11
Inspections
On record
4
With violations
Visits that cited something
7
Clean visits
Nothing cited
8
Violations cited
Individual findings
8
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint
Braddock Glen was inspected 11 times between February 17, 2021 and June 8, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 8 violations under 8 distinct standards. 2 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. 9 of these 11 are still on the state's site; the other 2 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
04/20/2027
Administrator
Jay Gyawali
Licensing inspector
Marshall Massenberg
Inspector phone
(804) 543-5188
Approved for
Assisted Living · Non-Ambulatory
Inspection History
11Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
June 8, 2026Inspection
Inspection dates
06/08/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 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
Technical assistance
Documentation was discussed with the provider.
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: 6/8/26 (8:40 AM - 4:45 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: 55
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of staff records reviewed: Three
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Three
Observations by licensing inspector: Meals, Medication Administration, Activity
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-660-B
Based on observation, interview and record review, the facility did not limit medication storage to out-of-sight places in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication.
Evidence
- Miralax and Dulcolax were observed on the counter of Resident #5. Resident #5's physical examination form, dated 1/2/26, states that she is not capable of administering her medication. Resident #5's Uniform Assessment Instrument (UAI), dated 3/19/26, states that she needs staff assistance for medication administration. Staff #4 confirmed that the Miralax and Dulcolax were present on Resident #5's counter.
Plan of correction
Resident #5 did not experience any negative outcomes because medication was unsecured at resident's room. Medication removed and secured. Provider was contacted and new order received.
The Assisted Living Coordinator (ALC) conducted room sweep to ensure medication properly secured. Issues identified are addressed and resolved. ED re-educated front line team members on reporting importance of unsecured medication to wellness office.
The Assisted Living Coordinator or/ Designee will conduct weekly room sweeps for 2 months to ensure medications are properly secured. Issues identified addressed and resolved.
For 2 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director and/or Designee is responsible for the implementation and ongoing compliance with the components of this plan of correction and for addressing and resolving variances that may occur.
22VAC40-73-640-A
Based on documentation, the facility did not implement the medication management plan to ensure that each resident's prescription medications are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- Resident #2's Medication Administration Record (MAR) was observed during the inspection. Resident #2's June MAR indicates that her Tramadol-Acetaminophen was not administered on 6/6/26 (10 PM administration), 6/7/26 (6 AM and 10 PM administrations) and 6/8/26 (6 AM administration). The MAR states that Resident #2's Tramadol-Acetaminophen was pending delivery on the above listed dates. The facility's medication management plan states that medications should be reordered when a five-day supply remains. Facility documentation indicates that Resident #2's Tramadol-Acetaminophen was reordered on 6/6/26.
Plan of correction
Resident #2 did not experience any negative outcomes because of Tramadol - Acetaminophen was not administered per physician order. Medication is available for administration.
The Resident Care Director (RCD) conducted EMAR to medication cart audit to confirm medication were available per physician's order. Issues identified were addressed and resolved.
Refresher training with Medication Care Managers and Wellness Nurse was conducted by the RCD regarding the medication reordering procedure.
The Resident Care Director (RCD) and / or designee, will conduct weekly cart audit for 2 months to confirm medications are available per physician's order. Issues identified will be resolved.
For 2 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director and/or Designee is responsible for the implementation and ongoing compliance with the components of this plan of correction and for addressing and resolving variances that may occur.
22VAC40-73-680-M
Based on observation and interview, the facility did not ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
- Resident #4's Systane solution, ordered 7/9/24, was not present at the time of the medication cart inspection. Staff #4 confirmed that the medication was not present at the time of the medication cart inspection.
Plan of correction
Resident #4 did not experience any negative outcomes because of Systane Solution was not available per physician order. Medication is available for administration.
The Resident Care Director (RCD) conducted EMAR to medication cart audit to confirm medication were available per physician’s order. Issues identified were addressed and resolved.
Refresher training with Medication Care Managers and Wellness Nurse was conducted by the RCD regarding the medication ordering/reordering procedure.
The Resident Care Director (RCD), and or designee will conduct random medication card audit for 2 months to confirm medications are available for administration per physician’s order. Issues identified addressed and resolved.
For 2 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director and/or Designee is responsible for the implementation and ongoing compliance with the components of this plan of correction and for addressing and resolving variances that may occur.
22VAC40-73-650-B
Based on record review, the facility did not ensure that physician's orders include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and the diagnosis, condition, or specific indications for administering each drug.
Evidence
- Resident #4's record contained an order for Vitamin D, dated 4/16/24. Resident #4's Vitamin D order did not include the strength.
Plan of correction
Resident #4 did not experience any negative outcome. Provider was contacted and new order were received.
The Resident Care Director (RCD) conducted Physician order audit to confirm orders included the appropriate strength where applicable. Issues identified were resolved.
Resident Care Director (RCD) conducted the refresher training with the Wellness Nurse on a proper identification of valid orders.
