Virginia DSS · Assisted Living Facility

Timberview Crossing Assisted Living

📍 351 New Market Road, Timberville, VA, 22853

ID 35940One Year licenseActive
15
Inspections
On record
10
With violations
Visits that cited something
5
Clean visits
Nothing cited
53
Violations cited
Individual findings
40
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint

Timberview Crossing Assisted Living was inspected 15 times between April 26, 2021 and March 4, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 53 violations under 40 distinct standards. 6 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 13 of these 15 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
Sara Darnell
Licensing inspector
Leslie Roberts
Inspector phone
804-298-5524
Approved for
Assisted Living · Non-Ambulatory

Inspection History

15

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

March 4, 2026Inspection1 violation
Inspection dates
03/04/2026
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND63.2- (17) Licensure and Registration Procedures22VAC40-80 The License
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: March 4, 2026, from 5:00 p.m. until 5:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/07/2026 regarding allegations in the area(s) of: RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS BUILDINGS AND GROUND Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector toured the facility, including the newly constructed resident room, and took measurements of the newly constructed room. Additional Comments/Discussion: Non An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-860-C
Based on direct observation, staff communication, and staff interview, the facility failed to ensure before construction begins or contracts are awarded for any new construction, remodeling, or alterations, plans were submitted to the department for review.
Evidence
  1. Licensing inspector (LI) received an email from staff 1 on 01/07/2026 asking to increase capacity of facility from 45 to 47 residents due to new construction that would be ready in approximately two weeks once painting was completed.
  2. Plans for construction were not submitted to the department for review prior to construction beginning.
  3. On 03/04/2026, LI and collateral contacts 1 and 2 arrived at the facility to take measurements of the newly constructed area, as required prior to increasing capacity.
  4. Facility had already moved a resident into the newly constructed area.
  5. During an interview with LI on 03/04/2026, staff 2 confirmed that resident 1 had moved into room on 02/04/2026.
Plan of correction
ED or Owner in the future will notify inspector of any changes pertaining to any renovation or construction plans prior to the project’s beginning. Regarding suite room number 6 and Therapy Gym; ED provided building permits, Class A general contractor and Fire Marshall reports, measurements and permit details including walls created for a new resident room to licensing inspector. In addition, plans to enclose a screened porch to create an Exercise/Therapy Gym with split HVAC unit was provided. ED provided an interior renovated map/floor plan for A100. NOTE: All renovations involved a Class A Bonded General Contractor working closely with Rockingham County Building Officials and Fire Marshal to complete this project in compliance with all building and fire codes. No residents were put in harms way during any work being performed.
December 4, 2025Inspection20 violations
Inspection dates
12/04/2025
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 PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) General Provisions22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
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: 12/4/2025 from 9:30 a.m. until 5:00 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: 40 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: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission.
Evidence
  1. Record for resident 7, admitted 6/5/2025, did not contain a comprehensive ISP. Staff 2 looked through resident 7’s record and confirmed there was not a comprehensive ISP completed for resident 7.
Plan of correction
Nurse ED Team Lead will ensure this is corrected.
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 is conspicuous to both residents and the public.
Evidence
  1. During the facility tour completed on 12/4/2025, LI and licensing administrator (LA) did not observe the current staff person in charge posted in the facility.
  2. During an interview on 12/4/2025 with LI, staff 2 stated that the asterisks next to the staff members’ name on the dry erase board indicated who the current on-site person in charge was. When LI asked staff 2, how someone would know that staff 2 responded, “they wouldn’t, you got me, but now it has been fixed”.
Plan of correction
Procedure for posting person in charge has been corrected as of 12/4/25.
22VAC40-73-260-C
Based on direct observation and staff interview the facility failed to ensure a listing of all staff with current certification in first aid or CPR was posted in the facility so the information was readily available to all staff at all times.
Evidence
  1. During the facility tour completed on 12/4/2025, there was no evidence of a posted listing of staff with current certification in first aid or CPR. Staff 1 took licensing inspector (LI) to two offices to look for the posting, but it was not present.
  2. Upon request, staff 2 provided a listing of staff with current certification in first aid or CPR.
  3. During an interview with staff 2 on 12/4/2025, when asked if there was a posted listing of all staff who have current certification in first aid or CPR, staff 2 stated there should have been but it was not posted at the time of the inspection.
Plan of correction
This has been corrected 12/5/25.
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure fire drills were completed on each shift in a quarter in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. During a record review on 12/4/2025, the Licensing Administrator (LA) observed that fire drills were conducted 10/29/2025 on second shift, 10/1/2025 on second shift, 9/8/2025 on second shift, 8/11/2025 at an unknown time, 7/16/2025 on first shift, and 6/19/2025 on third shift. No fire drills were completed during second shift from June 2025 through August 2025, and no fire drills were completed during first or third shifts from September 2025 through November 2025.
  2. Staff 2 confirmed that fire drills were not completed on each shift during the quarter.
Plan of correction
Not published by VDSS.
22VAC40-73-280-B
Based on record review and staff interview, facility failed to maintain a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care and directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. Upon request, the facility did not provide a written staffing plan or have one to provide.
  2. During an interview on 12/4/2025 with staff 2, when asked if there was a written staffing plan staff 2 provided a copy of the disclosure statement, which does not meet the requirement.
Plan of correction
Staffing plan/RMA overnight regulations state you do not need a RMA on duty as long as there is a RMA on call within 10-20 min. Radios TVC has an on call RMA every night that is in compliance with travel time.
22VAC40-73-710-C
Based on record review and staff interview, the facility failed to ensure a physician's written order was obtained that specified the condition, circumstances, and duration under which the restraint was to be used.
