Virginia DSS · Assisted Living Facility

Journeys Crossing Assisted Living

📍 102 N. Stuart Avenue, Elkton, VA, 22827

ID 35939One Year licenseActive
12
Inspections
On record
8
With violations
Visits that cited something
4
Clean visits
Nothing cited
29
Violations cited
Individual findings
26
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Journeys Crossing Assisted Living was inspected 12 times between April 16, 2021 and December 17, 2025 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 29 violations under 26 distinct standards. 3 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 10 of these 12 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
One Year
License expires
11/26/2026
Administrator
Brian Phelps
Licensing inspector
Leslie Roberts
Inspector phone
804-298-5524
Approved for
Assisted Living · Non-Ambulatory

Inspection History

12

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

December 17, 2025Inspection13 violations
Inspection dates
12/17/2025
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 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSA63.2- (1) GENERAL PROVISIONSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OF AFFIRMATION
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: December 17, 2025, from 11:15 a.m. until 5:30 p.m. 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: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in the facility that was conspicuous to both residents and the public.
Evidence
  1. During the facility tour completed on 12/17/2025, LI and licensing administrator (LA) did not observe the current staff person in charge posted in the facility.
  2. During an interview on 12/17/2025 with LI, staff 7 stated that the med tech on duty is in charge. When LI asked staff 7, how someone would know that staff 7 responded, “they wouldn’t”.
Plan of correction
Resident Care Coordinator corrected while Inspectors were on site.
22VAC40-90-40-B
Based on staff record reviews and staff interview, the facility failed to obtain an original criminal history record report for each employee within 30 days of employment.
Evidence
  1. The Licensing Inspector (LI) requested all criminal history record reports (CHRR) for all new staff hired since the last renewal inspection conducted on 11/14/2023.
  2. Record for staff 3, hired 8/26/2025, did not contain a CHRR.
  3. Staff 9, hired 4/12/2025, contained a CHRR dated 4/9/2024.
  4. Record for staff 10, hired 1/21/2025, did not contain a CHRR.
  5. Record for staff 14, hired 11/17/2025, did not contain a CHRR.
  6. Staff 15, hired 11/4/2025, contained a CHRR which was undated.
  7. Record for staff 16, hired 11/4/2025, did not contain a CHRR.
  8. During an interview with LI on 11/10/2025, staff 7 acknowledged the facility failed to obtain the required reports within 30 days of employment as required by the standard.
Plan of correction
Administrator will ensure that all criminal background checks are completed within 30 days of hire.
22VAC40-90-30-B
Based on staff record reviews and staff interview, the facility failed to obtain a sworn statement or affirmation disclosing whether the applicant for employment had a criminal conviction or was the subject of any pending criminal charges within or outside the Commonwealth.
Evidence
  1. The Licensing Inspector (LI) requested all sworn statements for all new staff hired since the last renewal inspection conducted on 11/14/2023.
  2. Staff 3, hired 8/26/2025, contained a sworn statement dated 9/3/2025.
  3. Staff 9, hired 4/12/2025, contained a sworn statement dated 9/2/2025.
  4. Staff 10, hired 1/21/2025, contained a sworn statement dated 1/22/2025.
  5. Staff 11, hired 8/20/2025, contained a sworn statement dated 8/22/2025.
  6. Staff 12, hired 11/19/2025, contained a sworn statement dated 11/21/2025.
  7. During an interview with the LI on 12/17/2025, staff 7 acknowledged the sworn statement for staff 3, 9, 10, 11, and 12 were dated after the hire date and should have been obtained prior to employment.
Plan of correction
Administrator will audit all employee files to ensure Sworn Affirmations are in compliance.
22VAC40-73-470-D
Based on record review and staff interviews, the facility failed to develop and implement a written policy to ensure that staff are made aware of allergies and allergic reactions and any life-threatening conditions of residents, and actions that staff may need to take.
Evidence
  1. Resident 6, admitted 12/5/2025, had no known drug allergies (NKDA) listed on the resident face sheet.
  2. Report of physical examination for resident 6, dated 11/20/2025, listed allergies to cefuroxime axetil and hydrochlorothiazide.
  3. During an interview with LI and LA on 12/17/2025, staff 7 and 8 confirmed the facility did not have a written policy to ensure staff are made aware of resident allergies and allergic reactions. Staff 7 acknowledged the face sheet for resident 6 was inaccurate and did not include known drug allergies.
