Virginia DSS · Assisted Living Facility

Carriage Hill Retirement

📍 1203 Roundtree Drive, Bedford, VA, 24523

ID 36225One Year licenseActive
107
Inspections
On record
75
With violations
Visits that cited something
32
Clean visits
Nothing cited
338
Violations cited
Individual findings
110
Standards cited
Distinct rules
80
Complaint visits
Prompted by a complaint

Carriage Hill Retirement was inspected 107 times between November 23, 2020 and May 6, 2026 by the Virginia Department of Social Services. 75 of those visits ended with violations cited and 32 with none. Across that history VDSS cited 338 violations under 110 distinct standards. 80 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. 98 of these 107 are still on the state's site; the other 9 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
06/30/2025
Administrator
Christine Pruett
Licensing inspector
Jennifer Stokes
Inspector phone
(540) 589-5216
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

107

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

May 6, 2026Complaint survey6 violations
Inspection dates
05/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/06/2026 8:08AM to 12:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 04/29/2026 and 05/04/2026 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 91 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 interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall for residents who meet the criteria for assisted living care.
Evidence
  1. The uniform assessment instrument (UAI) in the record for resident 1, dated 05/13/2025, states on page 2 that resident 1 is assisted living level of care.
  2. Staff person 5 documented that on 03/11/2026 at 6:34PM resident 1 had a fall and staff person 6 documented that on 04/16/2026 at 3:33PM resident 1 was found on D hall on the ground and resident 1 stated he lost his balance while walking to his room; staff person 2 confirmed to the two licensing inspectors (LIs) that this would have been considered a fall.
  3. The record for resident 1 does not contain documentation that the fall risk rating was reviewed and updated after the resident fell on 03/11/2026 and 04/16/2026. Staff person 2 confirmed this is accurate.
Plan of correction
Not published by VDSS.
22VAC40-73-930-D
Based on observations of the facility physical plant and staff interview, the facility failed to ensure there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During on-site inspection on 05/06/2026, resident 1 pushed the button on the call pendant around his neck at approximately 9:05AM and multiple times after until 9:40AM. The two licensing inspectors (LIs) were made aware by staff person 1 that staff person 3 had the receiver box to the call pendant in her possession. The two LIs interviewed staff person 3 and staff person 3 informed the two LIs that the receiver box was not showing that resident 1’s call pendant had been pushed.
  2. Upon further observation, it was noted that the call bell pull cord in the resident’s room behind his bed on the wall is inoperable. When the call bell pull cord in the resident’s bathroom was pulled, it was noted that the light over the resident’s door in the hallway lights up but is not audible. In addition, staff person 3 and the two LI’s observed the box at the nurses’ station lights up as “56D” which is the employee lounge and is not resident 1’s room.
  3. Staff person 1 revealed during an interview that resident 1 was given a call pendant to wear around his neck because the facility is aware that the call light system in the resident’s room does not function properly.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observations of the facility physical plant, the facility failed to ensure any menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents and any menu substitutions or additions shall be recorded on the posted menu.
Evidence
  1. During on-site inspection on 05/05/2026, the menu posted in the assisted living building stated that breakfast on 05/05/2026 consists of an omelet, fresh fruit, 100% juice and whole grain toast; however, two licensing inspectors (LIs) observed resident 1 had been served a small egg, 1 slice of toast and juice but was not served fresh fruit.
Plan of correction
Not published by VDSS.
22VAC40-73-450-H
Based on observations of the facility physical plant, facility documentation, and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. The ISP for resident 1, dated 05/13/2025, has a description of needs and date identified of housekeeping on 05/13/2025 that housekeeping is to sweep/mop/vacuum bedroom and bathroom floors, empty trash, dust and clean bathroom fixtures and that this is to be provided by housekeeping/all staff daily and PRN in resident’s bedroom and bathroom and resident 1 will reside in a clean, safe and secure environment. Staff person 1 provided the two licensing inspectors (LIs) a cleaning schedule that states resident rooms are to be swept, mopped and the trash needs to be emptied daily, on Monday clean all the resident rooms and look for “contraband items”, Saturday/Sunday clean resident bathrooms and documentation that resident’s 1 room is to be cleaned on Thursdays. Staff person 2 confirmed to the two LIs that the resident’s room is not being cleaned daily as indicated on resident 1’s ISP.
  2. The ISP for resident 1, dated 05/13/2025, has a description of needs and date identified of medication administration on 05/13/2025 that the resident is able to safely administer medications without any staff assistance per physician’s orders and all medications will be kept in a locked compartment with a key separate from the locked compartment in the resident’s room. During on-site inspection, the two LIs and staff person 1 observed that resident 1 has numerous bottles of medications that were sitting out in various areas of the resident’s room and are not kept in a locked compartment in resident 1’s room. This was also observed by staff person 1.
Plan of correction
Not published by VDSS.
22VAC40-73-680-A
Based on observation, resident interview and staff interview, the facility failed to ensure staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the uniform assessment instrument (UAI).
Evidence
  1. The UAI in the record for resident 1, dated 05/13/2025, states on page 2 that the resident does not require assistance with medication administration. Staff person 1 confirmed that resident 1 self-administers his medications.
  2. At approximately 9:28AM during the on-site inspection on 05/06/2026, the two licensing inspectors (LIs) observed three bottles of Latanoprost eye drops in the resident’s refrigerator in his room. The two LIs asked resident 1 if he uses the Latanoprost eye drops and resident 1 informed the two LIs that staff person 4 had administered the eye drops to him the night before and showed the two LIs a calendar that had staff person 4’s name and a time written on 05/05/2026.
  3. During an interview with staff person 1 regarding staff person 4 administering the aforementioned eye drops to resident 1 on 05/05/2026, staff person 1 informed the LIs that she reached out to staff person 4 during the on-site inspection and staff person 4 informed her that the resident had walked to the nurses’ station the night of 05/05/2026 and asked her to administer his eye drops, staff person 4 went with resident 1 to his room and administered the eye drops and signed her name and the time on his calendar as he requested staff person 4 to do.
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observations and resident interview, the facility failed to ensure the interior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. At approximately 9:15AM during on-site inspection on 05/06/2026, two licensing inspectors (LIs) observed multiple areas of a dried, brown substance on resident 1’s bathroom floor, a plastic urinal in the bathroom sink with multiple areas of a dried, yellow substance on the inside of the plastic urinal, multiple items of rubbish on the floor around and under the resident’s bed and also in numerous other areas in the resident’s room and soiled bed linens on the resident’s bed in which resident 1 was sitting on top of on his bed while the LIs were in the resident’s room.
  2. Interview with resident 1 revealed that the brown substance on the floor in his bathroom was feces as he had had diarrhea on 05/03/2026 and had tried to clean up the substance himself and that he does use the plastic urinal that was in the bathroom sink instead of using the toilet. Staff person 1 also observed the condition of resident 1’s room.
Plan of correction
Not published by VDSS.
May 5, 2026Complaint survey5 violations
Inspection dates
05/05/2026, 05/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/05/2026 8:06AM to 6:00PM and 05/06/2026 8:08AM to 2:00PM 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 03/03/2026 regarding allegations in the area of: resident care & related services Number of residents present at the facility at the beginning of the inspection: 91 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-450-H
Based on observations of the facility physical plant, facility documentation, and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. The ISP for resident 1, dated 08/06/2025, has a description of needs and date identified of housekeeping on 08/06/2025 that housekeeping is to sweep/mop/vacuum bedroom and bathroom floors, empty trash, dust and clean bathroom fixtures and that this is to be provided by housekeeping/all staff daily and PRN in resident’s bedroom and bathroom and resident 1 will reside in a clean, safe and secure environment. Staff person 1 provided the two licensing inspectors (LIs) a cleaning schedule that states resident rooms are to be swept, mopped and the trash needs to be emptied daily, on Monday clean all the resident rooms and look for “contraband items”, Saturday/Sunday clean resident bathrooms and documentation that resident’s 1 room is to be cleaned on Thursdays. Staff person 2 confirmed to the two LIs that the resident’s room is not being cleaned daily as indicated on resident 1’s ISP.
Plan of correction
Not published by VDSS.
22VAC40-73-470-B
Based on observation, resident record review, resident interview and staff interview, the facility failed to ensure a resident’s need for skilled nursing treatments within the facility shall be met by the facility’s employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 02/26/2026, for home health skilled nursing wound care/skin assessment for bilateral lower extremities and ACE wraps to bilateral lower extremities for lymphedema care. Documentation by staff person 2, dated 03/05/2026 at 2:54PM, states that an order was received for home health to manage lymphedema to bilateral lower extremities and the order was sent to Collateral 4. 2. Documentation by staff person 4, dated 03/06/2026 at 10:27AM, states that resident 1 was sent out to the emergency department due to leg pain, legs are draining liquid and resident 1 called EMS. The record for resident 1 contains emergency department (ED) notes, dated 03/06/2026, that the chief complaint is that the resident has had a weeping wound for 3 days and per EMS resident 1 has wounds in skin folds on torso, large weeping wound on right lower leg, and open cracked skin on left lower leg. Documentation in the ED notes state that the resident reports that she has been having some chronic bilateral lower extremity pain which has been attributed to diabetes and neuropathy, this is chronic and unchanged, and the resident is uncertain what the source of the lesions are on her legs are or how long they have been present. Further documentation in the ED notes state under physical exam the following: extremity 2+ nonpitting edema bilateral extremities fungating lesions that are raised and variable in size from 1 CM to several centimeters along, they are nontender and there is no erythema although lesions on the left lower extremity are covered in dried serosanguineous discharge, there is no erythema induration purulence or warmth noted to the bilateral lower extremities the fungating lesions on the anterior right shin are draining active serosanguineous discharge without any purulence erythema induration or increased warmth. Page 3 of 4 of the ED notes state that resident 1 should follow-up with dermatology for punch biopsy and primary care physician to ensure resolution and return to the ED if symptoms change or worsen. Documentation by staff person 4, dated 03/09/2026 at 9:38AM, states that resident 1 refused all medications, resident refused to go with staff person 4 to get legs cleaned up and resident 1’s legs are draining and residents that are in the dining area eating are complaining. Documentation in the record for resident 1 by Collateral 2, dated 03/09/2026, states on page 1 of 2 and 2 of 2 that Collateral 2 requested home health skilled nursing to resume for ongoing skin assessment and wound care – discussed potential loss of limb with resident due to noncompliance with diabetic medication as well as wound care and that resident 1 expressed understanding. The record for resident 1 also contains a signed physician’s order, dated 03/09/2026, for home health physical therapy/occupational therapy/skilled nursing for bilateral lower extremities wound care. Documentation in the record for resident 1 by Collateral 2, dated 03/16/2026, states on page 1 of 1 that Collateral 2 updated orders to re-initiate home health skilled nursing for skin/wound care. (due to character limits, the rest of this violation notice will not appear on the VDSS website)
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to ensure that the interior of the building was kept clean and free of rubbish.
Evidence
  1. At approximately 9:26AM on 05/05/2026, 2 licensing inspectors (LIs) observed two (2) puppy pads on the floor behind the door in room 74, where resident 1 resides. The pads were urine-soaked and numerous feces droppings were observed on the pads as well as off onto the floor. In an interview with both LI’s and resident 1, resident 1 reported that her dog uses the bathroom on the puppy pads.
  2. Additional visits into resident 1’s room were made by 2 LI’s on 05/05/2026 at 10:40AM and again at 3:30PM on 05/05/2026 where the same urine-soaked pads and feces droppings were observed on the floor.
Plan of correction
Not published by VDSS.
22VAC40-80-120-A-7
3. Documentation by staff person 5, dated 04/04/2026 at 1:33PM, states that resident 1 stated the sores on her legs were hurting, resident refused to take scheduled Tylenol, resident 1 called the police and when the police asked the resident the reason for her call the resident stated it is because her legs hurt, 911 was called and EMS arrived at the facility at 12:12PM to take the resident to the hospital.
Plan of correction
Not published by VDSS.
22VAC40-73-870-B
Based on observations of the facility physical plant, the facility failed to ensure that all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. At approximately 9:26AM on 05/05/2026, 2 licensing inspectors (LIs) noted a strong pet urine/feces odor in room 74, where resident 1 resides. The pet urine/feces odor was still present and noted by 2 LI’s at approximately 9:00AM on 05/06/2026.
Plan of correction
Not published by VDSS.
May 5, 2026Inspection13 violations
Inspection dates
05/05/2026, 05/06/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
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: 05/05/2026 8:06AM to 6:00PM and 05/06/2026 8:08AM to 2:20PM 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: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 7 Number of interviews conducted with staff: 8 Observations by licensing inspector: breakfast, noon-time meal, medication administration, medication cart audits An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 8:14AM on 05/05/2026, 2 licensing inspectors (LIs) observed that the door to the housekeeping closet down the hall on the right side of the kitchen in the facility safe, secure unit was unlocked and the room was unattended. The room contained a bottle of Dawn Multi Surface Degreaser, Spic n Span Multi surface Cleaner and 6 bottles of Rapid Multi Surface Disinfectant Cleaner.
  2. At approximately 8:36AM on 05/05/2026, 2 LIs observed that the door to the nursing station in the facility safe, secure unit was unlocked. A bottle of Diversey Disinfectant Cleaner was observed sitting out on an unlocked shelf in the nurse’s station.
  3. At approximately 3:56PM on 05/05/2026, 2 LIs observed that the door to the Laundry Room next to the D Hall was unlocked and the room was unattended. A bottle of Tide Multi-Purpose Stain remover, several cans of Clorox Disinfectant Spray, 2 bottles of Diversey Disinfectant Cleaner, a bottle of Windex Cleaner, a can of Air Duster, a can of WD-40, a bottle of Lift off Latex Paint Remover and an unlocked housekeeping cart with numerous cleaning supplies were observed sitting out around the room. A yellow pill with numbers 1428/10 was lying on the floor in front of the dryer.
Plan of correction
1. All doors were locked during inspection. 2. Staff verbally counseled on the importance of keeping all doors closed and locked that contain cleaning supplies. 1. Maintenance Director or designee will ensure all doors have working locks. Maintenance Director to audit all doors in the secured unit that stock cleaning supplies; and any housekeeping closets in the Main building weekly to ensure all doors are locked and closed.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that all required information was included on resident medication administration records (MARs).
Evidence
  1. The May 2026 medication administration record (MAR) for resident 2 does not have staff initials for the administration of the prescribed medication Rivastigmine 13.3mg/24hr patch daily at 2PM on 05/02/2026. The MAR has a dash (-) and does not include information for what this symbol means.
  2. The April 2026 MAR for resident 7 has documentation that the prescribed medication Rivastigmine Tart 1.5mg Caps twice daily was held (HLD) at 9AM on 04/18/2026 through 04/21/2026 and at 9PM on 04/17/2026 through 04/20/2026. The MAR does not have documentation as to why the medication was not administered for these days/times.
  3. The April 2026 MAR for resident 7 does not have staff initials for the administration of the prescribed medications Simvastatin 20mg at bedtime and Trazadone 50mg at bedtime on 04/24/2026. The MAR has a dash (-) and does not include information for what this symbol means.
Plan of correction
1. Unable to retroactive previous medication 2. Staff education on medication administration and completion of documentation 1. DORS or designee will audit medication administration records daily for any unsigned or Unavailable medication via the EMAR dashboard to ensure medications are available for administration DORS or designee will audit daily EMAR dashboard for any missed or unavailable medications.
22VAC40-73-660-B
Based on observations of the facility physical plant, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication.
Evidence
  1. At approximately 9:20AM on 05/05/2026, 2 licensing inspectors (LIs) observed 2 bottles of Tylenol Rapid Release Gel, a bottle of Pepto Bismol and 2 containers of Nystatin Topical Powder sitting out in the room and open closet in the room for resident 7. The uniform assessment instrument (UAI) dated 08/13/2025 in the record for resident 7 has documentation that the resident’s medications are administered/monitored by layperson with RMA/LPN written in for who administers resident 7’s medications. The individualized service plan (ISP) dated 08/25/2025 had documentation that a registered medication aide/nurse will administer medications per MD orders to resident. The record for resident 7 did not contain physician orders for the Tylenol Rapid Release Gel Caps or the Pepto Bismol found in resident 7’s room. A physician order signed 02/06/2026 for Nystatin Powder 100000, apply topically to affected area on abdominal folds every shift for redness was observed in the record for resident 7; however, the order did not contain instructions for the resident to self-administer this medication. Staff initials are present on the April and May 2026 medication administration records (MARs) for administering the Nystatin Powder at 9AM and 9PM from 04/01/2026 through 05/05/2026.
  2. At approximately 11:06AM on 05/05/2026, 2 LIs observed a container of Remedy essentials protect Zinc Oxide paste skin protectant in the windowsill of resident 5’s room. The UAI in the record for resident 5, dated 01/30/2026, has documentation that the resident’s medications are administered/monitored by layperson with RMA/LPN written in for who administers resident 5’s medications. Staff initials are present on the April and May 2026 MARs for administering Zinc Oxide at 9AM and 9PM from 04/01/2026 through 05/05/2026.
Plan of correction
1. Medications were removed from each apartment on day of inspection 1. DORS or designee will audit rooms daily for items in apartments. 2. Education with all staff on the items to be removed for safety. 3. All residents were made aware of items are not to be in apartments or brought in by family or friends without orders. 1. DORS, ED, or designee will audit rooms daily to ensure medication or other non-safe items are removed.
22VAC40-73-640-A
Based on observations of the facility physical plant, resident record review, review of the facility medication management plan (MMP) and staff interview, the facility failed to ensure that their MMP contained procedures for methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages and failed to implement its MMP in regard to methods for monitoring medication administration and the effective use of the medication administration records (MARs) for documentation.
Evidence
  1. The March and April 2026 medication administration records (MARs) for resident 1 contains documentation that the prescribed Temazapam 30MG take one capsule at bedtime daily was not administered as the drug not available (DNA) 8 times from 03/01/2026 through 03/31/2026 and 4 times from 04/01/2026 through 04/30/2026. The May 2026 MAR for resident 2 has documentation that the prescribed medication Rivastigmine 13.3mg/24hr patch was not applied on 05/01/2026 as the drug not available (DNA). The April 2026 medication administration record (MAR) for resident 7 has documentation that the prescribed medication Rivastigmine Tart 1.5mg Caps twice daily was not administered as the drug not available (DNA) 21 times from 04/01/2026 through 04/25/2026 and the prescribed medication Trazadone 50mg at bedtime was not administered as the drug not available (DNA) 17 times from 04/01/2026 through 04/29/2026. The Licensing inspector (LI) requested the facility MMP for review on the day of on-site inspection and noted that the MMP provided for review did not contain methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. In an interview conducted on 05/06/2026 with 2 LIs and staff persons 1 and 5, staff person 5 reported that they would review the facility policy/procedure books to locate the facility entire MMP. As of 05/11/2026, the LI has not received any additional information pertaining to the facility MMP.
  2. The facility’s MMP states under policy number 5.09 – associate-administered medication procedure that to ensure the safe management of medications and that proper procedures are followed by trained associates who may assist resident who are self-administering, or licensed nursing associates who may directly administer medications in a community that staff are to hand the medication in a medication cup to the resident and observe him or her swallowing it – never leave a medication unattended when it is outside of the medication cart. At approximately 9:14AM during on-site inspection on 05/05/2026, two LIs observed 4 round white pills with RE 23 and one Omeprazole capsule in resident 13’s room on the bedside table. In an interview with two LIs and resident 13, resident 13 informed the two LIs that they were medications that medication administration staff had given to her, one of which is Lasix; however, she chose not to take the Lasix because “they make her use the bathroom too much” and laid them on her bedside tablet. These medications were also observed by staff person 1. (due to limited character space, the rest of this violation notice will not appear on the VDSS website)
Plan of correction
1. Unable to retroactive previous medication DNA. 2. Family member that gets medication from outside pharmacy and delivers medication for resident 1 were alerted to the need for delivery in a timely manner. 3. Staff education on medication administration and not leaving medication with resident alone. 1. DORS or designee will audit medication administration records daily for any DNA or Unavailable medication via the EMAR dashboard to ensure medications are available for administration. DORS or designee will audit daily EMAR dashboard for any missed or unavailable medications.
22VAC40-80-120-E-3
Based on observations of the facility’s physical plant and staff interview, the facility failed to ensure the notice of the commissioner’s intent to revoke or deny renewal of the license of an assisted living facility such notice will be provided by the department and shall be posted in a prominent place at each public entrance of the facility to advise consumers of serious or persistent violations.
Evidence
  1. The Virginia Department of Social Services (VDSS) Division of Licensing Programs (DOLP) emailed a notice of intent (NOI) to deny the facility’s renewal application for a license via email to the licensee on 03/04/2026 and the NOI was acknowledged by the licensee via email on 03/18/2026; however, the NOI was not posted in the facility during on-site inspection on 05/05/2026. Staff person 1 confirmed this is accurate.
Plan of correction
1. Notice was posted day of inspection 1. ED to ensure all notices from DSS are posted in a timely manner ED will audit monthly for all notice postings.
22VAC40-73-870-B
Based on observations of the facility physical plant, the facility failed to ensure that all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. At approximately 8:10AM on 05/05/2026, 2 licensing inspectors (LIs) in the presence of staff person 6 noted a urine odor in the dining/common rooms of the facility safe, secure unit. In an interview with 2 LI’s and staff person 1, it was reported that the odor is coming from the chairs in the common area. The urine odor was still present and noted by 2 LI’s at approximately 8:15AM on 05/06/2026.
  2. At approximately 8:29AM on 05/05/2026, 2 LIs in the presence of staff person 6 noted a foul, stale odor in rooms 19 and 23 in the facility safe, secure unit. The foul, stale odor was still present in rooms 19 and 23 and noted by 2 LI’s at approximately 8:20am on 05/06/2026.
  3. At approximately 9:56AM on 05/05/2026, 2 LIs noted a foul stale odor in room 6 located on the facility A-Hall.
Plan of correction
1. Quotes for new furniture have been sent for approval to purchase due to age of furniture. 2. Housekeeping cleaned all common area and dining area chairs after the meal. 3. Housekeeping/Clinical picked up laundry after morning meal and care. 1. Housekeeping and Clinical Staff will ensure all dirty laundry is removed from apartments post care and placed in the laundry room. Housekeeping supervisor and/or DORS will audit weekly for odors in both buildings to ensure laundry is pulled as soiled and then weekly.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to ensure that the interior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. At approximately 8:24AM on 05/05/2026, 2 licensing inspectors (LIs) observed that the doors to rooms 27 and 29 in the facility safe, secure unit were unlocked and the rooms were unattended. Various amounts of supplies, equipment, decorations, clutter and debris were piled up and sitting around in the rooms.
  2. At approximately 8:27AM on 05/05/2026, 2 LIs observed empty cardboard boxes stacked up on a chair, a reclining chair and a broken dresser sitting out in the hallway to the right of the kitchen in the facility safe, secure unit.
  3. At approximately 9:42AM on 05/05/2026, 2 LIs in the presence of staff person 11 observed several empty cardboard boxes, plastic bags and bubble wrap, several totes and other equipment, clutter/debris were piled up and sitting out in the hallway/loading dock by the dry food storage rooms.
  4. At approximately 12:15PM on 05/05/2026, 2 LIs observed a used heating/air-conditioning unit and a used washing machine sitting out in the hallway to the left of the kitchen in the facility safe, secure unit.
Plan of correction
1. All doors were locked during inspection. Staff verbally counseled on the importance of keeping all building equipment out of hallways and that all doors are closed and locked that contain unused furniture and Maintenance supplies. Removed all building supplies in hallways on 6/5/2026. 1. Maintenance Director or designee will ensure all doors have working locks. 2. Maintenance Director or designee will audit hallways weekly to ensure no furniture or rubbish is out in walking areas. Maintenance Director will audit all doors in the secured unit that contain overflow furniture and equipment weekly to ensure all doors are locked and closed. Will ensure that no overflow furniture or equipment is in the walking areas.
22VAC40-73-680-M
Based on medication cart audit, resident record review, and staff interview, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 11/25/2025, for Cough Drops 5.4MG take 1 lozenge by mouth every 2 hours as needed for cough and Glutose 15 Gel 40% give 37.5ML by mouth as needed for low blood sugar and both of these are reflected as active orders on resident 1’s May 2026 medication administration record (MAR).
  2. During the medication cart audit with staff person 7, staff person 7 informed the licensing inspector (LI) that the two aforementioned PRNs were not available in the facility for the resident.
Plan of correction
1. Medication was ordered from pharmacy on 5/4/2026 and had not been delivered on day of inspection. 1. DDORS or designated person will audit carts weekly to ensure all ordered medication is available. 2. Pharmacy nurse will do monthly cart audits. All medication staff will be trained on Cart Audits and importance of ordering medications timely for delivery.
22VAC40-73-680-D
Based on medication cart audit, resident record review, resident interview and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. At approximately 8:18AM during on-site inspection on 05/05/2026, the licensing inspector (LI) was observing staff person 2 prepare resident 8’s morning medications. Staff person 2 added Levothyroxine to the clear, plastic cup with the other medications they had prepared for resident 8; however, resident 8’s electronic medication administration record (MAR) stated to administer Levothyroxine 175MCG 30 minutes prior to other medications or food. Staff person 2 and the LI observed resident 8 eating breakfast and staff person 2 stated that breakfast was served at 8:00AM. Staff person 2 proceeded to waste the Levothyroxine 175MCG and documented on resident 8’s May 2026 MAR her initials and “DNG” for drug not given.
  2. The record for resident 1 contains a signed physician’s progress note, dated 02/03/2026, that resident 1 was being seen by Collateral 2 on 02/03/2026 for a diabetic foot exam and care for painful fungal nails and has a prescription for Ciclopirox solution; however, resident 1 stated that her facility has a policy that her physician needs to specify that she may have the medication and apply it herself and because she has to ask for it each time it has affected her compliance. The progress notes state that resident 1 is prescribed Ciclopirox solution to apply to all affected nails due to onychomycosis – please allow the patient to have topical medication in her possession so she may apply daily as compliance with daily application is essential for treatment. During the medication cart audit with staff person 7, staff person 7 and the licensing inspector (LI) observed resident 1’s Ciclopirox solution in the top drawer of the medication cart. Resident 1’s February, March, April and May 2026 medication administration records (MARs) contain staff initials for the administration of this medication. During an interview with resident 1, resident 1 indicated to the LI that she does not have Ciclopirox in her room, that it is located on the medication cart and that she was unaware of the 02/03/2026 physician’s order by Collateral 2 that she can have it in her possession to administer herself.
Plan of correction
1. Medication time was changed to reflect accurate administration. 2. Self-administer evaluations will be completed by DDORS for current residents, and any new self-administer orders that are written. 1. DDORS will assess residents that have current self-administer orders quarterly. 2. DDORS will assess any new resident orders that are self-administered to ensure safety of self-administering medications. DDORS will evaluate all self-administrated residents for safety in administering their own medication.
22VAC40-73-1180-B
Based on observations of the facility physical plant, the facility failed to ensure that when indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. At approximately 8:36AM on 05/05/2026, 2 licensing inspectors (LIs) observed an electric hairdryer laying out on an opened shelf at the nurses’ station on the facility safe, secure unit. The door to the nurses’ station was observed to be unlocked; this was brought to staff person 1’s attention during the on-site inspection on 05/05/2026. The nurses’ station was also observed by 2 LI’s at approximately 8:20AM 05/06/2026 and an electric hair dryer was noted to still be laying out on an open shelf.
  2. At approximately 8:24AM on 05/05/2026, 2 LIs observed the door to room 29 on the facility safe, secure unit to be unlocked and unattended. The room contained pieces of a broken light bulb and screws laying out on the windowsill in the room.
Plan of correction
1. Hairdryer was removed from nurses’ station at time of inspection. 2. Staff trained on items being left out in open areas. 1. Maintenance Director or designee will ensure all doors have working locks. Maintenance Director to audit all doors in the secured unit that stock cleaning supplies; and any housekeeping closets in the Main building weekly to ensure all doors are locked and closed.
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator or his designee (i.e., the person who has developed the plan).
Evidence
  1. The ISP in the record for resident 1, dated 06/10/2025 and signed by resident 1 on 06/12/2025, does not contain the signature of the staff person who developed the plan or the date the ISP was completed.
Plan of correction
Audits of ISP will be done weekly to ensure signatures are completed on ISP. DORS, ED, or Designated person will audit 5 random ISP for signature completions Weekly audits of 5 random charts to ensure completion and that signatures are obtained.
22VAC40-73-650-E
Based on resident record review and staff interview, the facility failed to ensure that resident records contained all physicians signed orders.
Evidence
  1. The May 2026 medication administration record (MAR) for resident 2 has staff initials for the administration of the prescribed medications Nicotine 21mg/24hr patch and Risperidone 0.5mg BID. The record for resident 2 did not contain the signed physician orders for these medications. In an interview with staff person 5 and 2 licensing inspectors (LIs) on 05/05/2026, staff person 5 reported that the signed physician orders were located in the nursing office in a stack of paperwork to be filed.
  2. The record for resident 3 has signed physician orders dated 02/05/2026 that contains orders for Cranberry Capsules QD, Lorazepam 0.5mg tablet three times a day, Polyethylene Glycol Powder 17gms daily, and Probiotic 250mg capsule twice a day. The May 2026 MAR for resident 3 does not have documentation of the Cranberry Capsules, Polyethylene Glycol or Probiotics being administered and the Lorazepam 0.5mg tablet is documented as concentrate (liquid) form on the May 2026 MAR but the record for resident 3 does not contain a physician order to change/discontinue these medications. In an interview with staff person 5 and 2 LIs on 05/05/2026, staff person 5 reported that the order changing the Lorazepam from tablet to concentrate was located in the nursing office in a stack of paperwork to be filed and the order to discontinue the Cranberry Capsules, Polyethylene Glycol and Probiotics was faxed on the day of on-site inspection from resident 3’s provider.
  3. The May 2026 MAR for resident 4 has staff initials for the administration of the prescribed medications Acetaminophen 500MG take 2 tablets by mouth three times daily, Dapagliflozi 10MG take 1 tablet by mouth every day, Ferrous Sulfate 325MG take 1 tablet by mouth every Monday, Wednesday, and Friday, and Lamotrigine 25MG take 2 tablets by mouth twice daily. The record for resident 4 did not contain the signed physician’s orders for these medications. In an interview with staff person 5 and 2 LIs on 05/05/2026, staff person 5 reported that the signed physician orders were located in the nursing office in a stack of paperwork to be filed.
  4. The May 2026 MAR for resident 8 has staff initials for the administration of the prescribed medications Eliquis 5MG take 1 tablet by mouth 2 times daily, Ferrous Sulfate 325MG take 1 tablet by mouth every Monday, Wednesday, and Friday, Furosemide 40MG take 1 tablet by mouth daily hold for blood pressure less than 100/60, Quetiapine 25MG daily at 9AM and 9PM, Vitamin D3 take 2 tablets by mouth daily and Levothyroxine 175MCG take 1 tablet by mouth every morning 30 minutes prior to other medications or food. The record for resident 8 did not contain the signed physician’s orders for these medications. In an interview with staff person 5 and 2 LIs on 05/05/2026, staff person 5 reported that the signed physician orders were located in the nursing office in a stack of paperwork to be filed.
Plan of correction
1. All orders that were to be filed have been placed in resident records or thinned to overflow record. 1. DORS or designee will file all physician orders and other paperwork as it is received. 1. DORS or designee will audit daily that filing has been completed for the previous day.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that Individualized service plans (ISPs) were updated as needed for change in resident condition.
Evidence
  1. The record for resident 3 has a physician order dated 03/16/2026 for fall mats for safety. The record also has documentation in Hospice notes that resident 3 wears arm/leg protectors. The ISP dated 07/28/2025 in the record for resident 3 does not address these identified needs.
  2. The uniform assessment instrument (UAI) dated 08/13/2025 in the record for resident 7 has documentation that the resident is on a chopped meat diet. The special diet board in the facility kitchen has resident 7 listed for cut up meat. The ISP dated 08/25/2025 in the record for resident 7 does not address the identified need for chopped/cut meats.
  3. The record for resident 7 has a signed physician order dated 04/01/2026 for PT to eval and treat. PT notes from 04/01/2026 through 04/29/2026 are present in resident 7’s record. The ISP dated 08/25/2025 does not reflect resident 7’s identified needs for PT services.
  4. The record for resident 7 has documentation in daily logs of the resident falling on 03/26/2026, 03/31/2026 and 04/11/2026. Fall risk ratings completed on 01/21/2026, 03/26/2026, 03/31/2026 and 04/11/2026 have documentation that resident 7 is a high potential for falls. The ISP in the record for resident 7 has not been updated to reflect any additional needs/services for resident 7’s falls/ high potential for falls since the ISP was developed on 08/25/2025.
Plan of correction
1. Resident care plans were updated to reflect changes 1. DORS or designee will update ISPs for completion and update accordingly as changes occur. DORS or designee will audit 5 charts weekly to ensure all updated items are documented on the care plan.
May 5, 2026Complaint survey0 violations
Inspection dates
05/05/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/05/2026 8:06AM to 3:30PM 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 05/04/2026 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 91 Number of resident records reviewed: 1 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2026Complaint survey0 violations
Inspection dates
05/05/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/05/2026 8:06AM to 3:30PM 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 04/24/2026 regarding allegations in the area(s) of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 91 Number of resident records reviewed: 1 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 30, 2026Complaint survey4 violations
Inspection dates
04/30/2026, 05/05/2026, 05/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/30/2026 12:20AM to 1:05AM; 05/05/2026 8:06AM to 6:00PM & 05/06/2026 8:15AM to 12:15PM 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 04/13/2026 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 91 Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on resident record review and staff interview, the facility failed to ensure medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensing, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person.
Evidence
  1. During on-site inspection on 05/06/2026, staff person 2 revealed to two licensing inspectors (LIs) that if the controlled drug record sheet has a medication administration staff persons signature, that indicates they are the staff person who obtained the controlled drug from the medication cart that is indicated for the controlled drug and should also be the staff person who administers the controlled drug to the resident they obtained the controlled drug for and their initials would also be present on the resident’s medication administration record (MAR).
  2. The controlled drug record sheet for resident 1’s prescribed Tramadol HCL 25MG take ½ tablet (12.5MG) by mouth twice daily for osteoarthritic pain contains staff person 1’s signature at 9:00PM on 04/06/2026 for 1 Tramadol tablet administered to resident 1; however, resident 1’s April 2026 MAR contains staff person 4’s initials as the staff person who administered resident 1’s Tramadol at 9:00PM on 04/06/2026.
  3. The controlled drug record sheet for resident 2’s prescribed Lorazepam 0.5MG take one tablet by mouth twice daily contains staff person 1’s signature at 8:00PM on 04/06/2026 for 1 Lorazepam tablet administered to resident 2; however, resident 2’s April 2026 MAR contains staff person 4’s initials as the staff person who administered resident 2’s Lorazepam at 9:00PM on 04/06/2026.
  4. The controlled drug record sheet for resident 3’s prescribed Morphine – take the contents of 1 prefilled syringe (0.25ML=5MG) by mouth twice daily for shortness of breath contains staff person 1’s signature at 8:00PM on 04/06/2026 for 1 syringe administered to resident 3; however, resident 3’s April 2026 MAR contains staff person 4’s initials as the staff person who administered resident 3’s Morphine at 9:00PM on 04/06/2026.
  5. The controlled drug record for resident 4’s prescribed Gabapentin 300 MG take 1 capsule by mouth twice daily for neuropathic pain contains staff person 1’s signature at 8:00PM on 04/06/2026 for 1 Gabapentin 300MG capsule administered to resident 4; however, resident 4’s April 2026 MAR contains staff person’s 4’s initials as the staff person who administered resident 4’s Gabapentin 300MG capsule at 8:00PM on 04/06/2026.
Plan of correction
Not published by VDSS.
22VAC40-73-150-D
Based on staff interview, the facility failed to ensure that the administrator shall report to the Director of the Department of Health Professions (DHP) information required by and in accordance with 54.1-2400.6 of the Code of Virginia regarding any person (i) licensed, certified, or registered by a health regulatory board or (ii) holding a multistate licensure privilege to practice nursing or an applicant for licensure, certification, or registration and information required to be reported, under specified circumstances includes substance abuse and unethical or fraudulent conduct.
Evidence
  1. Staff person 1 is a registered medication aide (RMA). During the on-site inspection on 05/06/2026, staff person 2 revealed to the two licensing inspectors (LIs) that staff person 1 had been terminated from the facility due to job abandonment and that staff person 1’s last day of work at the facility was 04/06/2026. On 05/13/2026, staff person 3 revealed in a follow-up email that staff person 1 had been terminated on 04/13/2026.