Evidence
  1. During tour of the facility the LA and LI observed bed rails on the beds of residents 7, 8, 9, and 10.
  2. Records for residents 7, 8, 9, and 10 did not contain any documentation from the physician or prescriber for bed rails.
  3. During an interview on 12/4/2025 with the LI, staff 2 confirmed the facility had not obtained a physician’s order which specified the condition, circumstances, and duration under which the restraint (bedrail) was to be used.
  4. Photo evident taken.
Plan of correction
Orders will be obtained by MD for Repositioning- ED RCC will have resident sign a form they know how to release bed rail.
22VAC40-73-410-A
Based on resident record reviews and staff interview, the facility failed to provide an orientation, upon admission, for new residents and their legal representatives, which included emergency response procedures, mealtimes, and use of the call system with acknowledgment of having received the orientation dated by the resident and/or legal representative, with documentation kept in the resident's record.
Evidence
  1. Record for resident 4, admit date 4/12/2025, did not contain a documented orientation that was signed by the resident.
  2. Record for resident 5, admit date 10/22/2024, did not contain a documented orientation that was signed by the resident.
  3. Record for resident 6, admit date 4/2/2025, did not contain a documented orientation that was signed by the resident.
  4. During an interview with the LI on 12/4/2025, staff 2 confirmed there was no documented orientation signed by residents 4, 5, and 6.
Plan of correction
ED will ensure any alert resident moving forward will sign orientation to facility not POA.
22VAC40-73-860-I
Based on observation and staff interview, the facility failed to store cleaning supplies in a locked area.
Evidence
  1. During a tour of the facility on 12/4/2025, LA observed bottles of cleaning liquids hanging on mop sink and under mop sink, lemon furniture polish, OdoBan disinfectant spray, Clorox Clean-Up spray next to Polident denture tabs, in the unlocked electrical room.
  2. Photo evidence taken.
Plan of correction
All staff have been advised the door must stay locked at all times and a note will be posted.
22VAC40-73-200-C
Based on record review and staff interview, the facility failed to ensure direct care staff met one of the requirements in this subsection within two months of employment.
Evidence
  1. Staff 4, hired 7/11/2025, did not obtain direct care assistant (DCA) certification until 9/26/2025, which was not within two months of employment.
  2. Staff 2 acknowledged Staff 4 did not obtain direct care staff requirements within two months of employment as required by standard.
Plan of correction
Ed Rec will ensure that all direct care staff are in compliance with regulations within 60 days of hire.
22VAC40-73-830-E
Based on facility document review and staff interviews, the facility failed to ensure that a written response was provided to the council prior to the next meeting.
Evidence
  1. The facility provided LI and LA with a copy of the resident council meeting minutes.
  2. All of the resident council meeting minutes did not include updates or adequate responses to previous meeting requests.
  3. During interviews with LI, both residents 14 and 15 voiced concerns regarding receiving no response to concerns voiced during resident council meetings. When LI asked resident 15 if they receive a written response from resident council, resident 15 responded, “Heck no, I never know what happens. We should know before next meeting what happened.”
  4. Staff 2 and 9 confirmed that written responses had not been provided to residents prior to the next council meeting.
Plan of correction
Resident will be given follow up minutes/correction after each resident council meeting.
22VAC40-73-250-D
Based on staff record reviews and staff interview, the facility failed to ensure documented absence of tuberculosis in a communicable form as
Evidence
  1. d by completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Record for staff 3, hired 11/20/2025, contained an undated tuberculosis (TB) risk assessment.
  3. Record for staff 7, hired 10/31/2025, did not contain a tuberculosis risk assessment.
  4. Staff 2 acknowledged there was no date on the TB risk assessment for staff 3, and no completed TB risk assessment for staff 7.
Plan of correction
Ed Rec will monitor to ensure that staff are in compliance with state regulations has been corrected 12/5/25.
22VAC40-73-980-A
Based on resident record review and staff interviews, the facility failed to ensure a complete first aid kit was on hand at the facility and contained all the required items as listed in the subsection.
Evidence
  1. The facility first aid kits, which included one backpack and one tub, were inventoried by LA. The backpack first aid kit was missing a thermometer and extra batteries for flashlight. The tub first aid kit was missing Band-Aids in assorted sized, disposable single-use waterproof gloves, gauze pads and roller gauze in assorted sizes, triangular bandages, and a first aid manual.
  2. Staff 2 and 10 confirmed the backpack first aid kit was used on the bus during trips, and the tub first aid kit was used in the facility.
  3. During an interview with the LI and LA on 12/4/2025, staff 2 confirmed that the first aid kits did not contain all the required elements, because staff use the items and do not replenish them.
Plan of correction
First Aide Kit Blanket/Gloves will be monitored by RCC/Team Lead monthly to ensure it is in compliance with regulations.
22VAC40-73-450-F
Based on record reviews and staff interview, the facility failed to ensure the individualized service plans (ISP) are reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Record for resident 5, admitted 10/22/2024, only contained an ISP dated 10/10/2024. There was no ISP for October 2025.
  2. During an interview with staff 2 on 12/4/2025, when asked if an ISP was updated annually for resident 5, staff 2 stated “no”.
  3. Record for resident 7, admitted 6/5/2025, contained only an initial ISP, which did not include Hospice services being received or residents use of bed rails.
  4. Record for resident 8, admitted 2/13/2023, contained documentation that Hospice services began on 5/13/2025. ISP did not include Hospice services or residents use of bed rails.
  5. Record for resident 11 contained an order from Hospice, dated 10/29/2025, for the use of a bed and chair alarm. ISP for resident 11, dated 7/31/2025, was not updated with this information.
  6. During interview with LI and LA, staff 2 confirmed that ISPs for residents 7,8, and 11 had not been updated with significant changes.
Plan of correction
ISP was completed on 10/12/25 Which at this point would be in compliance.