Plan of correction
All staff will be oriented to residents with allergies. Administrator will utilize current staff orientation process to ensure all staff are aware of residents with allergies.
22VAC40-73-310-B
Based on resident record review and staff interview, the facility failed to ensure a documented interview was completed between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any.
Evidence
  1. Record for resident 6, admitted 12/5/2025, did not contain a documented interview between the administrator and individual.
  2. During an interview with LI on 12/17/2025, staff 7 confirmed record for resident 6 did not contain a documented interview as required by standard.
Plan of correction
Administrator will complete Face to Face Assessments on all new Admissions. Administrator will audit all resident files for compliance.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure staff completed first aid (FA) certification within 60 days of hire.
Evidence
  1. Staff 1, hire date 9/22/2025, had not completed FA training as of date of inspection on 12/17/2025, which is not within 60 days of hire.
  2. During an interview with LI on 12/17/2025, staff 7 confirmed FA training for staff 1 did not occur within 60 days of employment.
Plan of correction
Administrator to ensure all CPR/First Aid are in compliance.
22VAC40-73-640-A
Based on resident record review and staff interviews, the facility failed to follow facility’s medication management plan to prevent the use of outdated medication.
Evidence
  1. During medication cart audit on 12/17/2025, LI observed expired medications.
  2. Resident 7 had True metrix level 1 control solution, which expired on 09/30/2025, and loperamide 2 mg capsules, which expired on 8/19/2025.
  3. Resident 9 had Bisacodyl EC 5mg tablets, which expired on 11/15/2025.
  4. Resident 10 had Acetaminophen 325 mg tablets, which expired on 11/26/2025.
  5. Resident 11 had Acetaminophen 325 mg tablets, which expired on 12/06/2025.
  6. Staff 4 and 7 acknowledged to LI that medications were expired.
  7. The LA requested a copy of the facility’s medication management plan. On page 7, the plan stated that “each month by a designated medication aide, all medications will be checked for expiration date, dispose of expired medications, and reorder expired medication”.
Plan of correction
Administrator or designee will audit medication carts weekly to ensure all medications are compliant with Medication Management Plan.
22VAC40-73-325-C
Based on resident record review and staff interviews, the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. Record for resident 8, admit date 7/1/2025, had a documented falls on 7/2/2025 and 8/9/2025, which resulted in ER visits.
  2. Record for resident 8 did not contain documentation of an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce risk of subsequent falls.
  3. Staff 7 and 8 confirmed there was no documentation of an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of correction
Administrator will review all incident reports, documentation and Interventions to ensure compliance.
22VAC40-73-680-K
Based on record review and staff interviews, the facility failed to ensure when a medication was ordered for as needed (PRN) use and administered by registered medication aides that the physician order was a detailed order that included directions as to what to do if symptoms persisted.
Evidence
  1. LI observed resident 4’s, admitted 4/3/2025, PRN orders for acetaminophen and oxycodone did not include physician instructions on what to do if symptoms persisted.
  2. LI observed resident 8’s, admitted 7/1/2025, PRN orders for acetaminophen, albuterol, diclofenac, haloperidol, milk of mag, Systane, and tums did not include physician instructions what to do if symptoms persist.
  3. During interview with LI and LA on 12/17/2025, staff 7 and 8 confirmed that all PRN orders for residents 4 and 8 did not include instructions on what to do if symptoms persist.
Plan of correction
Administrator or designee will audit all resident's orders to ensure instructions are included for symptoms that persist.
22VAC40-73-350-B
Based on record review and staff interviews the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained.
Evidence
  1. Record for resident 5, admitted 1/24/2025, contained evidence of a registered sex offender search conducted on 2/4/2025, which was not prior to admission.
  2. During an interview with the LI on 12/17/2025, staff 7 confirmed the registered sex offender search was not completed prior to admission.
Plan of correction
Administrator will audit all resident records to ensure Registered Sex Offender report is compliant.
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall.
Evidence
  1. Record for resident 8, admitted 7/1/2025, contained only one fall risk assessment dated 7/1/2025, day of admission.
  2. Resident 8 had documented falls on 7/2/2025 and 8/9/2025, which resulted in emergency room (ER) visits, but no additional fall risk assessments were completed.
  3. During an interview with LI on 12/17/2025, staff 7 confirmed record for resident 8 contained only an initial fall risk assessment, not an updated fall risk assessment after every fall as required by the standard.