  2. During the on-site inspection on 05/06/2026, staff person 3 revealed that they had not reported staff person 1 to the Department of Health Professions.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 2’s April 2026 medication administration record (MAR) contains documentation that the resident is prescribed Kapspargo 50MG take one capsule by mouth at 9:00AM daily – hold if systolic blood pressure (SBP) is below 90 or heart rate is below 50. Resident 2’s April 2026 MAR contains staff initials for the administration for Kapspargo daily except at 9:00AM on 04/16/2026; however, there is no documentation of what the resident’s heart rate was for the days this medication was administered to resident 2. Interview with staff person 2 revealed there is no documentation available of what the resident’s heart rate was.
  2. Resident 4’s April 2026 MAR contains documentation that the resident is prescribed Furosemide 20MG take one tablet by mouth at 8:00AM daily for edema - hold for blood pressure systolic under 120 or diastolic under 80. The April 2026 MAR contains documentation that resident 4’s blood pressure at 8:00AM on 04/09/2026 was 88/57 and at 8:00AM on 04/17/2026 was 145/67; however, there are staff initials present that Furosemide 20MG was administered to the resident when it should have been held.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observations of the facility posted menu, the facility failed to record changes to the posted menu.
Evidence
  1. The facility posted menu in the safe, secure unit building has documentation that Chef’s choice omelet, fresh fruit, 100% juice, and whole grain toast was to be served for the breakfast meal on 05/05/2026. Two (2) licensing inspectors observed 25 residents seated in the dining room in the safe, secure unit between 8:08AM and 8:30AM on 05/05/2026. 3 of the 25-residents seated were observed to have a mechanical soft/puree diet that included oatmeal, of which oatmeal is not listed on the posted menu. The remaining 22 residents were observed to have been served a small omelet portion and one (1) half slice of toast. The fresh fruit posted on the facility menu was not served during the breakfast meal.
  2. The facility posted menu in the safe, secure unit building has documentation that hamburger ‘n fixings, tropical pineapple salad, fresh mixed vegetable salad and banana pudding was to be served for the lunch meal on 05/05/2026. One licensing inspector (LI) observed 26 residents seated in the dining room in the safe, secure unit at 12:00PM on 05/05/2026. 4 of the 26 residents seated were observed to have a mechanical soft/puree diet with ground meat and beans on their plate. No options for a tropical fruit salad or a mixed vegetable salad were observed to have been served for these residents. The remaining 22 residents were observed to have been served a hamburger bun with patty and mustard only and beans. No hamburger fixins, tropical pineapple salad or fresh mixed vegetable salad were observed to have been served for these residents. Banana pudding, being served as dessert, was observed by the LI in the kitchen.
Plan of correction
Not published by VDSS.
March 23, 2026Complaint survey0 violations
Inspection dates
03/23/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/23/2026 10:30AM to 11:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/16/2026 regarding allegations in the area(s) of: personnel & resident care and related services Number of residents present at the facility at the beginning of the inspection: 87 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 26, 2026Complaint survey4 violations
Inspection dates
02/26/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2026 9:00AM to 3:00PM 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 02/26/2026 regarding allegations in the areas of: resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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: resident care and related services 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. 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 Jennifer Stokes Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on observations on the day of on-site inspection, resident record review and interviews, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as needed for a change in resident condition.
Evidence
  1. On 02/26/2026, the day of on-site inspection, two licensing inspectors (LIs) observed resident 1 laying in a hospital bed with arm and leg skin protectors on and a fall mat on the floor by the bed.
  2. In an interview with two LI’s and collateral witness 1 conducted on 02/26/2026 during the on-site inspection, collateral witness 1 explained that that the hospital bed, arm/leg skin protectors and fall mat have been added for resident 1 for fall preventions and skin protection.
  3. The ISP in the record for resident 1, last review dated 09/03/2025, does not have documentation of the added services for a hospital bed, arm/leg protectors or fall mats.
Plan of correction
- Resident 1’s ISP was immediately reviewed and updated to reflect current condition. - All resident ISPs to be audited for updates related to condition changes by 3/25/2026. - ISP reviews triggered by any significant change - Monthly ISP audit by DORS
22VAC40-73-650-E
Based on observations on the day of on-site inspection and resident record review, the facility failed to ensure that physician’s written orders or notation of physician’s oral orders were maintained in resident records.
Evidence
  1. On 02/26/2026, the day of on-site inspection, two licensing inspectors (LIs) observed resident 1 with arm and leg skin protectors on. The record for resident 1 did not contain physician orders for the instructions or use of the arm and leg skin protectors.
Plan of correction
- Missing physician orders to obtained and filed appropriately. - All resident records to be audited by 3/25/2026. - Weekly chart audits x4 weeks, then monthly - Staff to be re-educated on documentation requirements during meeting on 3/19/2026.
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure that a fall risk rating was completed after a fall for a resident who is assessed as assisted living level of care.
Evidence
  1. The record for resident 1 has documentation in a daily log dated 02/18/2026 at 5:50 am that resident 1 rolled off her bed during the night.
  2. A Hospice note dated 02/19/2026 in the record for resident 1 has documentation that Resident 1 was in bed and had stool. While Aide was trying to clean resident 1 up, resident 1 was trying to assist in getting her pants off and flipped out of bed and was repositioned on fall mat. Hospice contacted resident 1’s family and moved resident 1 back to her bed.
  3. The uniform assessment instrument (UAI), dated 07/21/2025, in the record for resident 1 has documentation that the resident is assessed as assisted living level of care.
  4. The record for resident 1 has documentation that the last fall risk rating completed for this resident was dated 11/04/2025. In an interview with staff person 2 conducted on 02/26/2026, staff person 2 explained that no additional fall risk ratings were available for review for resident 1.
Plan of correction
- Resident 1 received an updated fall risk assessment immediately. - All residents with falls in the past 30 days to be audited for completed fall risk assessments by 3/23/2026. - RMA/Shift Supervisor/DORS to complete fall risk same day of incident - Weekly fall audit x4 weeks, then monthly.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that all required documentation was included on medication administration records (MARs).
Evidence
  1. The February 2026 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the prescribed medications Acetaminophen 325mg 2 tablets and Lorazepam 0.5mg tablet at 5pm on 02/19/2026 and the residents 10pm medication Albuterol Sulfate Inhalation Nebulization Solution on 02/16/2026. The February 2026 MAR also has documentation of a dash (-) for documentation of the resident’s meal intake and safety rounds for numerous times/days from 02/01/2026 through 02/26/2026. The MAR does not have information to explain what the dash indicates, and staff initials are not present for the administration of these medications or for documentation of meal percentages or safety rounds completed for resident 1.
  2. In an interview with two licensing inspectors (LIs) and staff person 2 on the day of on-site inspection, staff person 2 was unable to explain what the dash (-) documentation indicates on the MAR for resident 1.
Plan of correction
- Staff meeting to be held on 3/19/2026 to reiterate proper Mar documentation. - DORS to review dashboard daily to ensure medications have been administered as ordered. - Daily MAR review by shift supervisor/ DORS. - Disciplinary action for repeat documentation issues
February 26, 2026Complaint survey4 violations
Inspection dates
02/26/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2026 8:30AM to 12:45PM 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 01/23/2026 regarding allegations in the areas of: personnel & resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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: resident care and related services 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. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required.
Evidence
  1. The public pay UAI, dated 07/02/2025, in the record for resident 1 is incomplete as it lacks documentation on the Virginia Uniform Assessment Instrument Attachment to Public Pay Short Form Assessment regarding resident 1’s medication administration, psycho-social status, orientation, assessment summary and level of care approved.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The record for resident 1 has documentation of a signed physician order dated 12/01/2025 to hold routine medications, controlled substances for excessive sleepiness, BP less than 100/60, respirations less than 15 breaths per minute.
  2. The January 2026 medication administration record (MAR) has documentation of staff initials with “DNG” beside them for resident 1’s 9am medications on 01/23/2026. The legend on the MAR has documentation that “DNG” indicates that Drug not given. There is no documentation on the January 2026 MAR for resident 1 as to why the medication was not administered.
  3. The February 2026 MAR for resident 1 has documentation of staff initials with “DNG” beside them for resident 1’s 9am medications on 02/13/2026. The legend on the MAR has documentation that “DNG” indicates that Drug not given. Documentation in the daily log for resident 1 dated 02/13/2026 at 8:57am has that resident 1 was heavily sedated and that resident 1’s medications were not given. There is no documentation of resident 1’s blood pressure or respirations being checked prior to holding resident 1’s medications.
Plan of correction
- Resident 1’s medication orders were clarified. - Staff to be re-educated on following parameters during staff meeting on 3/19/2026. - All physician orders with parameters to be audited by 3/25/2026. - Parameter orders flagged in MAR - Medication aides trained on when to hold meds - Ongoing MAR audits
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that all required documentation was included on medication administration records (MARs).
Evidence
  1. The January 2026 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the prescribed medications Acetaminophen 500mg 2 tablets, Ibuprofen 200mg 2 caplets, Methocarbamol 750mg 1 tablet and Venlafaxine HCL ER 150mg 1 tablet at 5pm on 01/18/2026, for the prescribed medication Trulicity 1.5/0.5ml injection once a week on 01/09/2026, 01/23/2026 and 01/30/2026, and the prescribed medication Oxycodone IR 5mg tablet at 3:00pm on 01/27/2026.
  2. The February 2026 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the prescribed medications Atorvastatin 40mg 1 tablet, Benztropine 1mg 1 tablet, Carbamazepine 200mg 1.5 tablets, Lithium Carbonate 300mg 2 capsules, Melatonin 3mg 1 tablet, Trazadone 100mg 1 tablet, Aripiprazole 5mg 1 tablet and Advair Diskus Inhaler 1 puff at 9:00pm on 02/13/2026 and 02/16/2026, for the prescribed medications Gabapentin 400mg 1 tablet at 6am on 02/17/2026 and at 10:00pm on 02/13/2026 and 02/16/2026 and for the prescribed medications Ibuprofen 200mg 2 capsules, Methocarbamol 750mg 1 tablet and Acetaminophen 500mg 2 tablets at 5:00pm on 02/20/2026.
  3. The January and February 2026 MARs for resident 1 did not have documentation in a legend of what the dash symbol signifies. In an interview with two licensing inspectors (LIs) and staff person 2 on the day of on-site inspection, staff person 2 was unable to explain what the dash (-) documentation indicates on the MAR for resident 1.
Plan of correction
- Staff meeting to be held on 3/19/2026 to reiterate proper Mar documentation. - DORS to review dashboard daily to ensure medications have been administered as ordered. - Daily MAR review by shift supervisor/ DORS. - Disciplinary action for repeat documentation issues
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as needed for a change in resident condition.
Evidence
  1. The record for resident 1 has documentation on a report of physical examination dated 05/28/2025 that the resident has a diagnosis of history of opiate abuse.
  2. The record for resident 1 has a psychiatry progress note dated 02/11/2026 that has documentation that resident 1 has allegedly asked older residents for their medications.
  3. The Daily Log in the record for resident 1 has documentation on 02/19/2026 11:31 that resident 1 was caught in another resident’s room going through drawers and trying to steal the resident’s alcohol and on 02/23/2026 at 7:02 that resident 1 was smoking marijuana several times in the front entrance.
  4. The ISP dated 07/05/2025 in the record for resident 1 does not include the identified need or services to be provided related to resident 1’s history of opiate/drug abuse.
Plan of correction
- Resident 1’s ISP was immediately reviewed and updated to reflect current condition. - All resident ISPs to be audited for updates related to condition changes by 3/25/2026. - ISP reviews triggered by any significant change - Monthly ISP audit by DORS
February 26, 2026Complaint survey2 violations
Inspection dates
02/26/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2026 8:30AM to 3:00PM 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 02/05/2026 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a physician’s order, dated 02/05/2026, for Mupirocin 2% topical ointment apply a thin film to left upper extremity and left posterior knee for 1 week two times daily.
  2. The February 2026 medication administration record (MAR) for resident 1 contains 29 instances of staff initials as administering Mupirocin to resident 1 from 02/10/2026 thought 02/26/2026.
Plan of correction
- Resident 1’s medication order was clarified with the physician, and Mupirocin was discontinued per order duration. - Staff meeting to be held on 3/19/2026 and staff will be retrained on proper medication administration protocols; this will include following a physicians order. - A 100% audit of all current physician orders vs MARs was completed on 2/25/2026. Next Audit will be completed on 3/25/2026. - MAR to Cart audits will continue monthly - Stop dates to be verified. - Medication aides re-trained on order duration compliance - DORS Oversight.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that all required documentation was included on medication administration records (MARs).
Evidence
  1. The February 2026 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the resident’s following prescribed medications: 9:00PM medications on 02/16/2026, 02/26/2026, 02/27/2026, and 02/28/2026; 9:00AM medications on 02/27/2026 and 02/28/2026; and 5:00PM medications on 02/20/2026, 02/26/2026, 02/27/2026, and 02/28/2026.
  2. The February 2026 MAR for resident 1 does not have documentation in a legend of what the dash symbol signifies. In an interview with two licensing inspectors (LIs) and staff person 2 on the day of on-site inspection, staff person 2 was unable to explain what the dash (-) documentation indicates on the MAR for resident 1.
Plan of correction
- Staff meeting to be held on 3/19/2026 to reiterate proper Mar documentation. - DORS to review dashboard daily to ensure medications have been administered as ordered. - Daily MAR review by shift supervisor/ DORS. - Disciplinary action for repeat documentation issues
February 26, 2026Complaint survey2 violations
Inspection dates
02/26/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2026 8:30AM to 3:30PM 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 12/30/2025 regarding allegations in the areas of: resident care and related services & buildings and grounds Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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: resident care and related services 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. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-860-G
Based on measurements and observations, the facility failed to ensure hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit.
Evidence
  1. At approximately 10:25AM during the on-site inspection, two licensing inspectors (LIs), in the presence of staff person 3, observed that the hot water in resident 1’s shower only measured 96.4 degrees Fahrenheit after the hot water had been running in resident 1’s shower for approximately 5 minutes.
Plan of correction
- Water temperatures were immediately tested and adjusted to ensure compliance within 105°F–120°F range. - A full building audit of all resident-accessible sinks and showers to be completed by 3/24/2026. - Maintenance will check water temps weekly x4 weeks, then monthly - Temperature logs will be maintained - Any out-of-range temps will be corrected immediately - Preventative maintenance schedule to be implemented.
22VAC40-73-460-H
Based on resident record review and staff interview, facility documentation, and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired.
Evidence
  1. Interview with staff person 1 revealed that the facility utilizes the skin monitoring comprehensive CNA shower review document as a way of documenting when a resident has received a shower or bath.
  2. Resident 1 was admitted to the facility on 11/24/2025. The uniform assessment instrument (UAI) in the record for resident 1, dated 11/10/2025, indicates that the resident requires mechanical and supervision human help with bathing. The individualized service plan (ISP) in the record for resident 1, dated 11/24/2025, indicates that the resident requires mechanical and supervision human help with bathing – resident 1 will be able to bathe with the assistance of grab bars and staff will supervise to ensure proper hygiene, resident and direct care staff will provide the service and this will be done a minimum of twice weekly and as needed.
  3. During on-site inspection, the licensing inspector (LI) requested shower sheets for resident 1 from November 2025 to current. Staff persons 1 and 3 were only able to provide Skin monitoring comprehensive CNA shower review sheets for the following dates that resident 1 has received a shower since his admission to the facility: 01/20/2026, 01/23/2026, 02/02/2026, 02/03/2026, 02/06/2026, 02/10/2026, 02/16/2026, and 02/26/2026.
Plan of correction
- All residents requiring assistance with bathing to be immediately reviewed. Resident 1’s bathing schedule was confirmed to reflect a minimum of twice weekly bathing or more frequently based on preference/need. Staff responsible for personal care to be re-educated on bathing requirements per regulation. - A 100% audit of all resident care plans and shower schedules will be completed by the Administrator/Designee on 3/20/2026 to ensure all residents receive bathing at least twice weekly or as desired. - Shower schedules will be reviewed weekly by the DORS/ ED. - Bathing documentation will be audited weekly x4 weeks, then monthly. - Staff will receive ongoing training on ADL care expectations. - Any missed showers will be addressed same shift. - ADL Documentation will be progressed to Electronic documentation of task
February 26, 2026Complaint survey0 violations
Inspection dates
02/26/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/26/2026 8:30AM to 12:30PM 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 02/02/2026 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 25, 2025Complaint survey0 violations
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 12:30PM 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 11/14/2025 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: 92 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 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 25, 2025Complaint survey1 violation
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 12:30PM 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 11/11/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 92 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@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) shall include a description of identified needs and date identified based upon the (i) uniform assessment instrument; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
  1. The ISP in the record for resident 1, dated 05/19/2025, contains documentation that the resident will receive a low-concentrated sweets (LCS) diet as ordered by medical doctor (MD); however, the record for resident 1 does not contain a physician’s order for the resident to receive a LCS diet. Interview with staff persons 1 and 2 confirmed that the resident does not have a physician’s order for a LCS diet and the ISP is inaccurate.
Plan of correction
1. The ISP for Resident 1 was immediately updated to remove the inaccurate LCS diet documentation. 1. Diet audit to be completed on every resident by 12/12/25 2. A comprehensive audit of all current resident ISPs will be completed by 12/12/25 to ensure accuracy and alignment with assessments and physician orders. 1. Diet audit to be completed on every resident by 12/12/25 2. A comprehensive audit of all current resident ISPs will be completed by 12/12/25 to ensure accuracy and alignment with assessments and physician orders.
November 25, 2025Complaint survey1 violation
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 12:30PM 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 10/01/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 92 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 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident 1 contains a staff progress note, dated 09/10/2025 at 6:25AM, with the following information: around 9:30PM resident was smoking while taking a bath in her room, resident said she got out of the bathtub to answer her door and when she returned the towel and clothes were on fire. Resident’s right pointer finger was burned, EMT checked out the resident, but the resident refused to go to the ER and hospice was called and stated they would be in on Wednesday to see the resident.
  2. The aforementioned incident involving the resident was not reported to the regional licensing office as of on-site inspection on 11/25/2025. Staff person 1 confirmed this is accurate.
Plan of correction
1. All current open incidents to be reviewed to ensure no additional events are missed or under-reported. 1. All department managers and nursing staff to be re-educated on: • Definition of a major incident. • Required steps for internal reporting. • The 24-hour reporting requirement to the licensing office 2. In-Service to be completed by 12/12/25 3. Effective immediately, all incident reports must be submitted to the Administrator or designee within one hour of occurrence. Any incident meeting “major incident” criteria will be submitted to the licensing office within the required timeframe. 1. All department managers and nursing staff to be re-educated on: • Definition of a major incident. • Required steps for internal reporting. • The 24-hour reporting requirement to the licensing office 2. In-Service to be completed by 12/12/25 3. Effective immediately, all incident reports must be submitted to the Administrator or designee within one hour of occurrence. Any incident meeting “major incident” criteria will be submitted to the licensing office within the required timeframe.
November 25, 2025Complaint survey1 violation
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 12:30PM 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 10/27/2025 regarding allegations in the area of: buildings and grounds Number of residents present at the facility at the beginning of the inspection: 92 Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observations during a tour of the building, the facility failed to ensure the interior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During on-site inspection on 11/25/2025, at approximately 10:27AM two licensing inspectors (LIs) and staff persons 1 and 2 observed multiple Hefty plastic storage bags beside resident 1’s recliner in a basket that contained chips, popcorn, candy and crackers. At approximately 10:41AM, a housekeeper went into resident 1’s room and swept a pile of crumbs from under resident 1’s recliner which was also observed by staff person 1.
  2. At approximately 10:34AM, two LIs and staff person 2 observed multiple fruit flies flying around the foot of resident 2’s bed. Staff person 2 found a bag of expired grapes that was located within a pile of items at the foot of resident 2’s bed and multiple fruit flies were coming from the bag of expired grapes as well.
Plan of correction
1. Room sweep to be completed by 12/5/2025. All rooms to be in well-kept conditions. 1. Nursing and housekeeping supervisors will jointly complete weekly room audits focusing on food storage, cleanliness, and pest-attracting conditions. 2. Any findings will be documented and corrected same-day. 1. Nursing and housekeeping supervisors will jointly complete weekly room audits focusing on food storage, cleanliness, and pest-attracting conditions. 2. Any findings will be documented and corrected on the same-day.
November 25, 2025Complaint survey0 violations
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 11:15AM 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 11/24/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 92 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 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 25, 2025Complaint survey0 violations
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 9:06AM 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 10/06/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 92 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: 2 Observations by licensing inspector: medication carts 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 25, 2025Complaint survey0 violations
Inspection dates
11/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/25/2025 8:00AM to 10:04AM 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 11/29/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 92 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 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 19, 2025Complaint survey1 violation
Inspection dates
11/19/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/19/2025 11:46AM to 2:25PM 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 11/19/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation, resident record review and staff interview, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During on-site inspection on 11/19/2025, at approximately 12:20PM the licensing inspector (LI), staff person 1 and Collateral 1 observed resident 1 asleep on the couch in the main lobby and with a small, clear plastic cup containing medication (pills) in front of her on the couch. Interview with staff person 1 revealed that staff person 2 was the registered medication aide (RMA) on duty during this time and was the staff person who left the medication with the resident and did not ensure the resident took their medication.
  2. Staff person 3 noted on the resident’s November 2025 medication administration record (MAR) that was provided to the LI that the medications in the small, clear plastic cup were Simethicone 80MG, Sucralfate 1 GM and Benztropine 1MG. Staff person 1 confirmed that resident 1 requires their medications to be administered by the facility.
Plan of correction
1. Staff member involved has been suspended pending further disciplinary action. 1. DORS to review medication administration policy 5.09 with all RMAs and have all sign off on understanding. In-service to be completed with all necessary staff by 12/12/2025 1. DORS to review medication administration policy 5.09 with all RMAs and have all sign off on understanding. In-service to be completed with all staff by 12/12/25.
October 24, 2025Complaint survey0 violations
Inspection dates
10/24/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/24/2025 11:05AM to 1:30PM 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 10/24/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 28, 2025Complaint survey1 violation
Inspection dates
08/28/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/28/2025 8:17AM to 10:15AM 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 07/03/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: resident room 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on observation, resident record review and staff interview, the facility failed to ensure a medicine cabinet, container, or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility.
Evidence
  1. At approximately 9:24AM during on-site inspection on 08/28/2025, two licensing inspectors (LIs) observed a Bero Ellipta inhaler sitting on top of the unattended A-Hall medication cart that was located in the hallway. The two LIs alerted staff persons 2 and 3 to the inhaler that was sitting on top of the unattended medication cart.
  2. During an interview with staff person 1, staff person 1 revealed that she was the assigned registered medication aide (RMA) to the A-Hall Medication cart. Staff person 1 revealed to the two LIs that the aforementioned inhaler belonged to resident 1 and that staff person 1 had accidently left the inhaler in resident 1’s room and that resident 1 had placed it on top of the A-Hall medication cart to be placed back in the medication cart.
Plan of correction
Corrective Action: • Pharmacy Audits conducted monthly for 3 months and then quarterly • Community Cart Audits conducted twice weekly • Director of Resident Services twice daily reviews Steps taken to identify if this deficiency spans throughout the community and date of completion Measures: • Pharmacy Audits conducted monthly for 3 months • Community Cart Audits conducted weekly • Staff training was completed by DORS on medications in apartments without orders. Systems or changes put into place to ensure this deficiency will not reoccur: Pharmacy Audits conducted monthly for 3 months Community Cart Audits conducted weekly
July 2, 2025Inspection6 violations
Inspection dates
07/02/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2025 10:04AM to 5:00PM 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 06/28/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-70-B
Based on facility documentation review and staff interview, the facility failed to report all required information to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The licensing inspector (LI) received a self-reported incident via email from staff person 1 on 06/28/2025 at 2:04PM regarding resident 1. In the report staff person 1 stated that resident 1 was involved in a resident-to-resident altercation on 06/28/2025 at 4:45AM and that resident 1 was grabbed around her throat by another resident; law enforcement, 911, and EMS was called and the resident was taken to the hospital.
  2. As of on-site inspection on 07/02/2025, the LI had not received information from staff person 1 that resident 2 was the resident that was involved in the resident-to-resident altercation with resident 1.
Plan of correction
Corrective Action: • Training with all staff about reportable incidents to be held at all staff meeting. Steps taken to identify if this deficiency spans throughout the community and date of completion: • This was reported on the injured resident on time. • The other resident was not injured – did not think I had to report that. Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • DORS to report any needed injury requiring hospitalization to ED immediately. • ED to report to DSS within 24 hours.
22VAC40-73-640-A
Based on resident record review, the facility failed to ensure to implement its written plan for medication management in regard to methods to ensure that each resident’s prescription medications ordered for the resident are filled in a timely manner to avoid missed dosages and methods to ensure methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order.
Evidence
  1. The facility’s medication management plan states in the section “MAR/MOR – CHANGE OF SHIFT ACCURACY CHECK” that if a new medication has been ordered by the health care provider, the Nurse/Medication Assistant Tech ensures that it is available to be given to the resident at the prescribed time and date and all new orders post transcription to the MAR are reviewed by DORS or designee for accuracy.
  2. The record for resident 2 contains a psychiatry progress note, dated 06/24/2025 and electronically signed by a psychiatrist on 06/26/2025 at 8:54PM, to initiate Risperidone 0.5MG twice daily.
  3. Resident 2’s June 2025 MAR does not contain a section for Risperidone 0.5MG twice daily and does not contain documentation that the resident was administered Risperidone 0.5MG twice daily per the aforementioned physician’s order.
Plan of correction
Corrective Action: • EHR/Emar/Pharmacy Interface Implemented • Care stream verification of any uncomplete task is reporting to the existing • DORS and ED to check multiple times daily for verification of all orders Steps taken to identify if this deficiency spans throughout the community and date of completion: • DORS and ED to check multiple times daily for verification of all orders • DORS and ED to check multiple times daily for verification of all orders Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • DORS and ED to check multiple times daily for verification of all orders
22VAC40-73-680-E
Based on resident record review and staff interviews, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions, documented and the documentation shall be maintained in the resident’s record.
Evidence
  1. The June 2025 MAR for resident 1 has documentation of a physician order dated 06/19/2025 for Accuchecks, check blood glucose everyday X 30 days. The June 2025 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials for completion of the blood glucose check or the blood glucose results at 9:00AM on 06/22/2025. The June 2025 MAR for resident 2 has documentation of a physician order dated 05/19/2025 for Accuchecks, check blood glucose before meals and the MAR indicates this is done daily at 7:30AM, 11:30AM, and 4:30PM. The June MAR for resident 2 has documentation of only a dash symbol (-) and does not have staff initials for completion of the blood glucose check or the blood glucose results at 4:30PM on 06/12/2025 and at 11:30AM on 06/16/2025.
  2. Interviews conducted on 07/02/2025 during on-site inspection with staff persons 2 and 3 expressed that the dash (-) symbol is an indication that the staff person conducting the blood glucose check did not initial/sign the MAR for these procedures for residents 1 and 2 and staff persons 2 and 3 were unable to provide documentation of residents 1 and 2’s blood glucose checks or the blood glucose results.
Plan of correction
Corrective Action: • Pharmacy enters all AccuCheck orders as medication orders in the EHR system. This process ensures that any missed checks are flagged as “missed medications” and identified by DORS during the daily MAR review, prompting the appropriate staff member to obtain the blood glucose reading. • DORS reviews EHR/Emar Dashboard at least twice daily • • EMAR training with DORS • EHR Inservice with staff (See attachment) • Collins and Relias HER Training Steps taken to identify if this deficiency spans throughout the community and date of completion: • DORS reviews EHR/Emar Dashboard at least twice daily • EMAR training with DORS • EHR Inservice with staff (See attachment) • Collins and Relias HER Training Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • Pharmacy enters all AccuCheck orders as medication orders in the EHR system. • DORS reviews EHR/Emar Dashboard at least twice daily • EMAR training with DORS • EHR Inservice with staff (See attachment) • Collins and Relias HER Training
22VAC40-73-460-A
Based on resident record review and staff interview, the facility failed to assume responsibility for the health, safety, and well-being of the residents.
Evidence
  1. The uniform assessment instrument (UAI) for resident 2, dated 02/01/2025, contains documentation that the resident is abusive/aggressive/disruptive less than weekly and the type of inappropriate behavior is anger outbursts – random. 2. The individualized service plan (ISP) for resident 2, dated 02/25/2025, contains documentation that the resident is abusive/disruptive/aggressive – resident will be redirected as needed by removing (from) stimuli, or engaging in activities when aggressive, disruptive, abusive behaviors occur and be given the opportunity to calm down naturally before re-approaching resident and notify MD if symptoms worsen. 3. Hospital documentation in the record for resident 2 states that the resident was in the hospital from 09/24/2024 until discharged to Carriage Hill Retirement on 02/25/2025. The hospital discharge summary in the record for resident 1, dated 02/25/2025, contains documentation on page 3 of 15 that it is recommended that the resident takes all medications as prescribed and engages with her community provider on an appropriate medication regimen. The UAI in the record for resident 2 that was completed by the hospital, dated 12/05/2024, contains documentation on page 1 that the resident has been diagnosed with schizoaffective disorder and PTSD and there is also documentation on page 7 that the resident has an extensive history of rapid rehospitalization due to medication non-adherence resulting in decompensation when she has not had access to ongoing assistance from trained staff and without trained staff for ongoing assistance with medication administration, it is likely that the resident will destabilize quickly and return to a state hospital facility for emergency treatment of psychiatric symptoms caused by her severe mental illness diagnoses. The UAI in the record for resident 2 that was completed by the hospital, dated 12/05/2024, contains documentation on page 12 that the resident has long-term medical and psychiatric needs which require supervision and medication administration assistance to prevent acute exacerbation and subsequent hospitalizations. Medication non-adherence and chronic homelessness have resulted in the resident presenting frequently to the emergency department in crisis, often requiring subsequent transfer to psychiatric hospitals for involuntary commitment and treatment. When not appropriately medicated and in the community, the resident has been noted to exhibit behaviors consistent with her psychiatric diagnoses which cause her to be a danger to herself and others. Documentation by staff person 5 at 1:27Pm on 06/09/2025 states that resident 2 signed herself out of the facility on 06/05/2025 and informed the facility she was going to a dental appointment and would be back later in the day or the next morning. Additional documentation by staff person 5 at 1:28PM on 06/09/2025 states that staff person 5 spoke with the resident’s family member who stated the resident took a cab to Lynchburg and told her family she was going to the “SS office” and that the resident called and left a message with her family member stating that “someone stole her debit card and she was stuck in Lynchburg.”. Staff person 5 documented in the resident’s daily log notes that they requested the family member ask the resident to contact the facility and let the facility know she is okay and that the resident has not had any of her medications since she left on “Thursday, 5 days ago”. Resident 2’s June 2025 medication administration record (MAR) contains documentation that the resident wasn’t administered her medications from the morning of 06/05/2025 until the evening of 06/10/2025 due to “LOA”. (please see additional documentation for this notice as all characters would not fit on this violation notice)
Plan of correction
Corrective Action: • Improved review of Psychiatric Diagnosis of Potential New residents to ensure that they meet admission criteria by any concerns are up lined to the Chief Clinical Officer review and Denial approval • All UAI and ISP’s completed prior to physical Move in • Weekly Reviews of all Potential Move ins for the next week. Steps taken to identify if this deficiency spans throughout the community and date of completion:• Improved review of Psychiatric Diagnosis of Potential New residents to ensure that they meet admission criteria by any concerns are up lined to the Chief Clinical Officer review and Denial approval • All UAI and ISP’s completed prior to physical Move in • Weekly Reviews of all Potential Move ins for the next week. Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • Improved review of Psychiatric Diagnosis of Potential New residents to ensure that they meet admission criteria by any concerns are up lined to the Chief Clinical Officer review and Denial approval • All UAI and ISP’s completed prior to physical Move in • Weekly Reviews of all Potential Move ins for the next week
22VAC40-73-150-C
Based on facility inspections, the administrator failed to ensure responsibility for the general administration and management of the facility and failed to oversee the day-to-day operation of the facility.
Evidence
  1. Staff person 1 became the facility’s administrator of record effective 08/19/2024. During this time, the facility has had 18 closed inspections, having at least one or more violations per inspection. The violations that have been cited are in the areas of administration and administrative services, personnel, staff and supervision, resident care and related services, resident accommodations and related provisions, buildings and grounds, emergency preparedness, and safe, secure environment.
  2. Repeat and high-risk violations have been cited in the areas of staffing and supervision, resident care and related services and buildings and grounds from multiple complaint investigations, multiple monitoring inspections, and a mandated renewal inspection completed during this current licensure period.
Plan of correction
Corrective Action: • State Survey ED Responsibility Tracker Implemented and weekly meetings with Corporate Support (See Attachment) • New Resident Services Director hired 6/29/2025. • Multiple Divisional Directors have been on site bi - weekly since 7/2025. • RMA refresher trainings have been completed by contracted pharmacy with all RMAs on staff. • Weekly Oversite Collaboration meetings with Corporate Team Steps taken to identify if this deficiency spans throughout the community and date of completion:• State Survey ED Responsibility Tracker Implemented and weekly meetings with Corporate Support (See Attachment) • New Resident Services Director hired 6/29/2025. • Multiple Divisional Directors have been on site bi - weekly since 7/2025. • • RMA refresher trainings have been completed by contracted pharmacy with all RMAs on staff. • Weekly Oversite Collaboration weekly with Corporate Team Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • State Survey ED Responsibility Tracker Implemented and weekly meetings with Corporate Support (See Attachment) • New Resident Services Director hired 6/29/2025. • Multiple Divisional Directors have been on site bi - weekly since 7/2025. • RMA refresher trainings have been completed by contracted pharmacy with all RMAs on staff • . • Weekly Oversite Collaboration weekly with Corporate Team
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that all required information was included on medication administration records (MARs).
Evidence
  1. The June 2025 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the prescribed medications Acetaminophen 500mg 2 tablets, Ibuprofen 200mg 2 capsules, Ingrezza 80mg 1 capsule and Gabapentin 100mg 1 capsule at 9:00AM on 06/22/2025. The June 2025 MAR for resident 2 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the prescribed medications Buspirone 15MG at 5:00PM on 06/12/2025 and at 12:00PM on 06/16/2025, Humalog Insulin 10 units at 4:30PM on 06/12/2025 and at 11:30AM on 06/16/2025, Ibuprofen 600MG at 5:00PM on 06/12/2025, Lantus Insulin 45 units at 9:00PM on 06/13/2025, Trulicity 0.75MG/0.5ML at 9:00AM on 06/18/2025,
  2. The June 2025 MARs for residents 1 and 2 did not have documentation in a legend of what the dash symbol signifies. Interviews conducted during the 07/02/2025 on-site inspection by 2 licensing inspectors (LIs) with staff persons 2 and 3 expressed that the dash (-) symbol is an indication that the staff person administering medications did not initial/sign the MAR for the aforementioned medications.
  3. The June 2025 MAR for resident 1 has documentation of staff person 4’s initials for the administration of Trulicity 0.5ml sub-q weekly on 06/19/2025. Interview conducted on 07/02/2025 on-site inspection by 2 LIs with staff person 1 expressed that staff person 5 had administered this medication but staff person 1 could not explain why staff person 4 had documented their initials on the MAR for the administration of this medication instead of staff person 5.
Plan of correction
Corrective Action: • DORS continuously monitors the Medication Administration Record throughout the day to prevent any gaps. If a medication is marked as “missed,” a paper MAR is printed and signed by the responsible staff member. Steps taken to identify if this deficiency spans throughout the community and date of completion: • DORS continuously monitors the Medication Administration Record throughout the day to prevent any gaps. Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • DORS continuously monitors the Medication Administration Record throughout the day to prevent any gaps.
July 2, 2025Complaint survey2 violations
Inspection dates
07/02/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: 07/02/2025 10:04AM to 5:00PM 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 06/30/2025 regarding allegations in the areas of: resident care and related services & additional requirements for facilities that care for adults with serious cognitive impairments 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: 4 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that all required information was included on medication administration records (MARs).
Evidence
  1. The June 2025 MAR for resident 1 has documentation of only a dash symbol (-) and does not have staff initials present for the administration of the prescribed medications Acetaminophen Arth ER 650mg 1 tablet, Atorvastatin 10mg 1 tablet, Escitalopram 5mg 1 tablet, Fluticasone Nasal Spray 2 spray into each nostril, Loratadine 10mg 1 tablet, Losartan 50mg 1 tablet, Meclizine 12.5 1 tablet, Polyethlene Glycol 17gm, Propanolol 10mg 1tablet, Quetiapine 25mg 1 tablet, Trazadone 50mg 1 tablet, Vitamin B-12 1000mcg 1 tablet,Vitamin D-3 50mcg 1 tablet and Lidocaine 4% Patch to pain site at 8:00AM on 06/22/2025 and Aspirin 81mg 1 tablet at 9:00AM on 06/22/2025.
  2. The June 2025 MAR did not have documentation in a legend of what the dash symbol signifies. Interviews conducted on day of on-site inspection by 2 licensing inspectors (LIs) with staff persons 1 and 2 expressed that the dash (-) symbol is an indication that the staff person administering medications did not initial/sign the MAR for these medications at 8:00AM and 9:00AM on 06/22/2025.