22VAC40-73-970-E
Based on record review and staff interview, the facility failed to ensure documentation of fire drills had all required information.
Evidence
  1. The fire drill form used by the facility to document completed drill on 5/29/2025 did not include the location of the fire drill, the weather at the time of drill, the action taken/drill procedure, or the duration of the drill.
  2. The fire drill form used by the facility to document completed drill on 8/11/2025 did not include the action taken during the fire drill, the number of staff that participated in the drill, the time it took to complete the drill, or the start time/shift the fire drill occurred on.
  3. During an interview on 12/4/2025 with the LI and LA, staff 2 acknowledged the fire drills did not contain all of the required information.
Plan of correction
Ed has corrected.
22VAC40-73-560-F
Based on observation and staff interview, the facility failed to ensure that all records were treated confidentially.
Evidence
  1. During tour of the facility the LA and LI observed narcotics books left on top of each of the two medication carts.
  2. During an interview with staff 2 on 12/4/2025, when asked if the narcotics books were left on top of medication carts, staff 2 stated “yes”. Staff 2 stated the books are left closed but LA explained there is nothing preventing someone from opening book and reading orders when medication carts are unattended, which is fairly often throughout the day.
  3. Photo evidence taken.
Plan of correction
RMA TEAMLEAD RCC will ensure the narcotic books are locked in cart.
22VAC40-73-310-D
Based on resident record review and staff interview, the facility failed to provide written assurance to the resident that the facility had the appropriate license to meet his care needs at the time of admission with a signed copy of the written assurance retained in the resident’s record.
Evidence
  1. Record for resident 4, admitted 4/12/2025, did not contain a written assurance that was signed by the resident or legal representative.
  2. Staff 2 looked through resident record and confirmed there was no written assurance obtained for resident 4.
Plan of correction
ED Rec will monitor charts to ensure that written assurance are completed 12/5/25.
22VAC40-73-310-M
Based on record review and staff interview, the facility failed to ensure there was a written agreement between the assisted living facility and any hospice program that provides care to residents in the facility.
Evidence
  1. When asked during an interview on 12/4/2025, if there were any residents receiving hospice services, staff 2 stated that there were six residents in the facility currently receiving Hospice services.
  2. Upon request, staff 2 stated the Hospice contracts were available in the state book, except for the contract for Serenity Hospice, which was sent on 12/3/2025. LI and LA were unable to locate Hospice agreements for the five hospice programs providing services in the facility.
  3. During another interview with LI and LA on 12/4/2025, when asked if written agreements were in place with the five hospice programs, staff 2 answered, “no”.
Plan of correction
Currently working on getting contracts signed.
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. During tour of the facility the LA and LI observed bed rails on the beds of residents 7, 8, 9, and 10.
  2. Records for residents 7, 8, 9, and 10 did not contain any documentation or signed orders from the physician or prescriber for bed rails.
  3. During an interview with LI on 12/4/2025, staff 2 stated that residents 11, 12, and 13 wear a Wander guard device.
  4. Records for residents 11, 12, and 13 did not contain any documentation or signed orders from the physician or prescriber to apply a Wander guard device.
  5. During an interview with LI on 12/4/2025, when asked if residents 11, 12, and 13 have a physician’s order for Wander guard, staff 1 stated, “No, they do not have a physician’s order. The family agreed.”
Plan of correction
Physician's order for wander guard/ hospital bed rails orders will be obtained 12/5/25 signed by MD.
22VAC40-73-390-A
Based on record review and staff interview, the facility failed to ensure at or prior to the time of admission, there was a written agreement or acknowledgment of notification, that was dated and signed by the resident or the appropriate legal representative and by the licensee or administrator.
Evidence
  1. Resident 4, admitted 4/12/2025, had a resident agreement dated 4/14/2025, which is not prior to or at time of admission.
  2. During an interview with LI on 12/4/2025, staff 2 confirmed the facility failed to ensure there was a written admission agreement signed at or prior to admission for resident 4.
Plan of correction
Ed will ensure that dates match date of admission.
22VAC40-73-1070-B
Based on observation by licensing staff, the facility failed to ensure that ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment were inaccessible to the resident except under staff supervision.
Evidence
  1. This facility serves a mixed population, including residents with serious cognitive impairment.
  2. During a tour of the facility on 12/4/2025, LA observed two unlocked electrical breaker panels in the main hallways, which were easily accessible to residents.
  3. Photo evidence taken.
Plan of correction
Ed will ensure locks are placed on boxes.
May 13, 2025Inspection3 violations
Inspection dates
05/13/2025
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: 5/13/2025 from 9:15 a.m. to 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: 39 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The following were reviewed at the time of inspection: menu, activity calendar, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight, Virginia Department of Health inspection. The Licensing Inspector reviewed and verified liability insurance. 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 Jill James, Licensing Inspector at (540) 416-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on record reviews and staff interview, the facility failed to ensure risk assessments for tuberculosis (TB) were completed annually.
Evidence
  1. A TB assessment was completed on 1/25/2024 for residents 1 and 4.
  2. On 5/13/2025, staff 1 acknowledged there was not a TB screening completed for residents 1 and 2 after 1/25/2024.
Plan of correction
Ensure Resident TB screening annually The Executive Director and Wellness Coordinator will review monthly to ensure that they are complying, review of resident’s charts was completed all annual assessment have been completed and update.
22VAC40-73-440-H
Based on record review and staff interview, the faculty failed to ensure an annual reassessment using the Uniform assessment instrument (UAI) had been completed to determine resident’s needs.