Plan of correction
Administrator has audited all resident files to ensure fall risk ratings are Compliant. Administrator will audit monthly.
22VAC40-73-650-A
Based on record review and staff interviews, the facility failed to ensure no medical procedure or treatment had been started, changed, or discontinued by the facility without a valid order from the physician.
Evidence
  1. Record for resident 6 contained a Do Not Resuscitate (DNR) dated 12/5/2025, but there was no corresponding physician’s order.
  2. Record for residents 6 did not contain any documentation or signed order from the physician or prescriber for oxygen.
  3. During an interview with LI on 12/17/2025, when asked if resident 6 had a physician’s order for DNR or oxygen, staff 7 and 8 verified in record that resident 6 did not have orders for DNR or oxygen.
Plan of correction
Administrator will ensure all DNR's have written prescription.
22VAC40-73-440-F
Based on record review and staff interviews, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed within 90 days prior to admission to the assisted living facility.
Evidence
  1. Record for resident 4, admitted 4/3/2025, contained a typed UAI completed 4/24/2025, which was not prior to admission.
  2. During an interview with the LI and Licensing Administrator (LA) on 12/17/2025, staff 7 was asked why the UAI from the facility where resident 4 transferred from was not obtained at the time of admission. Staff 7 stated that other facility did not provide.
  3. Upon request the facility provided another UAI dated 4/3/2025, which was handwritten, but the date of the administrator’s signature was 4/3/2024. LA asked staff 7 and 8 why a UAI would have been completed on 4/3/2025 and then again on 4/24/2025 when there was no change in the condition of the resident. Staff 7 and 8 did not have a response.
Plan of correction
Not published by VDSS.
December 17, 2025Complaint survey1 violation
Inspection dates
12/17/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: December 17, 2025 from 12:20 p.m. until 1:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/17/2025 regarding allegations in the area(s) of: Personnel, staffing and supervision, and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication pass, meal observation and general interactions of staff with residents. Additional Comments/Discussion: NA An exit meeting will be conducted to review the inspection findings. A violation notice was issued; any violation(s) not related to the complaint(s) 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at angela.via@dss.virginia.gov
Violations
22VAC40-73-280-B
Based on record review and staff interview, the facility failed to implement and maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs, along with any identified special care needs for the residents currently in care with those staffing requirements directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. Licensing Inspector (LI) and Licensing Administrator (LA) requested a copy of the facilities written Staffing Plan.
  2. On 12/17/2025, staff 1 provided the LI and LA with a page from the disclosure statement which provides a general breakdown of staff by shift.
  3. When asked if the facility had a written staffing plan based on acuity levels and the individualized care needs of the residents in care, staff 1 stated they did not and could only provide the information from the disclosure statement.
Plan of correction
Administrator will monitor staffing pattern and current facility census, making changes when needed to ensure staffing is appropriate.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
Administration and Administrative Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/17/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/11/2025 regarding allegations in the area(s) of: Number of residents present at the facility at the beginning of the inspection: 29 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents participating in activity programs. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
Administration and Administrative ServicesResident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/17/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/21/2025 regarding allegations in the area(s) of: Administration and Administrative Services and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 29 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents participating in activity programs. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 9, 2025Inspection3 violations
Inspection dates
06/09/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: June 9, 2025, from 10:00 a.m. to 5:15 p.m. 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector (LI) completed a tour of the facility. The LI observed staff engaged with the residents during activities, meals and medication administration. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight, Fire Marshall and Virginia Department of Health inspections. Liability insurance was verified. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540)418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure the storage area for medications remained locked.
Evidence
  1. On 6/9/2025, during a tour of the facility, two LI’s observed the medication area unlocked.
  2. Photo 2 taken.
Plan of correction
Entry door to storage area is secured with new locking system to ensure door is secure at all times. Completed on 06/30/2025.
22VAC40-73-560-A
Based on observation and a staff interview, the facility failed to ensure that resident records were kept in a locked area.
Evidence
  1. On 6/9/2025 during a tour of the facility, two LI’s observed resident records in an open cabinet in an unlocked medication area.
  2. Photo 1 taken.
Plan of correction
All residents’ records are secured in cabinet with a locking system. Completed 06/15/2025.
22VAC40-73-250-C
Based on record reviews and staff interview, the facility failed to ensure that staff verified the receipt of their job description.