Plan of correction
Corrective Action: • EMAR Implemented which is interfaced with Guardian Pharmacy. All medications are entered into the Emar by a pharmacist. (Fully Implemented 7.15.15) Steps taken to identify if this deficiency spans throughout the community and date of completion: • EMAR Implemented • DORS Emar reviews a minimum of twice Daily • Corporate Reviews Daily Measures, Systems or changes put into place to ensure this deficiency will not reoccur: EMAR Implemented • DORS Emar reviews a minimum of twice Daily • Corporate Reviews weekly
22VAC40-73-325-B
Based on resident record review, the facility failed to ensure that a fall risk rating was completed after a fall for a resident who is assessed as assisted living level of care.
Evidence
  1. The record for resident 1 has documentation in Daily Logs of the resident falling on 06/07/2025 and 06/17/2025. The only fall risk ratings available for review on the day of on-site inspection for resident 1 were dated 06/04/2025 and 07/02/2025, the day of on-site inspection.
  2. The record for resident 1 has documentation that the resident was sent to a local hospital on 06/21/2025 and as of the day of on-site inspection has not returned to the facility. The uniform assessment instrument (UAI), dated 05/28/2025, in the record for resident 1 has documentation that the resident was assessed as assisted living level of care.
Plan of correction
Corrective Action: EHR Implemented to have Fall assessment completed with each move in, each fall, and annually. Director of Resident Services has a Tracker of when all UAI’s become for update and completes the Fall Risk Assessment in order to add the Risk Assessment to the updated UAI. Steps taken to identify if this deficiency spans throughout the community and date of completion: Fall Assessment Audit 100% Director of Resident Services has a Tracker of when all UAI’s become for update and completes the Fall Risk Assessment in order to add the Risk Assessment to the updated UAI. Measures, Systems or changes put into place to ensure this deficiency will not reoccur: Fall Assessment Audit 100% EHR Dashboard reviews completed by community and Divisional Level
July 2, 2025Complaint survey3 violations
Inspection dates
07/02/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2025 10:04AM to 5:00PM 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 06/30/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: noon-time meal, medication cart audit An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-560-E
Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility.
Evidence
  1. Interview with staff person 1 revealed that resident 1 had received wound care services from a home health agency starting in March 2025; however, during on-site inspection on 07/02/2025, staff person 1 was only able to provide wound care notes from the home health agency from 04/23/2025 and 05/05/2025. Staff person 1 informed the LI that the facility would have to contact the home health agency and obtain the additional wound care notes and that staff person 1 would email them to the LI.
  2. Staff person 1 emailed the LI the additional wound care notes on 07/03/2025 that were obtained from the home health agency.
Plan of correction
Corrective Action: • DORS gathered all outstanding records for each resident and filed them in their respective charts. • Resident was discharged on 8/6/2025. Steps taken to identify if this deficiency spans throughout the community and date of completion: • DORS gathered all outstanding records for each resident and filed them in their respective charts. • Record Oder sheet placed in front of all the residents charts Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • DORS will meet with third-party vendors weekly to ensure resident records are received promptly and placed in resident file.
22VAC40-73-470-B
Based on resident record review, collateral documentation, observations and staff interviews, the facility failed to ensure that residents skilled nursing treatments within the facility were met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.
Evidence
  1. Resident 1 was admitted to the facility on 03/07/2025. The record for resident 1 contains a signed physician’s order from a local hospital, dated 02/18/2025, that indicates the resident is receiving wound care for a Stage 3 pressure wound on left heel and the treatment order is for skilled nursing wound care Monday, Wednesday, and Friday to rinse with saline, pat dry, apply small amount Medihoney, cover with Tegederm foam type dressing until healed.
  2. The aforementioned wound care was provided by a home health agency on 03/12/2025, 03/14/2025, 03/17/2025, 03/19/2025, 03/21/2025, 03/24/2025, 03/26/2025, and 03/28/2025; however, the home health agency’s documentation, dated 03/31/2025, 04/02/2025, 04/04/2025, and 04/06/2025, states wound care was not provided by the home health agency (missed visits) due to “Cancelled By Agency – Reduction of Auth/Order” and “Awaiting Authorization”. The home health agency’s documentation contains information that the wound care was not provided to the resident again by the home health agency until 04/18/2025, 04/21/2025, and 04/23/2025. Resident 1’s wound care was not provided again (missed visits) by the home health agency on 04/25/2025, 04/28/2025, 04/30/2025 and 05/02/2025 due to “Cancelled By Agency – Reductions of Auth/Order” and “Awaiting Authorization” The home health agency provided wound care to the resident on 05/05/2025 and then the resident was hospitalized from 05/06/2025 until 05/08/2025. Staff person 1 provided the licensing inspector (LI) an email from the home health agency that was sent to staff person 3, dated 07/03/2025 at 10:26AM, that stated the resident had a lot of missed visits because the home health agency was waiting on authorization to resume wound care and also that the home health agency had emailed staff person 6 “quite a bit” and also called the facility “multiple times” to get the resident’s signed plan of care back because it was needed to approve more wound care visits.
  3. During an on-site inspection on 07/02/2025, two licensing inspectors (LIs) and staff persons 1, 2, 3, 4, and 5 observed that there was a bandage on resident 1’s left heel and a bandage on resident 1’s right heel. Staff persons 1 and 3 revealed that they were not aware of the bandages on the resident’s heels until the on-site inspection. Staff person 1 removed the bandages from the resident’s heels and stated that the wound dressing was not done at the facility because the facility does not have the supplies that were used on the resident’s heels. The LIs observed the removal of the bandages by staff person 1 and the left heel contained an open area with dark drainage on the bandage which was also observed and acknowledged by staff persons 1, 2 and 3.
  4. Interview with staff person 1 on 08/28/2025 revealed that when the resident returned from the hospital on 05/08/2025, the home health agency’s wound care services were not restarted. Also, staff person 1 stated that there was no documentation that wound care had been provided to the resident during the aforementioned times that the home health agency did not provide the wound care due to “Cancelled By Agency – Reductions of Auth/Order” and “Awaiting Authorization” nor is there any documentation that wound care had been provided to the resident after returning from the hospital on 05/08/2025.
Plan of correction
Corrective Action: The order for HH was obtained and restarted 7/2/25. She has since been discharged. • HH Census/Discipline Audits • Folder system implemented where the DORS has all requested orders from HH for the ARNP to sign on to during her weekly visits • ARNP is connected to all email correspondence with the Director of Resident Services and HH • Interdisciplinary notes required of all disciplines and visits Third party binders can be found in nursing stations. Third party providers are aware to complete interdisciplinary form with each visit. Steps taken to identify if this deficiency spans throughout the community and date of completion: • HHCensus/Discipline Audits • Folder system implemented where the DORS has all requeste4d orders from HH for the ARNP to sign on to during her weekly visits • ARNP is connected to all email correspondence with the Director of Resident Services and HH • Interdisciplinary notes required of all disciplines and visits Third party binders can be found in nursing stations. Third party providers are aware to complete interdisciplinary form with each visit. Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • HHCensus/Discipline Audits • Folder system implemented where the DORS has all requeste4d orders from HH for the ARNP to sign on to during her weekly visits • ARNP is connected to all email correspondence with the Director of Resident Services and HH • Interdisciplinary notes required of all disciplines and visits Third party binders can be found in nursing stations. Third party providers are aware to complete interdisciplinary form with each visit.
22VAC40-73-610-D
Based on observation during the noon-time meal, resident record review, and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician’s or other prescriber’s orders.
Evidence
  1. The record for resident 1 contains a signed physician’s note, dated 06/24/2025 and electronically signed 06/27/2025 at 2:38PM, on page 3 of 4 that the resident’s diet is to be changed to pureed consistency.
  2. During on-site inspection on 07/02/2025 at approximately 10:23AM, two licensing inspectors (LIs) observed special diet board that was posted in the facility’s kitchen that listed resident 1’s diet as mechanical soft.
  3. At approximately 12:09PM on 07/02/2025, the two LIs and staff persons 4 and 5 noted that the lunch the resident was served in her room consisted of chunks of meat and brussel sprouts that were not consistent with a pureed diet.
Plan of correction
Corrective Action: • An audit of the diet board was conducted to verify that all non-regular accepted diets were accurately posted. • Corporate Dietary Director onsite for training of the staff July and August Steps taken to identify if this deficiency spans throughout the community and date of completion: • An audit of the diet board was conducted to verify that all non-regular accepted diets were accurately posted. • Diet Board audit was completed on 9/18/2025. • Most recent update to diet board was 9/25/2025. Communication with Case management at the hospital has been implemented DORS receives and reviews orders and notes from hospital before admission back to the facility. Measures, Systems or changes put into place to ensure this deficiency will not reoccur: • A monthly audit of the diet board will be completed to verify that all non-regular accepted diets are accurately posted.
June 18, 2025Complaint survey0 violations
Inspection dates
06/18/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/18/2025 10:00AM to 3:40PM 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 06/10/2025 regarding allegations in the area of: building and grounds 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: 6 Observations by licensing inspector: facility kitchen An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 29, 2025Complaint survey6 violations
Inspection dates
05/29/2025, 06/18/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/29/2025 10:15AM to 4:30PM and 06/18/2025 10:00AM to 3:40PM 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 05/20/2025 and 06/05/2025 regarding allegations in the areas of: resident care and related services & building and grounds Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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: building and grounds A violation notice was issued; any violation(s) not related to the complaints 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on resident record review, medication cart audit, and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 05/06/2025, for Albuterol - 2 inhalations PRN every 4-6 hours for shortness of breath/wheezing.
  2. During on-site inspection on 05/29/2025, staff person 3 revealed to the licensing inspector (LI) and Collateral 1 that this medication was not available in the facility for the resident.
Plan of correction
Facility staff to conduct cart audit and ensure all as needed medications are available for all residents. • Audits to be completed weekly thereafter
22VAC40-73-680-D
Based on resident record review, medication cart audit, and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 05/06/2025, for Umeclidinium 62.5MCG/Vilanterol 25MCG 1 inhalation daily for COPD.
  2. The 04/13/2025 to 05/12/2025, 05/13/2025 to 05/29/2025, and 05/16/2025 to 06/15/2025 medication administration records (MARs) provided to the licensing inspector (LI) during on-site inspection on 05/29/2025 does not contain documentation that the resident was administered this medication during this time-period. The eMAR summary from date 05/19/2025 to 05/29/2025 provided to the LI during on-site inspection on 05/29/2025 contains staff initials for administering this medication at 9:00AM on 05/28/2025 and 05/29/2025; however, interview with staff person 3 revealed to the LI and Collateral 1 that this medication was not available in the facility for the resident. Staff person 3 was asked by the LI and Collateral 1 why their initials were present for administering this medication at 9:00AM on 05/29/2025 on the MAR, the day of the on-site inspection, and staff person 3 stated that they documented that they administered it; however, the medication is not available in the facility to administer and they should not have documented they administered the medication.
Plan of correction
Facility to conduct complete medication cart audit to ensure all medications are available for all residents. • Audits to be completed weekly thereafter
22VAC40-73-640-A
Based on resident record review, facility policy review, and staff interview, the facility failed to ensure to implement its medication management plan (MMP).
Evidence
  1. The facility’s medication management plan and medication training information, received via email from staff person 1 on 09/27/2024, indicates on page 10 of the training material that medication staff are to follow the facility’s policy and procedure when a resident refuses medications (policy and procedure ensures that physician is notified in a timely manner based on resident’s physical and mental condition and the medication) and page 27 of the training material indicates that medication refusal needs to be documented on the medication sheets and brought to the attention of the prescribing doctor. Interviews with staff persons 1 and 2 during on-site inspection revealed that the facility’s medication management plan is still current and that a resident’s refusal of treatments and medical procedures should be treated the same as a resident’s refusal of medications and should be reported to the resident’s physician.
  2. The record for resident 1 contains a signed physician’s order, dated 03/10/2025, for Incentive Spirometry Perform 10 repetitions. Note C = clear, A = abnormal, or D = diminished every shift for Prophylaxis document pre and post lung sounds and document amount of minutes for respiratory treatment. The resident’s 03/13/2025 t0 04/12/2025, 04/13/2025 to 05/12/2025, 05/13/2025 to 05/29/2025, and 05/16/2025 to 06/15/2025 medication administration records (MARs) contain multiple days and times that the resident refused to use the Incentive Spirometry; however, the record for the resident does not contain any documentation that the resident’s physician has been notified about the refusals. Interview with staff persons 1 and 2 confirmed this is accurate.
Plan of correction
The facility will educate staff on proper procedures if a resident refuses medication or treatment.
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative.
Evidence
  1. The ISP in the record for resident 1, dated 03/13/2025, has not been signed and dated by the resident or the resident’s legal representative.
Plan of correction
The facility will audit all ISPs for resident/representative signature.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) shall include any medication errors or omissions.
Evidence
  1. The 05/16/2025 to 06/15/2025 MAR for resident 1 contains circled staff initials for Incentive Spirometry Perform 10 repetitions Notate C = clear, A = abnormal, D = diminished every shift for shortness of breath on 05/23-28/2025 during AM; 05/23/2025, 05/24/2025, 05/26-28/2025 during PM and on 05/28/2025 during night.
  2. Interview with staff person 2 revealed that the circled staff initials indicate that the resident refused the aforementioned medical procedures; however, the staff persons did not document this on the MAR.
Plan of correction
The facility will educate staff on the procedure for medication errors or omissions.
22VAC40-73-750-B
Based on observation, the facility failed to ensure bedrooms shall contain a sturdy chair for each resident.
Evidence
  1. During on-site inspection on 05/29/2025, the licensing inspector (LI) and Collateral 1 noted that resident 1’s room does not contain a chair.
Plan of correction
Facility staff conduct walk-through of all current occupied apartments to ensure they contain a sturdy chair for each resident. • Each new resident apartment will be equipped with a sturdy chair for each resident
May 9, 2025Complaint survey5 violations
Inspection dates
05/09/2025, 05/29/2025, 06/18/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/09/2025 1:00PM to 4:20PM, 05/29/2025 10:15AM to 4:30PM and 06/18/2025 10:00AM to 3:40PM 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 05/06/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: medication cart audit 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review, collateral interview, and staff interviews, the facility failed to ensure the medication administration record (MAR) shall include any medication errors or omissions and date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident 1’s March and April 2025 MARs contain documentation for Clozapine 25MG (also referred to as Clozaril) scheduled daily at 8:00AM and Clozapine 100MG scheduled daily at 8:00PM. The resident’s March and April 2025 MARs contains staff initials as administering both aforementioned medications numerous days during March and April 2025; however, the record for the resident contains a signed physician’s order, dated 03/09/2025, to hold Clozaril 25MG daily until further notice – awaiting pharmacy delivery and on 05/16/2025 Collateral 3 provided documentation to the licensing inspector (LI) that revealed that 28 Clozapine 100MG tablets and 28 Clozapine 25MG tablets were not delivered to the facility from the pharmacy until 04/12/2025 at 1:27AM. Interview with the staff person 2 on 05/28/2025 confirmed this is accurate.
  2. Hospital discharge paperwork for resident 1, dated 05/08/2025, contains a signed physician’s order for Aspirin 81MG one tablet once daily and Atorvastatin (Lipitor) 40MG one tablet daily at bedtime. The resident’s May 2025 MAR contains documentation that Aspirin 81MG is scheduled for 8:00AM daily and Atorvastatin 40MG is scheduled daily at 9:00PM. The May 2025 MAR does not contain staff initials that Aspirin 81MG was administered to the resident at 8:00AM on 05/15/2025, 05/16/2025, and 05/28/2028 and that Atorvastatin 40MG was administered to the resident at 9:00PM on 05/14/2025 and 05/15/2025.
Plan of correction
The facility will ensure that the medications are given per physicians’ orders. • DORS to complete a weekly mar to cart audit • Pharmacy to complete a monthly mar to cart audit
22VAC40-73-470-A
Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of resident are met.
Evidence
  1. Progress note by Collateral 2, dated 04/23/2025 and electronically signed by Collateral 2 on 04/25/2025, contains documentation on page 4 of 5 to obtain CBC (Complete Blood Count) with differential to monitor for potential side effects of Clozaril.
  2. Interview with staff person 2 during on-site inspection on 05/29/2025 revealed to the licensing inspector (LI) and Collateral 1 that there has not been a CBC completed on the resident since 03/18/2025.
Plan of correction
The facility will ensure any lab work documented to be drawn is ordered and obtained. • Lab orders will be dated when faxed to Lab and held in a binder until completed. Once completed .It will be notated that it was completed and placed in the chart.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to implement its medication management plan to ensure resident's prescription medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s medication management plan states the following: All MAR/MORs will be reviewed at the change of shift. All meds passed are initialed and no holes exist. The MAR/MOR sign off sheet will be initialed by outgoing and incoming Nurse/Medication Assistant Tech at the change of every shift after MAR/MOR has been pursued for accuracy. NOTE: At no time is it acceptable to find that a resident has less than 5 doses of medications available to them. Therefore, it is not acceptable to circle and indicate that we are waiting for pharmacy or family to deliver meds. It is the Nurse’s/Medication Assistant Tech’s responsibility to ensure that all orders are consistently filled and available to resident. If the medication(s) is supplied by the time the existing supply is depleted to five (5) doses the Nurse/Medication Assistant Tech will order five (5) doses of the medication (s) from the community pharmacy. This procedure will continue until the medication has arrived.
  2. The report of resident physical examination for resident 1, dated 02/27/2025, contains a signed physician’s order for Clozapine 100MG (also referred to as Clozaril) every day at bedtime. The resident’s March and April 2025 medication administration records (MARS) contain documentation that Clozapine 100MG was scheduled to be administered to the resident daily at 8:00PM. The March 2025 MAR contains documentation that on 03/16/2025 the medication was not given due to “refill medications”; on 03/20/2025 and 03/21/2025 the medication was not given due to “New Order not in from pharmacy”; 03/22/2025 the medication was not given due to “Other: PHARMACY WAITING ON HARD COPY”; 03/28/2025 the medication was not given due to “refill medications” and 03/30/2025 the medication was not given due to “Med not available”. The April 2025 MAR contains documentation that on 04/08/2025 the medication was not given due to “Med not available”. Interviews with staff persons 1 and 2 revealed that the aforementioned medication was not delivered to the facility from the pharmacy until 04/12/2025.
Plan of correction
The facility will ensure that the pharmacy has up to date hard scripts on all narcotics. • Narcotic needs reviewed weekly • We have recently transferred to another pharmacy, Southern Pharmacy.
22VAC40-73-680-D
Based on resident record review and collateral interviews, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. A physician’s order, dated 04/10/2025, contains documentation for Clozapine 25MG (also referred to as Clozaril) take one tablet by mouth every night at bedtime for mood in addition to 100MG. Documentation provided to the licensing inspector (LI) by Collateral 3 on 05/16/2025 reveals that 28 tablets of Clozapine 25MG and 28 tablets of Clozapine 100MG were delivered from the pharmacy and received by the facility on 04/12/2025 at 1:27AM. The resident’s April 2025 medication administration record (MAR) contains documentation that the resident was not administered Clozapine 25MG at 9:00 PM on 04/12/2025 and at 8:00PM on 04/13/2025 and 04/14/2025 due to “doctor order” and the resident was not administered Clozapine 100MG at 8:00PM on 04/12/2025, 04/13/2025, and 04/14/2025 due to “doctor order”. The record for resident 1 does not contain documentation that Clozapine 25MG and Clozapine 100MG were not to be administered to the resident during the aforementioned dates/times.
  2. A physician’s order, dated 04/18/2025, contains the following documentation: problems/issues: continued issues with getting Clozapine (also referred to as Clozaril) dosage into facility – stop all Clozaril – discontinue Clozaril 100MG every day and discontinue Clozaril 25MG every day. The resident’s May 2025 MAR contains documentation that the resident was administered Clozaril 100MG at 8:00PM on 05/03/2025, 05/04/2025 and 05/05/2025; however, the record for resident 1 does not contain a signed physician’s order restarting this medication.
  3. Progress note by Collateral 2, dated 04/23/2025 and electronically signed by Collateral 2 on 04/25/2024, contains documentation on page 5 of 5 that to restart Clozaril at 25MG at bedtime for one day, then increase to 50MG at bedtime. Documentation provided by Collateral 3 on 05/16/2025 revealed that this order was not received by the facility until 05/01/2025. The resident’s April and May 2025 MARs do not contain documentation that the resident received the one dose of Clozaril 25MG at bedtime prior to receiving Clozaril 50MG at 8:00PM on 05/02/2025 as the aforementioned physician’s order had not been transcribed to either the resident’s April or May 2025 MARs.
Plan of correction
The facility will ensure that the medications are given per physicians’ orders. • DORS to complete a weekly cart audit • Pharmacy to complete a monthly cart audit
22VAC40-73-460-A
Based on resident record review, collateral interviews, and staff interviews, the facility failed to ensure to assume responsibility for the health, safety, and well-being of the residents.
Evidence
  1. Resident 1 was admitted to the facility at 9:09AM on 03/07/2025.
  2. The report of resident physical examination for resident 1, dated 02/27/2025, contains a signed physician’s order for Clozapine 100MG (also referred to as Clozaril) every day at bedtime. The resident’s March and April 2025 medication administration records (MARS) contain documentation that Clozapine 100MG was scheduled to be administered to the resident daily at 8:00PM. The resident’s March 2025 and April 2025 MARs contain staff initials as administering Clozapine 100MG at 8:00PM daily on numerous days during 03/09/2025 to 04/11/2025; however, on 05/16/2025 Collateral 3 provided documentation to the licensing inspector (LI) that revealed 28 tablets of Clozapine 100MG were not delivered to the facility from the pharmacy until 04/12/2025 at 1:27AM. During a phone interview with the LI and Collateral 3 on 05/16/2025, Collateral 3 revealed to the LI that before the pharmacy could dispense Clozapine to resident 1, lab work was required to be completed on the resident, the lab work was to be reviewed by the physician, the physician then would have to write a hard script that they have reviewed the lab work for the resident and then the hard script is to be sent to the pharmacy. Once the pharmacy receives the hard script, then they can dispense the medication to the resident. Collateral 3 stated that they did not receive this from Collateral 2 until 04/10/2025. Progress notes by Collateral 2, dated 4/10/2025, includes documentation on page 1 of 5 that the resident is prescribed clozapine 100 mg and clozapine 25 mg once daily as well as divalproex 125 mg, two capsules twice daily for schizoaffective disorder and that there was a delay in receiving clozapine due to pending lab results but the labs have since returned normal and the medication was ordered and that the resident is awaiting the medication (clozapine) from the pharmacy. Interviews with staff persons 1 and 2 confirmed that Clozapine 100MG was not delivered from the pharmacy to the facility until 04/12/2025 at 1:27AM and that the facility had not received this medication prior to 04/12/2025 from any other entity therefore staff should not have been documenting that the medication had been administered.
  3. The report of resident physical examination for resident 1, dated 02/27/2025, contains a signed physician’s order for Clozapine 25MG (also referred to as Clozaril) one tablet once a day; however, a signed physician’s order, dated 03/09/2025, states to hold Clozapine 25MG every day until further notice – awaiting pharmacy delivery. The resident’s March 2025 and April 2025 MARs contain staff initials as administering Clozapine 25MG at 8:00AM daily on numerous days during 03/09/2025 to 04/11/2025; however, on 05/16/2025 Collateral 3 provided documentation to the LI that revealed that 28 tablets of Clozapine 25MG were not delivered to the facility from the pharmacy until 04/12/2025 at 1:27AM. Interviews with staff persons 1 and 2 confirmed that Clozapine was not delivered from the pharmacy to the facility until 04/12/2025 at 1:27AM and that the facility had not received this medication prior to 04/12/2025 from any other entity therefore staff should not have been documenting that the medication had been administered.
  4. Progress notes by Collateral 2, dated 03/07/2025, 03/13/2025, and 03/19/2025, contain documentation that the resident is currently on Clozapine 125MG at bedtime and that the resident is stable at current doses and dose reduction attempt at this time would risk decompensation of the resident. (this inspection notice contains additional information that is not included on this notice due to limited character space)
Plan of correction
The facility will ensure to audit the admission medication list and ensure clarification is obtained when needed.
April 29, 2025Complaint survey3 violations
Inspection dates
04/29/2025, 06/18/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/29/2025 7:45AM to 5:45PM and 06/18/2025 10:00AM to 3:40PM 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 04/17/2025 and 04/21/2025 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on resident record review, collateral documentation and staff interview, the facility failed to assume responsibility for the health, safety, and well-being of the residents.
Evidence
  1. Resident 1 was admitted to the facility’s safe, secure unit on 04/16/2025.
  2. Documentation in the record for resident 1 from Collateral 1 contains information that the resident can be sexually inappropriate and gives an example of the resident masturbating in dayroom but does respond to redirection.
  3. Progress note written by staff person 3, dated 04/18/2025 at 6:17AM, revealed that staff person 3 found resident 2 in her bed and that resident 1 was lying beside her. Resident 1 was completely naked and resident 2 was naked from the waist (interview with staff person 3 revealed resident 2 was unclothed from her waist down). Resident 1 was redirected to his room. Staff person 3 also documented that the local police were called, and two officers arrived, and Collateral 4 was contacted and that resident 2 was taken to the hospital to be checked out by a doctor. Interview with staff persons 1 and 2 revealed this incident occurred during the evening of 04/17/2025.
  4. A written statement by Collateral 2, dated 04/18/2025, reveals that Collateral 2 interviewed resident 1 on 04/18/2025 for an initial psychiatric examination and the written statement contained the following information: Resident 1 is aware of his actions and able to follow directions, nursing reports the resident has been going in female residents’ rooms even after being told not to, he has been found going to a restricted room and he was stopped before he got there, had previously been instructed to only go to his room and not any other residents rooms, and his response to nursing per their report was that he swore and that he could go in any “swear” room he wants. Collateral 2 also stated that physically he is a healthy burly male, mentally has mild cognitive impairment but is knowledgeable of what he is doing and that in Collateral 2’s professional opinion resident 1 is not safe to be in this environment (memory care) with a frail vulnerable population and should be removed ASAP.
  5. Interview with staff person 2 revealed that it had been brought to her attention by staff person 4 a day or so prior to the 04/17/2025 incident between residents 1 and 2 that resident 1 kept going into resident 2’s room due to resident 2’s room being right across from resident 1’s room. Staff person 2 stated that she had a conversation with resident 1 on 04/16/2025 or 04/17/2025 prior to the incident between residents 1 and 2 that he was not to be going into any room that was not his and especially not any female residents’ rooms because the females “could be changing”.
  6. Paperwork from Collateral 3 indicates that resident 2 arrived from the facility where staff reported that they found a male resident naked in resident 1’s bed and per Collateral 4, resident 1 admitted to Collateral 4 that he had sexual intercourse with resident 2. Paperwork from Collateral 3 also contains a discharge summary that states discharge diagnosis: reported sexual assault of adult – adult sexual abuse, confirmed.
  7. Interview with staff persons 1 and 2 revealed that resident 1 was arrested on 04/20/2025 and taken to jail. The Virginia Judiciary System online website indicates that the resident was arrested on 04/20/2025, the offense date was 04/17/2025 and the resident was charged with aggravated sexual battery.
Plan of correction
The facility will ensure all notes and documentation is received prior to admission for proper review of placement. • ED will make final review to ensure proper placement
22VAC40-73-440-F
Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed 90 days prior to admission to the assisted living facility, except that if there has been a change in the resident’s condition since the completion of the UAI that would affect the admission, a new UAI shall be completed.
Evidence
  1. Resident 1 was admitted to the facility on 04/16/2025.
  2. The record for resident 1 contained a private pay UAI that was completed by staff persons 1 and 2 on 04/03/2025 and updated on 04/16/2025; however, the resident received public funding and therefore a public pay UAI would be required to be completed for the resident.
  3. The record for resident 1 contained a public pay UAI, dated 10/11/2024; however, it was completed more than 90 days prior to the resident’s admission. Interview with staff persons 1 and 2 confirmed this is accurate.
Plan of correction
The facility will ensure that UAIs received from a public pay entity are dated within 90 days prior to admission • DORS and ED to review for 90 day compliance.
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure that each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The licensing inspector (LI) received a complaint on 04/17/2025 that facility staff had found a male resident (resident 1) in bed with resident 2 (female), the male had no clothes on and resident 2 had no pants on, staff had reported that the male was “wiping himself off” when facility staff walked in and that resident 2 couldn’t report if any sexual contact had occurred.
  2. Additional information received during the complaint investigation revealed that residents 1 and 2 reside in the facility’s safe, secure unit (memory care) and resident 1 was found in resident 2’s bed completely naked during the evening of 04/17/2025. Resident 1 informed Collateral 4 that he did have sexual intercourse with resident 2; however, resident 2 was unable to state whether anything had occurred. Collateral 4 instructed resident 2 to be sent out to the hospital for evaluation to see if a sexual assault had occurred.
  3. As of on-site inspections on 04/29/2025 and 06/18/2025, the LI has not received the aforementioned information from the facility. Interview with staff person 2 on 06/18/2025 confirmed this is accurate.
Plan of correction
The facility will ensure that any major incidents are reported to the regional licensing office within 24 hours by someone at the facility.
April 29, 2025Inspection22 violations
Inspection dates
04/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE 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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/29/2025 7:45AM to 7:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: morning medication administration, noon-time meal, medication cart audits Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on staff record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person and the staff person’s written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person’s record.
Evidence
  1. The records for staff persons 3 (date of hire 06/16/2009) and 4 (date of hire 11/26/2022) did not include documentation that staff person 3, training year 06/16/2023 to 06/15/2024, and staff person 4, training year 11/26/2023 to 11/25/2024, had reviewed the rights and responsibilities of residents. Interview with staff person 1 confirmed this is accurate.
Plan of correction
• The facility will ensure the rights and responsibilities of all residents in assisted living facilities are reviewed annually with all staff and a written acknowledgement is signed to include the date of review and will be placed in the staff’s record. • The facility will hold an in-service to include resident rights for all staff.
22VAC40-73-660-B
Based on observation during a tour of the facility, resident record review, resident interviews and staff interviews, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. At approximately 9:11AM during on-site inspection, the licensing inspector (LI) observed a container of CVS health anti-fungal powder on the bathroom sink in resident 6’s bathroom. During an interview with resident 6, resident 6 informed the LI that the anti-fungal powder is hers and that she is currently using the powder for current rashes she has under her breasts. The report of resident physical examination for resident 6, dated 01/24/2025, states on page 2 that the resident is not capable of self-administering their own medication and the resident’s UAI, dated 02/03/2025, states on page 2 that the resident’s medication is administered/monitored by lay person – RMA, LPN, RN. The record for resident 2 does not contain a physician’s order for the resident to have and self-administer anti-fungal powder nor does it include a physician’s order for anti-fungal powder. Interview with staff person 2 confirmed this is accurate.
  2. During the afternoon of the on-site inspection, the LI observed a box of lidocaine patches and a bottle of ibuprofen sitting on the bedside table of resident 8’s room. During an interview with the LI and resident 8, resident 8 informed the LI that the patches and ibuprofen are his and that he uses the patches when he needs to and takes the ibuprofen when he needs to as well. The report of resident physical examination for resident 8, dated 04/16/2025, states on page 2 that the resident is not capable of self-administering their own medication and staff person 2 confirmed that the resident’s UAI, dated 04/17/2025, states on page 2 that the resident’s medication is administered/monitored by lay person – RMA, LPN, RN. The box for administered/monitored by lay person was not checked; however, staff person 2 confirmed that this box should have been checked. The record for resident 8 does not contain a physician’s order for the resident to have and self-administer lidocaine patches or ibuprofen. Interview with staff person 2 confirmed this is accurate.
Plan of correction
• The facility will ensure any residents permitted and indicated on UAI, to keep their own medications, are out of sight from other residents. The facility will perform monthly room sweeps of all apartments to ensure those that self-medicate are keeping medications out of sight and for those that do not, no medications are in their apartments.
22VAC40-73-650-E
Based on resident record review, the facility failed to ensure the resident’s record shall contain the physician’s or other prescriber’s signed written order or a dated notation of the physician’s or other prescriber’s oral order and orders shall be organized chronologically in the resident’s record.
Evidence
  1. Resident 2’s April 2025 medication administration record (MAR) contains documentation of Ondansetraon HCL 4MG take one tablet by mouth every 8 hours as needed for nausea/vomiting and that the resident was administered this medication on 04/02/2025 at 11:33PM and on 04/03/2025 at 8:25AM; however, the record for resident 2 does not contain an order for this medication.
  2. Resident 5’s 03/28/2025 to 4/28/2025 MAR contains documentation of the resident being administered Destin Cream daily at 8:00AM, 2:00PM and 8:00PM with an effective date of 04/04/2025 ( was first administered on 04/05/2025 at 2:00PM) and Hydroxyzine HCL 25MG 3 times daily at 9:00AM, 12:00PM, and 5:00PM; however, the record for resident 5 does not contain an order for either of these medications.
Plan of correction
• The facility will ensure all orders are placed in the residents’ records, in chronological order. • The facility will audit resident records to ensure all current orders are in the chart and in chronological order. The facility will perform resident record audits at least quarterly.
22VAC40-73-930-D
Based on resident record review, for each resident with an inability to use the signaling device, in addition to any other services, the facility failed to ensure once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility and facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the wounds and the documentation shall be retained for two years.
Evidence
  1. Resident 5 resides in the facility’s safe, secure unit. The individualized service plan (ISP) for resident 5, dated 06/08/2024, contains an identified need that the resident is unable to use the call bell to alert staff when assistance is needed, and staff will check on the resident and document a minimum of every 2 hours while the resident is asleep.
  2. Resident 5’s 03/28/2025 to 4/28/2025 MAR contains a statement that rounds will be made every two hours to monitor for emergencies or other unanticipated need while sleeping and that the resident will be checked on nightly at 8PM, 10PM, 12AM, 2AM, 4AM, and 6AM. The 03/08/2025 to 04/28/2025 MAR for the resident does not contain staff initials for rounding/checking on the resident on 04/01/2025 at 10:00PM and on 04/08/2025 at 6:00AM and 10:00PM.
Plan of correction
• Residents with the inability to use a signaling device will be rounded on at a minimum every two hours from the time they go to bed each evening until they arise each morning. The documentation will include the names of the residents, the date and time of the rounds, and the staff member who made the rounds. • Facility will audit rounding from the night before, each morning.
22VAC40-73-950-E
Based on staff interview, the facility failed to ensure to implement a semi-annual review on the emergency preparedness and response plan for all residents with emphasis placed on an individual’s respective responsibilities and the review shall be documented by signing and dating.
Evidence
  1. During on-site inspection, staff person 1 was unable to produce documentation/evidence of when the facility’s last semi-annual review was of the facility’s emergency and response plan that was conducted with residents.
Plan of correction
• The facility will conduct semi-annual reviews of the emergency preparedness and response plan. • The facility will complete during May training and reinforce the importance of individual responsibilities during emergency situations.
22VAC40-73-220-B
Based on facility document review and staff interview, the facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under 22VAC73-220 A 2 through A 6, and in addition, before direct care or companion services are initiated, the facility shall ensure all requirements of this standard are met.
Evidence
  1. During on-site inspection on 04/29/2025, staff person 2 informed the licensing inspector (LI) that the facility is using Collateral 4 as a means of obtaining direct care staff to administer medications and provide personal care to residents in the assisted living and safe, secure building; Collateral 4 is not a licensed home care organization.
  2. Collateral 5, who is employed by Collateral 4, was the registered medication aide (RMA) who was observed by the LI as administering medications to residents during the morning of the on-site inspection.
  3. Staff person 2 provided documentation for Collateral 5; however, the documentation did not contain information on the type and frequency of the services to be delivered to residents by Collateral 5, evidence of orientation and training provided to Collateral 5 regarding the facility’s policies and procedures related to the duties of private duty personnel, and an original criminal history record reported issued by the Virginia Department of State Police.
  4. In addition, the April 2025 MARs for residents 2, 3, 5 and 7 contain the initials ALPN and AN9 which are for agency staff that have administered medications; however, these residents’ individualized services plans (ISPs) (resident 2’s ISP dated 03/14/2025; resident 3’s ISP dated 08/27/2024; resident 5’s ISP dated 06/08/2024; and resident 7’s ISP dated 11/15/2024) have not been updated to reflect that agency staff are being utilized to meet these residents’ needs of medication administration.
Plan of correction
Not published by VDSS.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. The individualized service plan (ISP) for resident 7, dated 11/15/2024, contains documentation that the resident requires mechanical/physical human assistance with transferring, is incontinent of bladder weekly or more, requires mechanical/physical human assistance with walking, requires human physical assistance with wheeling, and is disoriented to most spheres all of the time to place, time, and purpose. The UAI for the resident, dated 11/18/2024, contains documentation that the resident requires supervision human-help with transferring, does not have bladder incontinence, requires supervision human-help with walking, wheeling is not performed and is disoriented – all spheres, some of the time. Interview with staff person 2 revealed that the resident’s ISP is correct and the UAI is incorrect for the above-mentioned identified needs.