Evidence
  1. On 5/13/25, the licensing inspector was shown a list of residents due to have a UAI reassessment which included: resident 4 (UAI completed 4/17/2024) resident 8 (UAI completed 4/16/2024) resident 9 (UAI completed 4/16/2024) resident 10 (UAI completed 4/25/2024)
  2. On 5/13/2025, staff 6 acknowledged that UAI reassessments got behind when there was not a nurse on staff and the UAI had not been updated for residents 4, 8, 9, 10 since April 2024.
Plan of correction
UAI ensure annual assessment to be completed and reviewed by Executive Director , Wellness coordinator has reviewed UAI due date report and UAI are in compliance.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure that individualized service plans (ISP) were updated at least every twelve months.
Evidence
  1. On 5/13/25, the licensing inspector was shown a list of residents due for an UAI and ISP reassessment which included: resident 4 (ISP completed 4/17/2024) resident 8 (ISP completed 4/16/2024) resident 9 (ISP completed 4/16/2024) resident 10 (ISP completed 4/25/2024)
  2. On 5/13/2025, staff 6 acknowledged that the ISP is completed at the same time as the UAI and these had not been updated since April 2024 for residents 4, 8, 9 and 10.
Plan of correction
ISP updated with assessment Executive Director completed and reviewed to assure all is updated at this time.
May 13, 2025Complaint survey0 violations
Inspection dates
05/13/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/13/2025 5:30 p.m. to 6:00 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 8/6/24 regarding allegations in the area of: Admission, retention and Discharge of residents. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were preparing for dinner and having visits with family members. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. 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 Jill James, Licensing Inspector at (540) 5418-2631 or by email at jill.james@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 15, 2023Inspection0 violations
Inspection dates
11/15/2023
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 15, 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 43 Number of records reviewed and interviews conducted- 7 records (staff and residents), 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, pharmacy review, healthcare oversight and dietician report.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 25, 2023Complaint survey9 violations
Inspection dates
04/25/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
1. The review of Rights and Responsibilities of Residents must be signed and dated by each resident/legal representative and staff to ensure written acknowledgment of the review. 2. The direct care training certificate must be signed by the nurse that taught the class, not the administrator of the facility.
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/25/2023 from approximately 10:55 am to 7:15 pm 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 4/12/2023 regarding allegations in the areas of: Administration, Personnel, Staffing, Admission, Retention, Discharge of Residents, Resident Accommodations, Building and Grounds and Emergency Preparedness. Number of residents present at the facility at the beginning of the inspection: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 + selected sections of 5 additional records Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: Staff and resident interactions, resident rooms, etc. Additional Comments/Discussion: Interviews were conducted with residents, a family member and staff. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were in the areas of: Personnel; Admission, Retention and Discharge of Residents. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-560-H
Based upon interviews, the facility failed to ensure one of one discharge record remained on site for at least the first year after discharge.
Evidence
  1. On 4/25/2023, the LI requested to review the record for resident 1 (discharged 12/14/2022). The wellness coordinator and administrator both stated the record was off site in storage and could not be obtained on the day of the inspection.
Plan of correction
Administrator or Resident Care Director will ensure that all residents records are kept onsite in community storage area and available for one year, as per standard. Administrator will monitor monthly.
22VAC40-73-610-B
Based upon observations, documentation and an interview, the facility failed to ensure menus were dated.
Evidence
  1. On 4/25/2023, the LI observed the posted menu by the dining room. The holder for the menu also included three additional menus. None of the menus were dated. The menus only included the week number and day of the week – no month, day or year.
  2. On 4/25/2023, the LI interviewed the administrator who checked the menus with the LI and stated the menus were not dated.
  3. On 4/25/2023, the LI interviewed the dietary manager who stated they had not been putting dates on the menus.
Plan of correction
Administrator retrained dietary manager on 5/10/23, to ensure menu is posted with month with daily dates and resident copies of menus are complete with daily dates. Administrator, Resident Care Director or Dietary Manager will review monthly as menu is posted, for continued compliance.
22VAC40-73-550-G
Based upon documentation and an interview, the facility failed to ensure written acknowledgement of an annual review of the rights and responsibilities of residents was documented in five of eight staff records reviewed.
Evidence
  1. The training records for staff 5, 6, 7, 8 and 9 listed resident rights and the date training was completed; however, the training record was not signed by the staff and no training sign-in sheets were in the records.
  2. On 4/25/2023, the LI interviewed the administrator who stated they did not have the staff sign or have the staffs’ written acknowledgement that they completed an annual review of the residents rights.
Plan of correction
Administrator completed an additional review of Residents Rights with each staff member. Training was documented by completing an acknowledgement form, signed and dated 4/24/23. Administrator will ensure the acknowledgement form is utilized upon hire and annually.
22VAC40-73-350-A
Based upon interviews, the facility failed to ensure registration was completed and remained current with the Department of State Police in order to receive notifications of sex offenders residing in the facility’s zip code area.
Evidence
  1. On 4/25/2023, the LI asked the administrator to provide verification of registration with the state police for receiving sex offender registry notifications and she stated she had not received any notifications since employed at the facility. She also stated she did not have any kind of verification of the facility being registered.
  2. On 4/26/2023, the licensee contacted LI by email and stated they would contact LI if they found anything regarding the facility being registered. He stated they were receiving the notifications when he was the administrator in October 2021. No verification was provided regarding the facility being registered.
Plan of correction
Administrator registered the community with Department of State Police on 5/11/23. All Sex Offender notifications will be available to residents and their representatives at all times.
22VAC40-73-260-C
Based upon documentation and an interview, the facility failed to ensure the posted list of staff with current FA and cardiopulmonary resuscitation training (CPR) was kept up to date.
Evidence
  1. The posted list included staff 10, 11, 12 and 13.
  2. On 4/25/2023, the LI interviewed the administrator who reviewed the list and stated staff 10, 11, 12 and 13 were no longer employed at the facility.