Evidence
  1. On 6/9/2025 the Licensing Inspector (LI) reviewed three staff records, and a signed job description was not found for: staff 3 (hired 2/3/2025) staff 4 (hired 3/28/2025) staff 5 (hired 1/31/2025)
  2. On 6/9/2025, staff 1 acknowledged that all staff should have a signed job description but was unable to locate for staff 3,4, or 5.
Plan of correction
The Administrator or designee will audit all employee files. Job descriptions, duties and responsibilities will be reviewed with all employees, signed and placed in employee files. Completed 06/15/25
November 14, 2023Inspection0 violations
Inspection dates
11/14/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population
Comments
Date of Inspection: November 14, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 33 Number of records reviewed and interviews conducted- 6 records (staff and residents), 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents at activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, staff drills and healthcare oversight.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 13, 2022Inspection1 violation
Inspection dates
12/13/2022
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
1.Reviewed updated Covid operational plan. 2.Reviewed the difference between terminology of “not preformed” versus “unable to perform” in reference to the UAI and ISP. 3. Noted that remodel continues, and future plans were reviewed. 4. Medication documentation training forthcoming.
Comments
Renewal Inspection 12/13/2022 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building was clean and odor free. Outside inspections were current as were all related drills: Fire: 9/7/22 Health: 10/31/22 Additional Comments/Discussion: N/A An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with one applicable standard or law, and violation was 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov
Violations
22VAC40-73-620-A
There was no documentation of oversight at least every six months by a dietician or nutritionist or documentation that a contract had been signed. Administrator verified the facility had been unable to secure a dietician or nutritionist to conduct review but physician had been reviewing all diet needs along with hospice.
Plan of correction
The facility has struggled to locate a dietician since covid became an issue. The administrator assumes responsibility to continue to locate and contract with a dietician or nutritionist. This effort is also being pursued by three sister facilities in the area. In the interim the physician. nurse practitioner and hospice will continue to review diet needs of residents.
October 4, 2022Inspection1 violation
Inspection dates
10/04/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A self-reported incident was received by VDSS Division of Licensing on 09/21/2022 regarding allegations in the area(s) of: Resident Care. 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 Rhonda Whitmer Licensing Inspector at (540 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on document review and an interview, the facility failed to ensure medications are administered in accordance with the physician’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Based on communication from the facility via email on 09/21/2022, the “Incident Reporting to Licensing Office Form” indicates resident 1 did not receive 2mg of Warfarin that was ordered for daily administration effective 09/08/2022.
  2. The report indicates medication was not administered to resident 1 on 09/15/2022; 09/17/2022; 09/18/2022 and 09/20/2022. The report indicates 1mg of Warfarin was administered to resident 1 on 09/16/2022 and 09/19/2022 when 2mg was to be administered.
  3. Submitted documentation from the facility via email on 10/04/2022 indicates resident 1’s INR was 2.6 on 09/07/2022 at 3:58pm and 1.2 on 09/21/2022 at 3:40pm.
  4. The LI interviewed the administrator on 10/04/2022 who confirmed resident 1 did not receive the correct amount of Warfarin as ordered by the physician.
  5. Page 25 #6 A.3 of the current registered medication aide curriculum approved by the Virginia Board of Nursing indicates the right of medication administration as the “right dose.”
Plan of correction
Facility administrator will ensure Registered Medication Aides monitor and report any issues with medication administration for residents receiving Warfarin, issues with the pharmacy supplying medication, or entering the information correctly into the MAR.
November 23, 2021Inspection4 violations
Inspection dates
11/23/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 General Provisions63.2 Protection of adults and reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
An unannounced renewal inspection was completed by two licensing inspectors on 11/23/2021. The census was 28. A walk through was completed and all required postings were visible. The facility was clean and free from any foul odors. A review was conducted of four resident records and five staff records. The activities calendar and lunch menu were reviewed. An audit of the medication carts was completed. There were four violations during this renewal inspection. Details of non-compliance can be viewed in the violation notice of this report. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance of the regulation(s); 2) measures to prevent reoccurrence of non-compliance; 3) person(s) responsible for implementing each step and/or monitoring any preventative measures; 4) the date by which the non-compliance will be corrected. If you have any questions regarding this inspection, please contact the licensing inspector at (540) 292-5932 or rhonda.whitmer@dss.virginia.gov.
Violations
22VAC40-73-250-C
Based on review of staff records, the facility failed to ensure the record contained all required documentation.
