and report for Staff #4 (DOH: 3/14/22).
Plan of correction
The staff member is no longer employed at the community. Going forward the BOM and/or Designee will ensure that each new hire has had the Screening form completed before hiring and also completed annually for each employee. Employee files will be Audited by August 8th for the Screening record.
22VAC40-73-450-E
Based upon record review, the facility failed to ensure that the individualized service plan be signed by the licensee, administrator, or his designee, (i.e., the person who has developed the plan) and by the resident.
Evidence
  1. The most recent individualized service plan for Resident # 2 and Resident #3 was not signed by Resident or Resident’s Legal Representative. .
Plan of correction
The RCD will set of a Date & Time to meet with and review ISP with the Responsible Party and/or obtain Signatures. Going forward the RCD and/or Designee will obtain the Resident and/or Responsible Party signature on the ISP when it has been updated and/or completed. Resident Charts to be Audited for this document by August 8th.
22VAC40-73-440-A
Based on review records the facility failed to ensure that the Uniform Assessment Instrument (UAI) prior to admissions.
Evidence
  1. The record for resident #3 did not contain documentation of a completed uniform assessment instrument prior to admission.
Plan of correction
The resident’s Initial UAI was completed prior to move in and was located within our EHR system and placed in her chart. Going forward the RCD and/or Designee will complete the UAI before admission and ensure it is placed in the chart, as well as the EHR. This will also be done for each resident on a yearly and/or “as needed” basis. Resident Charts will be Audited to ensure printed copy is in each chart to be done by August 8th.
22VAC40-73-250-C
Based on record review and discussion, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description.
Evidence
  1. The records for Staff #4 and Staff #5 did not include verification that the staff person has received a copy of their current job description
Plan of correction
The two staff members have received their respective Job Descriptions and documentation is in their employee files. Going forward the BOM and/or Designee will ensure that each new hired employee and/or promoted employee receives a copy of their Job Description and that it is documented in their employee file. Auditing of Employee files to be completed by August 8th to ensure compliance.
22VAC40-73-950-F
Based on record review and discussion, the facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions.
Evidence
  1. Staff #8 was unable to provide verification that the emergency preparedness plan was reviewed annually.
Plan of correction
The Maintenance Director and/or Business Office Director and/or Designee will ensure that All Staff Members have had the Emergency Preparedness Plan reviewed with them on a yearly basis. All Staff will be in-serviced and completed by August 8th.
22VAC40-73-325-A
Based on record review and interview, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed.
Evidence
  1. Resident #1 and resident #2 meet the criteria for assisted living care and did not have a written fall risk rating completed.
  2. Staff #3 acknowledged the aforementioned residents meet the criteria for assisted living care and did not have a written fall risk rating.
Plan of correction
Fall Risk Assessments were located for the two residents within our EHR system, as they were completed prior to move in. Going forward the Resident Care Director (RCD) and/or Designee will ensure Fall Assessment is printed and placed in the resident chart each time a residents (current/new) ISP is completed when due. All resident charts will be Audited by August 8th to ensure future compliance.
22VAC40-73-310-D
Based on record review and interview, the facility failed to provide written assurance to the resident or legal representative documenting that the facility has the appropriate license to meet their care needs.
Evidence
  1. Resident #3 did not have a copy of a written assurance in their record during record review.
  2. Staff #3 acknowledged the aforementioned residents did not have a signed written assurance in the record at the time of inspection.
Plan of correction
The resident Letter of Assurance was completed on July 19th and placed into their Business Office Chart. Going forward the RCD and/or BOM and/or Designee will ensure that this document is reviewed and signed by the Responsible Party prior to Admission. Resident Charts to be Audited for this document by August 8th.
22VAC40-73-290-A
Based on observation and discussion, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility.
Evidence
  1. During on-site inspection of the facility there was no posting of the current on-site person in charge in a place in the facility that was conspicuous to the residents.
  2. Staff#8 acknowledged the on-site person in charge was not posted.
Plan of correction
The Daily Supervisor In-charge has been posted in the community and will be keep and updated Daily going forward. The Concierge and/or Designee will ensure it is updated daily. This is Completed.