Plan of correction
• The facility will ensure the UAI is completed prior to admission, at least annually, and whenever there is a change of condition. • Facility will compare all UAI and ISPs of current residents to ensure they match and accurately outline the resident’s needs.
22VAC40-73-870-B
Based on observation of the facility during the on-site inspection, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. Throughout the day during the on-site inspection on 04/29/2025, the licensing inspector (LI) noted a foul, stale, and musty odor throughout the A-hall in the facility’s assisted living building.
Plan of correction
• Facility shall ensure all buildings are well-ventilated and free from all odors. • The facility will attempt to identify if odor is coming from a particular room down A-hall, and if so, handle accordingly. • The facility will ensure HVAC systems are set up properly for ventilation and filtration. • The facility will utilize odor-neutralizing agents.
22VAC40-73-870-A
Based on observation during a tour of the facility, the facility failed to ensure the interior of all buildings shall be maintained in good repair and kept clean.
Evidence
  1. During the on-site inspection, the licensing inspector (LI) noted that the black rubber threshold on the floor that is between the safe, secure unit’s dining room and common area is coming apart from the floor in multiple sections.
  2. At approximately 9:00AM, the LI observed that the toilet in room 32 contained an area of a brown substance on the toilet lid and the toilet bowl.
Plan of correction
• The facility will ensure the interior of all buildings will be maintained in good repair and kept clean. • The facility will perform daily walk throughs to ensure the interior of the building remains in good repair and is kept clean.
22VAC40-73-680-I
Based on resident medication administration record (MAR) review and staff interview, the facility failed to ensure the name, signature, and initials of all staff administering mediations are included on all MARs.
Evidence
  1. The April 2025 MARs for residents 1, 2, 3, 5, 7 and 9 has documentation on numerous days/times of the initials ALPN and AN9 for administering medications to these residents and the April 2025 MAR for resident 8 has documentation on 04/25/2025 of the initials AN9 for administering medications to the resident. On the signature and title section of the MARs it has listed that these initials belong to Agency LPN and Agency Nurse 2 but the MARs do not have these individuals’ actual name, signature or initials.
  2. During an interview with staff person 2 during a previous inspection conducted on 01/21/2025, staff person 2 had informed two licensing inspectors (LIs) that these initials are used for different agency staff as the facility does not always know who the agency company is sending to be able to get their own credentials for logging into the EMAR system. During on-site inspection on 04/29/2025, staff person 2 confirmed this is still accurate.
Plan of correction
• The facility will ensure the name, signature, and initials of all staff including medication are included on all MARs. • The facility will create personal logins for any agency RMA on shift.
22VAC40-73-860-I
Based on observation during a tour of the facility, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 8:17AM during on-site inspection, the licensing inspector (LI) noted that the door to room 29 in the facility’s safe, secure unit was unlocked and unattended. The LI noted that a housekeeping cart was in the room which contained multiple spray bottles and spray containers of cleaning supplies that included a spray can of Presevation Glass Cleaner, a spray can of Premium Wood Polish, and a spray bottle of rapid multi-surface disinfectant cleaner. At approximately 8:58AM, the LI noted that the door to room 29 was still unlocked and unattended.
  2. At approximately 9:00AM during on-site inspection, the LI noted that the door to room 32 in the facility’s safe, secure unit was unlocked and unattended. The LI noted a container of Arm & Hammer Extra Strength carpet odor eliminator powder on a table beside the bathroom and a spray bottle of 409 cleaner on the top shelf of the closet.
  3. At approximately 9:02AM during on-site inspection, the LI noted that the door to the laundry room in the facility’s safe, secure unit was unlocked and unattended. The LI noted a bottle of Monogram disinfectant bleach sitting on top of a shelf located across from the washer and dryer.
Plan of correction
• The facility will ensure that cleaning supplies and other hazardous materials are stored in a locked area. • The facility will conduct daily walkthroughs to ensure hazardous materials are stored as they should be. • The facility will reeducate all staff to ensure hazardous materials are not to be left unattended and shall remain locked up when not in use.
22VAC40-73-940-A
Based on facility documentation review, the facility failed to ensure to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official and reports of the inspections shall be retained at the facility for at least two years.
Evidence
  1. During on-site inspection on 04/29/2025, the most recent report of a fire inspection conducted at the facility by the fire official was dated 01/04/2024.
Plan of correction
• The facility will ensure to have completed a fire inspection at least annually. • The facility will schedule a fire inspection to be done as soon as possible that the fire officials can conduct it. • The facility will set a schedule for fire inspections to be done at least 2 months prior to the expiration date of last inspection.
22VAC40-73-620-A
Based on resident record review and facility documentation review, the facility failed to ensure that there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.
Evidence
  1. An interview with staff person 2 revealed that residents 1 and 2 had been prescribed a low concentrated sweets diet (LCS) until Collateral 2 signed a diet order communication form, dated 02/04/2025, to change residents 1 and 2’s diet to regular; however, Collateral 3 signed a physician order sheet, dated 03/26/2025, that residents 1 and 2 are to be served a LCS diet.
  2. Dietitian oversight reports provided by staff person 1 during the on-site inspection contained documentation that the most recent oversight by a dietitian that residents 1 and 2 were included in was 05/21/2024.
Plan of correction
• The facility will ensure all special diets are audited at least every 6 months by dietitian or nutritionist. • The facility will audit oversights and determine which residents are out of compliance and schedule immediate review of special diets. The facility will conduct an internal quarterly review of special diet oversights to ensure compliance.
22VAC40-73-620-A
Based on resident record review and facility documentation review, the facility failed to ensure that there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.
Evidence
  1. An interview with staff person 2 revealed that residents 1 and 2 had been prescribed a low concentrated sweets diet (LCS) until Collateral 2 signed a diet order communication form, dated 02/04/2025, to change residents 1 and 2’s diet to regular; however, Collateral 3 signed a physician order sheet, dated 03/26/2025, that residents 1 and 2 are to be served a LCS diet.
  2. Dietitian oversight reports provided by staff person 1 during the on-site inspection contained documentation that the most recent oversight by a dietitian that residents 1 and 2 were included in was 05/21/2024.
Plan of correction
• The facility will ensure all special diets are audited at least every 6 months by dietitian or nutritionist. • The facility will audit oversights and determine which residents are out of compliance and schedule immediate review of special diets. The facility will conduct an internal quarterly review of special diet oversights to ensure compliance.
22VAC40-73-610-D
Based on resident record review, observation of the facility’s kitchen and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician’s or other prescriber’s orders.
Evidence
  1. The record for resident 1 and the record for resident 2 both contain a signed physician order sheet, dated 03/26/2025, that resident 1 and resident 2 are to be receiving a low concentrated sweets (LCS) diet.
  2. The LI asked staff person 6 what a resident would be served who is prescribed a LCS diet and staff person 6 informed the LI that today’s lunch included a dessert of peach cobbler and if a resident has a prescribed LCS diet order, the resident would be given peaches or sugar-free ice cream instead of peach cobbler. The LI observed residents 1 and 2 eating peach cobbler with their lunch and residents 1 and 2 confirmed to the LI that they were eating peach cobbler.
  3. An interview with staff person 6 revealed that dietary staff are using the whiteboard in the kitchen that is located above the serving line as a means of knowing which residents have a prescribed special diet.
  4. The LI noted that residents 1 and 2’s LCS diet was not listed on the special diet board. Staff person 6 informed the LI that they were not aware of the prescribed LCS diet for residents 1 and 2.
Plan of correction
• Diets prescribed will be prepared and served according to prescriber’s order. • If the resident chooses not to follow prescribed diet, then a Therapeutic Diet Waiver will be signed by the resident and a copy given to the culinary department. • The facility will audit diet board monthly to ensure dietary compliance. • The culinary staff will be educated on the accepted diets and what is not allowed to be served in each order.
22VAC40-73-270-4
Based on staff record review and staff interview, the facility failed to ensure refresher training for all direct care staff, when aggressive residents are in care, shall be provided at least annually or more often as needed.
Evidence
  1. Staff persons 3 and 4 work in the facility’s safe, secure unit and staff person 2 confirmed that the facility’s safe, secure unit does have in care residents who may have aggressive behaviors.
  2. The record for staff person 3, date of hire 06/16/2009, did not contain documentation that staff person 3 had aggressive behavior refresher training during the training year 06/16/2023 to 06/15/2024.
  3. The record for staff person 4, date of hire 11/26/2022, did not contain documentation that staff person 4 had at aggressive behavior training during the training year 11/26/2023 to 11/25/2024.
  4. Interview with staff person 1 confirmed this is accurate.
Plan of correction
• The facility will ensure to conduct refresher training at least annually for all direct care staff when aggressive residents are in care. • The facility will include these training courses at their all staff meeting on May 22nd, 2025.
22VAC40-73-250-C
Based on staff record review, the facility failed to ensure personal and social data to be maintained on staff and included in the staff record to include name and telephone number of person to contact in an emergency.
Evidence
  1. The record for staff person 5 did not include information of a person to contact for the staff person in case of an emergency.
Plan of correction
• The facility will ensure personal and social data is maintained on all staff. • The facility will audit current staff personal and social data and enter any missing information. • The facility will collect all the necessary data at the time of hiring. The facility will conduct quarterly audits to ensure all needed data is included in staff records.
22VAC40-73-640-A
Based on observations during an audit of the facility’s medication carts and facility medication management plan (MMP) review, the facility failed to ensure implementation of their MMP.
Evidence
  1. The facility policy 5.10 for medication storage has documentation that each container of medication shall contain all the information needed to safely administer the medication including: bullet #8 – expiration date (date after which drug is no longer effective)
  2. The A-hall medication cart contained a Basaglar Kwik Pen (insulin pen) and Novolog Insulin pen in the cart for resident 2. The Basaglar Kwik Pen was noted to be open/in use but did not contain an open or discard date to ensure that the medication is disposed of within 28 days after opening per manufacturer instructions. The Novolog insulin pen was observed to have an open date of 03/26/2025 which would have required the medication to be discarded on 04/23/2025, 28 days after opening per manufacturer instructions; however, the insulin pen contained a discard date of 04/24/2025 but was still on the cart and in use for resident 2. Staff person 5 observed the two insulin pens for resident 2.
  3. The medication cart that contained medications for resident 11 contained a Humalog Kwik Pen (insulin pen) and a Lantus Solostar insulin pen for resident 11. Both of the insulin pens were noted to be open/in use but did not contain an open or discard date to ensure that the medication is disposed of within 28 days after opening per manufacturer instructions. The staff person from Collateral 4 observed the two insulin pens for resident 11.
Plan of correction
• The facility will ensure implementation of their MMP. • The facility will conduct biweekly medication cart audits. • The facility will retrain staff on MMP protocols.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 2 contains a signed physician order sheet, dated 03/26/2025, that resident 2 is to be receiving a low concentrated sweets (LCS) diet. The uniform assessment instrument (UAI) in the record for resident 2, dated 03/14/2025, contains information on page 4 that the resident requires help with transportation and shopping and requires human-help supervision with mobility. The ISP for resident 2, dated 03/14/2025, has not been updated to reflect that the resident has been prescribed a LCS diet and does not include information that the resident requires help with transportation and shopping and human-help supervision with mobility.
  2. The record for resident 3 contains a signed physician’s order sheet, dated 03/26/2025, that resident 3 is to be receiving a LCS diet. The ISP for resident 3, dated 08/27/2024, has not been updated to reflect that the resident has been prescribed a LCS diet.
  3. The record for resident 4 contains a signed physicians’ order sheet, dated 02/04/2025, that resident 4 is to be receiving a pureed diet. The ISP for resident 4, dated 07/28/2024, has not been updated to reflect that the resident has been prescribed a pureed diet.
  4. The ISP for resident 7, dated 11/15/2024, contains an identified need that the resident requires mechanical help only with toileting; however, the resident’s UAI, dated 11/18/2024, contains documentation that the resident requires supervision human-help with toileting. Interview with staff person 2 revealed that the resident’s UAI is correct and the resident’s ISP is incorrect.
Plan of correction
• The facility will update ISPs as needed with each change of condition. • The facility will audit all current resident ISPs to ensure they are accurately based on the resident’s current needs.
22VAC40-73-210-F
Based on staff record review and staff interview, the facility failed to ensure at least two of the required hours of annual training shall focus on infection control and prevention and when adults with mental impairments reside in the facility, at least four hours of the required annual training shall focus on topics related to residents’ mental impairments.
Evidence
  1. The record for staff person 3, date of hire 06/16/2009, did not contain documentation that staff person 3 had at least two hours of infection control and prevention and only completed 3 hours of the 4 hours of training required related to residents’ mental impairments during the training year 06/16/2023 to 06/15/2024.
  2. The record for staff person 4, date of hire 11/26/2022, did not contain documentation that staff person 4 had at least two hours of infection control and prevention and at least four hours of training related to residents’ mental impairments during the training year 06/16/2023 to 06/15/2024.
  3. Interview with staff person 1 confirmed this is accurate.
Plan of correction
• The facility will ensure at least two hours of the annual training will focus on infection control and prevention and at least four hours focuses on topics related to residents’ mental impairments. • HR to set up 2 hr. infection control for all staff and then annually to be completed by 5/30/25
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. The record for staff person 3, date of hire 06/16/2009, contained documentation that the staff person had only completed 8 of the required 18 hours of training during the training year 06/16/2023 to 06/15/2024.
  2. The record for staff person 4, date of hire 11/26/2022, did not contain documentation that staff person 4 had at least 18 hours of training during the training year 11/26/2023 to 11/25/2024.
  3. Interview with staff person 1 confirmed this is accurate.
Plan of correction
• The facility will ensure all direct care staff attend at least 18 hours of training annually. • HR to set up those staff members that are overdue on their 18 hr. annual training to be completed in Collins immediately and to be completed by 5/30/25 and all others to be set up to have the 18 hours spread monthly to ensure the 18 hours ius completed.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 03/26/2025, for Miconazole Nitrate 2% cream for groin rash 3 times daily for 14 days. Resident 1’s March 2025 medication administration record (MAR) contains documentation that the effective date of the medication was 03/28/2025 and the end date was 04/11/2025; however, the April 2025 MAR for resident 1 contains documentation that this medication was still being administered to the resident on 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/16/2025, 04/17/2025, and 04/19/2025.
  2. The record for resident 2 contains a signed physician’s order, dated 04/10/2025, to stop Buspirone 10MG and start Buspirone 15MG 3 times daily. Resident 2’s April 2025 MAR contains staff initials that Buspirone 10MG was administered to the resident on 04/11/2025 at 8:00AM, 12:00PM and 5:00PM, 04/16/2025 at 8:00AM and 12:00PM and on 04/17/2025, 04/19/2025 and 04/20/2025 at 8:00AM even though the medication had been discontinued on 04/10/2025. The record for resident 2 contains a signed physician’s order, dated 03/26/2025, for Novolog inject 5 units daily before meals daily at 7:30AM, 11:30AM, and 4:30PM. Resident 2’s April 2025 MAR contains documentation that the resident was not administered this medication 13 times between 04/04/2025 and 04/25/2025 due to “doctor order” and was not administered this medication on 04/06/2025 at 7:30AM due to “other: BS 88”, on 04/06/2025 at 11:30AM due to “other: BS 76”, and on 04/07/2025 due to “other: BS 116”. The record for resident 2 does not contain any physician’s orders or instructions to not administer this medication during these dates/times. The record for resident 2 contains a signed physician’s order, dated 03/26/2025, for Basaglar inject 22 units daily at bedtime. Resident 2’s April 2025 MAR contains documentation that the resident was not administered this medication on 04/04/2025 at 8:00PM due to “Other: BS 80”; however, the record for resident 2 does not contain any physician’s orders or instructions to not administer this medication.
  3. The record for resident 3 contains a signed physician’s order, dated 03/26/2025, for Lispro Insulin (Humalog) check blood sugar (BS) and inject 5 units 3 times daily at 7:30AM, 11:30AM and 4:30PM and hold for glucose (blood sugar - BS) less than 150. Resident 3’s April 2025 MAR contains documentation that on 04/04/2025 the resident’s BS was 144 at 7:30AM, on 04/12/2025 the resident’s BS was 123 at 7:30AM, on 04/13/2025 the resident’s BS was 145 at 7:30AM, on 04/15/2025 the resident’s BS was 125 at 7:30AM, on 04/16/2025 the resident’s BS was 125 at 7:30AM, on 04/18/2025 the resident’s BS was 147 at 11:30AM, and on 04/19/2025 the resident’s BS was 111 at 11:30AM; however, staff initials were present during these dates/times as having administering the insulin to the resident when it should have been held. The April 2025 MAR does not include staff initials to indicate whether or not the resident was administered this medication on 04/16/2025 at 11:30AM.
Plan of correction
• Facility will ensure medications are administered according to the prescribers’ instructions. • The facility will complete biweekly medication cart audits. The facility will schedule a Registered Medication Aide refresher course for all certified RMAs to complete
April 29, 2025Complaint survey1 violation
Inspection dates
04/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/29/2025 7:45AM to 5:45PM 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 03/28/2025 and 03/31/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 71 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 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 was: two-hour rounding of residents with an inability to use the signaling device system A violation notice was issued; any violation(s) not related to the complaints 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on resident record review and staff interview, for each resident with an inability to use the signaling device, in addition to any other services, the facility failed to ensure once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility and facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the wounds and the documentation shall be retained for two years.
Evidence
  1. Resident 1 resided in the facility’s safe, secure unit from 03/24/2025 to 03/28/2025. Interviews with staff persons 1 and 2 confirmed that the resident was unable to use the facility’s signaling device and therefore required rounding every two hours once the resident had gone to bed each evening.
  2. During on-site inspection on 04/29/2025, staff persons 1 and 2 were unable to provide documentation that the resident had been rounded on every two hours once the resident had gone to bed each evening on 03/24/2025, 03/25/2025, 03/26/2025, and 03/27/2025.
Plan of correction
Residents with the inability to use a signaling device will be rounded on at a minimum every two hours from the time they go to bed each evening until they arise each morning. The documentation will include the names of the residents, the date and time of the rounds, and the staff member who made the rounds. Facility will audit rounding from the night before, each morning
March 28, 2025Complaint survey2 violations
Inspection dates
03/28/2025, 04/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/28/2025 9:30AM to 2:30PM and 04/29/2025 7:45AM to 5:40PM 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 03/19/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 71 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 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@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) shall be completed within 30 days after admission and shall include the description of identified needs and date identified based upon the (i) uniform assessment instrument (UAI); (ii) admission physical examination; (iii) interview with resident; (vi) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
  1. Resident 1 was admitted to the facility on 02/04/2025.
  2. The UAI in the record for resident 1, assessment date 01/17/2025 and reassessment date 02/04/2025, states that the resident requires mechanical and human help- physical assistance with bathing, toileting, and transferring and the resident requires mechanical help only – rollater/walker with walking.
  3. The ISP in the record for resident 1, dated 02/04/2025, states the following: bathing - resident requires mechanical/supervision – staff will supervise resident while bathing and cue resident as needed, staff will ensure resident is able to get in/out of shower safely with a gentle hand while using the following DME equipment (grab bars); toileting – resident requires mechanical/supervision assistance – staff will supervise and cue resident on and off toilet with the use of grab bars to promote safety, staff will supervise/cue resident to perform proper hygiene and ensure incontinent products are changed every 2 hours and PRN; transferring – resident requires mechanical/supervision assistance – staff to supervise and cue resident while transferring in and out of bed/wheelchair/chair while using assistive device (walker/wheelchair/grab bars) to promote safety, staff to encourage assistive device is in proper working condition; and walking – independent – resident does not require any assistance with walking proper working condition.
  4. Interview with staff person 1 revealed that the resident’s UAI is correct for bathing, toileting, transferring, and walking and the resident’s ISP is incorrect.
Plan of correction
Facility will compare all UAI and ISPs of current residents to ensure they match and accurately outline the resident’s needs.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications were administered according to the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 1 was admitted to the facility on 02/04/2025. The record for resident 1 contains a signed physician’s order from Collateral 3, dated 02/04/2025, for Amlodipine 2.5MG one tablet daily.
  2. The February and March 2025 medication administration records (MARs) for resident 1 do not contain documentation that the resident was being administered this medication.
  3. Email from staff person 1 on 04/18/2025 revealed that since this medication was not listed on the resident’s health and physical exam, staff person 2 thought that the medication had been discontinued. The record for the resident does contain a discontinued order for this medication.
Plan of correction
Facility will ensure medications are administered according to the prescribers’ instructions. The facility will complete biweekly medication cart audits. The facility will schedule a Registered Medication Aide refresher course for all certified RMAs to complete.
February 5, 2025Complaint survey4 violations
Inspection dates
02/05/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
A discussion was held with two licensing inspectors and the facility’s administrator and resident care director regarding standards 22VAC40-73-70-A and 22VAC40-73-510-A.
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: 02/05/2025 8:15AM to 1:30PM 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 02/04/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 60 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: 4 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-470-A
Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident were met.
Evidence
  1. A psychiatry progress noted, dated 01/22/2025, in the record for resident 1 contains documentation on page 3 that Depakote dosage increased to 750 milligrams twice a day. Order change from Valproic acid to Depakote. Will continue with the current medication regimen and monitor the patient’s response. Lab work will be obtained in a week to check the patients Valproic acid level.
  2. The record for resident 1 also contains a facility staff progress note by staff person 1, dated 01/22/2025 at 9:15PM, that the resident was seen by Geri-psych NP for follow up, new orders to discontinue current Depakote DR order and start Depakote DR 750MG two times a day and to obtain Depakote level in 1 week.
  3. Interview with staff person 1 revealed that Depakote levels were not obtained for the resident.
Plan of correction
Audit of ISP and UAIs to ensure they accurately represent the direct or indirect healthcare needs of the residents. DORS to complete an audit of ISP and UAIs by March 14th, 2025. DORS will ensure ISPs are audited monthly and implemented within 7 days of admission, updated within 30 days of move in and then updated at least every 6 months thereafter or as needed when a change of condition occurs. Ensure residents’ UAI is accurate prior to admission and updated at least annually or when the resident has a change of condition. Date to be completed: March 14, 2025
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the uniform assessment instrument (UAI), admission physical examination, interview with resident, fall risk rating (if appropriate), assessment of psychological, behavioral, and emotional functioning (if appropriate), and other sources.
Evidence
  1. The UAI for resident 1, dated 12/20/2024 contains documentation on page 1 that the resident’s communication of needs is verbally/Spanish. A Psychiatry Initial Consult, dated 01/08/2025, contains documentation on page 1 that the patient is Spanish speaking only and the translation app on the phone was used for the visit. A progress note dated, 01/21/2025, contains documentation on page 1 that the patient is a Spanish speaking male with limited understanding of English, requiring translation for communication. The ISP in the record for resident 1, dated 01/02/2025, does not contain the identified need for communication for resident 1 or any services to be provided to be able to effectively communicate with resident 1. Interview with staff person 1 confirmed this is accurate.
  2. The UAI for resident 1, dated 12/20/2024, contains documentation on page 5 that the resident’s current diagnosis is schizoaffective disorder, and on page 9 for emotional status in the past month that the resident feels anxious or worries constantly about things often, feels irritable/has crying spells or gets upset over little things some of the time, feels alone and that he doesn’t have anyone to talk to most of the time, feels sad or hopeless often, feels that life is not worth living or thinking of taking his life some of the time and sees or hears things that other people did not see or hear some of the time. The resident-personal/social date sheet in the record for resident 1 contains documentation on page 2 of 2 that the resident has a history of schizoaffective disorder and for current behavioral and social functioning: hears voices, depression, anxiety and problems: needs reassurance. A behavioral health transition record dated 01/02/2025 contains documentation on page 1 under reason for admission that resident 1 has a history of severe recurrent major depression with psychosis, schizoaffective disorder who presents with suicide thoughts and command hallucinations. Patient reports he constantly hears voices telling him to kill himself, sees shadows. He has a plan to slit his throat with a knife. A psychiatry progress noted dated 01/22/2025 has documentation on page 1 that resident 1 has a recent dose change in his Depakote for hallucinations and recent self-harming thoughts. The ISP in the record for resident 1, dated 01/02/2025, does not contain the identified need or services to be provided for behavior/suicidal ideation monitoring. Interview with staff person 1 confirmed this is accurate.
Plan of correction
DORS will use the UAI to develop the ISPs within 7 days of move in. DORS to complete audit of all ISPs by March 14th, 2025, to ensure completion and accuracy. All new admissions shall have ISPs implemented within 7 days. Date to be completed: March 14, 2025
22VAC40-73-300-B
Based on resident record review, staff interview, and review of facility communication logs, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. The record for resident 1 contains an electronic note that was entered on 02/02/2025 at 9:47PM that the resident was sent out to hospital due to episode that appeared to be a severe panic attack/seizure like activity transferred via stretcher with EMS, notified DON and an electronic note that was entered on 02/02/2025 at 11:51PM that consultant from hospital mental health unit called the facility stating that they will be admitting the resident because he apparently said “he wants to hurt himself” to someone at the hospital. These electronic notes; however, are only available to medication administration staff persons as verified by staff persons 1 and 3.
  2. During an interview on 02/05/2025 in the nurses’ station with two licensing inspectors (LIs), Collateral 1, and staff person 2, staff person 2 was asked what the facility uses as its written communication for all staff. Staff person 2 referenced a white binder (CNA Daily Communication – 24 Hours Log CNA’S) and a black binder with a statement on the front “24-HOUR REPORTING IS TO BE DONE ON A DAILY BASIS FOR ALL HALLS IF NOT YOU WILL BE WRITTEN UP PER MANAGEMENT” that staff are to use as a means of communication. The white binder contained a 24-Hour Report document, dated 02/02/2025; however, the document did not contain any information about the resident being sent out to the hospital on 02/02/2025. Also, the black binder did not contain any information that the resident had been sent out to the hospital on 02/02/2025.
Plan of correction
Staff shall begin utilizing the written 24-hour log to document significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions DORS to schedule in-service and implement 24-hour log before March 7th, 2025. DORS to perform daily checks to ensure that 24-hour log is being utilized. Shift Supervisors to ensure charting is being completed throughout shifts. Date to be completed: March 7, 2025
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician orders and instructions.
Evidence
  1. The history and physical, signed and dated on 12/14/2024 in the record for resident 1, has documentation of the prescribed medication Haldol 10mg bid. The January and February 2025 medication administration records (MARs) do not have documentation of the prescribed medication Haldol and the record for resident 1 does not have any documentation of physician orders to discontinue this medication.
  2. The history and physical, signed and dated on 12/14/2024 in the record for resident 1, has documentation of the prescribed medication Prazosin 2mg daily at bedtime. The January 2025 MAR for resident 1 has documentation that this medication was administered at 8AM instead of bedtime on 01/04/2025 through 01/07/2025. Staff initials are also present for the administration of this medication at 8AM and 8PM on 01/08/2025.
Plan of correction
Audit of cart and Emar to be done by DORS. DORS to oversee medication passes to ensure proper administration of medications. DORS to complete cart audits and schedule and oversee medication passes before March 7th, 2025. Cart audits are to be completed weekly by staff. Pharmacy will come monthly to perform cart audit and Emar review. Date to be completed: March 7, 2025
February 5, 2025Complaint survey0 violations
Inspection dates
02/05/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/05/2025 1:05PM to 1:30PM 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 01/23/2025 regarding allegations in the areas of: resident care and related services & buildings and grounds Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 21, 2025Inspection8 violations
Inspection dates
01/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/21/2025 8:15AM to 6:15PM 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audits 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation of the facility physical plant, the facility failed to ensure the interior of all buildings shall be maintained in good repair and kept clean.
Evidence
  1. At approximately 11:42AM on 01/21/2025, the day of on- site inspection, the licensing inspector observed that the floor in the bathroom of residents 3 and 4 contained a puddle of water in between the toilet and the bathtub along with a black substance on the floor around the bottom of the handrail of the toilet and the toilet.
Plan of correction
1. Maintenance Director to perform weekly walk-through of entire building. 2. Maintenance Director to submit Environmental Checklist to ED once weekly. 1. Continue to maintain full-time maintenance personnel 2. Maintenance Director to check all resident bathrooms for leaks in toilets as well as black substance around toilet and repair. 3. Repairs to be completed by 2/14/25. 1. Continue to maintain full-time maintenance personnel 2. Maintenance Director to check all resident bathrooms for leaks in toilets as well as black substance around toilet and repair. 3. Repairs to be completed by 2/14/25. Date to be completed: 2/14/2025
22VAC40-73-660-A-2
Based on observations of the facility medication carts, the facility failed to ensure that schedule II drugs and any other drugs subject to abuse were kept in a separate locked storage compartment (a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart).
Evidence
  1. At approximately 8:50AM on 01/21/2025, the day of on-site inspection, 2 licensing inspectors (LI’s), in the presence of staff person 3, observed that the lock on the narcotic drawer located on the safe, secure unit medication cart was inoperable and that the schedule II medications located in this drawer were kept under only one lock that locks the entire medication cart.
Plan of correction
1. Cart audits to be continued weekly by staff. (To include ensuring that carts are working and locking properly. 2. Staff to notify DORS or ED of any cart malfunction immediately. 1. Audit completed of all medication carts to ensure all are locking as they are supposed to be. To be completed by 2/5/2025. 1. Audit completed of all medication carts to ensure all are locking as they are supposed to be. To be completed by 2/5/2025. 2. Express Care to repair cart malfunction. Date completed: 1/24/2025
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure medical procedures ordered by a physician or other prescriber shall be provided in accordance with his instructions and documented and the documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 01/07/2025, to check the resident’s blood sugar three times daily for 14 days and a signed physician’s order, dated 12/03/2024, for the resident’s blood sugar to be checked daily before meals and at bedtime for monitoring.
  2. Interview with staff person 1 revealed that when staff check the resident’s blood sugar, the blood sugar reading is then to be documented on the resident’s medication administration record (MAR). The January 2025 MAR for resident 1 contains documentation that the resident’s blood sugar was only checked at 7:30AM daily on 01/17/2025 through 01/21/2025, 8:00AM daily on 01/07/2025 through 01/11/2025, 11:30AM daily on 01/16/2025 through 01/21/2025, 4:30PM daily on 01/16/2025 through 01/20/2025 and 8:00PM daily on 01/16/2025 through 01/20/2025.
  3. Interview with staff person 1 confirmed that there are no other documented blood sugar readings for the resident.
Plan of correction
1. Staff in-service to be completed no later than 2/14/25. In-service is to cover medication administration and the importance of following the MAR. 1. DORS to review MARs daily to ensure medication is being administered as ordered. 1. DORS to review MARs daily to ensure medication is being administered as ordered. Date to be completed: 2/28/2025
22VAC40-73-660-B
Based on observations of the facility physical plant and staff interviews, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. At approximately 11:06AM on the day of on-site inspection, a bottle of Micro-Guard Powder Antifungal Powder with Miconazole Nitrate 2% was observed sitting out in a basket in the room for resident 7. The UAI dated 08/23/2024 in the record for resident 7 has documentation that the resident’s medication is administered/monitored by a layperson. The record for resident 7 did not contain an order for Antifungal Powder with Miconazole Nitrate 2%. In an interview with both licensing inspectors (LIs) and staff person 1 on the day of on-site inspection, staff person 1 expressed that the powder came from a Hospice agency.
Plan of correction
1. Room checks to be completed on all resident rooms who are not considered self-administer. Checks will include ensuring that no medication is in the resident’s room. 1. DORS to require weekly room checklist from care staff to clear any medications of being found in rooms. 2. In-service to be held by no later than 2/14/25 reviewing medication management. 1. DORS to require weekly room checklist from care staff to clear any medications of being found in rooms. 2. In-service to be held by no later than 2/14/25 reviewing medication management. Date to be completed: 2/28/2025
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contained a signed physician’s order, dated 01/07/2025, for Lasix 20MG for five days for edema LES. The January 2025 medication administration record (MAR) contains documentation that the resident has been administered Lasix (Furosemide) 40MG one tablet every day for 5 days for edema and has been administered this medication at 8:00AM on 01/19/2025, 01/20/2025, and 01/21/2025. One licensing inspector (LI) observed that the medication in the cart for resident 1 is Lasix 40MG and no Lasix 20MG.
  2. The record for resident 2 contained a signed physician’s order, dated 11/26/2024, to discontinue Lidocaine, Refresh Eye Drops, and Albuterol due to the resident refusing these medications; however, the November 2024 MAR from 11/27/2024 to 11/30/2024, the December 2024 MAR, and the January 2025 MAR from 01/01/2025 to 01/05/2025 at 12:00PM contain the initials that this medication was administered to the resident numerous dates/times during this time period even though the medications had been discontinued on 11/26/2024.
  3. The record for resident 8 has a physician order for Insulin Lispro 100unit/ml Pen (Humalog Kwikpen), check blood sugars and inject 5units subcutaneously 3 times a day with meals for DMII- Hold for glucose less than 150. The January 2025 medication administration record (MAR) for resident 8 has documentation that the residents blood sugar was less than 150 at 7:30am on 01/04/2025, 01/05/2025, 01/06/2025, 01/13/2025 and 01/18/2025, at 11:30am on 01/05/2025 and at 4:30pm on 01/14/2025. There are staff initials present for the administration of the Insulin Lispro for these dates/times and documentation of a number that reflects the site the insulin was administered.
  4. The January 2025 MAR for resident 9 has staff initials that are circled as not administering the prescribed medication Trulicity 4.5mg/0.5ml pen subcutaneously once a week on Thursdays on 01/09/2025. The MAR has documentation of “doctor order” for not administering the medication. The record for resident 9 does not contain a physician order to hold/stop this medication on 01/09/2025 and was not discontinued by the resident’s physician until 01/16/2025. In an interview with 2 LI’s and staff person 1 on the day of inspection, staff person 1 expressed that resident 1 refused the medication but there is no documentation of this refusal in the resident’s record or on the January 2025 MAR. The record for resident 9 has a progress note with medications electronically signed by the resident’s provider on 01/15/2025 that has the medication Humalog KwikPen (U-100) Insulin 100/ml subcutaneous-inject 10 unit subcutaneously three times a day before meals for diabetes mellitus and the medication Humalog 8 units TID (three times a day). The January 2025 MAR for resident 9 does not reflect these orders and has that the resident is receiving Insulin Lispro 100 unit/ml Pen (Humalog KwikPen), inject 15 units subcutaneously twice daily before meals for DM-hold for BS less than 140.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering 3. Education with staff about reordering medication timely. 4. DORS to complete cart audit on 5 residents per day to ensure all medications are available. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. Date to be corrected: 3/15/2025
22VAC40-73-640-A
Based on observations of the facility medication carts, the facility failed to ensure implementation of their medication management plan (MMP).
Evidence
  1. The facility policy 5.10 for Medication Storage has documentation that each container of medication shall contain all the information needed to safely administer the medication including: bullet #8-Expiration date (Date after which drug is no longer effective.) The memory care medication cart contained a Basaglar Kwik Pen and an Insulin Lispro Kwik Pen in the cart for resident 5. Both pens were noted to be opened/in use but did not contain an open or discard date to ensure that the medication is disposed of within 28 days after opening per manufacturer instructions.
  2. The A-Hall medication cart contained a Humalog Kwik Pen and an Insulin Glargine yfgr pen in the cart for resident 4. The Humalog Kwik Pen was noted to be open/in use but did not contain an open or discard date to ensure that the medication is disposed of within 28 days after opening per manufacturer instructions. The Insulin Glargine yfgr pen was observed to have an open date of 12/20/2024 which would have required the medication to be discarded on 01/17/2025, 28 days after opening per manufacturer instructions.
  3. The D-Hall medication cart contained a Humalog 75/25 Mix pen in the cart for resident 6. The pen was noted to be opened/in use but did not contain an open or discard date to ensure that the medication is disposed of within 28 days after opening per manufacturer instructions.
Plan of correction
1. Medication Pass observation audits to be completed weekly and forwarded to Divisional Director of Clinical Services for review. 2. Cart to MAR audit to be completed with all new orders. 3. Staff to continue with weekly cart audits. 4. DORS to perform cart audit on 5 residents per day to ensure all medications are available. 1. Director of Resident Services to forward medication pass observation to Divisional Director of Clinical Services each Thursday for review. 2. Staff in-service provided. Staff are aware to notify ED or DORS of any medications not available. 1. ED to ensure all audits are completed. Date to be corrected: 3/1/2025
22VAC40-73-680-I
Based on resident medication administration record (MAR) review, the facility failed to ensure that all required information was documented on resident MARs.
Evidence
  1. The January 2025 MAR for resident 1 does not have documentation of staff initials for the administration of the prescribed medications Levothyroxine 175MCG on 01/04/2025 at 6:00AM and the resident’s prescribed Trulicity 3MG/0.5ML inject once weekly on Thursday on 01/09/2025.