Plan of correction
Administrator updated and posted current list on 5/12/23. Administrator will ensure posted list of staff with FA and CPR is up to date, displaying FA and CPR certified staff in accordance with current employe roster.
22VAC40-73-260-A
Based upon documentation and an interview, the facility failed to ensure two of the four staff completed first aid (FA) training within 60 days of hire.
Evidence
  1. Staff 3 and 4 (hired October 2022) completed FA training on 3/14/2023.
  2. On 4/25/2023, the LI interviewed the administrator who stated the staff did not complete FA training within 60 days of hire and the 3/14/2023 training was the only FA training completion on file.
Plan of correction
Administrator reviewed all staff records on 5/10/23 for compliance. Administrator will review all new hire certifications upon hire and ensure FA is completed within 60 days of hire.
22VAC40-73-350-C
Based upon record reviews and an interview, the facility failed to ensure sex offender registry information was reviewed annually for one of three resident records reviewed.
Evidence
  1. Resident 3 (admitted 9/4/2017) had no documentation on file of an annual review of the sex offender registry information.
  2. On 4/25/2023, the LI interviewed the administrator who stated they did not have documentation of annual reviews of the sex offender registry information for residents
Plan of correction
Administrator will review Sex Offender Registry standard with all residents and document by completion of an acknowledgement form, signed and dated by resident or resident representative by 5/15/23 and annually.
22VAC40-73-325-B
Based upon documentation and an interview, the facility failed to ensure fall risk ratings were completed after each fall for one of three resident records reviewed.
Evidence
  1. Resident 2 had incident reports for falls 4/17/2022, 5/14/2022, 8/1/2022 and 1/23/2023; however, there were no fall risk ratings on file for these incidents.
  2. On 4/25/2023, the LI interviewed the administrator who checked the files and stated there were no fall risk ratings completed for these incidents.
Plan of correction
Administrator completed and updated residents fall risk rating on 5/08/23. Administrator and Resident Care Director will review all falls to ensure fall risk ratings are completed at time of incident and policy is followed. Administrator or Resident Care Director will complete a falls and fall risk rating staff re-training by 5/15/23, to ensure continued compliance.
22VAC40-73-620-A
Based upon interviews, the facility failed to ensure dietary reviews were conducted at least once every six months.
Evidence
  1. On 4/25/2023, the licensing inspector (LI) requested the administrator provide the dietary reviews from the previous year. A dietary review dated 3/22/2023 was the only review provided.
  2. On 4/25/2023, the LI interviewed the administrator who stated the facility did not have a dietitian when she started as administrator in October 2022.
  3. On 4/25/2023, the LI interviewed the dietary manager who stated they did not have any dietary reviews and that “a dietary review has not been completed since before COVID.”
Plan of correction
Registered Dietitian is contracted and completed dietary review 3/9/23. The Administrator will ensure the contracted Dietitian completes resident diet review semi-annually for each resident and will ensure review results are available to the inspector upon request. Timberview was unable to secure a Dietitian post Covid, to complete dietary services. The licensing inspector was notified by Administrator and CEO of parent company. Dietitian was secured in March of 2023 and completed review on March 9, 2023.
November 30, 2022Inspection0 violations
Inspection dates
11/30/2022
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 PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
1. Continue to seek dietician since previous contract did not work out. 2. Seek clarification from VA on orders, notification and documentation for resident C as per discussion. 3. Notify licensing when December fire inspection is completed.
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: 11/30/2022 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: 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: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Outside inspections were current at the time of the inspection. A fire inspection was scheduled for later in the month. Additional Comments/Discussion: The evidence gathered during the inspection determined no violations with applicable standard(s) or law. 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. An exit meeting was conducted to review the inspection findings. 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 Rhonda Whitmer, Licensing Inspector by email at rhonda.whitmer@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 5, 2022Inspection1 violation
Inspection dates
01/05/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 01/05/2022 and concluded on 01/05/2022. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued.
Violations
22VAC40-73-460-D
Based on documentation and an interview the failed to provide supervision to prevent a fall.
Evidence
  1. Documentation received from the facility on 12/23/2021 indicates resident 1's wheelchair tipped backwards and resident fell due to staff not locking the wheelchair wheels.
  2. The LI interviewed the administrator on 12/23/2021 who confirmed staff were interviewed and the wheelchair break lock was not engaged at the time of the fall.
Plan of correction
Not published by VDSS.
December 8, 2021Inspection1 violation
Inspection dates
12/08/2021
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 EMERGENCY PREPAREDNESS63.2 General Provisions63.2 Protection of adults and reporting63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A renewal inspection was initiated on 12/08/2021 and concluded on (12/15/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 26. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, fire drills, pharmacy review and criminal history reports submitted by the facility to ensure documentation was complete. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and a violation was 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 non-compliance; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s); 4) the date by which the non-compliance will be corrected.
Violations
22VAC40-73-450-D
Based on review of residents' records, the facility failed to ensure services provided by hospice are included on the Individualized Service Plan (ISP)
Evidence
  1. The hospice plan of care for resident 1 indicates social worker, skilled nursing and hospice aide services are provided. These are not included on the ISP.
Plan of correction
Administrator will review Hospice plan of care to ensure that all participants providing care from Hospice are noted within the ISP. Hospice services are added the ISP for resident 1.
October 8, 2021Inspection0 violations
Inspection dates
10/08/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 10/08/2021 and concluded on 10/25/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 6, 2021Inspection0 violations
Inspection dates
09/06/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
A non-mandated self-report inspection was initiated on 09/06/2021 and concluded on 09/27/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The acting administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the acting administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 1, 2021Complaint survey3 violations
Inspection dates
09/01/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 09/01/2021 and concluded on 09/20/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-D
Based on document review, the facility failed to ensure the Individualized Service Plan (ISP) included services provided by hospice.