22VAC40-73-950-F
Based on record review and discussion, the facility failed to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions.
Evidence
  1. Staff #8 was unable to provide verification that the emergency preparedness plan was reviewed annually.
Plan of correction
The Maintenance Director and/or Business Office Director and/or Designee will ensure that All Staff Members have had the Emergency Preparedness Plan reviewed with them on a yearly basis. All Staff will be in-serviced and completed by August 8th.
22VAC40-73-1100-A
Based on record review, prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnoses of dementia in a safe, secure environment.
Evidence
  1. Resident #3 was admitted to the facility’s safe secure environment on 5/16/22; however, there is no documentation of approval for placement in the special care unit.
Plan of correction
The resident Approval for Placement document was obtained on July 19th and placed into their healthcare record. Going forward the RCD and/or Designee will ensure that the form is completed be the Responsible Party and updated in the records no later than the date of admission to the Memory Care neighborhood. Memory Care Resident Charts to be Audited for this document by August 8th.
May 24, 2021Inspection1 violation
Inspection dates
May 24, 2021 , May 25, 2021 and May 27, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on May 24, 2021 and concluded on May 27, 2021. The (person in charge) was contacted by telephone to initiate the inspection. The Senior Executive Director reported that the current census was 51. The inspector emailed the Senior Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, health and fire inspections, healthcare, dietary, and pharmacy oversights, activities calendar, staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standard or law, and a violation was documented on the violation notice issued to the facility.
Violations
22VAC40-73-450-D
Based on record review and discussion, the facility failed to ensure when hospice care is provided to a resident, the services provided by each is included on the individualized service plan (ISP).
Evidence
  1. Resident #1’s “Progress Notes” dated 04-20-2021 documented resident returned from the hospital on hospice care.
  2. Resident #1’s ISP dated 05-10-2021 identified hospice, however; did not identify the hospice services provided.
Plan of correction
What Has Been Done to Correct? Resident’s ISP has been updated to include the frequency of Hospice PA, RN, Aide, Social Worker & Chaplain visits. How Will Recurrence Be Prevented? When Residents return from the hospital on Hospice the Resident Care Director or Assistant Resident Care Director will input the specific details on their ISP. Person Responsible: Resident Care Director and or Assistant Resident Care Director.
April 20, 2021Complaint survey1 violation
Inspection dates
April 20, 2021 , April 21, 2021 , April 22, 2021 and April 23, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on April 20, 2021 and concluded on April 23, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Senior Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Senior Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. The complaint is valid.
Violations
22VAC40-73-460-B
Based on record review and discussion, the facility failed to ensure prompt response by staff to resident needs.
Evidence
  1. Resident #1’s call bell log documented the call bell activated a call on 02/04/2021 at 1:12 p.m. and staff response time was approximately 31 minutes later at 1:43 p.m.
  2. Facility incident report received on 02/04/2021 documented Resident #1’s incident that occurred on 02/04/2021 at 2:00 p.m., ?RCD [Resident Care Director] was making rounds and observed resident [#1] on the floor in [resident #1’s] room. Hematoma noted to the back of [resident #1’s] head.? Subsequently, Resident #1 required medical attention and was hospitalized for two days.
  3. The facility’s call bell logs documented staff response times ranged from approximately 10 minutes to approximately 573 minutes during January 2021 and February 2021.
  4. Residents indicated that staff are taking ?more than 25 minutes to respond to calls for assistance to include toileting, bathing and response to falls?.
  5. Staff #1 and Staff #2 confirmed during interview that the call bell logs showed varied lengths of times and did not report issues with the functionality of the call bell system.