  2. The December 2024 MAR for resident 10 does not have documentation of staff initials for the administration of the prescribed medications Atorvastation 10mg at 5pm on 12/04/2024 and 12/30/2024, Desitin Daily Defens at 6pm on 12/04/2024, 12/05/2024 and 12/30/2024,Divalproex DR 125mg at 5pm on 12/04/2024 and 12/30/2024, Memantine HCL 5mg at 5pm on 12/04/2024 and 12/30/2024, Olanzapine 15mg at 8pm on 12/03/2024, 12/04/2024, 12/05/2024, 12/30/2024 and 12/31/2024, Senna 8.6mg at 8pm on 12/03/2024, 12/04/2024, 12/05/2024, 12/30/2024 and 12/31/2024 and Trazadone 50mg 1 and a half tablets at 3pm on 12/04/2024 and 12/18/2024.
  3. The December 2024 and January 2025 MARs for resident 11 does not have documentation of staff initials for the administration of the prescribed medications Amantadine 100mg at 5pm on 12/04/2024 and 12/30/2024, Eliquis 5mg at 5pm on 12/04/2024 and 12/30/2024, Haloperidol 5mg at 5pm on 12/04/2024 and 12/30/2024, Metoprolol Tart 25mg at 9am on 12/05/2024, Mirtazapine 15mg at 5pm on 12/04/2024 and 12/30/2024, Rosuvastatin Calcium 10mg at 5pm 12/04/2024 and 12/30/2024, Synthroid 50mcg at 6am on 12/04/2024, 12/06/2024, 12/25/2024, 01/04/2025 and 01/12/2025, and Vitamin D-3 2,000 units at 9am on 12/05/2024.
Plan of correction
1. All agency staff to use paper MARs moving forward. 2. Projected end of agency – End of February. 3. Staffing in-service to be completed no later than 2/14/25 on medication management and proper MAR documentation. 1. DORS to have paper MARS readily available when agency shifts are scheduled. 1. DORS to have paper MARS readily available when agency shifts are scheduled. Date to be corrected: 2/28/2025
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 8:37AM on the day of on-site inspection, 2 licensing inspectors (LIs) observed a door labeled Housekeeping on the hallway to the right of the kitchen on the memory care unit to be unlocked. The room contained a bottle of Green Earth Peroxide Cleaner, a bottle of Quat Pro 16 Cleaner, Disinfectant, Virucide, several bottles of Ecolab Dual Action Floor Cleaner, 2 cans of Premium Wood Polish and a bottle of Ecolab Bio-Emzymatic Odor Eliminator.
Plan of correction
1. A housekeeping and maintenance department in-service on the importance of ensuring all doors remained closed and locked in memory care. 2. Maintaining Housekeeping/Maintenance room rounds weekly. 3. Continuing memory care wellness rounds weekly. 1. Maintenance Director to perform daily walk throughs of memory care to ensure actions are completed. 2. Maintenance Director to submit environmental checklist to the Executive Director once weekly. 1. Maintenance Director to perform daily walk throughs of memory care to ensure actions are completed. 2. Maintenance Director to submit environmental checklist to the Executive Director once weekly. 3. Executive Director to do weekly walk-through of memory care to ensure actions are being completed. Date to be completed: 2/28/2025
January 21, 2025Complaint survey10 violations
Inspection dates
01/21/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
To ensure that the facility has a thorough understanding of standards, the licensing inspector had a discussion with the Administrator regarding standards 22VAC40-73-220, 22VAC40-73-440-A, and 22VAC40-73-1100A.
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: 01/21/2025 8:15AM to 6:15PM 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 12/20/2024 regarding allegations in the areas of: admission, retention and discharge of residents, staffing and supervision, & resident care and related services Number of residents present at the facility at the beginning of the inspection: 60 Number of resident records reviewed: 9 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: audit of medication carts An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the compliant 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review, medication cart audit and staff interviews, the facility failed to implement its medication management plan (MMP) in regard to methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s medication management plan (MMP), provided by staff person 2, states under policy 5.04 that a MAR/MOR will be completed and maintained for all residents who require supervision or administration of medications, all MAR/MOR will be initiated as medications are distributed, there will be no holes in MAR/MORs, and if a new medication has been ordered by the health care provider, the Nurse/Medication Assistant Tech ensures that it is available to be given to the resident at the prescribed time and date. The record for resident 4 contains an order, dated 12/13/2024, for Lorazepam 0.5MG tablet give one tablet every 12 hours for anxiety. The December 2024 medication administration record (MAR) for the resident contains documentation that the resident was not administered this medication on 12/14/2025 and 12/15/2024 at 8:00AM and 8:00PM due to “new order not in from pharmacy”, on 12/13/2024 at 8:00PM due to “doctor won’t refill”, on 12/17/2024 due to “other: Medication need a refill” and 12/18/2024 due to “Hospice was notified that medication still not at facility due to Phar” (statement cut off on MAR).
  2. The facility’s medication management plan states the following: “NOTE: At no time is it acceptable to find that a resident has less than 5 doses of medications available to them. Therefore, it is not acceptable to circle and indicate that we are waiting for pharmacy or family to deliver meds. It is the Nurse’s/Medication Assistant Tech’s responsibility to ensure that all orders are consistently filled and available to resident.” and “If the medication(s) have not been supplied by the time the existing supply is depleted to five (5) doses, the Nurse/Medication Assistant Tech will order five (5) doses of the medication(s) from the community pharmacy. This procedure will continue until the medication has arrived.” The December 2024 MAR for resident 3 indicates that the resident did not receive Ramelteon 8MG at 9:00PM on 12/02/2024 and 12/17/2024 due to “refill medications” and did not receive Lispro insulin on 12/26/2024 at 11:30AM and 4:30PM due to “Other: awaiting arrival”.
Plan of correction
1. Medication Pass observation audits to be completed weekly and forwarded to Divisional Director of Clinical Services for review. 2. Cart to MAR audit to be completed with all new orders. 3. Staff to continue with weekly cart audits. 4. DORS to perform cart audit on 5 residents per day to ensure all medications are available. 1. Director of Resident Services to forward medication pass observation to Divisional Director of Clinical Services each Thursday for review. 2. Staff in-service provided. Staff are aware to notify ED or DORS of any medications not available. 1. ED to ensure all audits are completed. Date to be corrected: 3/1/2025
22VAC40-73-290-A
Based on facility documentation and staff interview, the facility failed to ensure to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. Daily assignment sheets, dated 12/22/2024 to 01/21/2025, provided by staff person 1 during on-site inspection on 01/21/2025, did not include the name of all staff working each shift and did not include an indication of the staff who were in charge. Interview with staff person 1 confirmed this is accurate.
Plan of correction
1. Assignment sheet updated to include: - Line Item for supervisor in charge - Line item for shift worked. - Signature lines for MedTech and caregiver on duty. 1. DORS to verify assignment sheets daily with shift supervisor prior to placing them out. 1. DORS to verify assignment sheets daily with shift supervisor prior to placing them out. Date to be corrected: 3/1/2025
22VAC40-73-680-I
Based on resident medication administration record (MAR) review, the facility failed to ensure that all required information was documented on resident MARs.
Evidence
  1. The November 2024, December 2024, and January 2025 MARs for resident 3, the December 2024 and January 2025 MARs for residents 1, 2 and 5, the December 2024 MAR for resident 4, and the January 2025 MARs for residents 6, 7 and 8 has documentation on numerous days/times of the initials ALPN and AN9 for administering medications to these residents. On the signature and title section of the MARs it has listed that these initials belong to Agency LPN and Agency Nurse 2 but the MARs do not have these individuals actual name, signature or initials. In an interview with both licensing inspectors (LI’s) and staff person 1, staff person 1 expressed that the initials ALPN and AN9 are used for different agency staff as the facility does not always know who the Agency company is sending to be able to get their own credentials for logging in to the MAR system.
  2. The record for resident 3 contained a report of resident physical examination, signed and dated 11/18/2024, that contains documentation the resident is prescribed Lispro insulin 4 units with meals and a signed physician’s order, dated 11/27/2024, for Basaglar insulin inject 10 units every day for DM. The facility’s medication management plan (MMP) indicates in policy 5.04 that a circle is drawn around the square and initialed when the resident is observed not taking an ordered medication, the back of the MAR/MOR indicates the reason the medication was not taken, EMARs document the reason when a resident may not take an ordered medication. The November 2024 MAR for resident 3 contains staff initials and is circled on 11/28/2024 at 7:30AM for Basaglar insulin and Lispro insulin and contains a note for both stating “Other: fsbs 66”, the December 2024 MAR for the resident contains staff initials and is circled on 12/23/2024 at 7:30AM and contains a note stating “Other: BS 74, hasn’t eaten”, and the January 2025 MAR for the resident contains staff initials and is circled on 01/18/2025 at 7:30AM and contains a note stating “Other: b/s81”; however, the MAR doesn’t contain whether or not the resident was or wasn’t administered the medication.
Plan of correction
1. All agency staff to use paper MARs moving forward. 2. Projected end of agency – End of February. 3. Staffing in-service to be completed no later than 2/14/25 on medication management and proper MAR documentation. 1. DORS to have paper MARS readily available when agency shifts are scheduled. 1. DORS to have paper MARS readily available when agency shifts are scheduled. Date to be corrected: 2/28/2025
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 2 contains documentation that the resident was admitted to the facility’s assisted living building on 11/22/2024. Interview with staff person 2 revealed that the resident was admitted to the facility’s safe, secure environment (memory care) from its assisted living building on 12/13/2024.
  2. Interview with staff person 1 confirmed that the resident’s ISP, dated 11/20/2024, was not updated to reflect that the resident now resides in memory care.
Plan of correction
1. Audit to be completed on all ISPs and reviewed for change of condition and accuracy. 1. DORS to complete audit by 2/10/2025 1. All new changes of conditions will require an update to ISP. 2. DORS to notify DDOCS of any change in condition. Date to be Corrected: 3/1/2025
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The uniform assessment instrument (UAI) for resident 2 indicates the resident is assisted living level of care.
  2. The record for the resident contains a staff progress note, dated 12/18/2024 at 4:40AM, that the staff person was doing a round and heard resident yell out “help” from his room around 3:45AM and when the staff person arrived to the room, the resident was seated on the floor alongside of the bed and another staff progress note, dated 12/21/2024 at 7:03PM, that the staff person found the resident on the floor that morning.
  3. Interview with staff person 2 on 01/29/2025 revealed that these two incidents would have been considered falls. The record for resident 2 did not contain fall risk ratings for these two falls.
Plan of correction
1. Care staff to complete fall assessment following each incident. 1. DORS to review incidents daily to ensure fall assessments are completed. DORS will submit completed assessments to ED for review. 1. ED to review fall assessments as they come in. 1. DORS to review incidents daily to ensure fall assessments are completed. DORS will submit completed assessments to ED for review. 2. ED to review fall assessments as they come in. Date to be corrected:3/1/2025
22VAC40-73-1090-A
Based on resident record review and staff interview, the facility failed to ensure that prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. During an interview with staff person 2 and two licensing inspectors (LIs) on 01/21/2025, staff person 2 revealed that resident 2 was admitted to the facility’s safe, secure environment (memory care unit) on 12/13/2024; however, the record for resident 2 contained an assessment of serious cognitive impairment, dated 12/23/2024, which was completed after the resident was admitted to the memory care unit and another assessment of serious cognitive impairment that did not contain a date of when the assessment was completed. Staff person 2 confirmed this was accurate.
Plan of correction
1. Audit to be completed on all memory care charts. 2. ED and DORS to complete move-in checklist and ensure that all needed documents are complete prior to move-in. 1. DORS to ensure that all new admissions to memory care have an assessment for serious cognitive impairment prior to moving in. 2. DORS to ensure all aspects of assessment are complete including date of assessment. 1. DORS to ensure that all new admissions to memory care have an assessment for serious cognitive impairment prior to moving in. 2. DORS to ensure all aspects of assessment are complete including date of assessment. Date to be Corrected: 3/15/2025
22VAC40-73-460-H
Based on resident record review, facility documentation, and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired.
Evidence
  1. Interview with staff persons 1 and 2 revealed that the facility utilizes the skin monitoring: comprehensive CNA shower review sheets as a way or documenting when a resident has received a shower or bath.
  2. The uniform assessment instrument (UAI) for resident 1, dated 06/08/2024, indicates the resident requires mechanical help and human help physical assistance with bathing. The individualized service plan (ISP), dated 06/08/2024, states that staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able while using the following DME equipment: shower bench/seat and grab bar at a minimum of twice weekly and as needed. During on-site inspection, staff persons 1 and 2 only provided Skin monitoring: comprehensive CNA shower sheets for the following dates: 12/02/2024, 12/03/2024, 12/05/2024, 12/09/2024, 12/16/2024, 01/02/2025, 01/13/2025, 01/16/2025, and 01/20/2025.
Plan of correction
Audit to be completed on shower schedules and resident shower days. 1. Staff continue using assignment sheets with shower assignments, sheets to be turned into shift supervisor each shift, and submitted to DORS at the end of each week. 2. Shower schedule to be posted in each wellness office for staff to see. 1. Director of Resident Services to review assignment sheets weekly to ensure showers and care are being completed. 1. Director of Resident Services to review assignment sheets weekly to ensure showers and care are being completed. Date to be corrected: 3/1/2025
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber's instructions.
Evidence
  1. The record for resident 2 contains a progress note by Collateral 1, dated 01/07/2025 and electronically signed by Collateral 1 on 01/10/2025, states on page 2 of 3 that the resident is prescribed Prozac 20MG once daily, Seroquel 12.5MG two times daily, Seroquel 25MG once daily, and Hydroxyzine 25MG every 12 hours as needed for anxiety if not redirectable. The record for resident 2 contains an electronically signed progress note by Collateral 2, dated 01/08/2025 and electronically signed by Collateral 2 on 01/10/2025, that states on page 3 of 5 that the resident is currently on Quetiapine (Seroquel) 12.5MG two times daily and Seroquel 25MG once daily and the plan is to discontinue the 1 milligram once a day and start Seroquel 25MG two times daily for his mood disorder, resulting in a total of 37.5 milligrams two times daily. Page 4 of 5 of the progress note states that it is recommended the resident take his pain medication of Tylenol at bedtime which may help so he is not restless from pain of rib fractures. Page 4 of 5 of the progress note also states “orders for this visit” which states increase Seroquel 25MG to 37.5MG two times daily and recommend adequate pain control to lessen agitation or restlessness related to pain from fractures and that Collateral 2 spent an hour with the resident’s wife prior to the visit and it was agreed to administer Tylenol twice a day, especially at bedtime.
  2. The January 2025 medication administration record (MAR) for resident 2, as of on-site inspection on 01/21/2025, contains documentation that the resident is only being administered Seroquel 12.5MG two times daily at 8:00AM and 8:00PM. The January 2025 MAR contains documentation that Tylenol 325MG take two tablets three times daily for pain ended on 01/02/2025 and Tylenol EX-STR 500MG take two tablets every 8 hours for pain for seven days ended on 01/14/2025.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering 3. Education with staff about reordering medication timely. 4. DORS to complete cart audit on 5 residents per day to ensure all medications are available. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. Date to be corrected: 3/15/2025
22VAC40-73-680-K
Based on resident record review and staff interview, the facility failed to ensure the use of PRN (as needed) medication is prohibited, unless the resident is capable of determining when the medication is needed, licensed health care professionals administer the as needed medication or medication aides (RMAs) administer the as needed medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order and shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
Evidence
  1. Resident 2 was admitted to the facility’s safe, secure environment (memory care) on 12/13/2024. Interview with two licensing inspectors (LIs) and staff person 1 during on-site inspection on 01/21/2025, staff person 2 revealed that since the resident was admitted to the memory care, the resident is not capable of determining when an as needed medication is needed.
  2. The record for resident 2 contained a signed physician’s order, dated 01/07/2025, for Hydroxyzine hcl 25MG take one tablet by mouth every 12 hours as needed for anxiety/agitation with an effective date of 11/27/2024. The January 2025 medication administration record (MAR) for resident 2 indicates that the resident was administered Hydroxyzine on 01/19/2025 at 8:05PM by staff person 3 who is an RMA. The order for the as needed Hydroxyzine does not include symptoms that indicate the use of the medication and directions as to what to do if symptoms persist.
Plan of correction
1. Inservice of proper medication management to be completed. 2. Audit of all orders to ensure all PRN orders are specific with measurable data. 3. PRN Statement will be sent to MD/NP for use on all PRN medications. 4. Express Care will add PRN instructions to all PRN medications. 5. Audit of PRNs to be completed. Any PRNs taken on a regular basis will be discussed with Practitioner to readjust. 1. Audit of all orders to ensure all as needed medications are needed and require measurable data. 1. Bi-weekly audit of all new orders. Date to be corrected: 3/1/2025
22VAC40-73-460-E
Based on resident record review and staff interviews, the facility failed to ensure that a change in a resident’s condition or functioning was documented in the resident’s record.
Evidence
  1. During an on-site complaint investigation conducted on 01/21/2025, the licensing inspector (LI) requested the record for resident 9 for review. A discharge notice due to death was observed in the resident’s record but the record did not contain any documentation of when resident 9’s condition and functioning changed.
Plan of correction
1. Staff in-service to be completed no later than 2/14/25 on proper charting to include change of condition. 1. DORS to check charting daily in EHR system to ensure proper documentation is being completed. 1. DORS to check charting daily in EHR system to ensure proper documentation is being completed. Date to be corrected: 2/28/2025
January 21, 2025Complaint survey0 violations
Inspection dates
01/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8:15AM to 6:15PM 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 01/21/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 60 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 20, 2024Complaint survey3 violations
Inspection dates
11/20/2024, 01/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:34PM and 01/21/2025 8:15AM to 6:15PM 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 10/31/2024 regarding allegations in the areas of: resident care and related services & additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 63 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1130-C
Based on facility documentation and staff interviews, the facility failed to ensure during night hours when 22 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents.
Evidence
  1. Staff person 1 stated during an interview that the facility’s night shift is 7:00PM to 7:00AM. Timesheets provided to the licensing inspector (LI) on 11/20/2024 indicate that staff person 3 clocked in at 6:55PM on 10/30/2024 and clocked out at 7:36AM on 10/31/2024, staff person 4 clocked in at 7:25PM on 10/30/2024 and clocked out at 6:53AM on 10/31/2024, and staff person 5 clocked in at 6:28PM on 10/30/2024 and clocked out at 8:17AM on 10/31/2024 therefore indicating only three direct care staff were on duty during the night shift of 7:00PM to 7:00AM 10/30/2024 to 10/31/2024.
  2. During two separate phone interviews with the licensing inspector (LI) and staff persons 3 and 4 on 11/22/2024, both staff persons 3 and 4 informed the LI that they both worked in the assisted living building together and that staff person 5 worked alone in the memory care building. Interviews with staff persons 1 and 2 on 01/21/2025 confirmed that there should have been at least two direct care staff on duty in the memory care building during the night shift of 10/30/2024 to 10/31/2024.
Plan of correction
1. Schedule audit to be completed daily to ensure 2 staff members minimum are in memory care at all times. 1. DORS to begin utilizing assignment sheets in memory care to ensure proper staffing. 2. Executive Director/DORS to verify staffing schedule daily. 1. DORS to begin utilizing assignment sheets in memory care to ensure proper staffing. 2. Executive Director/DORS to verify staffing schedule daily.
22VAC40-73-930-D
Based on resident record review and staff interview, for each resident with an inability to use the signaling device, in addition to any other services, the facility failed to ensure once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility and the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds and the documentation shall be retained for two years.
Evidence
  1. Resident 1 resided in the facility’s safe, secure unit. Interview with staff person 1 on 01/21/2025 revealed that the resident was unable to use a signaling device.
  2. The October 2024 medication administration record (MAR) contains the following: safety check – perform safety rounds every two hours from 8PM to 6AM for patient care. The October 2024 MAR does not contain documentation that rounds were completed on the resident at 10:00PM on 10/29/2024 and at 4:00AM, 6:00AM, 8:00PM and 10:00PM on 10/31/2024. Interview with staff person 1 confirmed this is accurate.
Plan of correction
1. Resident rounds checklist to be completed daily for night shift, staff to submit checklist to shift supervisor. 1. DORS to perform audit of residents requiring frequent checks. 2. 2-hour checks to be added to Emar in Eldermark and signed off on by care staff. 1. DORS to review resident rounds checklist daily. 2. DORS to review checklists each week with DDOCS on weekly call.
22VAC40-73-300-B
Based on resident record review, facility documentation review and staff interviews, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. During two separate phone interviews with the licensing inspector (LI) and staff persons 3 and 4 on 11/22/2024, both staff persons 3 and 4 informed the LI that they worked the evening/night shift on 10/30/2024 to 10/31/2024 and that resident 1 had a fall during this shift. During a phone interview with the LI and staff person 5 on 11/25/2024, staff person 5 informed the LI that she worked the evening/night shift on 10/30/2024 to 10/31/2024 and that resident 1 had a fall during this shift.
  2. The binder located in the memory care medication cart containing documents titled “Carriage Hill Retirement Charting Schedule” and a binder located at the nurses’ station with a statement on the front of the binder “24-HOUR REPORTING IS TO BE DONE A DAILY BASIS FOR ALL HALLS IF NOT YOU WILL BE WRITTEN UP PER MANAGEMENT” that contains documents “Impact Senior Living – Healthcare Management 24 Hour Report – Form 2.05A” did not contain documentation that the resident had a fall during the evening/night of 10/30/2024 to 10/31/2024. Progress notes provided by staff person 1 on 11/20/2024 also did not contain documentation that the resident had a fall during this time period.
Plan of correction
1. Staff in-service to be completed on importance of utilizing the 24-hour log. 1. DORS to perform daily walkthrough of both assisted living and memory care to ensure that 24-hour log is being completed. 2. Shift Supervisors to ensure charting is being completed each shift. 1. DORS to perform daily walkthrough of both assisted living and memory care to ensure that 24-hour log is being completed. 2. Shift Supervisors to ensure charting is being completed each shift.
November 20, 2024Complaint survey1 violation
Inspection dates
11/20/2024, 01/21/2025
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:27PM and 01/21/2025 8:15AM to 6:15PM 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 11/11/2024 regarding allegations in the area of: additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 63 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1130-C
Based on facility documentation, the facility failed to ensure during night hours when 22 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents.
Evidence
  1. Documentation provided by staff person 1 on 01/21/2025 revealed that the facility’s special care unit had a census of 20 residents on 11/10/2024 and 11/11/2024 indicating that the memory care unit would need to have two direct care staff members at all times. Staff person 1 stated during an interview that the facility’s night shift is 7:00PM to 7:00AM.
  2. Timesheets provided by staff person 1 on 11/20/2024 indicated that staff person 3 clocked in at 6:08PM on 11/10/2024 and clocked out at 10:02AM on 11/11/2024, staff person 4 clocked in at 7:02PM on 11/10/2024 and clocked out at 9:39AM on 11/11/2024, staff person 5 clocked in at 3:12PM on 11/10/2024 and clocked out at 4:30AM on 11/11/2024, and staff person 6 clocked in at 8:15PM on 11/10/2024 and clocked out at 10:26AM on 11/11/2024.
  3. During a phone interview with the licensing inspector (LI) and staff person 3, staff person 3 indicated that she and staff person 6 worked in the assisted living building during the night shift on 11/10/2024 to 11/11/2024. Staff person 3 informed the LI that when she went to the memory care building to pass 6:00AM medications on 11/11/2024, staff person 4 informed her that they (staff person 4) had been alone in the memory care unit since staff person 5 left at 4:30AM.
Plan of correction
1. Schedule audit to be completed daily to ensure 2 staff members minimum are in memory care at all times. 1. DORS to begin utilizing assignment sheets in memory care to ensure proper staffing. 2. Executive Director/DORS to verify staffing schedule daily. 1. DORS to begin utilizing assignment sheets in memory care to ensure proper staffing. 2. Executive Director/DORS to verify staffing schedule daily.
November 20, 2024Complaint survey0 violations
Inspection dates
11/20/2024, 01/21/2025
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:36PM and 01/21/2025 8:15AM to 6:15PM 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 11/18/2024 regarding allegations in the area of: additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 63 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: 2 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 20, 2024Complaint survey0 violations
Inspection dates
11/20/2024, 01/21/2025
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:27PM and 01/21/2025 8:15AM to 6:15PM 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 11/04/2024 regarding allegations in the area of: additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 63 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: 4 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 20, 2024Inspection4 violations
Inspection dates
11/20/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:51PM 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: 63 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-660-A-2
Based on observations of the facility medication carts, the facility failed to ensure that schedule II drugs and any other drugs subject to abuse were kept in a separate locked storage compartment (a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart).
Evidence
  1. On 11/20/2024, the day of on-site inspection, 2 licensing inspectors (LI’s) observed that the lock on the narcotic drawer located on the safe, secure unit medication cart was inoperable and that the schedule II medications located in this drawer were kept under only one lock that locks the entire medication cart. In an interview with 2 LI’s and staff person 1, staff person 1 expressed that this was correct and that the lock to the narcotic drawer did not work.
Plan of correction
1. Cart audits to be continued weekly by staff. (To include ensuring that carts are working and locking properly. 2. Staff to notify DORS or ED of any cart malfunction immediately. 1. Audit completed of all medication carts to ensure all are locking as they are supposed to be. To be completed by 12/4/2024. 1. Audit completed of all medication carts to ensure all are locking as they are supposed to be. To be completed by 12/4/2024. 2. Express Care Pharmacy to come to community on 124/2024 to correct the locking mechanism on medication cart. Completed 12.4.2024
22VAC40-73-870-A
Based on observation of the facility physical plant, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. At 10:22AM on 11/20/2024, the day of on-site inspection, 2 licensing inspectors (LIs) observed that the floor in the bathroom of residents 1 and 2 contained a puddle of water in between the toilet and the bathtub. The overhead light in the bedroom of residents 1 and 2 did not contain a covering.
  2. At 10:45AM, 2 LIs observed that the outside area at the end of the D hall exit doors contained a boxspring that was propped up against the wooden fence, there was a missing section of the wooden fence and there were exposed nails from the wooden fence panels that were taken off the fence and propped up against the building. Also, a section of the awning located on the outside of the D hall exit door into the outside walkway was missing panels and the light fixture was exposed.
  3. At 10:47AM, 2 LIs observed multiple areas of a flaking substance around the two black vents in the kitchen above the food prep table.
Plan of correction
1. Maintenance Director to perform weekly walk-through of entire building. 1. Continue to maintain two full-time maintenance personnel 2. Repairs to light fixtures to be completed by 12/6/24 3. Vents in Kitchen to be repaired and repainted by 12/13/2024 4. Fence to be repaired by 12/27/2024 1. Continue to maintain two full-time maintenance personnel 2. Repair to light fixtures to be completed by 12/9/2024 3. Vents in Kitchen to be repaired and repainted by 12/13/2024 4. Fence to be repaired by 12/27/2024 5. Environmental checklist to be submitted to Executive Director once weekly. Completion by 12.30.2024
22VAC40-73-610-B
Based on observations of the facility physical plant, the facility failed to ensure that the menu for the current week was dated and posted in an area conspicuous to residents.
Evidence
  1. At 8:38AM on 11/20/2024, the day of on-site inspection, 2 licensing inspectors observed that the menu posted in the facility safe, secure unit was for the week of 11/03/2024 through 11/09/2024.
Plan of correction
1. Dietary staff provided in-service on posting current menus. 1. Culinary Director to check dining room and common areas daily for proper menu placement. 1. Culinary Director to check dining room and common areas daily for proper menu placement. 2. Executive Director to do walk through of dining room and common areas twice weekly to ensure proper menu placement. Completed 12.6.2024
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At 8:36AM on 11/20/2024, the day of on-site inspection, 2 licensing inspectors (LIs) observed that the door labeled “HOUSEKEEPING” on the left side of the hall to the right of the kitchen was unlocked. The room contained a bottle of Quat Pro 16 Cleaner Disinfectant Virucide, a bottle of FastDraw 11 Green Earth Peroxide Cleaner, a can of Premium Wood Polish and a bottle of Ecolab Bio-Enzymatic Odor Eliminator.
Plan of correction
1. The housekeeping and maintenance department in-service on the importance of ensuring all doors remained closed and locked in memory care. 2. Maintaining Housekeeping/Maintenance room rounds weekly. 3. Continuing memory care wellness rounds weekly. 1. Maintenance Director to perform daily walk throughs of memory care to ensure actions are being completed. 2. Maintenance Director to submit environmental checklist to the Executive Director once weekly. 1. Maintenance Director to perform daily walk throughs of memory care to ensure actions are completed. 2. Maintenance Director to submit environmental checklist to the Executive Director once weekly. 3. Executive Director to do weekly walk-through of memory care to ensure actions are being completed. Completion by 12.20.2024
November 20, 2024Complaint survey4 violations
Inspection dates
11/20/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:33PM 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 10/22/2024 regarding allegations in the areas of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 63 Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-610-D
Based on resident record review, observations of the facility kitchen and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician's or other prescriber's orders.
Evidence
  1. The record for resident 2 has documentation of signed physician order sheets on 10/02/2024 and again on 10/29/2024 that the resident is to be receiving a mechanical soft-regular heart healthy diet. Hospice notes dated 08/15/2024 has documentation that resident 2 has Dysphagia, difficulty swallowing and is a risk for aspiration.
  2. Two licensing inspectors (LIs) observed the special diet board located in the facility kitchen at 10:10AM on 11/20/2024 and noted that resident 2’s mechanical soft diet order was not listed on the special diet board.
  3. In an interview with staff person 4 conducted by both LI’s at 10:12AM on 11/20/2024, staff person 4 expressed that kitchen staff were aware of resident 2’s order for a mechanical soft diet, but that kitchen staff had been advised to serve resident 2 a regular diet as the resident was on Hospice and could eat whatever they wanted. Staff person 4 expressed that they were preparing and serving a regular diet to resident 2. In an interview with staff person 1 conducted on 11/20/2024 with both LI’s, staff person 1 expressed that they had talked with staff person 4 and had also been told that kitchen staff had been advised to serve a regular diet to resident 2.
Plan of correction
1. Audit to be completed on all resident diets. 2. Diet Board in kitchen to be updated following audit. 1. Audit in kitchen to be completed by 12/13/2024 1. DORS to send DDORS list of all non-regular diets. 2. Staff in-service to be provided to staff on the importance of following meal orders. Completion by 12.30.2024
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. The dietitian oversight list of assisted living residents, dated 05/21/2024, provided by staff person 1 during on-site inspection, contains documentation that resident 1’s diet order was low concentrated sweets (LCS)/finger foods and the dietitian stated that the resident’s diet was served in accordance with the diet order. The record for resident 1 contains a physician’s order, dated 10/29/2024, that the resident is prescribed a finger foods/LCS diet. The ISP for resident 1, with a subsequent review/update date of 02/03/2024, does not contain documentation that the resident is to be served a finger foods diet.
  2. The record for resident 2 has documentation of signed physician order sheets on 10/02/2024 and again on 10/29/2024 that the resident is to be receiving a mechanical soft-regular heart healthy diet. The ISP dated 09/09/2024 in resident 2’s record is inconsistent as it has that the resident is on a regular diet and does not identify the need for the resident to be on a mechanical soft diet.
Plan of correction
1. Audit to be completed on all ISPs and reviewed for change of condition and accuracy. 1. DORS to complete audit by 12/20/2024 1. All new changes of conditions will require an update to ISP. 2. DORS to notify DDORS of any change in condition. Completion by 1.30.2025
22VAC40-73-680-D
Based on resident record review, observations and staff interviews, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The record for resident 2 has documentation of signed physician order sheets on 10/02/2024 and again on 10/29/2024 that the resident is to be receiving Oxygen- Administer 4L/min via Nasal Cannula continuous for shortness of breath-AM, PM, Night indicated for shortness of breath.
  2. During observations of the facility physical plant conducted while on-site at 10:28AM on 11/20/2024, two licensing inspectors (LI’s) observed resident 2 sitting in a wheelchair out in the Lobby near the front doors. Both LI’s observed that resident 2 did not have a nasal cannula in place on her face/nose to receive oxygen and that the oxygen nasal cannula tubing was wrapped in a figure “8” style around the handles located on the back of the wheelchair near the oxygen tank. When asked about her oxygen by both LI’s, resident 2 felt her face and head then expressed that she did not know where her oxygen tubing was at.
  3. At 11:43AM on the day of on-site inspection, two LI’s observed that resident 2 had been moved from the Lobby area and was sitting in her wheelchair at a table in the dining room. Both LI’s noted that resident 2 did not have a nasal cannula in place on her face/nose to receive oxygen and that her oxygen tubing was still located on the back of the wheelchair draped by the oxygen tank.
  4. At 11:45AM, both LI’s discussed resident 2’s oxygen order and tubing with staff persons 1 and 2. Staff person 2 returned resident 2 to her room and placed a nasal cannula from the resident’s oxygen concentrator on resident 2. In an interview with staff persons 1 and 2 it was expressed that the oxygen tank that was located on the back of resident 2’s wheelchair was empty, and that resident 2’s hospice company does not deliver enough oxygen tanks routinely for the resident to use while out in the community. While both LI’s were present in resident 2’s room, staff person 1 located a full oxygen tank in resident 2’s closet to place on resident 2’s wheelchair.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering 3. Education with staff about reordering medication timely. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. Completion by 1.10.2025
22VAC40-73-610-E
Based on facility material review, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition shall be kept current and readily available to personnel responsible for food preparation.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 10/29/2024, for the resident to be served a finger foods, low concentrated sweets diet with a red plate due to vision impairment.
  2. The 2 licensing inspectors (LIs) requested to review the facility’s diet manual that is available to the staff responsible for food preparation. The manual that was provided to the 2 LIs by staff person 3 did not contain any information about how staff are to prepare a finger foods diet.
  3. Later during the on-site inspection, while the 2 LIs were making copies at the copier, it was noted that information was being printed about finger foods to be placed in the diet manual and staff person 3 took the information.
Plan of correction
1. In-service to be provided to dietary staff on acceptable practices and standards for nutrition. 1. Culinary Director to provide quarterly in-service on proper diets, and acceptable practices and standards for nutrition. 1. Copy of manual has been printed out and placed in kitchen Completed on 12.6.2024
November 20, 2024Complaint survey3 violations
Inspection dates
11/20/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/20/2024 8:21AM to 3:26PM 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 11/06/2024 regarding allegations in the areas of: personnel & resident care and related services Number of residents present at the facility at the beginning of the inspection: 63 Number of resident records reviewed: 10 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-H
Based on resident record review and facility document review, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 10/01/2024, for amantadine 100MG one capsule every day at bedtime, apixaban 5MG (Eliquis) one tablet two times a day, haloperidol 5MG one tablet every day at bedtime, mirtazapine 15MG one tablet every day at bedtime and rosuvastatin 10MG one tablet every day at bedtime.
  2. The October 2024 MAR for resident 1 does not contain the initials of the medication staff that administered amantadine 100MG at 8:00PM on 10/12/2024 and 10/13/2024 and at 7:00PM on 10/26/2024 and 10/31/2024; Eliquis 5MG at 5:00PM on 10/26/2024; haloperidol 5MG at 8:00PM on 10/12/2024 and 10/13/2024 and at 7:00PM on 10/26/2024 and 10/31/2024; mirtazapine 15MG at 8:00PM on 10/12/2024 and 10/13/2024 and at 7:00PM on 10/26/2024 and 10/31/2024; rosuvastatin calcium 10MG at 8:00PM on 10/12/2024 and 10/13/2024 and at 7:00PM on 10/26/2024 and 10/31/2024.
  3. Staff person 1 stated via email to the licensing inspector (LI) on 11/26/2024 that the resident had received these medications, but it wasn’t documented on the resident’s MAR.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. MAR audit to be completed weekly by DORS 3. Education with staff about the importance of documenting medications given on MAR. 1. DORS to review weekly cart audits 1. Staff in-service to be completed by 12/17/24 Completion 12.17.2024
22VAC40-73-460-H
Based on resident record review, facility documentation, and staff interview, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired.
Evidence
  1. Interview with staff persons 1 and 2 revealed that the facility utilizes the skin monitoring: comprehensive CNA shower review sheets as a way of documenting when a resident has had a shower or bath.
  2. The uniform assessment instrument (UAI) for resident 3, dated 04/12/2024, indicates the resident requires mechanical help and supervision human help with bathing. The individualized service plan (ISP) for resident 3, dated 09/07/2024, indicates that staff will supervise resident while bathing and cue resident as needed, staff will ensure resident is able to get in/out of shower safely with a gentle hand while using the following equipment: shower bench/seat, grab bars at a minimum of twice weekly and as needed. Skin monitoring: comprehensive CNA shower review sheets provided by staff persons 1 and 2 during on-site inspection on 11/20/2024 indicated that the resident has only received a shower on 10/24/2024, 10/28/2024, 11/07/2024, and 11/14/2024.