The Resident Care Director (RCD) and / or designee, will conduct weekly physician’s orders audit for 2 months to confirm we have valid orders in place. Issues identified will be resolved.
For 2 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director and/or Designee is responsible for the implementation and ongoing compliance with the components of this plan of correction and for addressing and resolving variances that may occur.
22VAC40-73-650-F
Based on documentation and interview, the facility did not ensure that new orders are obtained for all medications and treatments, whenever a resident is admitted to a hospital for treatment of any condition.
Evidence
- Resident #1's record contained a hospital discharge summary from his stay at the hospital from 2/18/26 through 2/20/26. The discharge summary indicated that a change should be made to the administration of Resident #1's Bumetanide. Resident #1's MAR indicated that on 2/21/26 and 2/22/26, he was administered Bumetanide using the instructions from his physician’s order, dated 2/15/26. Staff #4 confirmed that new orders were not present, in Resident #1's record, to reflect the change to Resident #1's Bumetanide after he was discharged from the hospital on 2/20/26.
Plan of correction
Resident #1 did not experience any negative outcomes. Physician was contacted and obtained the order.
The Resident Care Director (RCD) conducted Physician order audit on residents discharge paperwork to confirm Physician orders were followed. Issues identified were resolved.
Resident Care Director (RCD) conducted the refresher training with the Wellness Nurse to confirm Physician orders.
The Resident Care Director (RCD), or designee will conduct discharge summary audit after resident discharge from the hospital. Issues identified and addressed.
For 2 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted. The Executive Director and/or Designee is responsible for the implementation and ongoing compliance with the components of this plan of correction and for addressing and resolving variances that may occur.
June 26, 2025Inspection
Inspection dates
06/26/2025, 7/03/2025, 8/14/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 FACILITIES AND PROGRAMS
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: 6/26/25 (10:50 AM – 11:20 AM); 7/3/25 (12:45 PM – 2:20 PM); 8/14/25 (11:00 AM – 11:20 AM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Self-reported incidents were received by VDSS Division of Licensing regarding allegations in the area(s) of: Resident Care and Related Services; Personnel; Facilities and Programs
Number of residents present at the facility at the beginning of the inspection: 54
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Nine
Number of interviews conducted with residents: One
Number of interviews conducted with staff: Three
Observations by licensing inspector: Lunch, Activity
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
63.2-1808-A-17
Based on documentation and interview, the facility did not ensure that each resident is afforded daily privacy in all aspects of daily living.
Evidence
- On 6/2/25, Resident #1 fell in her room. Staff #1 was the first staff member to encounter Resident #1 after the fall. Resident #1 and Staff #1 had a disagreement that was captured on a video camera that was in the resident’s room. Staff #1 was on a telephone call with a friend during the disagreement with Resident #1. The interaction, between Resident #1 and Staff #1, was overheard by the individual on the telephone. The facility's cell phone usage policy states that “"he use of personal cellular telephones or other handheld electronic devices by team members while they are taking care of residents and/or family members during working hours is prohibited."
Plan of correction
With respect to the specific resident/situation cited:
Following the incident, the staff member involved was immediately placed on administrative leave and no longer working with the company.
With respect to how the facility will identify residents/situations with the potential for the identified concerns:
The Executive Director (ED) or designee will conduct a 100% audit of all interviewable residents to assess their understanding of and satisfaction with their privacy rights in daily living. Any concerns identified during this audit will be documented and addressed promptly.
With respect to what systemic measures have been put into place to address the stated concern:
The Executive Director or designee will re-educate all staff on resident rights, including policies related to personal device usage, with specific emphasis on maintaining privacy in all aspects of care.
With respect to how the plan of correction will be monitored:
Department Coordinators will perform unannounced spot checks during care activities, to assess adherence to resident privacy protocols and appropriate device usage. This will be presented to the Quality Assurance Performance Improvement (QAPI) committee weekly for 1 month and monthly for two months. Audit findings will be reported to the QAPI committee for review, additional audits and education may be determined based on findings.
March 19, 2025Inspection
Inspection dates
03/19/2025
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 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
Technical assistance
Documentation was discussed with the provider.
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: 3/19/25 (8:10 AM - 5:00 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: 59
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of interviews conducted with residents: Four
Number of interviews conducted with staff: Four
Observations by licensing inspector: Meals, Activities, Medication Administration
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-490-A-2
Based on documentation and interview, the facility did not ensure that a health care oversight is performed at least every six months.
Evidence
- The most recent health care oversight report, completed at the facility, was dated 6/30/24. Facility staff confirmed that no additional oversight reports have been completed since that date.
Plan of correction
ED received the health care oversight documentation for the past 12 months to identify specific lapses in the required updates and Health Care Oversight updated. Any corrections needed were completed.
ED and/or designee will audit Health Care Oversight to confirm proper documentation is in place quarterly.
ED and designee audits Health Care oversight to confirm proper documentation is in place. Any issues identified are resolved timely. ED presents the results of the audit to the Quality Assurance and Improvement committee quarterly for the next two quarters.