Plan of correction
What Has Been Done to Correct? Nursing staff has been in-serviced on the integral part a call bell is to the life-safety of Residents. Medication Aides are to assist in answering call bells if they see excessive duration of a particular bell. Resident Care Associates will ensure they reset each call bell station and pendant after responding. How Will Recurrence Be Prevented? Call bells will be pulled randomly by Directors and response time noted. Disciplinary actions will be issued if not favorable. Any pulls that do not register accordingly will be reported to the vendor for resolution. Person Responsible: All Directors
January 25, 2021Complaint survey2 violations
Inspection dates
Jan. 25, 2021 , Jan. 26, 2021 and Jan. 27, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on January 7, 2021 and concluded on January 27, 2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services, involving staff cell phone personal use and resident care being delayed. The Senior Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Senior Executive Director a list of documentation required to complete the investigation, as well as conducted staff interviews. The evidence gathered could not substantiate the allegation in the complaint; however, non-compliance with standards or law were cited, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Consultation provided regarding oral orders, staff documentation of assisting residents during COVID with calls, etc.
Violations
22VAC40-73-300-B
Based on record review and discussion, the facility did not maintain written communications f used for keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, for at least the past two years.
Evidence
  1. Staff #1 and Staff #2 could not provide August and September 2020 nor January 2021 “Shift to Shift” Notes. Staff #1 stated “We don’t keep them past 30 days” and Staff #2 had stated ?We are no longer were documenting in between shifts.“ Additionally, Staff #1 stated the facility uses oral communication during ”Standup? morning meetings.
  2. Staff #1 and Staff #2 confirmed during discussion that the requested documents were not available and could not be provided for review.
Plan of correction
What Has Been Done to Correct? During each shift there is a log for Direct Care Staff to document in on each side of the Community, Assisted Living & Memory Care. At the end of the month, Resident Care Director stores the notes in a binder and it will be maintained in her office. How Will Recurrence Be Prevented? Resident Care Director and or Asst. Resident Care Director will initial the Direct Care logs daily. Person Responsible: Resident Care Director and or Asst. Resident Care Director.
22VAC40-73-450-F
Based on record review and discussion the facility failed to ensure Individualized service plans (ISPs) were reviewed and Description: Based on record review and discussion, the facility failed to ensure Individualized service plans (ISPs) were reviewed and updated as needed as the condition of the resident changes.
Evidence
  1. Resident #1’s ISP dated 11-10-2020 documented resident receives “Human Help, Physical Assistance” with eating/feeding, and Uniform Assessment Instrument (UAI) dated 10-31-2020 documented resident receives ?Human Help, Supervision? with eating/feeding. Resident #1’s ISP did not document a service need for stairclimbing; however, the UAI documented resident requires “Human Help, Physical Assistance” with stairclimbing.
  2. Resident #2’s ISP dated 08-12-20 did not document a service for resident’s bowels; however, UAI dated 08-12-20 documented resident is “Incontinent, Weekly or More” with bowels.
  3. Staff #2 confirmed Resident #1 and Resident #2’s UAIs were correct; however, ISP services were not updated to reflect residents? changes.
Plan of correction
What Has Been Done to Correct? Cited Resident’s ISP’s have been updated to accurately reflect the information on the UAI’s. How Will Recurrence Be Prevented? Senior Executive Director & Resident Care Director will review together new residents and current residents care plans to ensure they are a mirror-image of the UAI’s. Person Responsible: Senior Executive Director & Resident Care Director.
November 30, 2020Complaint survey2 violations
Inspection dates
Nov. 30, 2020 , Dec. 1, 2020 and Dec. 2, 2020
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on November 24, 2020 and concluded on December 2, 2020. A complaint was made with allegations related to staffing and call bell response times. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive a list of documentation required to complete the investigation. A video call was conducted to test the call bell system virtually. Records reviewed and interviews conducted. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The staffing allegation was not be substantiated however, complaint is valid.
Violations
22VAC40-73-680-I
Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering each drug or supplement.
Evidence
  1. The following MARs did not include the diagnosis, condition, or specific indications for administering the following drugs or supplements: A. Resident #1’s October 2020 MAR for Ciprofloxacin HCI; and August 2020, September 2020, October 2020 and November 2020 MAR for Memantine HCI; B. Resident #2’s August ? November MARs for Ergocalciferol, Lactulose, Donepezil; October and November MARs for Haloperidol; and C. Resident #3’s August ? November MARs for Amino Acids, Aspirin, Jobst Antiem KN LG/RG, Vitron-C; Metolazone for September MAR; October and November MARs for Mag Oxide Tab, Docusate Sodium, and Fluticasone Propionate.