  3. The uniform assessment instrument (UAI) for resident 4, dated 05/30/2024, indicates the resident requires mechanical help and supervision human help with bathing. The individualized service plan (ISP) for resident 4, dated 01/31/2024, indicates that staff will supervise resident while bathing and cue resident as needed, staff will ensure resident is able to get in/out of shower safely with a gentle hand while using the following equipment: shower bench/seat, grab bars at a minimum of twice weekly and as needed. Skin monitoring: comprehensive CNA shower review sheets provided by staff persons 1 and 2 during on-site inspection on 11/22/2024 indicated that the resident only received one shower during the week of 11/03/2024 through 11/09/2024 which was on 11/08/2024.
  4. The uniform assessment instrument (UAI) for resident 5, dated 04/04/2024, indicates the resident requires mechanical help and physical human help with bathing. The ISP for resident 5, dated 08/10/2024, indicates that staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able while using DME equipment shower bench/seat and grab bars at a minimum of twice weekly and as needed. Skin monitoring: comprehensive CNA shower review sheets provided by staff persons 1 and 2 during on-site inspection on 11/22/2024 indicated that the resident only received a shower on 10/03/2024, 10/10/2024, 10/21/2024, 10/24/2024, 10/28/2024 and 11/07/2024.
  5. The uniform assessment instrument (UAI) for resident 6, dated 09/14/2024, indicates the resident requires mechanical help and supervision human help with bathing. The ISP for resident, dated 09/18/2024, indicates that staff will supervise resident while bathing and cue resident as needed, staff will ensure resident is able to get in/out of shower safely with a gentle hand while using the following equipment: shower bench/seat, grab bars at a minimum of twice weekly and as needed. Skin monitoring: comprehensive CNA shower review sheets provided by staff persons 1 and 2 during on-site inspection on 11/22/2024 indicated that the resident only received a shower on 10/28/2024, 10/31/2024, 11/07/2024, and 11/14/2024. (continued)
Plan of correction
1. Audit to be completed on shower schedules and resident shower days. 2. Staff to begin using assignment sheets with shower assignments, sheets to be turned into shift supervisor each shift, and submitted to DORS at the end of each week. 1. Director of Resident Services to review assignment sheets weekly to ensure showers and care are being completed. 1. Staff in-service to be completed on the importance of showers and basic hygiene with residents. Completion by 1.15.2025
22VAC40-73-680-D
Based on resident record review and staff interviews, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 1 was admitted to the facility on 10/03/2024. The record for resident 1 contains a report of resident physical examination, dated 10/01/2024, that states the resident has hypothyroidism. The record for resident 1 contains a physician’s order, dated 10/01/2024, for levothyroxine 50MCG take one tablet daily for hypothyroidism.
  2. Medication administration records (MARs) for resident 1 indicate that this medication is scheduled to be administered at 6:00AM on an empty stomach for hypothyroidism daily to the resident.
  3. The October 2024 MAR for resident 1 does not contain any documentation that levothyroxine was administered to the resident on 10/11/2024, 10/13/2024, 10/14/2024, 10/17/2024, 10/18/2024, 10/22/2024, 10/23/2024, and 10/27/2024. The November 2024 MAR for resident 1 does not contain any documentation that levothyroxine was administered to the resident on 11/05/2024 and 11/11/2024. Interview with staff person 2 revealed that she had verified the resident had not received the medication on these dates.
  4. The record for resident 1 contains lab results, dated 11/05/2024 at 2:02AM, that includes information the range for the resident’s thyroid is 0.27-4.20 and the resident’s thyroid was 63.90 indicating the resident’s thyroid was high. Interview with staff person 1 revealed that the resident’s physician stated the resident’s thyroid was high due to the resident not receiving their prescribed levothyroxine.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering 3. Education with staff about reordering medication timely. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. Completion by 1.10.2025
October 4, 2024Complaint survey6 violations
Inspection dates
10/04/2024, 10/11/2024, 10/31/2024
Areas reviewed
22VAC40-73 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: 10/04/2024 9:07AM to 1:15PM, 10/11/2024 10:00AM to 1:45PM and 10/31/2024 8:30AM to 9:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/03/2024 regarding allegations in the areas of: staffing and supervision & resident care and related services Number of residents present at the facility at the beginning of the inspection: 57 Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and observation of facility medication cart, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 09/23/2024, for hydrocodone 5MG – acetaminophen 325MG table take one tablet by mouth three times a day for 10 days. Staff person 1 informed the licensing inspector (LI) that staff person 2 stated the resident had a fall and hospice prescribed the resident this medication pain. The September and October 2024 medication administration records (MARs) for the resident contains documentation that the medication’s effective date was 09/24/2024 and the end date was 10/03/2024 and it was to be administered three times daily at 8:00AM, 2:00PM and 8:00PM. The first dose of the medication was administered at 8:00AM on 09/24/2024. During on-site inspection on 10/04/2024, at approximately 1:05PM, the licensing inspector (LI), staff person 1 and Collateral 1 noted there were 7 hydrocodone tablets still in the medication cart for the resident. The September 2024 MAR does not contain documentation that this medication was administered to the resident on 09/26/2024 at 8:00PM and on 09/27/2024 at 2:00PM. The October 2024 MAR does not contain documentation that this medication was administered to the resident on 10/03/2024 at 2:00PM and 8:00PM.
  2. The record for resident 2 contains a physician’s order, dated 08/13/2024, for novolog insulin – inject 5 units under the skin before meals for DM at 7:30AM, 11:30AM and 4:30PM. The October 2024 MAR for resident 2 contains documentation that novolog insulin was not administered to the resident by staff person 6 at 11:30AM on 10/04/2024 due to “Other: Pen Needles N/A”.
  3. The record for resident 5 contains a physician’s order, dated 10/02/2024 with an effective date of the medication on 08/28/2024, for insulin lispro check blood sugar and inject five units three times daily with meals for DMII – hold for blood sugar less than 150. Interview with staff person 6 revealed that they accidently entered on the October 2024 MAR at 11:30AM on 10/03/2024 that the resident was out of the building; however, the resident was in the building and staff person 6 could not administer the resident insulin due to there not being any pen needles to administer the resident the insulin. The October 2024 MAR contains documentation by staff person 6 that the resident’s blood sugar was 215 at 12:00PM on 10/03/2024.
  4. The record for resident 6 contains a physician’s order, dated 08/13/2024, for Humalog inject 10 units three times daily before meals for DM – 7:30AM, 11:30AM and 4:30PM. The October 2024 MAR for resident 6 contains documentation that Humalog insulin was not administered to the resident by staff person 8 at 4:30PM on 10/02/2024 due to the resident being out of the building. Humalog insulin was also not administered to the resident by staff person 5 at 7:30AM on 10/03/2024 due to “Other: MEDICATION ON HAND; NO NEEDLE PENS TO GIVE INSULIN” and not administered to the resident by staff person 6 at 11:30AM on 10/03/2024 due to “Other: Pen needle N/A”. The October 2024 MAR for resident 6 states that the resident’s blood sugar was 410 at 7:30AM on 10/03/2024 and was “HI” at 4:30PM. Staff person 1 stated that when the resident’s blood sugar was taken at 4:30PM on 10/03/2024, the glucometer displayed the resident’s blood sugar was high and that the resident’s glucometer only reads to 600. The record for resident 6 contains an emergency room discharge summary, dated 10/03/2024, that the resident arrived at the emergency room at 8:24PM on 10/03/2024 due to high blood sugar and was treated with IV regular insulin until her blood glucose was 292 and was discharged back to the facility on 10/04/2024 at 8:45AM.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering. 3. Education with staff about reordering medication timely. 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. 3. Medication pass observation audits to be continued weekly. 1. DORS to oversee 2 separate passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. 3. Medication pass observation audits to be continued weekly. Completion by 1.30.25
22VAC40-73-290-B
Based on observation, the facility failed to implement its procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. At approximately 9:07AM on 10/04/2024, the licensing inspector (LI) observed that there was no posting of who the current on-site person in charge was.
Plan of correction
1. Executive Director to ensure placement of person in charge daily. 1. On-site person in charge to be discussed at daily stand-up meeting. 1. On-site person in charge has been placed in front lobby.
22VAC40-73-930-D
Based on resident record review and staff interview, for each resident with an inability to use the signaling device, in addition to any other services, the facility failed to ensure once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility and the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds and the documentation shall be retained for two years.
Evidence
  1. Resident 1 resides in the facility’s safe, secure unit. The individualized service plan (ISP) for the resident states that the resident is unable to use call bell to alert staff when assistance is needed, and staff will check on and document a minimum of every two hours while the resident is asleep. Interview with staff person 1 revealed the facility’s nighttime hours are 8:00PM to 6:00AM.
  2. The September 2024 MAR for resident 1 does not contain documentation/initials that staff checked on the resident every two hours from 10:00PM on 09/12/2024 to 6:00AM on 09/13/2024, 10:00PM on 09/14/2024 to 6:00AM on 09/15/2024, 10:00PM on 09/15/2024 to 6:00AM on 09/16/2024, 8:00PM on 09/17/2024 to 6:00AM on 09/18/2024, 10:00PM on 09/19/2024 to 6:00AM on 09/20/2024, 10:00PM on 09/23/2024 to 6:00AM on 09/24/2024, 10:00PM on 09/24/2024 to 6:00AM on 09/25/2024, 12:00AM to 6:00AM on 09/27/2024, 10:00PM on 09/28/2024 to 6:00AM on 09/29/2024 and 10:00PM on 09/29/2024 to 6:00AM on 09/30/2024. The October 2024 MAR for resident 1 does not contain documentation/initials that staff checked on the resident every two hours from 10:00PM on 10/01/2024 to 6:00AM on 10/02/2024 and 10:00PM on 10/03/2024 to 6:00AM on 10/04/2024.
Plan of correction
1. Resident rounds checklist to be completed daily for night shift, staff to submit checklist to shift supervisor. 1. DORS to perform audit of residents requiring frequent checks. 1. DORS to review resident rounds checklist each week. Completion by 1.30.2025
22VAC40-73-680-H
Based on resident record review and facility document review, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 09/23/2024, for hydrocodone 5MG – acetaminophen 325MG table take one tablet by mouth three times a day for 10 days.
  2. The controlled drug record for this medication contains documentation that staff person 4 gave this medication to the resident at 2:00PM and 8:00PM on 10/03/2024 and staff person 3 gave this medication to the resident on 10/04/2024 one time; however, staff persons 3 and 4 did not document on the resident’s October 2024 MAR that the resident was administered this medication.
Plan of correction
1. Cart audits to be continued twice weekly by staff. 2. MAR audit to be completed weekly by DORS 3. Education with staff about the importance of documenting medications given on MAR. 1. DORS to review weekly cart audits 1. Staff in-service to be completed by 12/17/24 Completion 12.17.2024
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure the medication administration record (MAR) shall include the date and time given and initials of direct care staff administering the medication.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 08/27/2024, for MPAP Arthritis ER 650MG take one tablet by mouth every 8 hours – 6:00AM, 2:00PM, and 10:00PM. The September 2024 MAR for the resident does not contain documentation/staff initials that staff administered this medication to the resident 24 times during the month and the October 2024 MAR does not contain documentation/staff initials that staff administered this medication to the resident 4 times during the month.
  2. The September 2024 MAR for resident 3 does not contain documentation/staff initials that staff administered the resident’s scheduled 9:00PM medications on 09/12/2024.
  3. The September 2024 MAR for resident 4 does not contain documentation/staff initials that staff administered lorazepam intensol 2MG/ML – give one 0.25ML (=0.5 MG) syringe by mouth under tongue every four hours for anxiety/agitation at 10:00PM on 09/12/2024, 09/14/2024, 09/15/2024, 09/17/2024, 09/19/2024, 09/23/2024, 09/28/2024, and 09/29/2024.
Plan of correction
1. Staff in-service to be completed on proper MAR documentation. 2. MAR audit to be completed weekly by DORS 3. Education with staff about the importance of documenting medications given on MAR. 1. DORS to ensure that weekly cart audits are completed 2. DORS to check dashboard daily to ensure medications have been documented properly 1. DORS to ensure that weekly cart audits are completed. 2. DORS to check dashboard daily to ensure medications have been documented properly.
22VAC40-73-640-A
Based on resident record review, medication cart audit and staff interviews, the facility failed to implement its medication management plan (MMP).
Evidence
  1. The facility’s MMP states the following: Narcotic count: A physical inventory (“Narcotic Inventory Count”) of Schedule II-V controlled substances (or a change of shift audit) occurs, at minimum: At the end of every shift by the nurse, Med Tech or Lead Resident Assistant going off duty and the nurse, Med Tech or Lead Resident Assistant coming on duty; AND whenever there is an exchange in possession of keys to any area where Controlled Substances are stored. The Narcotic Inventory Count includes a physical inventory and reconciliation of the medications against the Declining Inventory Records, and inspection of the packaging to ensure integrity. the process is documented on the Narcotic Inventory Count Verification by both staff members. The narcotic count document for on-coming and off-going medication administration staff located in the facility’s safe, secure unit medication cart did not contain the signature of the on-coming (7:00PM to 7:00AM) and off-going (7:00PM to 7:00AM) medication staff on 10/01/2024. 2. The facility’s medication management plan states the following: Any discrepancy in the Narcotic Inventory Count, or any suspicion that a Controlled Substance has gone missing, is reported to the Director of Nursing immediately. The Director of Nursing makes a reasonable effort to reconcile reported discrepancies. If a discrepancy cannot be reconciled, the Director of Nursing documents the details on the shift change signature sheet and notifies the Executive Director, local Law enforcement, the dispensing pharmacy, and regional staff, as appropriate. In states the require Terminal Distributor Licenses or Controlled Substance Permits, the individual responsible for maintaining the license or permit is also [SIC] be notified. A new dose of the medication is requested for delivery within a 24-hour period. An investigation into the discrepancy is initiated and conducted. During on-site inspection on 10/04/2024, the controlled drug record for resident 4’s as needed morphine contains documentation that the facility received 120 doses of this medication on 09/11/2024. The September 2024 medication administration record (MAR) for resident 4 contains documentation that the resident was administered this medication on 09/21/2024 at 11:39AM and the October 2024 MAR, as of 10/04/2024, does not contain documentation that this medication has been administered to the resident. On 10/04/2024, the controlled drug record contained documentation that there were only 117 doses of the as needed morphine for resident 4 and that the count had been corrected by staff person 2. Additional information received from staff person 1 on 11/27/2024 indicated that this is the only documentation regarding the controlled substance discrepancy and that there was nowhere for staff person 2 to put this information on the shift signature sheet as indicated in the facility’s medication management plan. (continued)
Plan of correction
1. Medication Pass observation audits to be completed weekly and forwarded to Divisional Director of Resident Services for review. 2. Cart to MAR audit to be completed with all new orders. 3. Staff to continue with weekly cart audits. 1. Director of Resident Services to forward medication pass observation to Divisional Director of Resident Services each Wednesday for review. 2. Staff in-service provided. Staff are aware to notify ED or DORS of any medications not available. 1. ED to ensure audits are being completed.
October 1, 2024Complaint survey1 violation
Inspection dates
10/01/2024, 10/04/2024, 10/11/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/01/2024 1:00PM to 1:45PM, 10/04/2024 9:07AM to 1:15PM, and 10/11/2024 10:00AM to 1:45PM 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 09/27/2024 regarding allegations in the areas of: personnel & resident care and related services Number of residents present at the facility at the beginning of the inspection: 57 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review, facility documentation review and staff interview, the facility failed to ensure to implement its medication management plan (MMP).
Evidence
  1. The facility’s medication management plan and medication training information, received from staff person 1 via email on 09/27/2024, indicates on page 10 of the training material that medication staff are to follow the facility’s policy and procedure when a resident refuses medications (policy and procedure ensures that physician is notified in a timely manner based on resident’s physical and mental condition and the medication) and page 27 of the training material indicates that medication refusal needs to be documented on the medication sheets and brought to the attention of the prescribing doctor. The record for resident 1 contains a physician’s order, dated 07/30/2024, for nicotine 14mg/24 hour daily transdermal patch (Nicoderm CQ) 1 patch every day by transdermal route. The August and September 2024 medication administration records (MARs) for the resident contain documentation on multiple days that the resident refused the Nicoderm CQ patch. The October 2024 MAR from 10/01/2024 to 10/04/2024 indicates the resident has refused the Nicoderm CQ patch every day. The July, August, September and October 2024 MARs for the resident indicate that the resident refused albuterol inhaler, physician’s order dated 10/29/2024 indicates the albuterol inhaler was effective 03/01/2024, and fluticasone allergy spray, physician’s order dated 10/29/2024 indicates the fluticasone allergy spray was effective in 2023, numerous days during these months. Staff person 1 was unable to provide documentation of the medication refusals being documented or that the resident’s physician had been made aware of the refusals.
  2. The facility’s medication management plan states the following: “NOTE: At no time is it acceptable to find that a resident has less than 5 doses of medications available to them. Therefore, it is not acceptable to circle and indicate that we are waiting for pharmacy or family to deliver meds. It is the Nurse’s/Medication Assistant Tech’s responsibility to ensure that all orders are consistently filled and available to resident.” and “If the medication(s) have not been supplied by the time the existing supply is depleted to five (5) doses, the Nurse/Medication Assistant Tech will order five (5) doses of the medication(s) from the community pharmacy. This procedure will continue until the medication has arrived.” Resident has an order, dated 08/13/2024, for gabapentin 300MG two times daily. The September and October 2024 MARs for the resident contains documentation that the resident did not receive gabapentin 300MG on 09/23/2024 and 09/26/2024 at 8:00PM due to “new order not in from pharmacy” and did not receive gabapentin 300MG at 8:00AM on 09/25/2024, 09/27/2024, 10/01/2024 and 10/02/2024 and at 8:00PM on 09/24/2024, 09/25/2024, 09/27/2024, 09/30/2024 and 10/02/2024 due to “refill medications”.
Plan of correction
1. Medication Pass observation audits to be completed weekly and forwarded to Divisional Director of Resident Services for review. 2. Cart to MAR audit to be completed with all new orders. 3. Staff to continue with weekly cart audits. 1. Director of Resident Services to forward medication pass observation to Divisional Director of Resident Services each Wednesday for review. 2. Staff in-service provided. Staff are aware to notify ED or DORS of any medications not available. 1. ED to ensure audits are being completed.
September 23, 2024Complaint survey2 violations
Inspection dates
09/23/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 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: 09/23/2024 12:53PM to 3:20PM 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 09/23/2024 regarding allegations in the areas: resident care and related services & buildings and grounds Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the assisted living building. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The licensing inspector (LI) provided a copy of the facility’s consent agreement/compliance plan to the administrator on 09/19/2024 and had a discussion with the administrator regarding the consent agreement/compliance plan on 09/19/2024 and 09/25/2024. The LI was provided a copy of the facility’s new medication management plan on 09/19/2024 and the LI conducted a follow-up via e-mail on 09/25/2024 with the administrator regarding the medication management plan requesting clarification on the plan and the required components of standard 22VAC40-73-640-A. 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: resident care and related services 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 09/10/2024, for amoxicillin 500MG three times a day for seven days for dental infection.
  2. The September 2024 medication administration record (MAR) for resident 1 does not contain documentation that the resident has been administered the aforementioned medication. Interview with staff person 1 on 09/23/2024 confirmed that the resident has not received this medication.
Plan of correction
Corrective Action 1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering. 3. Education with staff about reordering medication timely. Steps taken to identify if this deficiency spans throughout the community and date of completion 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. Measures, Systems or changes put into place to ensure this deficiency will not reoccur 1. The medication technician(s) involved placed on 30-day improvement plan.
22VAC40-73-470-A
Based on resident record review, resident interview and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 09/10/2024, for amoxicillin 500MG three times a day for seven days for dental infection and for there to be a referral made to a dentist for the resident.
  2. Resident 1 revealed to the licensing inspector (LI) and Collateral 1 during an interview on 09/23/2024 that the teeth underneath her crowns are deteriorating and she has been having pain due to this. Resident 1 also stated that she asked and received Tylenol for the pain in her teeth on 09/22/2024 two times. The September 2024 medication administration record (MAR) indicates that the resident has an as needed (PRN) order for Tylenol ex-str 500MG take two tablets (1000MG) by mouth every four hours as needed for pain. The resident was administered this medication on 09/22/2024 at 2:51PM and 9:15PM. Resident 1 stated that she has not been to a dentist.
  3. Interview with staff person 1 revealed that there is no information at the facility that there has been a referral made to a dentist for resident 1.
Plan of correction
Corrective Action 1. Medication training provided by pharmacy to be completed within 21 days. Steps taken to identify if this deficiency spans throughout the community and date of completion 1. 2-step check to ensure medications are ordered and received within 48 hours. Measures, Systems or changes put into place to ensure this deficiency will not reoccur 1. Staff member involved no longer employed with company.
September 19, 2024Inspection2 violations
Inspection dates
09/19/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/19/2024 9:10AM to 12:45PM 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review, medication cart audit and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 2 contains a physician’s order, dated 08/23/2024, for cephalexin 500MG take one tablet four times daily for seven days for a total of 28 tablets. The August 2024 medication administration record (MAR) for resident 2 contains documentation that the resident was only administered 25 tablets of cephalexin 500MG.
  2. The record for resident 2 contains a physician’s order, dated 09/16/2024, for Eliquis starter pack for treatment of DVT and PR 5MG oral tablet – take two tablets (=10MG) twice daily for seven days, then take one tablet (=5MG) twice daily for six months for blood clot in lungs. During on-site inspection, it was observed by the licensing inspector (LI) and staff person 2, two full cards of Eliquis 5MG for resident 2. In addition, the September 2024 MAR for resident 2 does not contain documentation that Eliquis has been administered to the resident. Interview with staff person 2 confirmed that Eliquis has not been administered to the resident.
  3. The record for resident 3 contains a physician’s order, dated 05/15/2024, for latanoprost 0.005% eye drops instill one drop into both eyes at bedtime for glaucoma. The August 2024 MAR for the resident contains documentation that the resident did not receive latanoprost eye drops on 08/23/2024 at 8:00PM due to “new order not in from pharmacy”. The record for resident 3 contains a physician’s order, dated 05/15/2024, for metformin hcl 1,000MG tablet take one tablet by mouth two times a day for diabetes. The September 2024 MAR for the resident contains documentation that the resident did not receive metformin hcl on 08/23/2024 and 08/24/2024 at 8:00PM due to “refill medications”. The record for resident 3 contains a physician’s order, dated 05/15/2024, for colace 100MG take one capsule by mouth two times day for constipation. The August 2024 September 2024 MARs for the resident contains documentation that the resident did not receive colace 100MG on 08/26/2024 at 8:00PM due to “doctor order”, 08/30/2024 at 8:00PM due to “refill medications”, 09/08/2024 at 8:00PM due to “refill medications” and 09/16/2024 due to “other: not available”. The record for resident 3 contains a physician’s order, dated 05/15/2024, for fluticasone 50MCG spray instill one spray into each nostril two times a day for congestion. The August 2024 MAR for the resident contains documentation that the resident did not receive fluticasone 50MCG spray on 08/27/2024 at 8:00PM due to “refill medications”.
Plan of correction
Corrective Action 1. Cart audits to be continued twice weekly by staff. 2. Ensure all refills are ordered and received within 24 hours of ordering. 3. Refill tickler to be made by DORS for checking off incoming medications. 4. Education with staff about reordering medication timely. Steps taken to identify if this deficiency spans throughout the community and date of completion 1. DORS to oversee 2 separate medication passes per week to ensure two-step verifications are being completed during medication pass. (Emars being cross compared to orders on medication) 2. Pharmacy to complete quarterly audits on emars and medications carts. Measures, Systems or changes put into place to ensure this deficiency will not reoccur The medication technician involved placed on 30-day improvement plan.
22VAC40-73-680-K
Based on resident record review, the facility failed to ensure that the use of PRN (as needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed, licensed health care professionals administer PRN medication, or if medication aides administer PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order that shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
Evidence
  1. Resident 1 resides in the facility’s safe, secure unit. Interview with staff person 1 confirmed that the resident is not capable of determining when a PRN medication is needed.
  2. The record for resident 1 contains a physician’s order, dated 09/10/2024, for Tylenol 650MG three times daily as needed for pain.
  3. The order for the as needed Tylenol does not include symptoms that indicate the use of the medication and directions as to what to do if symptoms persist.
Plan of correction
Corrective Action 1. Inservice of proper medication management to be completed. 2. Audit of all orders to ensure all PRN orders are specific with measurable data. 3. PRN Statement will be sent to MD/NP for use on all PRN medications. 4. Express Care will add PRN instructions to all PRN medications. Steps taken to identify if this deficiency spans throughout the community and date of completion Audit of all orders to ensure all as needed medications are specific and require measurable data. Measures, Systems or changes put into place to ensure this deficiency will not reoccur Bi-weekly Audit of all new orders.
July 25, 2024Inspection5 violations
Inspection dates
07/25/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/25/2024 9:30AM until 1:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on an audit of medication carts and resident record review, the facility failed to ensure to implement its medication management plan in regard to methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. The record for resident 2 contains a signed physician’s order, dated 05/15/2024, for latanoprost eye drops instill one drop into both eyes at bedtime for glaucoma, store in refrigerator until opened, stable for 6 weeks at room temperature. Manufacturer’s instructions for latanoprost eye drops state that the eye drops are good for 6 weeks once opened.
  2. During the A-hall medication cart audit, it was noted by the licensing inspector (LI) and staff person 2 that the opened latanoprost eye drops in the cart for resident 2 did not contain a date of when the eye drops had been opened by staff.
  3. The facility’s medication management plan states that its methods to prevent the use of outdated, damaged or contaminated medications is that medications that have been discontinued or found to be contaminated, damaged, and/or outdated should be disposed of properly. Interview with staff person 1 indicated that staff are to date medications that have an expiration date once they are opened, such as eye drops and insulin pens, with the date they are opened to ensure residents do not receive expired medications.
Plan of correction
• Open date for eye drops for resident #2 was clarified and corrected on 7/25/24. • Mandatory all staff meeting conducted on 8/12-8/13/24. Inclusive of all RMAs in attendance to review medication management violations during 7/25/24 site monitoring visit. • 4-hour virtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. • Comprehensive audit of all medication carts completed by nurse designee on 7/25- 7/26/24. All pharmaceuticals in need of open dates were noted to be in compliance. Weekly cart audits will continue by nurse designee and all results forwarded and reviewed by administrator of record.
22VAC40-73-660-A-3
Based on observation and staff interview, the facility failed to ensure when a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility, the individual responsible for medication administration shall keep the keys to the storage area on his person.
Evidence
  1. At approximately 10:15AM, it was noted by the licensing inspector (LI) and staff person 1 that the B hall medication cart had the keys to the cart in the lock of the medication cart. Staff person 1 found staff person 4, who was the assigned registered medication aide (RMA) for the cart, in a resident’s room providing care.
Plan of correction
• Employment with Carriage Hill Retirement for staff #4 was terminated on 7/25/24. • Mandatory staff meeting for all RMAs conducted on 8/12-8/13/24. Violation Notice from 7/25/24 site visit was reviewed. Agenda also included review of compliance plan dated 10/10/23 that outlines consequences with deficient practices with medication management standards. • 4-hourvirtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. • Ongoing weekly cart audits continue by nurse designee and results forwarded to administrator of record for review. All staff trained to notify a supervisor if any medication carts noted to be unlocked.
22VAC40-73-660-B
Based on observation during a tour of the building, resident interview and medication cart audit, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI (uniform assessment instrument) has indicated that the resident is capable of self-administering medication.
Evidence
  1. The UAI for resident 1, dated 06/04/2024, indicates that the resident requires their medication to be administered/monitored by lay person – registered medication aide (RMA) or licensed practical nurse (LPN). In addition, the resident’s report of physical examination, dated 05/24/2024, indicates that the resident is not capable of self-administering their medication.
  2. The licensing inspector (LI) and staff person 1 noted that resident 1 had a container of one-a-day multi vitamins in his room located on a table. Staff person 1 interviewed resident 1 about the vitamins and the resident stated that the vitamins are his and he takes one tablet daily. The record for resident 1 does not contain a physician’s order that the resident can self-administer the aforementioned medication.
Plan of correction
• Container of one-a- day multivitamin removed from resident's room on 7/25/24. Staff explained rationale to resident #1 and he voiced understanding of regulation. Physician notified and clarification order received for staff administration and storage of all medications including over the counters. • Mandatory all staff meeting conducted on 8/12-8/13/24. Agenda included review of violation notice from 7/25/24 inspection. • 4-hour virtual training conducted on 8/8/24 by contracted pharmacy nurse. Attached signature sheet for RMAs in attendance. Agenda inclusive of medication management standards. • Environmental Rounds inclusive of room inspections for medications continue no less than weekly. Findings reported to administrator and/or designee.
22VAC40-73-680-B
Based on observation during a tour of the building, resident record review, resident interview, and staff interview, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. At approximately 10:01AM, resident 1 was present in his room and upon the licensing inspector (LI) entering the resident’s room, the LI observed a small, clear plastic cup of medications sitting on the bedside table in resident 1’s room. Resident 1 informed the LI that the medications were his morning medications and that a staff person had left the medications for him to take that morning in the small, clear plastic cup. The medications were also observed and noted by staff persons 1, 2 and 3.
  2. Staff person 1 completed an audit of the medications in the small, clear plastic cup and noted that the pills in the cup were the resident’s prescribed 8:00AM medications: atorvastatin 10MG, citalopram HBR 40MG, donepezil HCL 10MG, losartan potassium 50MG, and omeprazole DR 40MG. Staff person 1 stated that staff person 4 was the registered medication aide (RMA) who took the resident’s medications to his room and did not ensure that the resident had taken his medications.
  3. The uniform assessment instrument (UAI) for resident 1, dated 06/04/2024, indicates that the resident requires their medication to be administered/monitored by lay person – registered medication aide (RMA) or licensed practical nurse (LPN). In addition, the resident’s individualized service plan (ISP) for resident 1 indicates that the resident’s medications are administered by a lay person: registered medication aide (RMA) and an RMA or nurse will administer the resident’s medications per physician orders to the resident and will ensure all medications were taken and swallowed before exiting the room.
Plan of correction
• Employment with Carriage Hill Retirement for staff #4 was terminated on 7/25/24. • Mandatory staff meeting for all RMAs conducted on 8/12-8/13/24. Violation Notice from 7/25/24 site visit was reviewed. Agenda also included review of compliance plan dated 10/10/23 that outlines consequences with deficient practices with medication management standards. • 4-hour virtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. • Mandatory all staff meeting on 8/13/24. Agenda inclusive of violation related to medications sitting unattended at resident's bedside. All departments aware to remove any unattended medications in resident's room; deliver to nurse supervisor on duty and report to administrator in real time.
22VAC40-73-660-A-1
Based on observation and staff interview, the facility failed to ensure a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility shall be locked.
Evidence
  1. At approximately 10:15AM, it was noted by the licensing inspector (LI) and staff person 1 that the B hall medication cart was unlocked. Staff person 1 found staff person 4, who was the assigned registered medication aide (RMA) for the cart, in a resident’s room providing care.
Plan of correction
• Employment with Carriage Hill Retirement for staff #4 was terminated on 7/25/24. • Mandatory staff meeting for all RMAs conducted on 8/12-8/13/24. Violation Notice from 7/25/24 site visit was reviewed. Agenda also included review of compliance plan dated 10/10/23 that outlines consequences with deficient practices with medication management standards. • 4-hourvirtual training conducted on 8/8/24 by contracted pharmacy nurse. Agenda inclusive of medication management standards. Attached signature sheet for RMAs in attendance. • Ongoing weekly cart audits continue by nurse designee and results forwarded to administrator of record for review. All staff trained to notify a supervisor if any medication carts noted to be unlocked.
July 11, 2024Complaint survey1 violation
Inspection dates
07/11/2024, 07/24/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/11/2024 11:00AM until 2:00PM and 07/24/2024 3:00PM until 4:00PM 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 07/09/2024 regarding allegations in the areas of: personnel and resident care & related services Number of residents present at the facility at the beginning of the inspection: 60 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-130-A
Based on documentation review, resident record review and staff interview, all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. The licensing inspector (LI) received a complaint on 07/09/2024 reporting a concern of physical abuse against resident 1. The complaint stated that during the first week of June, resident 1 had an incident during a shower, the resident gets a shower every Tuesday, and got a black eye. The complaint stated that resident 1 stated staff person 1 gave her a shower and that staff person 1 hit her in the eye and staff person 1 was then moved to another department; however, on 07/09/2024, staff person 1 was giving the resident a shower again.
  2. During on-site inspection on 07/11/2024, staff person 2 provided the LI and Collateral 1 a letter, dated 07/09/2024, that states staff person 2 spoke with staff person 1 on 06/11/2024 during the morning about the alleged incident with the resident. Staff person 2 informed staff person 1 at that time Collateral 2 had voiced some concerns and there was an open investigation about a bruise on resident 1’s face from a shower involving staff person 1. Staff person 2 asked staff person 1 not to care for the resident until the investigation was over. On 07/09/2024, Collateral 2 came to the facility and was upset that staff person 1 had given resident 1 a shower on this day. Staff person 2 spoke with staff person 1 and staff person 1 stated that she had been told the investigation was over and she was training a new employee and thought she was able to go into resident 1’s room again. Staff person 2 informed staff person 1 that at this time Collateral 2 does not want her to care for the resident and staff person 1 voiced understanding. Staff person 1 also signed a statement along with staff persons 2 and 3, dated 07/09/2024, that she will not provide care to resident 1 per Collateral 2’s request.
  3. The facility’s communication log, dated 06/17/1024, contains a written statement by staff person 3 that states the resident’s power of attorney came in to see the resident and seen “bruise on eye” and a staff progress note by staff person 3, dated 06/17/2024 at 10:08AM, that the resident’s daughter came in to see staff person 3 on 06/17/2024 and stated to staff person 3 that resident 1 had a bruise on her left eye. Staff person 3 stated that it was not reported to them from resident 1 nor staff person 4 who was also present for the conversation with staff person 3 and the resident’s daughter. Staff person 3 stated that the resident’s daughter was told that the facility will look into the matter by staff person 4.
  4. During an interview with staff persons 2 and 4 on 07/11/2024, it was revealed to the LI and Collateral 1 that the aforementioned allegations of suspected abuse had not been reported by the facility to their local Adult Protective Services Agency as required by § 63.2-1606 of the Code of Virginia.
Plan of correction
This occurred with the community’s past management. We will implement to following interaction: Inservice of Abuse Policy with mangers and staff Inservice of Injury of unknown origin Mandating Reporting will be covered in monthly staff meetings Note. These are the new Policies and Procedures from the new management group that started at the community August 15th, 2024.
July 11, 2024Complaint survey1 violation
Inspection dates
07/11/2024, 07/25/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/11/2024 10:00AM until 11:00AM and 07/25/2024 9:30AM until 1:30PM 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 07/10/2024 regarding allegations in the area of: resident care and related services Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-300-B
Based on staff interview and observation, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. The record for resident 1 contained a note that was entered on 07/10/2024 at 4:12PM by staff person 1 that indicated resident 1 had a fall during the evening on 07/09/2024 with no complaints; however, on 07/10/2024 the resident was complaining of pain in the right hip and that staff person 1 contacted a physician in order to see if the facility should send the resident out or not to be examined. The physician responded back for the resident to not be sent out and that a mobile x-ray would be coming to the facility to exam the resident.
  2. The record for resident 1 contained a note that was entered on 07/10/2024 at 4:21PM by staff person 1 that indicated the note was a late entry for 07/09/2024 1:00PM that resident 1 was found on the floor in another resident’s room and that another resident had pushed resident 1.
  3. Interview with staff person 3 on 07/11/2024 indicated that on 07/09/2024 resident 1 was pushed by resident 2 to the floor after lunch in the common area. The licensing inspector (LI) requested to see the facility’s method of written communication that is used to keep all direct care staff on all shifts informed about complaints and incidents and staff person 3 showed the LI a binder that is kept in the facility’s locked medication cart. The binder contained documents titled “Charting Schedule” that included five entries about four residents that had had falls and one resident on a leave of absence at the hospital; however, the document did not include documentation about resident 1 and resident 2’s incident that occurred on 07/09/2024.
Plan of correction
• Mandatory all staff meeting conducted on 8/12-8/13/24. Agenda included review of violation notice from 7/11 and 7/25/24 complaint inspection. • Staff communication book in memory care unit relocated from locked medication cart to centralized nurses station. • All nursing staff trained on significance of entries in communication book to include all changes in condition, variances in typical routine and grievances. Staff to reference communication book during shift change. • Administrator or designee to reference communication book no less than weekly to ensure all areas of concern have been managed from date of onset to resolution of situation.
June 11, 2024Complaint survey0 violations
Inspection dates
06/11/2024, 06/25/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 8:30AM until 12:30PM and 06/25/2024 9:50AM until 11:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/08/2024 regarding allegations in the area of: resident care and related services 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 11, 2024Complaint survey0 violations
Inspection dates
06/11/2024, 06/25/2024
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: 06/11/2024 12:00PM until 12:30PM and 06/25/2024 9:50AM until 11:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/07/2024 regarding allegations in the area of: additional requirements for facilities that care for adults with serious cognitive impairments An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2024Inspection3 violations
Inspection dates
05/22/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 05/22/2024 8:00AM until 2:00PM 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: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audits, noon-time medication pass, breakfast and lunch meals 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The criminal history record report for staff person 1, date of hire 06/22/2023, was not obtained until 05/22/2024.