Evidence
  1. The Individualized Service Plan dated 07/21/21 for resident 1, indicates resident receives hospice care and staff will follow the hospice care plan attached and staff to call hospice 24/7 if any concerns or needs of residents.
  2. The hospice care plan for resident 1 was not included with the ISP dated 07/21/2021.
  3. The Individualized Service Plan dated 07/21/21 for resident 1 does not include a description of hospice services provided as required.
Plan of correction
Administrator will assure all ISPs are complete and accurate. ISP audit/review will be completed by administrator.
22VAC40-73-450-E
Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) are signed and dated by the resident or his legal representative.
Evidence
  1. The Individualized Service plan for resident 1, dated 07/21/2021 is not signed by the resident or his legal representative.
Plan of correction
Administrator will assure all ISPs are presented for signature to appropriate resident or legal representative upon completion of audit/review.
22VAC40-73-680-D
Based on document review, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instruction and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The record for resident 1 contained the following physician's order dated 01/13/2021: Morphine SF 20mg/ML: Take 0.25ml (5mg) by mouth every 2 hours as needed.
  2. Hospice nursing note dated 06/28/2021 at 12:50pm indicates "Nurse is unsure of exact amount morphine administered. Nurse instructed that staff try Lorazepam as next intervention in case patient did take an excess of morphine last night."
  3. The June Medication Administration Record (MAR) for resident 1 confirms that Morphine was administered at 1:40pm prior to the Lorazepam, that was administered at 5:38pm.
Plan of correction
Administrator will coordinate a medication aide in-service on medication administration with facility pharmacy nurse. Staff involved in medication administration in this case will complete medication administration refresher course.
July 21, 2021Complaint survey9 violations
Inspection dates
07/21/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 07/21/2021 and concluded on 09/14/2021. A complaint incident was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-D
Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included services provided by hospice.
Evidence
  1. The hospice plan of care for resident 1 effective 07/06/2021 indicated resident receives skilled nursing twice weekly and medical social worker visits once a month, however this is not indicated on the Individualized Service Plan.
  2. The hospice plan of care for resident 13 effective 07/01/2021 indicated resident receives skilled nursing and hospice aide services twice weekly and medical social worker visits once a month, however this is not indicated on the Individualized Service Plan.
Plan of correction
All resident Individualized Service Plans (ISPs) will be audited to ensure all services provided by hospice are included. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
22VAC40-73-470-F
Based on document review, the facility failed to secure immediate medical attention from a licensed health care professional when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred.
Evidence
  1. The facility Resident Incident/Accident Report dated 06/21/2021 at 7:00pm for resident 1 indicates "staff saw resident starting to stumble and lean back. Staff tried running to catch resident. Resident reached out his arm to staff. Staff grabbed his hand but he still fell backwards. Staff noticed knees were scraped. Resident admitted he fell earlier and didn't say anything."
  2. The facility Resident Incident/Accident Report dated 06/21/2021 at 7:00pm for resident 1 indicates resident had scraped knees and blood pressure reading of 186/78.
  3. The facility chart note indicates the administrator was notified at 7:30pm.
  4. There is no documentation resident was seen by a licensed health care professional after having two falls and a systolic blood pressure of 186.
Plan of correction
Administrator will assure when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect such as occurred, medical attention from a licensed healthcare professional will be secured immediately. The administrator will ensure incidents are filed timely and when there is fall frequency or elevated blood pressure, medical attention will be secured immediately. Resident 1 is no longer in the facility.
22VAC40-73-325-C
Based on document review, the facility failed to document analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce the risk of subsequent falls.
Evidence
  1. Facility Resident Incident/Accident reports dated 06/28/2021 indicates resident 1 sustained falls on 06/28/2021 at 9:00am and 5:00pm.
  2. There is no documentation of analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce the risk of subsequent falls.
Plan of correction
Resident 1 is no longer in the facility. Administrator will assure analysis of fall prevention assessment and interventions are documented and implemented to prevent risk of subsequent falls.
22VAC40-73-450-G
Based on record review, the facility failed to ensure a current copy of the Individualized Service Plan (ISP) is provided to the resident.
Evidence
  1. The section on the ISP for resident 2 dated 05/10/2021 indicating if resident has received a copy of the ISP is not completed.
  2. The section on the ISP for resident 8 dated 08/22/2020 indicating if resident has received a copy of the ISP is not completed.
Plan of correction
All resident Individualized Service Plans (ISPs) will be audited to ensure acknowledgment of receipt by the resident. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
22VAC40-73-640-A
Based on record review, the facility failed to implement a written plan for medication management to ensure that residents do not receive medications or dietary supplements to which they have known allergies.
Evidence
  1. The July 2021 Medication Administration Record for resident 12 indicates resident has an allergy to Acetaminophen.
  2. The physical exam for resident 12 dated 09/21/2016 indicates resident has an allergy to Acetaminophen.
  3. Resident 12 has a physician's order effective 06/30/2020 for PRN Acetaminophen.
  4. The facility medication management plan dated 02/01/2018 indicates on page 4 #9a and page 5 #10a "when a medication aide receives a new order or change in order, that there are no known allergies to medication/nutritional supplement, fax order to facility pharmacy to be put in eMar, fax to supplying pharmacy and put order in merge folder."
  5. The facility medication management plan page 10 #29 indicates "The medication management plan, policy and procedure will be reviewed yearly by the administrator to assure accuracy."
  6. There is no documentation indicating the facility medication management plan has been reviewed since 02/01/2018.
Plan of correction
The administrator will ensure the medication management plan is followed regarding new orders and a change in orders. The plan will be reviewed with all staff who administer medications and documented in the staff file. The administrator will ensure all new staff who are qualified to administer medications are oriented to the facility's medication management plan. Resident 12 is no longer in the facility.