  2. Staff #1 and staff #2 acknowledged during discussion that the aforementioned MARs did not include the diagnosis, condition, or specific indications for administering each drugs or supplements.
Plan of correction
What Has Been Done to Correct? Resident MARS will be reviewed for any missing diagnosis, condition or specific indications for administering each drug or supplement and, if necessary, House N.P. will be contacted for clarification. How Will Recurrence Be Prevented? House N.P. was advised of the violation and will ensure he indicates the necessary information when prescribing any new orders. Orders will be reviewed before forwarding to the pharmacy for accuracy. Person Responsible: Resident Care Director and/or Assistant Resident Care Director
22VAC40-73-870-E
Based on record review and discussion, the facility failed to ensure all equipment was kept in good repair and condition.
Evidence
  1. The facility’s call bell logs documented staff response times that range from approximately 10 minutes to approximately 1403 minutes. The times varied during the months of December 2019, January 2020, February 2020, September 2020, and October 2020. The following are a sampling of the documented staff response times: A. 12/24/2019, 3:20 p.m. “ 3:30 p.m. (10 mins.); 12/27/2019, 1:03 p.m. ” 3:14 p.m. (130 mins); 12/29/2019, 10:20 p.m. ? 11:08 p.m. (48 mins.); 12/30/2019, 6:14 p.m. ? 12/21 8:33 a.m. (859 mins.); B. 01/13/2020, 5:32 a.m. “ 7:52 a.m. (140 mins.); 01/17/2020, 2:44 p.m. ” 7:29 p.m. (285 mins.); 01/05/2020, 11:34 a.m. ? 01/06/2020, 10:58 a.m. (1403 mins.); C. 02/02/2020, 10:19 p.m. “ 11:36 p.m. (76 mins.); 02/11/2020, 6:05 a.m. ” 12:03 p.m. (357 mins.); 02/12/2020, 7:19 p.m. ? 02/13/2020 12:13 p.m. (1014 mins.); D. 09/17/2020, 5:09 a.m. “ 7:48 a.m. (158 mins.); 09/14/2020, 10:14 a.m. ” 4:21 p.m. (366 mins.); 09/13/2020, 5:30 p.m. ? 09/14/2020, 9:44 a.m. (984 mins.); and E. 10/15/2020, 9:36 p.m. “ 10:17 p.m. (41 mins.); 10/03/2020, 1:45 p.m. ” 4:21 p.m. (155 mins.); 10/23/2020, 6:52 p.m. ? 10/24/2020 3:22 a.m. (509 mins.).
  2. Staff #1 acknowledged response variations in the call bell times that were documented in the ?Lively Home GreatCall Inc“ [call bell system] reports. Additionally, Staff #1 indicated the call bells were answered however, the equipment ”was not working correctly? and not in good repair. Staff #1 could not provide documentation indicating the facility staff had knowledge of the call bell system not working properly. No documentation indicating that a repair company had been contacted for the said needed repair was provided. Additionally, Staff #1 did not provide documentation, which indicated that the call bells had been answered despite the equipment not working properly.
Plan of correction
What Has Been Done to Correct? All call bell pull stations & pendants have been tested to ensure batteries are in working order. We performed a test; engaging a pull station in a model room & advised Staff to not answer it in an effort to ascertain if system alerting was in working order. Vendor assured us after 90 minutes a call will be placed first to the Community followed by Resident Care Director’s cell number. An email will then be sent to the Maintenance Director stating issue was satisfied. How Will Recurrence Be Prevented? Call bell records will be reviewed daily and any discrepancies will be highlighted & investigated. A statement about the outcome will be indicated on the sheet. If discrepancies are vendor related, a call or email will be sent to our representative for resolution. All staff will be in-serviced again on the proper protocol for responding to call bells & to ensure all pull stations in a room are re-set. Person Responsible: Resident Care Director, Maintenance Director, Concierge