Executive Director is responsible for implementation and ongoing compliance with the components of this plan of correction and addressing resolving any barriers that may occur.
January 31, 2025Inspection
Inspection dates
01/31/2025, 02/05/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/31/25 (3:30 PM - 4:18 PM), 2/5/25 (1:30 PM - 2:55 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: 58
The licensing inspector completed a tour of the physical plant that included the building and grounds at the facility.
Self-reported incidents were received by the VDSS Division of Licensing in the area(s) of: Personnel, Resident Care and Related Services.
Number of resident records reviewed: Three
Number of interviews conducted with residents: Two
Number of interviews conducted with staff: Four
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 13, 2024Inspection
Inspection dates
03/13/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Number of residents present at the facility at the beginning of the inspection: 60
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 5
Observations by licensing inspector: This LI observed residents participating in various activity programs and eating lunch. This LI observed a medication pass and compared physician orders to the medications available to administered to residents. LI reviewed fire inspection report, health inspection report, fire drills, emergency preparedness review with staff, emergency drills, healthcare oversight, medication review, dietary review and resident council minutes.
Additional Comments/Discussion:
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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident records review and staff interview, the facility staff failed to ensure that medications were administered in accordance with the physician’s or prescriber’s orders.
Evidence
- Resident E had a prescription dated 11/18/23 for Labetalol HCI oral tablet 200mg, take every 24 hours as needed if SBP greater than 180 or DBP less than 100. LI compared physician/prescriber’s order sheets with the medications available in the medication cart for Resident E and the medication card for Labetalol HCI oral tablet 200mg did not contain any tablets to dispense during the LI’s inspection on 3/14/2024. Staff A stated that the medication was not available and would need to be reordered.
Plan of correction
A.) With respect to the specific resident/situation cited: Res E did not experience any negative outcomes and the medication, Labetalol is available for administration.
B.) 4/10/2024-4/11/2024 - With respect to how the facility will identify residents/situations with the potential for the identified concerns: Wellness Nurse (WN) and Medication Care Manager (MCM) conducted eMAR to medication cart audit to confirm medications were available per physician's order. Refresher training with MCM and WN was conducted by Executive Director (ED) regarding procedures to follow in order to administer medications in accordance with the physician's order. When MCM is unable to locate a medication, the MCM is to check the cart to verify it has not been stored correctly, to report to the Resident Care Director (RCD) and notify the physician. If medication is unable to be located the medication will be reordered.
C.) 4/11/2024 - With respect to what systematic measures have been put into place to address the stated concern: The RCD or designee will continue to conduct eMAR to medication cart audits weekly for 3 months to confirm that medications are available and administered per physician's order.
D.) 4/16/2024 - With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training in order to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
August 30, 2023Inspection
Inspection dates
08/30/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
September 12, 2022Inspection
Inspection dates
09/12/2022
Comments
Type of inspection: Monitoring
An unannounced monitoring inspection was conducted on9/13/2022. At the time of entrance sixty residents were in care. Sample size consisted of seven resident records and four staff records. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection. Residents were observed eating engaging in activities. Medication administration was observed. An exit meeting was conducted to review the inspection findings.
The evidence gathered during the inspection determined there were no violations. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Tammy Pruitt, Licensing Inspector at (703) 314-0604 or by email at tammy.pruitt@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
April 8, 2022Complaint survey
Inspection dates
04/08/2022,04/20/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 Facilities and Programs
Comments
Licensing Inspector (LI) conducted unannounced complaint investigation on 4/20/22 regarding allegations of neglect and retaliation. Statements were obtained from seven staff members and the resident in question.
Complaint regarding neglect and retaliation is deemed not valid as a preponderance of evidence gathered during the investigation does not supported the allegations.
Thank you for your cooperation and if you have any questions please contact me via email at tammy.pruitt@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 25, 2022Inspection
Inspection dates
01/25/2022,01/26/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS32.1 Reported by persons other than physicians
Comments
A monitoring inspection was started on 1/25/2022 and concluded on 1/26/2022 with the inspection findings being reviewed. Today's census was 60. Facilities fire and health inspections are current and activities are varied to meet different level of care needs. Reviewed ten staff records including the criminal background checks on new hires and five resident records including MARs and medication. Other sources of documentation was also reviewed. No violations were found and exit interview conducted. If you have any questions regarding this inspection please contact Tammy Pruitt at tammy.pruitt@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 18, 2021Complaint survey
Inspection dates
Feb. 18, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Licensing Inspector (LI) conducted unannounced complaint investigation over multiple days in January and February 2021 regarding
treatment and care of residents. The inspection was conducted during the State of Emergency and was conducted without the LI going into
the facility. LI reviewed resident record, medication administration records, conducted staff, resident, and family interviews.
Complaint regarding resident treatment and care is deemed not valid as a preponderance of evidence gathered during the investigation does
not supported the allegations.
Thank you for your cooperation and if you have any questions please call 703-314-0604 or contact me via email at
tammy.pruitt@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.