22VAC40-73-680-D
Based on record review, the facility failed to administer medications in accordance with the physician's or other prescriber'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. Resident 1 has the following order: C/DOPA-L/DOPA 25-100 TB-Take one tablet by mouth four times a day for Parkinson's.
  2. The Medication Administration Record (MAR) for resident 1 indicates medication was not administered on 06/03/21 at 5:00pm "order needing clarification"; 06/03/21 at 8:00pm "medication not available"; 06/05/21 at 8:00pm "order needing clarification"; 06/06/21 at 5:00pm "order needing clarification"; 06/6/21 at 8:00pm "order needing clarification; 06/07/21 at 7:00am "order needing clarification"; 06/07/21 at 11:00am "order needing clarification"; 06/21/21 at 8:00pm "medication not available"
  3. Resident 1 has the following order: Hydrazaline 10mg tablet-Take one tablet by mouth every day as needed to systolic blood pressure greater than 180. The facility Resident Incident/Accident Report dated 06/21/2021 at 7:00pm for resident 1 indicates resident had scraped knees and blood pressure reading of 186/78. There is no documentation of Hydrazaline being administered on 06/21/2021.
Plan of correction
The administrator will have a licensed health care professional complete a medication administration observation on each staff who are qualified to administer medications and going forward, this will be completed quarterly. The administrator or licensed health care professional will review the Medication Administration Records (MARs) weekly for the first month and thereafter, monthly.
22VAC40-73-450-C
Based on record review, the facility failed to ensure that Individual Service Plans (ISPs) include all required components.
Evidence
  1. The ISP for resident 1, dated 05/10/2021 showed the resident is assessed as a high fall risk, but did not include a written description of interventions to prevent or reduce falls.
  2. The Uniform Assessment Instrument (UAI) for resident 2, dated 05/10/2021, shows this resident is assessed as needing physical and mechanical assistance with transferring; however mechanical assistance is not addressed on the ISP dated 05/10/2021.
  3. The ISP for resident 2, dated 05/10/2021, showed the resident is disoriented to real time, but did not include a written description of the services to be provided to address this need.
  4. The ISP for resident 3, dated 06/21/2021, showed the resident is disoriented to time and place, but did not include a written description of the services to be provided to address this need.
  5. The ISP for resident 4, dated 06/21/2021, showed the resident is disoriented to time and place, but did not include a written description of the services to be provided to address this need.
  6. The ISP for resident 8, dated 08/22/2020, showed the resident is disoriented to time and place, but did not include a written description of the services to be provided to address this need.
  7. The UAI for resident 9, dated 02/26/2021, shows this resident as assessed as wandering weekly or more, however the ISP indicates resident does not wander.
  8. The ISP for resident 10, (not dated), showed the resident is disoriented some spheres all of the time, but did not include a written description of the services to be provided to address this need.
  9. The UAI for resident 10, dated 06/26/2021 shows this resident as assessed as needing assistance with meals and spoon fed, however this is not addressed on the ISP.
  10. The ISP for resident 12, dated 09/16/2020, showed the resident is disoriented to place, person, and time but did not include a written description of the services to be provided to address this need.
  11. The UAI for resident 12, dated 09/12/2020 showed the resident as assessed as having wandering behavior, however the ISP indicates resident does not have wandering behavior.
  12. The UAI for resident 13, dated 12/15/2020 showed the resident as assessed as requiring professional nursing staff to administer medications; however the ISP indicates medication is to be administered by a Registered Medication Aide (RMA).
Plan of correction
All resident Individualized Service Plans (ISPs) will be audited to ensure all required components are included. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
22VAC40-73-450-E
Based on record review, the facility failed to ensure the Individualized Service Plans (ISPs) are signed and dated by the administrator and by the resident or his legal representative.
Evidence
  1. The Individualized Service Plan for resident 1, dated 05/10/2021 does not include the signature of the resident or legal representative.
  2. The Individualized Service Plan for resident 2, dated 05/10/2021 does not include the signature of the resident or legal representative.
  3. The Individualized Service Plan for resident 3, dated 06/21/2021 does not include the signature of the resident or legal representative.
  4. The Individualized Service Plan for resident 4, dated 06/21/2021 does not include the signature of the resident or legal representative.
  5. The Individualized Service Plan for resident 5, dated 06/21/2021 does not include the signature of the resident or legal representative.
  6. The Individualized Service Plan for resident 7, dated 05/12/2021 does not include the signature of the resident or legal representative.
  7. The Individualized Service Plan for resident 9, dated 02/21/2021 does not include the signature of the resident or legal representative.
  8. The Individualized Service Plan for resident 10, is not dated by the administrator and does not include the signature of the resident or legal representative.
Plan of correction
All resident Individualized Service Plans (ISPs) will be audited to ensure the required signature and date are included per requirements. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
22VAC40-73-450-F
Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) is reviewed and updated annually.
Evidence
  1. The most recent ISP for resident 6 is dated 08/26/2019.
Plan of correction
All resident Individualized Service Plans (ISPs) will be audited to ensure all are updated annually or as needed for a significant change in the resident's condition. The administrator will review all ISPs for all new admissions and there after, monthly to ensure accuracy and completeness.
July 6, 2021Complaint survey3 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 07/06/21 and concluded on 07/11/21. A complaint was received by the department regarding allegations in the areas of resident care. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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 noncompliance; 2) measures to prevent reoccurrence of noncompliance; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s); 4) the date by which the noncompliance will be corrected.
Violations
22VAC40-73-70-A
Based upon documentation review and communication received from the administrator, the facility failed to report to the licensing office, a major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident within 24 hours.