Evidence
  1. The record for staff 2, hired 10/04/2021 did not contain a copy of a signed job description.
  2. The record for staff 3, hired 05/31/2021 did not contain a sworn disclosure statement.
  3. The record for staff 4, hired 07/16/2021 did not contain a signed job description, or an original criminal record report
Plan of correction
Facility administrator to ensure that staff records and requirements are completed correctly and within the allotted time after hire. Double check to be completed by RCD for accuracy.
22VAC40-73-450-C
Based on a review of residents' records, the facility failed to ensure all required components are included on the comprehensive Individualized Service Plan (ISP)
Evidence
  1. The UAI for resident 2 indicates resident requires mechanical assistance with dressing. This is not reflected on the ISP.
  2. The ISP for resident 4 does not include thick liquids and pureed diet or behavioral interventions.
Plan of correction
Facility administrator to ensure Individualized Service Plan (ISP) shows specialized diet and correct ADLs as indicated by the UAI. Monthly checks to be completed and double checked by RCD for completion.
22VAC40-73-640-D
Based on direct observation and an interview, the facility failed to ensure the drug reference guide for staff who administer medications is no more than 2 years old.
Evidence
  1. The drug reference book available to staff who administer medications is dated 2016.
  2. The LI interviewed the administrator on 11/23/2021 who confirmed this was the most current drug reference guide available to staff.
Plan of correction
Facility administrator to ensure that drug reference manual is up to date and available to staff. Updated drug manual received and place in the nurse’s station and med storage closet.
22VAC40-73-970-A
Based on review of documents and an interview, the facility failed to ensure fire drills are completed in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51)
Evidence
  1. The facility Record of Required Fire and Emergency Evacuation Drills indicates the most recent fire drill was conducted on 08/10/2021 at 9:00am.
  2. An interview with the administrator on 11/23/2021 confirmed the last documented fire and evacuation drill was conducted on 08/10/2021 for the day shift at 9:00am.
Plan of correction
Facility administrator to ensure Fire and Emergency Evaluation Drills are completed monthly. Monthly schedule to be post in view to maintain accuracy.
September 27, 2021Inspection0 violations
Inspection dates
09/27/2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A non-mandated monitoring inspection was initiated on 09/27/2021 and concluded on 10/31/2021. The administrator was contacted to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The evidence gathered during the investigation did not support non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 10, 2021Inspection2 violations
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 focused monitoring inspection was initiated on 06/10/21 and concluded on 06/15/21. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 32. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed a selected portion of two resident records submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance; 2) Measures to prevent reoccurrence of noncompliance; 3) Person(s) responsible for implementing each step and/or monitoring preventative measures; 4) Date by which the noncompliance will be corrected.
Violations
22VAC40-73-450-D
Based upon the review of residents' records, the facility failed to ensure the hospice services provided are included on the Individualized Service Plan (ISP). FINDINGS: Residents A and B are receiving hospice services. The services provided are not included on the ISP.
Plan of correction
Facility administrator to ensure Individualized Service Plan (ISP) shows all services provided by hospice and updated diet order.
22VAC40-73-680-E
Based upon review of residents' records, the facility failed to ensure medical procedures ordered by a physician are provided according to his instructions and documented. FINDINGS: 1) Resident A has the following order effective 03/01/21: Check weight weekly. Report weight gain greater than 5lbs in one week. a. Documentation in the electronic Medication Administration Record (MAR) indicates resident refused to be weighed on 05/24/21. There is no documentation in the MAR indicating resident was weighed during the month of May. 2) Resident B has the following order effective 05/13/20: Daily weight: Notify NP if gain of 3lbs in a day or 5lbs in a week. a. There is no weight documented on 05/02/21. b. Documentation on 05/25/21 indicates resident's weight is 147.4lbs c. Documentation on 05/26/21 indicates resident's weight is 153.4lbs. d. There is no documentation of notification to the NP regarding 7lb weight gain.
Plan of correction
Facility administrator to ensure that monthly weights are recorded and follow-ups performed if resident refuses on date of monthly weight. Facility administrator to ensure that physician notification is completed if refusal or weight gain/loss per the written order.
April 16, 2021Inspection4 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
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 04/16/21 and concluded on 05/10/21. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 31. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, staff schedule, criminal history reports, and the medication management plan submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) Steps to correct non-compliance; 2) Measures to prevent reoccurrence of noncompliance; 3) Person(s) responsible for implementing each step and/or monitoring and preventative measure(s); 4) Date by which the non-compliance will be corrected.