  2. The criminal history record report for staff person 3, date of hire 09/14/2023, was not available during on-site inspection. Interview with staff person 2 confirmed that this was accurate.
Plan of correction
The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 5/22/2024. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvements to satisfy that objective. 22VAC40-90-40-B Criminal History Record Report • The Executive Director or designee will provide education for the Business Office Manager on Criminal History Records and Virginia regulations to be completed by 5/31/24. • The Business Office Manager or Designee will audit all current staff records for Criminal History Records to be completed by 5/31/24. • To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records once a month for three months 06/2024, 07/2024 and 08/2024. • Regional designee will conduct random audits of criminal history records (barrier crimes) for all new hires for the next three months. (6/2024, 7/2024, 8/2024)
22VAC40-90-40-D
Based on staff record review and document review, the facility failed to ensure that an employee has not been convicted of any of the barrier crimes when a criminal history record was requested.
Evidence
  1. The document “Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs”, dated October 2023, states that a licensed assisted living facility may hire an applicant convicted of one misdemeanor barrier crime not involving abuse or neglect, or any substantially similar offense under the laws of another jurisdiction, if five years have elapsed following the conviction.
  2. The record for staff person 4, date of hire 08/22/2023, contained a Virginia criminal record, dated 08/22/2023, that staff person 4 was found guilty of a misdemeanor 01/08/2021. The misdemeanor is listed as a barrier crime on the document “Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs” and five years have not elapsed following the conviction.
Plan of correction
The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 5/22/2024. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-680-K Criminal History Record Report • The Executive Director or designee will provide education for Business Office Manager on Criminal History Records and Barrier Crimes for Virginia regulations to be completed by 5/31/24. • The Business Office Manager or Designee will audit all current staff records for Criminal History Records and review all for barrier crimes to be completed by 5/31/24. • To assist with ongoing compliance, the Business Office Manager or Designee will audit all new staff records for Criminal History Records and review for any barrier crimes once a month for three months 06/2024, 07/2024 and 08/2024. • Regional designee will conduct random audits of criminal history records (barrier crimes) for all new hires for the next three months. (6/2024, 7/2024, 8/2024)
22VAC40-73-680-K
Based on resident record review, the facility failed to ensure the use of PRN medications is prohibited, unless the resident is capable of determining when the medication is needed, licensed health care professionals administer the PRN medications; or medication aides administer the PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order and the order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
Evidence
  1. The record for resident 2 contains an assessment of serious cognitive impairment, dated 04/26/2024, that states the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. The resident resides in the facility’s safe, secure unit.
  2. The record for the resident contains a physician’s order for lorazepam (Ativan) take 0.5ML liquid by mouth under tongue every four hours as needed for anxiety and terminal agitation.
  3. The May 2024 medication administration record (MAR) for resident 2 indicates that the aforementioned PRN medication was administered to the resident by a registered medication aide (RMA) on 05/07/2024 at 10:43PM; however, the physician’s order does not include symptoms that indicate the use of the medication. This was also noted by staff person 6.
Plan of correction
The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 5/22/2024. This Plan of Correction is not constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regular requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvements to satisfy that objective. 22VAC40-73-680-K Administration of medications and related provisions. • The Director of Nursing corrected immediately for resident #2 while the inspector was on site. Completed 5/22/2024. • The Director or Designee has audited all PRN orders. Corrections to be made to them if a resident is unable to voice why they need a prn to include symptoms for reason the PRN is needed. To ensure RMA can give the PRN by the symptoms listed on each order. Completed on 5/24/2024. • To assist with ongoing compliance, the Director of Nursing or Designee will review all new admit orders upon admission and with any new orders. To ensure the PRNs are written so an RMA can administer PRN’s if a resident cannot verbalize the need for one. • Regional Designee will conduct random audits of all new prn medication orders no less than monthly to monitor for ongoing substantial compliance.
May 22, 2024Inspection0 violations
Inspection dates
05/22/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 8:00AM until 2:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2024Complaint survey0 violations
Inspection dates
05/22/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 8:00AM until 2:00PM 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 05/06/2024 regarding allegations in the area(s) of: resident care and related services 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2024Complaint survey0 violations
Inspection dates
05/22/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 8:00AM until 2:00PM 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 05/06/2024 regarding allegations in the area(s) of: resident care and related services 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 19, 2024Complaint survey1 violation
Inspection dates
04/19/2024, 04/22/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 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: 04/19/2024 8:35AM until 10:30AM and 04/22/2024 2:45PM until 4:05PM 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 04/17/2024 regarding allegations in the area of: buildings and grounds 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-930-A
Based on observation, the facility failed to ensure to have a signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance.
Evidence
  1. During on-site inspection on 04/19/2024, it was noted by the licensing inspector (LI) and staff person 1 that resident 1’s bedroom did not contain a functioning signaling device that would allow the resident to pull a cord or push a button if the resident needed assistance. The white push button located on the Aiphone wall panel next to the resident’s bed did not send out an audible alert when the button was pushed, the hallway light above the resident’s door did not light up, and there was no indicator light on the Aiphone system box at the nurses’ station to indicate that the signaling device had been activated in the resident’s bedroom. In addition, when the black signaling device button was pushed in the resident’s bathroom located beside the resident’s toilet, there was no audible sound, the hallway light above the resident’s door did not light up, and there was no indicator light on the Aiphone system box at the nurses’ station that the signaling device had been activated in the resident’s bathroom. This was also noted by staff person 1.
Plan of correction
Resident is in memory care and does not have the cognition to use the call light. As guide lined in 930 section D, it is care planned that rounds are done every 2 hours due to the residents' inability to activate call light system. Wellness checks are documented on EMAR system and retained as part of the resident's permanent record. Resident was immediately relocated to room E15, which has a fully functional call light system. Room E20 will remain unoccupied until call system in bedroom and bathroom are completely functional. Safety checks of call lights in MC will be completed no less than monthly by Administrator or Designee. Results will be logged on Emergency System audit tool. Attached is the form for Audit.
March 12, 2024Inspection0 violations
Inspection dates
03/12/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/12/2024 8:45AM until 11:20AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 9, 2024Inspection0 violations
Inspection dates
02/09/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/09/2024 8:30AM until 10:15AM 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 02/05/2024 regarding allegations in the area of: resident care and related services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 9, 2024Complaint survey0 violations
Inspection dates
02/09/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/09/2024 8:30AM until 10:15AM 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 02/05/2024 regarding allegations in the areas of: personnel and resident care and related services. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 29, 2024Complaint survey1 violation
Inspection dates
01/29/2024, 02/09/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/29/2024 11:00AM until 1:00PM and 02/09/2024 8:30AM until 10:15AM and 12:00PM until 12:10PM 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 12/22/2023 regarding allegations in the area of: resident care and related services 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on collateral documentation, resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a facility staff note, dated 08/30/2023 at 3:58PM, that indicates the resident was admitted to the facility on this date.
  2. The record for the resident contains a physician’s order, dated 08/29/2023, for Hydrochlorothiazide 25MG oral tablet give one tablet by mouth one time a day for HTN.
  3. The August, September, and October 2023 medication administration records (MARs) from 08/31/2023 through 10/25/2023 indicate that the resident was administered one Hydrochlorothiazide 25MG tablet daily at 9:00AM for a total of 56 tablets; however, documentation from Collateral 1 indicates that 24 tablets of Hydrochlorothiazide 25MG was delivered to the facility on 08/29/2023 and 30 tablets of Hydrochlorothiazide 25MG was delivered to the facility on 09/23/2023 for a total of 54 tablets therefore the resident would have been administered only 54 tablets from 08/31/2023 through 10/25/2023. The medication was not delivered to the facility again until 10/26/2023 in which 28 tablets were signed for by staff person 1 at 2:31AM on 10/26/2023.
  4. Documentation from Collateral 2’s representative, dated 08/30/2023 at 1:52PM, states that the resident was discharged from Collateral 2 on this date and the only medication that the resident left Collateral 2 with were two Klonopin.
Plan of correction
The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 01/29/2024 and 02/09/2024 received on 02/23/2024. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-680-D . Administration of medications and related provisions • As indicated by the MAR , the medication was signed off as given on 10/24 and 10/25. Blood Pressures were obtained daily. There were no fluctuation of blood pressure reading to indicate that the Hydrochlorothiazide was not given. Attachment # 1 is a letter from resident’s Physician Assistant at facility. She is the Chief Operating Officer at Premier Geriatric Solutions PLLC. Moving forward all medications that are either brought into the building on admission or sent with resident/POA on discharge will be logged and filed in resident’s record. See attachment #2. • All RMA’s,LPN’s will be in serviced regarding the completion of medication inventory sheet by 03/31/2024.
January 29, 2024Complaint survey1 violation
Inspection dates
01/29/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/29/2024 12:06PM until 12:45PM 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 01/05/2024 regarding allegations in the area of: resident care and related services 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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident 1 contained facility staff notes, dated 12/04/2023 at 12:02AM, that the resident was sent to the emergency room due to a fall in the main lobby in which she hit her face on a glass top table and a cut on her nose was noted.
  2. Hospital discharge documentation, dated 12/04/2023 at 4:21AM, indicated that the resident was diagnosed with a nasal bone fracture, injury of tendon of biceps and laceration of nose and that the laceration on the resident’s face was closed with skin glue.
  3. As of on-site inspection on 01/29/2024, the aforementioned incident involving resident 1 had not been reported to the regional licensing office. Staff persons 1 and 2 confirmed that this is accurate.
Plan of correction
The following is the Plan of Correction for Carriage Hill Retirement regarding the Statement of Deficiencies date 01/29/2024 but received 02/09/2024. This Plan of Correction is not be constructed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, ii is submitted as confirmation of our ongoing efforts to comply with statutory and regularly requirements. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-70. Incident reports. All reportable incidents will be reported directly to the Director of Nursing or Designee. Nursing Director of Designee will notify Administrator and Regional Designees Director of Nursing or Designee will complete and submit reportable events within 24 hours of any major incident per regulation. Administrator and Regional Designees will be CC'd on all reportable events email.
January 29, 2024Complaint survey0 violations
Inspection dates
01/29/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/29/2024 10:15AM until 2:45PM 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 01/17/2024 regarding allegations in the area of: resident care and related services 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 29, 2023Inspection0 violations
Inspection dates
11/29/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 11/29/2023 8:15AM until 1:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 29, 2023Complaint survey0 violations
Inspection dates
11/29/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/29/2023 8:15AM until 1:00PM 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 11/28/2023 regarding allegations in the areas of: resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 9, 2023Inspection1 violation
Inspection dates
08/09/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 08/09/2023 8:45AM until 1:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a physician’s order, dated 07/06/2023, for Humalog insulin inject four units three times daily and the medication is to be held if the resident’s blood sugar is less than 150.
  2. The 07/21/2023 through 08/09/2023 medication administration record (MAR) for resident 1 indicates that the resident was administered Humalog insulin at 12:00PM and 8:00PM on 07/23/2023; however, there is no documentation of what the resident’s blood sugar was during these times. In addition, the resident’s blood sugar was documented as 143 at 12:00PM on 07/30/2023 and documented as 6 at 8:00PM on 08/08/2023; however, the MAR indicates that Humalog insulin was administered to the resident.
  3. This standard was previously cited on 07/15/2022, 10/20/2022 and 03/08/2023.
Plan of correction
Plan of Correction from Inspection August 9, 2023 - 22VAC40-73-680-D 1. Resident 1 file and med list was reviewed the day of inspection by DON/Administrator. 2. DON/Administrator completed training with all staff that administer medications regarding the violation notice, the reason for the violation, and notifying the DON for correction immediately when documentation errors occur. 3. All Staff that administer medications will complete 2 hours of training on Avoiding Common Medication Errors and Documenting Medications. 4. DON will review Medication Records for all insulin dependent diabetics monthly and will review results with Administrator and Regional Designee. 5. Completion Date- 10/20/2023
August 9, 2023Complaint survey0 violations
Inspection dates
08/09/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 08/09/2023 8:45AM until 1:15PM 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 07/18/2023 regarding allegations in the areas of: personnel, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 16, 2023Inspection5 violations
Inspection dates
05/16/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – 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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/16/2023 8:45AM until 3:00PM 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: 63 The licensing inspectors completed a tour of the physical plant that included the buildings and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audits, medication passes, noon-time meal, activities. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1140-B
Based on staff record review, the facility failed to ensure that within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment.
Evidence
  1. The record for staff 1, date of hire 11/01/2022, has documentation that the employee only received 8.75 hours of training in cognitive impairments within four months of the starting date of employment.
  2. The record for staff 3, date of hire 11/26/2022, has documentation that the employee only received 5 hours of training in cognitive impairments within four months of the starting date of employment.
Plan of correction
1. All staff will have the required training due by 06/30/2023. 2. Will ensure we are able to obtain required training from Relias for all employees once hired and afterwards. 3. An Inservice book for all staff is in place and Relias to ensure compliance with regulations. All new hires will receive the additional 10 hours upon hire. 4. BOM/ED will audit all new Employee File Audits within 45 days of hire to ensure compliance. 5. Completion Date 06/30/2023
22VAC40-73-700-2
Based on observation during a tour of the building, the facility failed to post a “No Smoking-Oxygen in Use” sign in any room of a building where oxygen is in use.
Evidence
  1. The record for resident 3 contained a physician’s order, dated 01/12/2023, for the resident to have as needed (PRN) oxygen. At approximately 1:31PM during on-site inspection, one licensing inspector (LI) noted that resident 3’s room contained an oxygen concentrator with tubing; however, there was not a “No Smoking-Oxygen in Use” sign posted in or around the resident’s room.
Plan of correction
• 22VAC40-73-700-2 • 1. Sign was placed on day of Inspection on 05/16/2023 • 2. DON notify all home health and Hospice of the need to place sign with any oxygen being ordered for residents. • 3. DON/ED will check monthly to ensure correct signs for oxygen are in place. • 4. Completion Date- 06/30/2023
22VAC40-73-950-E
Based on document review and staff interview, the facility failed to ensure there was a semi-annual review on its emergency preparedness and response plan for all residents.
Evidence
  1. The record for resident 10 contained documentation that the resident has not had a review on the facility’s emergency preparedness and response plan since 08/11/2022.
  2. The record for resident 11 contained documentation that the resident has not had a review on the facility’s emergency preparedness and response plan since 07/31/2022.
  3. The record for resident 12 contained documentation that the resident has not had a review on the facility’s emergency preparedness and response plan since 06/26/2022.
Plan of correction
• 1. All residents /Families will have facility emergency preparedness response plan reviewed to ensure compliance moving forward it will be due for all residents in June and December it will be sent via email and in the mail. • 2.All residents and families will receive an updated facility emergency preparedness response via email and mail by June 30, 2023 • 3.Completion Date- 06/30/2023
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required.
Evidence
  1. The UAI for resident 7, dated 12/18/2022, is marked that the resident is abusive/aggressive/disruptive less than weekly; however, the area for the resident’s type of inappropriate behavior is blank.
Plan of correction
1. 1. The UAI was corrected the day of inspection on 05/16/2023. 2. 2. All UAI’s will continue to be reviewed by the ISP/UAI Coordinator as well as DON and ED after completion. 3. 3. UAI/ISP Coordinator to conduct 3 audits monthly of ISPs for correction. 4. 4. Completion Date- 06/30/2023
22VAC40-73-870-E
Based on observations of the facility physical plant, the facility failed to ensure that all furnishings were maintained in good repair.
Evidence
  1. The footboard to the bed in room 8 was noted to be loose on the day of inspection and a crack was observed in the wood of the bed frame near the screws.
Plan of correction
1. The bed was replaced on the day of inspection. 2. All beds will be visualized and inspected to comply by housekeeping and maintenance by 06/30/2023. 3. Completion Date – 06/30/2023
May 16, 2023Complaint survey1 violation
Inspection dates
05/16/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/16/2023 8:45AM until 3:00PM 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 03/20/2023 regarding allegations in the areas of: personnel, resident care and related services and buildings and grounds. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. A bottle of Prime Source Germicidal Ultra Bleach was noted sitting out on a bottom shelf at the nursing station in the facility safe, secure unit. The door to the nursing station was noted to have a sliding latch on the door but was not able to be locked.
  2. This standard was previously cited on 10/20/2022, 12/08/2022, 01/17/2023 and 03/08/2023.
Plan of correction
• 1. Item was removed by staff on-site with inspector on 05/16/2023. • 2. The nurses area shelfing in the safe and secure area has now been covered by maintenance and a new locking mechanism will be placed to assist in keeping this area safe. • 3. All managers will continue to complete 3- 5 times a weekly room rounds to ensure that all rooms are in standard. All residents that have continued to have non-compliance issues will be issued a 30-day notice as well as it was discussed again during resident council meeting. We have 2 residents that continue to have 30-day notices after 6 months of the first issued notice due to non-compliance with no assistance in finding new placement for the residents. • 4.Completion Date -06/30/2023 and when assistance is received for placement for residents that continue having non-compliance issues. We continue to ask for assistance from all our local DSS and other agencies to ensure correct placement can happen.
May 16, 2023Complaint survey0 violations
Inspection dates
05/16/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/16/2023 8:45AM until 3:00PM 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 05/15/2023 regarding allegations in the areas of: personnel, staffing & supervision, and resident care & related services. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 8, 2023Inspection14 violations
Inspection dates
03/08/2023, 03/14/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 03/08/2023 8:30AM through 6:30PM in conjunction with two other licensing inspectors and on 03/14/2023 10:15AM through 2:30PM under the supervision of the Licensing Administrator. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process of correcting previously cited violations in the areas of standards referenced above. This inspection found the provider to demonstrate noncompliance with standards not identified in the plan of correction. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-120-A
Based on staff record review, staff interview and document review, the facility failed to ensure that orientation and training for new employees occurred within the first seven working days of employment.
Evidence
  1. The record for staff 11 did not contain documentation that the staff person has received orientation and training that is required within the first seven working days of employment. Interview with staff 1 expressed that this staff person’s date of hire was 02/21/2023.
  2. The record for staff 6 did not contain documentation that the staff person has received orientation and training that is required within the first seven working days of employment. A list of current staff provided by staff 14 during on-site inspection on 03/08/2023 indicated that staff 6’s date of hire was 12/16/2022.
Plan of correction
1. Information requested during exit interview and submitted per request after exiting due to not having the opportunity to produce information during the inspection from lack of request from inspectors on site. 2. Inspectors on site was aware that BOM had quit without notice and that ED was actively working that position and ample time to supply needed information was not given. 3. BOM hired and will start on 03/21/2023. 4. BOM and ED will continue prior POC audits as scheduled from prior POC that has not been followed up on from submission or “monitoring visits.” 5. Completion Date- 04/30/2023
22VAC40-73-250-D
Based on staff record review and document review, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE:
  2. The record for staff 5, date of hire 01/23/2023, contained a TB risk assessment that was dated 01/23/2023; however, the form itself was incomplete.
  3. The record for staff 9, date of hire 02/03/2023, contained a TB risk assessment that was completed; however, there was no date of completion.
  4. During on-site inspection on 03/08/2023, the record for staff 10, did not contain the results of a TB risk assessment.
Plan of correction
1. Staff file 5,9 corrected with MD visit. Staff information 10 once again submitted after reviewing due to not having ample time or request during initial inspection per inspector’s request. 2. Inspectors on site was aware that BOM had quit without notice and that ED was actively working that position as well and ample time to supply any additional information was not provided or asked for during inspection. 3. BOM and ED will continue prior POC audits as scheduled from prior POC that has not been followed up on from submission or on any “monitoring visits”. 4. Completion Date-04/30/2023
22VAC40-73-660-A-3
Based on observations of the facility medication carts, the facility failed to ensure that individuals responsible for medication administration keep the keys to medication carts/storage areas on their person.
Evidence
  1. At approximately 8:34AM on day of inspection, two licensing inspectors (LIs) and staff 1 observed a set of keys on a green key ring that was labeled “C” lying out on top of the D-Hall medication cart, which was unattended at the time of this observation. Staff 1 removed the keys from the top of the medication cart.
  2. Interview with staff 2 at 8:50AM on the day of inspection revealed that the keys belonged to the registered medication aide (RMA) administering medications to residents on the C-Hall and D-Hall. Staff 2 expressed that the keys lying on top of the D-Hall medication cart were keys to the C-Hall medication cart and that the keys were returned to her.
Plan of correction
1. ED corrected on site and placed keys in possession and returned to staff 2. 2. Wellness Director placed keys for carts C&D on lanyard to help assist staff to follow medication policy. As well as had a 1:1 coaching moment with a new employee that was working the area on her own after orientation. 3. Wellness Director and ED will continue spot checks and medication observation passes as stated and not viewed during “monitoring’ inspection. 4. This is in place and will continue. Completion Date- 04/30/2023
22VAC40-73-680-K
Based on observations of the facility medication carts and resident medication administration records (MARs), the facility failed to ensure that the use of PRN (as-needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed; licensed health care professionals administer PRN medication; or if medication aides administer PRN medication, the resident’s physician or other prescriber’s order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
Evidence
  1. The A-Hall medication cart contained the prescribed medication Narcan for resident 7. The record for resident 7 has a physician’s order for Narcan 4mg nasal spray, administer 1 spray in either nostril for suspected opioid overdose. May repeat every 3 minutes as needed, alternating nostrils for each spray, call 911 immediately. The order does not include symptoms that indicate the use of the medication which would be required as the facility employs RMA’s who administer PRN medications.
Plan of correction
1. MD notified on day of inspection and order was discontinued before exit interview was complete. 2. As stated in prior POC Wellness Nurse will continue Chart/MAR/Cart audits that continue to be conducted per prior POC. 3. Effective- Has been in place but not followed up on.
22VAC40-73-680-D
Based on observations of the facility medication carts, observation of the morning medication pass, review of resident medication administration records (MARs) and resident interview, the facility failed to ensure that medications were administered in accordance with physicians’ instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The February and March 2023 MAR for resident 1 has a physician order for Basaglar Insulin, 40units SQ twice a day. Hold for FBS (fasting blood sugar) less than 150. The MAR has documentation of the residents 8AM fasting blood sugar being 149 on 02/04/2023 and 115 at 8AM on 03/08/2023, which require the medication to be held per physician orders. Staff initials are present as administering the medication for both days.
  2. The uniform assessment instrument (UAI), dated 09/22/2022, for resident 3 has documentation that the facility administers this resident’s medications. The individualized service plan (ISP), dated 09/22/2022, has documentation under medication administration that “A Registered Medication Aide/Nurse will administer medications per MD orders to resident. RMA/Nurse will ensure all meds were taken and swallowed before exiting room. Resident will receive all medications in a timely manner to include correct medications, dose, route, time as ordered by MD. Follow MD orders and crush applicable medications and mix with food substance (yogurt, applesauce, pudding) as needed. Resident is known to hoard medications”. During the morning medication pass observations conducted on the day of inspection it was observed by the LI and staff 3 that resident 3’s prescribed medications Advair Discus, Spiriva and Symbcort Inhalers were not on the A-Hall medication cart but the medication box with the pharmacy label was. Interview with resident 3 expressed that staff give him his inhalers and he keeps them in his room and uses them himself. The current medication aide curriculum revised by the Virginia Board of Nursing in 2022 has documentation on page 38 “Stay with client until mediations have been consumed”.
  3. The February and March 2023 MAR for resident 7 has staff initials who are RMA’s for administering the prescribed medication Trulicity 0.75mg/0.5ml Pen, inject sq 0.5ml=0.75mg once weekly on Fridays for DM. The current medication aide curriculum revised by the Virginia Board of Nursing in 2022 has documentation on page 53 that “Non-Insulin Injections a. medication aides may not administer pursuant to 18VAC90-60-110(B)(5)”.
  4. This standard was previously cited on 07/15/2022 and 10/20/2022.
Plan of correction
1. MD notified after exit as inspector was at bedside with staff number 2 when insulin was given and per notice it was at “8am”. Inspector never reported the medication error that was conducted with inspector beside staff member until exit. Staff number 2 was completely nervous due to the intimidation that occurs once the inspectors enter and continue to make staff feel intimidated. Resident had no issues with error. 2. Resident #3 is on notice as our inspectors have been made aware due to non-compliance and along with the inspectors, we have had no assistance in 4 months to attempt to find adequate placement. 3. Medication error report completed and 1:1 counseling with new employee conducted after exit when Wellness Nurse and ED was made aware of 8 am medication error by inspector. 4. All Trulicity orders will now be administered by nursing staff on Fridays. My suggestion would be to ensure all facilities are aware and can make changes as necessary so that our community’s as well as Inspectors continue to work together to obtain the best care for our residents.
22VAC40-73-640-A
Based on observations of the facility’s medication carts and document review, the facility failed to ensure implementation of their medication management plan in regard to methods to prevent the use of outdated, damaged or contaminated medications.
Evidence
  1. The facility medication management plan provided to the licensing inspector (LI) by staff 1 on the day of inspection has documentation that “Medications that have been discontinued or found to be contaminated, damaged, and/or out dated should be disposed of properly”. The medication management plan also has documentation “check carts to ensure all medications are labeled properly (open dates)”.
  2. The following medications were observed by the LI to be opened on the medication carts but did not contain a date of opening to ensure disposal per manufacturer’s instructions: A Basaglar Insulin Pen was open on the D-Hall cart for resident 1. The pen did not contain a date that it was opened. Manufacturer’s instructions are to discard this medication 28 days after opening. A Lantus Solostar Insulin Pen was open on A-Hall cart for resident 8. The pen did not contain a date that it was opened. Manufacturer’s instructions are to discard this medication 28 days after opening. A Lantus Solostar Insulin Pen was open on B-Hall cart for resident 9. The pen did not contain a date that it was opened. Manufacturer’s instructions are to discard this medication 28 days after opening. A Humulin 70/30 Insulin Kwik Pen was open on C-Hall cart for resident 10. The pen did not contain a date that it was opened. Manufacturer’s instructions are to discard this medication 28 days after opening.
  3. This standard was previously cited on 01/17/2023.
Plan of correction
1. Wellness Nurse Corrected during monitoring visit. 2. All carts audited on 03/09/2023 and any corrections needed and 1:1 training with newer staff to ensure awareness of labeling medication with a open date. 3. Weekly med cart audits will continue as well as Medication Observations on staff. 4. Completion Date: 04/30/2023
22VAC40-73-860-I
Based on observation of the facility’s buildings, the facility failed to ensure that cleaning supplies and other hazardous materials are stored in a locked area.
Evidence
  1. At approximately 9:01AM in the facility’s assisted living building during inspection on 03/08/2023, the door to room 42 was unlocked and one LI noted a spray bottle of McKesson dermal wound cleanser, a bottle of Dakin’s wound antimicrobial cleanser, and two bottles of Hibiclen’s antiseptic/antimicrobial skin cleanser.
  2. At approximately 9:23AM in the facility’s assisted living building, one LI noted a small, plastic cup of a white unknown substance on the bedside table in resident 15’s room.
  3. At approximately 9:24AM in the facility’s assisted living building, one LI noted a container of Foca laundry detergent on the back of the toilet in resident 16’s room.
  4. At approximately 10:20AM during on-site visit on 03/14/2023 in the facility’s assisted living building, one LI noted that the door to the janitor’s closet near “D” hall was unlocked and contained multiple bottles of chemicals and cleaners. This was also observed by staff 1 and Collateral 1.
  5. This standard was previously cited on 10/20/2022, 12/08/2022 and 01/17/2023.
Plan of correction
1. Inspectors entered almost every room in both buildings including known empty rooms. During normal “inspection and or monitoring” this is not typical. Once they completed the entire building sweep our managers removed all hazardous noted items. 2. A keypad was ordered for the last housekeeping door. 3. Environmental rounds as per previous POC 5 times a week and 1:1 counseling completed regarding ensuring all empty rooms are locked to ensure safety. Inspectors viewed by walking with Maintenance the empty and remodeled rooms and they stated gratitude on improvement. 4. Completion Date- 04/30/2023
22VAC40-73-870-B
Based on observation during a tour of the facility’s buildings, the facility failed to ensure that all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. At approximately 8:50AM until 12:30PM during on-site inspection on 03/08/2023, one licensing inspector (LI) detected a foul odor throughout the memory care unit common area and down the hallway that contained resident rooms. When two other LIs entered the memory care unit at approximately 1:20PM, the same odor was noted.
  2. This standard was previously cited on 07/15/2022, 10/20/2022, and 12/08/2022.
Plan of correction
1. Inspectors stated on exit that a “musty” not foul odor was present during inspection this was not noted on prior inspection and the inspector had stated that they were impressed. No staff noted the “musty” smell and ED and Housekeeping manager completed round prior to arrival of inspectors. 2. Carpet cleaning continues to be completed 3 times a week and environmental checks at least 5 times a week that was placed on prior POC that continues to not be followed up on with “monitoring” visits. 3. Completion Date- 02/25/2023
22VAC40-73-680-B
Based on observation during a tour of the facility’s buildings, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to residents.
Evidence
  1. At approximately 11:10AM in the facility’s memory care unit during on-site inspection on 03/08/2023, one licensing inspector (LI) observed a small white round pill inscribed with “34” on the floor under the menu board in the dining room area of the memory care unit. In addition, at approximately 11:24AM in the facility’s memory care unit, the same LI observed a small orange-pink pill in the floor near the headboard of the bed in room 3.
  2. At approximately 1:32PM during on-site visit on 03/14/2023 in the facility’s assisted living building, one LI and Collateral 1 noted a white round pill inscribed with “058” lying along the threshold into resident 7’s room. It was verified by the LI and staff 1 that the pill was Prednisone 5MG and that resident 7 does have a current physician’s order for this medication every day.
  3. This standard was previously cited on 09/02/2022, 10/20/2022 and 01/17/2023.
Plan of correction
1. Inspector brought a possible 2 of 3 to a actual qualify staff member to dispose of per medication management plan and ED or Wellness Director on exit was not given pictures or any other proof. Unsure of the disposal method but after exit room and building sweep had no deficiencies. 2. Floor will continue to be swept daily during environmental rounds and this has been noted to be taking place during inspectors entrance on occasions. 3. Environmental Rounds will continue 5 times a weekly at a minimum by 1 staff member and has not been reviewed during “monitoring “ visits but will continue as stated in other POC. 4. Completion Date 04/30/2023
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. The ISP for resident 13, dated 11/01/2022, was not signed by the resident or legal representative.
Plan of correction
1. The ISP for Resident 13 has since been signed. 2. All ISPs will be mailed and emailed to all resident’s legal representative that have emails provided. 3. If an ISP has not been returned to the facility signed the facility will then send the legal representative a certified copy of the ISP and the log will be kept with the ISP. 4. Completion Date – 05/31/2023
22VAC40-73-680-E
Based on observation, staff interview, and resident record review, the facility failed to ensure that medical procedures and treatments ordered by a physician or other prescriber were provided according to his instructions and documented.
Evidence
  1. Resident 13 has physician’s orders for Tubi-grip stockings to be applied to the resident’s legs every morning and removed every evening at bedtime.
  2. The March 2023 medication administration record (MAR) for resident 13 indicates that resident 13 had her stockings applied at 10:00 AM on the date of inspection; however, one licensing inspector (LI) noted that from 8:50 AM until 12:30 PM, that resident 13 did not have on Tubi-grip stockings, and both staff persons 15 and 16 stated that they had not applied her stockings that morning. At approximately 1:20PM, two other LIs noted that resident 13 still not did have on Tubi-grip stockings and this was observed as well by staff person 16.
  3. This standard was previously cited on 12/08/2022.
Plan of correction
1. Inspectors noted during exit interview that this was Ted Hose order and proceed to make us aware she had something on her L knee area that was in fact the Tubi-grip that was stated not to be on this was verify by Wellness nurse and ED after exit. Resident had order for Tubi-grips not Ted hose. This order was Discontinue on day of inspection due to resident being non-compliant with keeping Tubi-grips in place. 2. All carts audited after information given during inspection and corrections completed at that time. 2.Wellness Nurse will review all Secured unit orders for compliance by 04/30/2023 and as stated on prior POC and not followed up on “monitoring visit” weekly medication cart audits will continue. 3. Completion Date- 04/30/2023
22VAC40-73-1110-A
Based on resident record review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and placed in the resident’s file.
Evidence
  1. The records for residents 11, 12 and 13 did not contain documentation that a determination by the licensee, administrator, or designee was completed on the residents that placement in the special care unit is appropriate for residents 11, 12 and 13. Interview with staff 1 confirmed this is accurate.
Plan of correction
1. Documentation provided to inspector for approval and information reviewed. 2. Form completed for all new Residents in safe and secure unit on 03/09/2023. 3. Documentation in place and will be completed on all new admissions to the safe and secure unit. 4. Completion Date- 04/30/2023
22VAC40-73-250-C
Based on staff record review, the facility failed to ensure all required information was included in staff records.
Evidence
  1. The record for staff 2 hired on 02/15/2023 did not contain verification that this employee has received a copy of their current job description.
  2. The records for staff persons 5, 6, 7, 8, 10 and 11 did not contain documentation of these employees’ date of hire. Also, the records did not contain verification that these employees have received a copy of their current job description.
  3. This standard was previously cited on 12/08/2022.
Plan of correction
1. Information requested during exit interview and submitted per request after exiting due to inspector needing to leave instead of having the opportunity to submit during the inspection due to lack of request from inspectors on site. 2. Inspectors on site was aware that BOM had quit without notice and that ED was actively working that position as well and ample time to supply any additional information was not provided or asked for during inspection. 3. BOM and ED will continue prior POC audits as scheduled from prior POC that has not been followed up on from submission or during any “monitoring visits.” 4. Completion -04/30/2023
22VAC40-73-660-B
Based on observation, resident record review and resident interview, the facility failed to ensure residents may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the residents are capable of self-administering medication.
Evidence
  1. At approximately 9:12AM during on-site inspection, one licensing inspector (LI) observed a bottle of Genteal tears lubricated eye drops, a bottle of Systane lubricant eye drops and container of Genteal tears lubricant eye gel on resident 5’s bathroom sink. The LI interviewed resident 5 and resident 5 informed the LI that she uses the eye drops herself and that staff do not administer the eye drops that are located on her bathroom sink. The record for resident 5 does not contain any physician’s orders that the resident may have and self-administer the aforementioned eye drops and eye gel. The UAI for resident 5, dated 03/02/2023, indicates that the resident requires her medications to be administered/monitored by a registered medication aide (RMA) and/or a nurse.
  2. This standard was previously cited on 10/20/2022, 12/08/2022 and 01/17/2023.
Plan of correction
1. All medications removed by Wellness Nurse on day of inspection. 2. A memo will be attached with Resident Agreement on all new admissions for POA and/or Residents signature to review policy and procedures regarding OTC medications. 3. April Resident Council shall have a discussion and have all Residents sign regarding policy and procedure and a meeting with all AL residents will be conducted 1:1 to discuss regulation. 4. Completion Date-04/30/2023
January 17, 2023Inspection6 violations
Inspection dates
01/17/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 01/17/2023 8:30AM until 2:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A non -mandated monitoring inspection was conducted by the inspector of record for the facility in conjunction with another licensing inspector with the VDSS DOLP. The inspection was conducted as a probation inspection that was indicated in the special order that was issued to the facility on 06/17/2022 and a denial inspection that was indicated in the notice of intent (NOI) that was issued to the facility on 09/10/2022. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on medication cart audit, staff interview and resident record review, the facility failed to implement its medication management plan regarding methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan states the following: “Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes: Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.
  2. While performing a sample audit of narcotics in the medication cart in the safe, secure unit, one licensing inspector (LI) and staff 6 observed that the controlled drug record for resident 11’s lorazepam 0.5 mg tab, “take one tablet by mouth at bedtime for anxiety”, indicated that there were nine pills in the pill card; however, upon review of its corresponding pill card, there were eight pills in the card.
  3. Interview with staff 6 revealed that staff 7 forgot to complete the controlled drug record after dispensing the medication.
Plan of correction
1. Count was corrected with Wellness Director on day of inspection. 2. One on One Staff training and Counseling completed with Employee 6&7 to be completed by Wellness Director / Administrator regarding Medication Management Plan and expectations. 3. A four-hour required Refresher course will be conducted by a third party for the Facility on February 9th, 2023, and again is set for August 24th, 2023 4. Completion Date- 02/25/2023
22VAC40-73-870-A
Based on observation during a tour of the buildings, the facility failed to ensure that the interior and exterior of all buildings were maintained in good repair and kept clean.
Evidence
  1. At approximately 8:30AM, one licensing inspector (LI) observed that the counter between the dining room and the kitchen in the facility’s safe, secure unit, contained a large area of a pink sticky substance on the counter and down the wall below the counter and the aforementioned substance was still noted at 9:58 AM.
  2. In the facility’s safe, secure unit, one LI observed several areas of a wet brown/yellow substance next to the resident’s bed in room 42.