Evidence
  1. Communication via email received from the administrator on 07/05/21 indicates resident A "slipped on her own urine as she was transferring herself to toilet and at the time she did not complain of any pain and no visible injuries." Email also indicates "the family decided to take her to the hospital." The email did not indicate when the resident fell.
  2. The administrator submitted a formal incident report on 07/08/21. The submitted report indicates fall occurred on 06/30/21 at 8:30pm and family took resident to emergency department.
Plan of correction
Facility administrator will report all falls regardless of injury as directed by licensing inspector and adult protective services.
22VAC40-73-450-C
Based on review of resident's record, the facility failed to have a comprehensive Individualized Service Plan (ISP) that includes the assessed needs of the resident.
Evidence
  1. The UAI dated 02/02/21 for resident A indicates mechanical assistance is needed with toileting. The ISP dated 02/02/21 indicates no assistance is required.
  2. The UAI dated 02/02/21 for resident A indicates no assistance is needed with transferring. The ISP dated 02/02/21 indicates use of wheelchair and grab bars.
  3. The UAI dated 02/02/21 for resident A indicates supervision is needed with walking. This is not reflected on the ISP dated 02/02/21.
Plan of correction
ISP and UAI undated. Resident is non-compliant for asking or accepting assistance with transferring and toileting.
22VAC40-73-470-F
Based on documentation review and communication received from the administrator, the facility failed to ensure when a resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately.
Evidence
  1. Facility form, "Resident Incident/Accident Report" prepared on 06/30/21 indicated resident A had a fall. Documentation shows "resident slipped in her urine; complains of pain on side."
  2. Chart note dated 06/30/21 at 6:20pm indicated resident complained of right lower chest pain and administrator was notified by phone on 06/30/21 at 9:58pm.
  3. DCA note dated 07/02/21 at 8:00am indicate "resident is complaining of left side pain from previous fall; gave PRN Tylenol; getting x-ray ordered for her; notified family and administrator."
  4. DCA note dated 07/02/21 2pm-10pm shift indicates resident is still complaining of side pain and resident was sent to hospital by rescue squad.
  5. Hospital records show resident A was admitted from 07/02/21 through 07/05/21 with three rib fractures on the left side.
  6. There is no documentation resident was seen by a licensed health care professional prior to being sent to the hospital.
Plan of correction
Administrator was notified verbally at 1007pm of slip in urine. DCA that reported did not stated resident had any discomfort. On 7/2 when pain was communicated, facility administrator obtain order for x-ray. Resident representative did not want to wait for x-ray company as it was getting late and Dr. office was closing. Resident representative requested to be sent to ER. Facility Administrator will verbally ask when receiving notification of an incident if there are any injuries or pain expressed.
April 26, 2021Complaint survey3 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 04/26/21 and concluded on 05/28/21. A complaint was received by the department regarding allegations in the areas of administration, resident care and staff. The administrator was contacted to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint, but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-70-A
Based on a review of documentation, the facility failed to report to the regional licensing office, within 24 hours, any major incident that affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Facility form, "Resident Incident/Accident Report" prepared on 12/29/2020, indicated that resident D reported an unwitnessed fall. Documentation shows the resident was "very confused, shakey", "appears to be very confused. Apparent R droop on face." Resident D was transported to the hospital at 9:00am on 12/29/2020. This incident had not been reported to the regional licensing office.
  2. Facility form, "Resident Incident/Accident Report" prepared on 02/14/2021, indicated resident H had an unwitnessed fall and was found on the floor with a skin tear on left ankle. Resident was sent to the hospital on 02/14/2021 at 7:30am. This incident had not been reported to the regional licensing office.
  3. "After Visit Summary" indicated resident E was seen in the emergency room and diagnosed "contusion of right chest wall" on 04/21/2021. This incident had not been reported to the regional licensing office.
  4. Facility form, "Resident Incident/Accident Report" prepared on 04/23/2021, indicated that resident B was found lying on his right side on the floor, complained of pain in both hips, on the right side of his forehead and was sent to the hospital at 10:15am. This incident was not reported to the regional licensing office.
Plan of correction
New administrator will be hired. Facility will report incidents that result in an emergency room evaluation according to policy and regulations.
22VAC40-73-250-D
Complaint related: Yes the staff; nor did the Health Care Professional document whether a Tuberculin Skin Test (PPD) was not indicated at the time due to the absence of symptoms; whether a Tuberculin Skin Test (PPD) was administered; whether the staff has a history of positive tuberculin skin tests due to latent TB infections; or whether the staff had a chest x-ray.
Plan of correction
New administrator will be hired. Facility will assure that TB screenings are complete per regulations.
22VAC40-73-470-F
Based on a review of documentation, the facility failed to ensure that when a resident suffers serious accident, injury, illness or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately.
Evidence
  1. Facility form, “Resident Incident/Accident Report” prepared on 05/18/2021, indicated that resident G ?fell backwards and hit her head on door before hitting floor?. There was no documentation to show that medical attention from a licensed health care professional was secured.
  2. Facility form, “Resident Incident/Accident Report” prepared on 03/13/2021, indicated that after hearing a loud bang, resident G was found “face down on the floor, with her heady laying against bed leg. flipped recliner” There was no documentation to show that medical attention from a licensed health care professional was secured.
  3. Facility form, “Resident Incident/Accident Report” prepared on 04/30/2021, indicated ?Pt (resident C) rang @ 2:30 a.m. When staff open door- PT on floor, Pt stated fell over face first to floor “ carpet burn abrasion to forehead- Pt ” stated he leaned over to far ?? There was no documentation to show that medical attention from a licensed health care professional was secured.
Plan of correction
New administrator will be hired. Facility will assure that when PCP is notified of an incident, that documentation is in the resident's chart regardless if the PCP decided to treat or evaluate or not.