Violations
22VAC40-73-460-B
Based upon review of resident's record, and an interview, the facility failed to provide resident centered care by ensuring prompt response by staff to resident needs as reasonable to the circumstances as required by 22 VAC 40-73-460-B-3. FINDINGS: 1) Resident A has the following order effective 11/23/20: Acetaminophen 500mg-Take one tablet by mouth every 4 hours as needed for pain or fever. Resident A also has an order written effective 02/05/21 to administer Acetaminophen 500 mg first for pain if able, before Oxycodone. 2) Resident A has the following order effective 01/27/21: Oxycodone Concentrate 20mg/ml-Take 0.25ml (5mg) by mouth every 1 hour as needed for pain. 3) The Medication Administration Record (MAR) indicates Oxycodone was administered on 04/27/21 at 5:49pm "resident yelling uncontrollable for 3 1/2 hours signs and symptoms of pain." a. Results following the administration of medication are documented as "resident in bed with eyes closed." 4) There is no documentation Acetaminophen was administered prior to the administration of Oxycodone. 5) There is no documentation of Oxycodone being administered prior to 5:49pm. 6) The physician's order sheet requested by the licensing inspector and submitted by the administrator on 05/07/21 has an informational order "resident is being followed by hospice. Please call with any change in condition." 7) The licensing inspector interviewed the administrator via phone on 05/06/21 who stated "hospice was not notified." 8) Based on the licensing inspector's interview with the administrator, the administrator also indicated she had interviewed the staff regarding the incident and the employee stated she had no reason for not administering the medication or calling hospice.
Plan of correction
Facility administrator to educate all medication aides on PRN administration, signs and symptoms of pain, and documentation of interventions attempted prior to medication administration. Facility administrator to check any order variances and follow up for correctness.
22VAC40-73-680-D
Based upon review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlines in the current registered medication aide curriculum approved by the Virginia Board of Nursing. FINDINGS: 1) Resident A has the following orders: Effective 11/23/20: Acetaminophen 500mg-Take one tablet by mouth every 4 hours as needed for pain or fever. Effective 02/05/21 administer Acetaminophen 500 mg first for pain if able, before Oxycodone. Effective 01/27/21: Oxycodone Concentrate 20mg/ml-Take 0.25ml (5mg) by mouth every 1 hour as needed for pain. 2) The Medication Administration Record (MAR) indicates Oxycodone was administered to resident A on 04/27/21 at 5:49pm "resident yelling uncontrollable for 3 1/2 hours signs and symptoms of pain." a. Results following administration of medication are documented as "resident in bed with eyes closed." 3) There is no documentation Acetaminophen was administered prior to the administration of Oxycodone. 4) There is no documentation of Oxycodone being administered prior to 5:49pm. 5) The physician's order sheet requested by the licensing inspector and submitted by the administrator on 05/07/21 has an informational order "resident is being followed by hospice. Please call with any change in condition." 6) The licensing inspector interviewed the administrator via phone on 05/06/21 who stated "hospice was not notified."
Plan of correction
Facility administrator to educate all medication aides on proper hospice medication procedures and follow up if symptoms persist after medication administration.
22VAC40-73-680-I
Based upon review of residents' records, the facility failed to ensure that the Medication Administration Record (MAR) includes the effectiveness of "as needed" PRN medications as required by 22 VAC 40-73-680-I-13-c. FINDINGS: 1) Resident B has the following order effective 04/09/21: Senna Laxative 8.6mg-Take 1 tablet by mouth every day as needed for constipation. a. Documentation in the MAR indicates medication was administered on 04/09/21 at 11:40pm due to "resident complaining of belly pain, constipation." Results documented "resident resting in bed with eyes closed" b. There is no documentation of follow-up for effectiveness of medication's specific use.
Plan of correction
Facility administrator to educate all medication aides on complete documentation to medication administration and follow up. Facility administrator to check any order variances and follow up for correctness.
22VAC40-90-40-B
Based upon review of staff records, the facility failed to ensure criminal history reports were obtained on or prior to the 30th day of employment for each employee. FINDINGS: 1) The criminal history report for staff A (hired on 11/11/20) is dated 12/29/20. 2) The criminal history report for staff B (hired on 12/19/20) is dated 07/23/20.
Plan of correction
Region administrator to `double check? facility administrator on completing criminal history checks within the proper time frame quarterly and as needed.