  3. At approximately 9:17AM, one LI observed that the bathroom in room 47 in the facility’s assisted living building contained a large brown substance on the floor and the trash can was full of trash. At approximately 12:02PM, the aforementioned issue was still present in the bathroom and was also observed by staff 3.
  4. At approximately 9:19AM, one LI observed that the bathroom in room 45 in the facility’s assisted living building contained multiple dirty towels hanging on the towel rod and the shower curtain contained multiple areas of brown stains toward the bottom of the curtain. At approximately 12:04PM, the aforementioned issue was still present in the bathroom and was also observed by staff 3.
  5. This standard was previously cited on 10/20/2022 and 12/08/2022.
Plan of correction
1. All areas sited was addressed during inspection while inspectors were on site. 2. One on One staff education to be given regarding all violations on the 01/17/2023 inspection will be conducted with every employee by Administrator or Wellness Director by 02/25/2023 3. Housekeeping Rounds will continue to occur daily by Administrator or Designee daily for compliance. 4. Completion Date- 02/25/2023
22VAC40-73-460-H
Based on resident record review, the facility failed to ensure that personal assistance and care were provided to each resident so that the needs of the resident are met, including bathing at least twice per week.
Evidence
  1. The documents “skin monitoring: comprehensive CNA shower review”, provided by the facility during on-site inspection on 01/17/2023, from the dates of 12/01/2022 through 01/17/2023 for resident 13 contained documentation regarding bathing on the following dates: 12/08/2022 with a refusal, 01/02/2023 with a refusal, 01/10/2023 with a refusal, and 01/13/2023 with a refusal which indicated that the resident had not received a shower during this time period.
  2. During the preliminary exit on 01/17/2023 regarding resident 13, there was no additional documentation provided by the facility regarding bathing/showers for resident 13 during on-site inspection on 01/17/2023.
  3. This standard was previously cited on 07/15/2022 and 12/08/2022.
Plan of correction
1.One on One staff training to be completed regarding Violation and ADL’s. 2.All safe and secure showers will now be completed and signed off in the EMAR system for the supervisor in charge of the unit to document daily showers. 3. A weekly Audit of Safe and Secure Showers will be conducted by Wellness Director/ Administrator or Designee to assure compliance. This will be discussed no less then weekly in the Managers Meeting. 4. Completion Date- 02/25/2023
22VAC40-73-860-I
Based on observation during a tour of the buildings, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 9:36 AM in the facility’s safe, secure unit, one licensing inspector (LI) observed a pair of scissors and a box of pushpins sitting inside of the nurses’ station which were accessible by residents. This was also observed by staff 6.
  2. In the facility’s assisted living building, one LI observed the following items: a container of Clorox disinfecting wipes located by the bathroom in resident 4’s room, a container of Clorox disinfecting wipes, a spray can of Lysol disinfecting spray, a spray can of Glade air freshener, and a container of Reliable citrus scent disinfectant spray in resident 5’s room, and two containers of Lysol toilet bowl cleaner in resident 10’s room. The aforementioned items were also noted by staff 3.
  3. This standard was previously cited on 10/20/2022 and 12/08/2022.
Plan of correction
1. On day of inspection all items were removed with inspector during tour of facility. All items were removed from nurse’s station on day of inspection. 2. One on One Staff education to be completed regarding all violations that occurred on 01/17/2023. 3. Room Sweep assignments to be scheduled daily for all Managers on duty at least 4-5 times weekly during the morning meeting and checklist to be turned in after to Wellness Nurse or Administrator. 4. Completion Date 02/20/2023
22VAC40-73-660-B
Based on observation during a tour of the buildings and resident record review, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the resident’s uniform assessment instrument (UAI) indicates that the resident is capable of self-administering medication.
Evidence
  1. The UAI for resident 4, dated 10/21/2022, indicates that the resident requires his medication to be administered by licensed medication staff. The record for resident 4 contained a physician’s order, dated 11/10/2022, for Nizoral shampoo to be used every Monday and Thursday.
  2. During on-site inspection on 01/17/2023, one licensing inspector (LI) observed that the aforementioned medicated shampoo was sitting on the back of the toilet in resident 4’s bathroom; however, the physician’s order does not indicate that the shampoo can be kept in the resident’s room and that the resident may self-administer the shampoo.
  3. This standard was previously cited on 10/20/2022 and 12/08/2022.
Plan of correction
1. Resident #4 had a complete room sweep conducted by Administrator and Wellness Director on day of inspection. 2. One on One Staff training with all RMAs regarding Medication Management Policy and expectations as well as required 4-hour refresher training to be completed by a third party on site for all RMAs on February 9th. 3. A meeting was conducted with the resident and family on January 20, 2023, to review policy and regulations on medications and chemicals in the facility. 4. Completion Date: 02/25/2022
22VAC40-73-680-B
Based on medication cart audit, resident record review and staff interview, the facility failed to ensure that a medication was in the pharmacy-issued container with the prescription label or direction label attached.
Evidence
  1. While performing a sample audit of narcotics in the medication cart in the safe, secure unit, one licensing inspector (LI) observed a plastic bag containing a brown pharmacy bottle which held a liquid substance; however, the information on the pharmacy label on the bottle was not legible and was missing components such as what the medication was, who the medication is for, and directions for administering medication.
  2. Interview with staff 6 revealed that the bottle had been leaking which caused the information on the pharmacy label to wash off. Staff 6 indicated that the aforementioned medication belonged to resident 12 and was the resident’s prescribed as needed Oxycodone HCL 5 mg/ 5 ml; however, the LI could not make this determination from the condition of the label.
  3. At approximately 9:32AM, one LI observed a small, round red pill by the white trash can in resident 5’s room with an inscription of 205 on one side and LS on the other side. The resident’s record contained a physician’s order for the aforementioned medication and it was also indicated on the resident’s December 2022 and January 2023 medication administration records. The pill was also observed by staff 3.
  4. This standard was previously cited on 09/02/2022 and 10/20/2022.
Plan of correction
1. Administrator and Wellness Director completed room sweeps while inspectors were on site day of the inspection. 2. Wellness Nurse had contacted 3rd party provider regarding medication and need to follow medication management plan and a new medication was ordered prior to the day of inspection for delivery to follow the Medication Management Plan. Medication was delivered the evening of inspection. 3. One on One staff education to be completed with all current RMAs/Nurses regarding a review of medication management and expectations to be completed by Wellness Nurse or Administrator. 4. Medication Pass Observations to be completed no less than monthly on all RMAs for the next 6 months and then as periodically by Wellness Director or Administrator. 5. Completion Date- 02/25/2023
December 8, 2022Complaint survey6 violations
Inspection dates
12/08/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 9:00AM until 3:15PM and one inspection on-site on 12/17/2022 from 6:55AM until 7:10AM. 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 12/05/2022 regarding allegations in the areas of: personnel, staffing and supervision, admission, retention and discharge of residents, resident care and related services and buildings and grounds. 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: resident care and related services, personnel, and buildings and grounds. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-460-H
Based on resident record review and staff interview, the facility failed to ensure that residents personal assistance and care as necessary, in regarding to bathing at least twice a week, was met.
Evidence
  1. The uniform assessment instrument (UAI) for resident 2, dated 03/25/2022, indicated that the resident requires mechanical and physical human assistance with bathing and the individualized service plan (ISP) for the resident, dated 03/25/2022, indicated that staff will provide the resident complete assistance with bathing and getting in/out of the shower safely while encouraging the resident to participate as able while using the shower bench and grab bars. During on-site inspection, the facility produced documentation that resident 2 had only received four showers from 11/01/2022 through 12/08/2022.
  2. The uniform assessment instrument (UAI) for resident 3, dated 10/24/2022, indicated that the resident requires mechanical and physical human assistance with bathing and the individualized service plan (ISP) for the resident, dated 10/25/2022, indicated that staff will provide the resident complete assistance with bathing and getting in/out of the shower safely while encouraging the resident to participate as able while using the shower bench and grab bars. During on-site inspection, the facility produced documentation that resident 3 had only received three showers from 11/01/2022 through 12/08/2022.
Plan of correction
1. Staff in-service to be completed regarding shower sheets and completion as well as the required documentation to be completed by nursing staff. 2. ISP/UAI to have audit completed to ensure accuracy. 3. DON/Designee and shift supervisor to review shower sheets for completion weekly and DON/Administrator or designee to complete monthly audits to ensure sheets have been completed for the month. 4. Completion Date- 01/15/2023
22VAC40-73-870-A
Based on observation during a tour of the buildings, the facility failed to ensure the interior of the buildings were kept clean and free of rubbish.
Evidence
  1. At approximately 9:29AM, two licensing inspectors (LIs) observed a sticky, medium sized red stain on the floor in front of the bedside table and multiple used cups and stains on the bedside table in resident 1’s room. Also in resident 1’s bathroom there was a small spill on the bathroom floor and the shower chair in the shower contained small brown stains. The two LIs observed one used blood glucose test strip in the hall in front of room D71 and one in the hall in front of room A43.
Plan of correction
1. All managers completed a room/building sweep to address housekeeping needs on completion of inspection on 12/08/2022. 2. Inservice for all Housekeeping staff /Nursing Staff regarding expectations as well as new cleaning schedule and daily assignments. Administrator and /or designee to continue recruiting efforts to build housekeeping department. 3. Environmental room checks to be completed no less than daily by administrator or designee. Findings to be reviewed and noted on daily stand-up agenda. 4. Completion Date- 01/15/2023
22VAC40-73-870-B
Based on observation during a tour of the buildings, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. Upon entering the facility’s safe, secure unit, one licensing inspector (LI) noted an overwhelming foul odor which continued to linger throughout the facility while the LI was present in the unit.
Plan of correction
1. Housekeeping sent to address issues on day of inspection of 12/08/2022. 2. Inservice for all Housekeeping Staff will be completed to review expectations as well as new cleaning schedule with daily assignments put in place. Administrator and/or Designee will continue recruiting efforts to build the housekeeping department. 3. Environmental room checks to be completed no less than daily by administrator or designee. Findings to be reviewed and noted on daily stand-up agenda. Regional Oversight to be conducted every 30-45 days. 4. Completion Date 01/15/2023
22VAC40-73-670-1
Based on a review of medication administration records (MARs), staff record review and staff interviews, the facility failed to ensure that staff who are responsible for the administration of medications were licensed by the Commonwealth of Virginia to administer medications.
Evidence
  1. The November and December 2022 MAR’s for resident 4 has staff 4’s initials for the administration of the residents 8:00PM medications on 11/30/2022 and 12/02/2022. The December 2022 MAR for resident 3 has staff 4’s initials for the administration of the residents 8:00PM medications on 12/05/2022.
  2. The facility provided documentation of a “Eligibility to Test/Authorization to Practice” letter dated 09/21/2022 for staff 4. The third paragraph of the letter has a sentence that states “You may practice in Virginia for a period not to exceed ninety (90) days from the completion of your nursing education program and the receipt of the results of your first licensing examination”. A phone call held on 12/15/2022 with collateral 1 clarified that an LPN-Applicant has 90 days from the date that they completed their nursing education program to practice as an LPN- Applicant and not 90 days from the date documented on the “Eligibility to Test/Authorization to Practice” letter.
  3. An interview conducted on the day of inspection with staff 4 expressed that the last day of their nursing education program was completed on 08/15/2022, which would have allowed this employee to practice as an LPN-Applicant up until 11/15/2022.
Plan of correction
1. Staff member 4 called Board of Nursing on site during inspection to verify information. Staff 4 was given in correct information during the phone call. 2. Staff 4 was removed from the schedule until pending testing date. 3. Business Office Manager/ Administrator will contact Board of Nursing to have education on regulations for LPN-A and clear understanding of the information on any letter presented for LPN-A applicants going forward. 4. Completion (Date- 01/15/2023
22VAC40-73-870-B
Based on observation during a tour of the buildings, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. Upon entering the facility’s safe, secure unit, one licensing inspector (LI) noted an overwhelming foul odor which continued to linger throughout the facility while the LI was present in the unit.
Plan of correction
1. Housekeeping sent to address issues on day of inspection of 12/08/2022. 2. Inservice for all Housekeeping Staff will be completed to review expectations as well as new cleaning schedule with daily assignments put in place. Administrator and/or Designee will continue recruiting efforts to build the housekeeping department. 3. Environmental room checks to be completed no less than daily by administrator or designee. Findings to be reviewed and noted on daily stand-up agenda. Regional Oversight to be conducted every 30-45 days. 4. Completion Date 01/15/2023
22VAC40-73-250-C
Based on staff record review and staff interview, the facility failed to ensure a record was established for a staff person.
Evidence
  1. Based on observations during a tour of the building, staff interviews and staff record review, the facility failed to ensure that a staff record was established for all employees. EVIDENCE: During a tour of the facility physical plant staff 1, who was noted to be wearing a facility name badge, was observed preforming maintenance duties in the facility. A review of staff records noted that this employee did not have a staff record containing all required information. During an interview with staff 2 on the day of inspection, it was expressed that staff 1 was hired as a contractor to preform maintenance duties in the facility for a 90 day trial basis. Staff 2 expressed that the facility did not have documentation of a contract with this employee.
Plan of correction
1. Staff 1 was hired as an employee and an employee file was created. 2. All Contractor files will be audited by Business Office Manager to ensure proper documentation and contract is in place for compliance. 3. Business Office Manager in-service on staff/contract files and required documentation with Regional Oversight to be given on any new contract files. 4. Completion Date- 01/15/2023
December 8, 2022Inspection6 violations
Inspection dates
12/08/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 12/08/2022 9:00AM until 3:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. mandated monitoring inspection was conducted by the inspector of record for the facility in conjunction with two other licensing inspectors with the VDSS DOLP. The inspection was conducted as a probation inspection that was indicated in the special order that was issued to the facility on 06/17/2022 and a denial inspection that was indicated in the notice of intent (NOI) that was issued to the facility on 09/10/2022. 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observation and resident record review, the facility failed to ensure that for a resident with medications in their room the uniform assessment instrument (UAI) indicated the resident is capable of self-administering medication.
Evidence
  1. At approximately 9:54AM during on-site inspection, one licensing inspector (LI) observed a bottle of Excedrin extra strength pain reliever, a spray bottle of Fluticasone Propionate nasal spray, an orange prescription bottle without a label that contained two unidentified pills (one oblong white and one oblong red), and a bottle of Advil pain reliever. The private pay UAI for resident 2, dated 09/14/2022, indicated that the resident requires their medication to be administered/monitored by a lay person. Interview with staff 1 and 2 confirmed resident did not contain a physician’s order for the resident to be able to have these medications in her room and self-administer.
Plan of correction
• 1.All mangers on duty completed an entire room/building sweep for compliance on 12/08/2022 after inspection. • 2. A deep clean/Room sweep checklist and daily room assignments of at least 2 rooms per day will be initiated for housekeeping and nursing staff. A checklist and sheet for Wellness Nurse/Administrator or designee to review for assigned rooms will be implemented. Completion Date- 01/15/2023 • 3. A memo will be sent out to all family/residents and staff regarding compliance of the regulations and allowed items in residents rooms and staff areas. Completion Date 12/31/2022 • 4.Completion Date -01/15/2023
22VAC40-73-680-E
Based on observation, resident record review, and staff interview, the facility failed to ensure treatments ordered by a physician or other prescriber were provided according to his instructions and documented.
Evidence
  1. The record for resident 2, admitted 11/27/2022, contained a history and physical examination report dated 11/06/2022, which included signed physician’s orders for compression stockings to be applied in the morning and removed at bedtime. In addition, new admit physician’s orders signed on 11/29/2022 indicated no new orders “NNO”. The December 2022 medication administration record (MAR) for resident 2 did not contain documentation of compression stockings nor that they have been applied and removed as per physician’s orders.
  2. Interview with staff 3 revealed that the compression stockings would not be found on a separate record such as a treatment administration record. Staff 3 added that she was unaware that resident 2 required compression stockings.
  3. At approximately 11:00AM, one licensing inspector (LI) observed that resident 2 was not wearing compression stockings.
Plan of correction
• 1. MD notified on 12/08/2022 and order reviewed and clarified. • 2. Wellness Director/DON and Designee will audit 5 files monthly for compliance on UAI/ISPs. – Completion Date – 01/01/2023 • 3. DON/Wellness Director and Designee to Audit all new Residents H&PS AND EMAR (orders) on Admission as well as within 5 days of Admission. • 4.Completion Date- 12/31/2022
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The ISP for resident 2, dated 11/26/2022, did not indicate that the resident requires compression stockings.
  2. The record for resident 3 contained a history and physical, dated 11/28/2022, that the resident is on a No Added Salt diet. The ISP dated 12/01/2022 in the record for resident 3 does not address this identified need.
Plan of correction
• 1.ISP for resident 2 and 3 updated on 12/09/2022 to reflect needed corrections. • 2.Wellness Nurse/DON/Administrator or Designee to review all ISP/UAIs for accuracy by 01/15/2023 • 3. Wellness Nurse/DON or designee to audit 5 files a month for accuracy on ISP/UAIs beginning 12/31/2022. • 4.Completion Date 01/15/2023
22VAC40-73-820-A
Based on observation, resident record review and staff interview, the facility failed to ensure smoking by a resident is only done in areas designated by the facility and approved by the State Fire Marshall of local fire official.
Evidence
  1. The record for resident 5 contained a safe smoking evaluation signed by the resident on 06/17/2022 that the resident is not a safe smoker due to smoking in his room. The record also contained a safe smoking evaluation signed by the resident on 08/09/2022 that he continues to not be a safe smoker due to being caught smoking in his room and that lighters and cigarettes will be secured with nursing staff and that the resident will be discharged if he is caught smoking again in his room. At approximately 9:48AM during on-site inspection, one licensing inspector (LI) noted upon entering resident 5’s room that the room smelled like cigarette smoke. The LI observed a cigarette butt with ashes in the toilet and a lighter on the resident’s bathroom sink along with an empty cigarette box.
Plan of correction
• 1.Resident 5 is currently on a discharge notice since 09/2022 awaiting placement. The caseworker and Administrator continue contact regarding placement to a new facility. • 2.Inservice to resident and staff regarding safe smoking procedures to ensure the safety of Resident #5. • 3. Administrator/ Wellness Nurse or Designee will implement every 1-hour checks to ensure safe smoking procedures and being followed along with room checks for smoking by nursing staff or designee every hour until discharge occurs. 4.Completion Date- 12/31/2022
22VAC40-73-860-I
Based on observation during a tour of the assisted living and safe, secure unit, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 10:00AM during on-site inspection, one licensing inspector (LI) noted a container of Clorox disinfecting wipes located by the bathroom in resident 6’s room which is located in the assisted living building.
  2. At approximately 10:02AM, two LIs noted that the door to the therapy room in the assisted living building was opened and no staff were present in or around the room. The LIs noted a container of Super sani-cloth germicidal disposable wipes, a container of Perk disinfecting wipes and multiple bottles of Purell hand sanitizer. All of the aforementioned items contained information to keep out of the reach of children.
  3. At approximately 9:05 AM, one LI entered the double doors to the right side of the kitchen in the facility’s safe, secure unit and at the far end of the left side of the hallway, the LI observed a door with keys hanging from the knob and a sign stating “SPRINKLER CONTROL IS BEHIND THIS DOOR”. The LI was able to enter the area and found overhead cabinets that contained the following cleaning products: Mop & Glo floor cleaner, Glade Pet carpet powder, SparCreme liquid crème cleanser, Conqueror 103 odor counteractant concentrate, HI TECH 401K organic acid bowl cleaner, Energy Mizer multi-surface and glass cleaner, McKesson hand sanitizer, Super Sorb spot absorbent, United Aqua Sponge gel and spill absorbent, Clean Shower daily shower cleanser, and Monogram stainless steel cleaner and polish. The lower cabinet contained bags of McKesson premium hand sanitizer with aloe. The room also contained an unlocked door with a sign that said “MECHANICAL ROOM” which contained what appeared to be water heater tanks, pipes, hoses, knobs, and breaker boxes.
  4. At approximately 9:13 AM, the bathroom in room 21 in the safe, secure unit had a bottle of Equate smoothing keratin shampoo sitting on the sink.
  5. At approximately 9:58 AM, at the nurses’ station, one LI observed a green and orange cylinder that said strawberry watermelon and had a pointed tip sitting next to the telephone in which the LI observed a resident standing at the nurses’ and the object was within reach of the resident. Interview with staff 3 indicated that the aforementioned object was a vaping device.
Plan of correction
• 1. All managers on duty conducted an entire sweep of building/rooms on 12/08/2022 after inspection. • 2. Keypad locks for both storage area doors ordered with an expected delivery date of 12-21-2022. Installation of keypads for 2 storage areas doors to be completed upon delivery. • 3. A letter/memo was created for all Residents/Family as well as staff to be sent out via mail and email to provide education and a review of policy’s regarding allowed items and to ensure knowledge of regulations by all Residents/Families and staff: Completion Date: 12/31/2022 • 4.Nurses Station areas to have twice weekly checks for compliance and education given by wellness director / housekeeping and designee. • 5. Completion Date- 12/31/2022
22VAC40-73-50-A
Based on resident record review, the facility failed to ensure that the disclosure statement provided to resident contained all required information.
Evidence
  1. The disclosures statements in the records for residents 2, 3 and 4 did not contain any information for the number of staff providing direct care per shift on the 11-7 shift.
Plan of correction
• 1.The residents Disclosure statements for residents 2, 3 and 4 was corrected and updated on 12/09/2022 with a new copy mailed for families to be aware of needed changes • 2. Marketing/ Administrator or Designee to audit all charts to ensure all disclosure statements reflect corrections. Completion Date-01/15/2023 • 3. Disclosure Statement revised to reflect needed changes on 12/09/2022 and updates made aware to Marketing Manager and Wellness Director. • 6.Completion Date- 12/09/2022
October 20, 2022Inspection12 violations
Inspection dates
10/20/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROU22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSND
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 10/20/2022 9:00AM until 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A non-mandated monitoring inspection was conducted by the inspector of record for the facility in conjunction with two other licensing inspectors with the VDSS DOLP. The inspection was conducted as a follow up for an inspection that required an intensive plan of correction (IPOC) that was issued to the facility on 08/26/2022, probation inspection that was indicated in the special order that was issued to the facility on 06/17/2022, and a denial inspection that was indicated in the notice of intent (NOI) that was issued to the facility on 09/10/2022. 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1110-B
Based on resident record review and staff interview, the facility failed to ensure that six months after placement of the resident in a safe, secure environment and annually thereafter, the licensee, administrator, or designee performed a review of the appropriateness of a resident’s continued residence in the special care unit.
Evidence
  1. Resident 6 resides in the facility’s safe, secure unit. The record for resident 6 contained the initial “approval for placement in special care unit” form which was completed on 11/18/2021 for the resident; however, the record did not contain documentation of the six month review for appropriateness for the resident. When questioned, staff 2 could not verify that the six month review had been completed.
Plan of correction
1.During inspection review Staff 2 was made aware of the findings of complaint and given the evidence at that time Staff 2 had only been employed for 2 days and was not aware of placement in chart of form. After receiving Violation Notice and review of chart for resident 6 completed with ISP/UAI coordinator the documentation for the 6-month placement was under the assessment tab and was signed by previous Administrator on 04/18/2022. This is the tab all assessments after initial are kept. 2. All records reviewed for proper documentation for the safe and secure unit. All records to be reviewed monthly for on-going compliance. 3. Completion Date 10/28/2022
22VAC40-73-870-D
Based on observation during a tour of the facility’s physical plant, the facility failed to ensure that buildings were kept free of infestations of insects.
Evidence
  1. From approximately 9:00 AM to 10:50 AM during on-site inspection on 10/20/2022, one licensing inspector (LI) noted numerous insect carcasses in multiple residents’ rooms as well as in common areas and in the three hallways located in the facility’s safe, secure unit.
Plan of correction
1.All areas of the safe and secure building will have twice weekly inspections by Housekeeping and Administrator or Designee to be completed no later than 12/01/2022. 2.Training for all safe and secure staff on housekeeping measures and scheduled housekeeping for nursing and housekeeping to be completed by 12/01/2022. 3.Completion Date- 12/01/2022
22VAC40-73-860-I
Based on observation during a tour of the facility’s physical plant, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 9:45AM during on-site inspection on 10/20/2022, one licensing inspector (LI) noted a bottle of Medline Skintegrity wound cleaner sitting on a rolling cart in C hall and at 9:51AM one LI noted the door to room 41 to be unlocked and it contained a bottle of Goo Gone latex paint clean up.
  2. At approximately 9:56AM, one LI noted the door to the laundry room to be unlocked and unattended in the assisted living building. The LI noted a bottle of Windex, a container of Pure Bright bleach, and a bottle of Persil Proclean laundry detergent that contained resident 1’s name.
  3. At approximately 11:08AM, one LI noted that room 14 was unlocked and contained a spray bottle of Great Value disinfectant spray and a bottle of Swan nail polish remover.
  4. At approximately 9:00 AM, one LI noted the laundry room door was propped open in the facility’s safe, secure unit and the LI observed a container of Purex laundry detergent and a bottle of blue dish detergent on the shelf in the laundry room.
  5. At approximately 9:02AM, one LI entered the unlocked laundry storage room and observed a tube of Loctite Construction Adhesive sitting on a shelf in the storage room in the facility’s safe, secure unit.
Plan of correction
1.Laundry Storage room Keypad battery replaced on day of on-site inspection at approximately 11:00am. 2.Monthly log to be maintained by Maintenance on the changeout of batteries monthly in high traffic areas that have keypad locks in place to include the housekeeping and laundry areas. Administrator/Designee will review monthly and sign log for accuracy. 3.Housekeeping to continue to complete twice weekly rounds and all managers and or staff to complete rounds/room sweeps 3-5 times a week after stand-up meeting to ensure all areas are properly secured and chemicals are placed in designated areas in both AL and MC areas. 4.The Safe and Secure Units laundry room had a lock keypad installed on 10/21/2022 to maintain safety going forward. 5.Safe and Secure unit to have rounds completed for ensuring compliance 5 times a week to be preformed by any staff member and or Administrator or Designee at least 5 times weekly to be in place by 12/01/2022 6.Inservice Education with all staff regarding Chemicals and Safety in the Safe and Secure Unit and AL by 12/01/2022. 7.Completion Date -12/01/2022
22VAC40-73-680-D
Based on observation during a tour of the facility’s physical plant, resident record review and resident interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The record for resident 3 contained a physician’s order, dated 06/16/2022, for Carvedilol 12.5mg twice a day for hypertension, hold for systolic blood pressure less than 110 or heart rate less than 60. The October 2022 medication administration record (MAR) for resident 3 contained documentation at 8:00PM on 10/06/2022 that the resident’s blood pressure was 105/61; however, staff initials were present for administering the aforementioned medication. Staff initials were circled on the October 2022 MAR as not administering this medication at 8:00AM on 06/08/2022 with a notation on the MAR of “doctors order”; however, resident 3’s blood pressure was documented as 116/82 and heart rate was documented as 67. The October 2022 MAR also contained staff initials that are circled as not administering this medication at 8:00PM on 06/08/2022 with a notation on the MAR of “doctors order” but resident 3’s blood pressure was documented as 112/72 and heart rate was documented as 60.
  2. Resident 5 was admitted to the facility on 07/31/2022. The record for resident 5 contained signed physician’s orders, dated 07/28/2022, for Calcium-Vitamin D one tablet daily and a Multivitamin one tablet daily. During on-site inspection on 10/20/2022, the two aforementioned medications were not documented on the resident’s September and October 2022 medication administration records (MARs) and were also not located in the facility. The record for the resident did not contain a physician’s order that the two medications had been discontinued. This was also verified by staff 3 and 5.
Plan of correction
1.The resident files for #3 and #5 will have a MD review on the next visit and MD will update orders as needed for corrections needed. 2.PCP to have a new PA to round and review orders for accuracy with Wellness Nurse/DON/Administrator. All new orders will be reviewed with rounding Wellness nurse and Administrator/Designee following rounding with PA/MD. 3.10 MARS/TARS to be reviewed by Wellness Nurse /Administrator or Designee each week for accuracy. 4.All MAR orders to be fully reviewed by Wellness Nurse/DON/Administrator or Designee by Dec 1, 2022. 5.Will contact Pharmacy to request any additional assistance for monitoring as well. 6.Completion Date- 12/01/2022
22VAC40-73-350-B
Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender.
Evidence
  1. Resident 1 was admitted to the facility on 07/31/2022; however, a Virginia state police sex offender registry search was not conducted for the resident until 08/01/2022.
Plan of correction
1.All files to have audit complete to ensure compliance with Sex offender search. 2.Administrator /Designee and DON or Wellness Nurse as well as Marketing Coordinator will review all prior admission paperwork prior to admissions going forward from 10/20/2022. 3.Checklist for all prior admissions will be established and signed by Administrator/Designee as well as Marketing Coordinator by 12/01/2022. This will be completed on all admission unless an emergency admission was to be presented to facility. 4.Completion Date- 12/01/2022
22VAC40-73-680-I
Based on resident record review, medication cart audit, and staff interview, the facility failed to ensure all required documentation was on the medication administration record (MAR).
Evidence
  1. The record for resident 5 contained the following three physician’s orders for “Zyrtec 10MG daily for head congestion for one week” dated 08/26/2022, 09/29/2022 and 10/17/2022. The September and October 2022 medication administration records (MARs) for resident 5 contained staff signatures that the aforementioned medication was administered daily at 8:00AM (except October 7, 2022 through October 13 due to the resident being hospitalized); however, interview with staff 3 indicated that the medication was only administered by staff according to the physician’s instructions on 08/26/2022 order for seven days from 08/26/2022 until 09/02/2022.
Plan of correction
1.MAR to Cart Audit to be complete by 12/15/2022 on all medication carts by Wellness Nurse/ Administrator or Designee. 2.Pharmacy will be contacted by 12/01/2022 to schedule a follow-up Audit within 60 days. 3.RMA/Nurse education to be reviewed during refresher course. Wellness Nurse/DON/ Administrator or designee to have a 2-person review of new orders placed in MAR system after completion by 12/01/2022. 4.Completion Date – See above
22VAC40-73-870-A
Based on observation during a tour of the facility’s physical plant, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. At approximately 9:51AM during on-site inspection on 10/20/2022, one licensing inspector (LI) noted that the bathroom floor in room 13 in the facility’s safe, secure unit contained a large, brown stain around and in front of the toilet. Staff 5 was observed cleaning the floor during this time and interview with staff 5 revealed that they had not been able to remove the stain during previous cleanings.
  2. At approximately 9:55AM, one LI noted that the carpet in the hallway outside of multiple residents’ room contained numerous stains.
  3. At approximately 9:17AM, one LI noted that the inside of the toilet bowl in resident 1’s bathroom contained a large stain.
Plan of correction
1.The floor in bathroom of room E10 was well cleaned and still had a noted darkened area. The material has been ordered and will be replace by November 15, 2022. A round after the on-site visit did not show a area in the floor of 13 as noted in the notice. 2. Rounds of all occupied rooms will be completed once weekly for a list of any needed repairs or needed cleaning by maintenance /Housekeeping and Administrator or designee. 3. Carpet cleaning schedule to be made for a weekly cleaning by housekeeping in Safe and Secure Unit by 12/01/2022 and plans for removal and replacement will be conducted by cooperate. 4.Cleaning Schedule for Housekeeping and Nursing staff to be in place at both AL and safe secure units to include housekeeping measures to be completed and in place by 12/01/2022. 5. Completion Date- 12/02/2022
22VAC40-73-680-B
Based on observation during a tour of the facility’s physical plant, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. At approximately 9:25AM during on-site inspection on 10/20/2022, one licensing inspector (LI) observed a white, oblong pill with an inscription of 164 on one side and a “G” inscribed on the other side on the floor in front of the nightstand in resident 3’s room. Interview with resident 3, in the presence of two licensing inspectors and staff 3, revealed that the aforementioned pill was hers.
Plan of correction
1.All RMAs/Nurses will have a medication refresher course completed by 12/01/2022. 2.Inservice to review medication management policy with all staff to be completed by 12/02/2022 3.Administrator/Designee to have all managers to continue with random room sweeps for compliance after morning stand-up meeting 3-5 times a week. 4.Completion Date- 12/01/2022
22VAC40-73-870-B
Based on observation during a tour of the facility’s physical plant, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During on-site inspection on 10/20/2022, one licensing inspector (LI) noted foul odors emanating from rooms 10 and 13 located in the facility’s safe, secure building.
Plan of correction
1.Cleaning Schedule to be created for housekeeping and nursing for both AL and safe and secure unit to be in place by 12/01/2022. 2.Management staff to do rounds 3-5 times a week after stand-up meeting to ensure areas are free from odor to be completed no later than 12/01/2022. 3.Completion Date- 12/01/2022
22VAC40-80-120-E-3
Based on observation during a tour of the facility’s physical plant, the facility failed to have posted on the premises of the facility the notice of the commissioner’s intent to revoke or deny renewal of the facility’s license to advise consumers of serious or persistent violations.
Evidence
  1. The document, notice of intent to deny renewal application for a license, dated 09/07/2022, was not posted in the facility during on-site inspection on 10/20/2022.
Plan of correction
1.Notice of intent was placed in required areas on 10/20/2022 after exit interview from on-site inspection. 2. Administrator/Designee will post all inspection required paperwork upon receipt as well as day of inspection going forward from 10/20/2022 3. Completion Date- 10/20/2022
22VAC40-73-660-B
Based on observation during a tour of the facility’s physical plant and resident record review, the facility failed to ensure that for residents with medications in their rooms the uniform assessment instrument (UAI) indicated the residents are capable of self-administering medication.
Evidence
  1. At approximately 9:18AM, one licensing inspector (LI) observed a tube of Triamcinolone 0.1% cream on the bathroom sink in resident 1’s room. The public pay UAI for resident 1, dated 06/15/2022, indicated that the resident requires their medication to be administered/monitored by a lay person “med tech on duty”. The record for resident 1 included a physician’s order, dated 04/11/2022 for Triamcinolone 0.1% cream apply topically to affected areas two times a day for treatment; however, the physician’s order does not indicate that the resident can self-administer the aforementioned medication and keep in their room.
  2. At approximately 9:38AM, one LI observed a bottle of Pepto Bismol on the floor beside resident 2’s room. The private pay UAI for resident 2, dated 09/14/2022, indicated that the resident requires their medication to be administered/monitored by lay a person. The record for resident 2 did not contain a physician’s order for the resident to be able to keep Pepto Bismol in their room and self-administer.
Plan of correction
1.Administrator and all on site management team completed a facility tour of all rooms after on-site inspection on 10/20/2022 to ensure no OTC medications or prescription medications was located at bedside. 2.Wellness Nurse/DON/Administrator will review the need for self-administer medication order if needed for OTC medications on a case-by-case bases for residents. 3.Medication Management to be reviewed with all staff regarding the process of having OTC medications at bedside or in resident’s rooms by 12/02/2022. 4.Administrator/Designee will begin effective 10/24/2022 to have all management staff monitor areas of non-compliance and have random room sweeps 3-5 times a week following stand-up meetings. 5.Completion Date 11/05/2022
22VAC40-73-150-B-6
Based on documentation and staff interview, the facility failed to ensure to not be operated by an acting administrator for no more than 90 days.
Evidence
  1. Staff 1 was appointed as the facility’s acting administrator on 07/01/2022 for 90 days. The licensing inspector (LI) received an email from staff 2 that they were now the facility’s administrator of record as of 10/17/2022 therefore meaning that staff 1 was the facility’s acting administrator for longer than 90 days. Interview with staff 2 and 3 confirmed the aforementioned information was accurate.
Plan of correction
1.Facility has in place as of 10/17/2022 a Licensed Acting Administrator. 2.The facility like many will continue to recruit quickly for all positions and train staff that are able to stand in during the need of an acting administrator. 3.Administrator in place will receive or be encouraged to obtain the preceptor license to begin this process with other eligible employees. 4.Completion Date -10/17/2022
October 4, 2022Complaint survey0 violations
Inspection dates
10/04/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 10/04/2022 5:54PM until 6:20PM 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 10/04/2022 regarding allegations in the area of: resident care and related services. 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 Jennifer Stokes, Licensing Inspector at (540) 589-5216 or by email at jennifer.stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 9, 2022Complaint survey2 violations
Inspection dates
09/09/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 09/09/2022 12:20PM through 1:35PM 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 09/09/2022 regarding allegations in the areas of: administration and administrative services and buildings and grounds. An exit meeting will be conducted to review the inspection findings. 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. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on observation and staff interview, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department.
Evidence
  1. Interview with staff 1 during on-site complaint inspection on 09/09/2022 revealed that he and his wife had been staying in room E29 located in the facility’s safe, secure unit. Staff 1 informed the licensing inspector, and the licensing inspector received confirmation from staff 2, that staff 1 had been informed by a corporate staff member that it was okay that they stay at the facility. Staff 1’s wife is not an employee of the facility. Interview with staff 2 on 09/09/2022 revealed that staff 1 and his wife had been staying in room E29 since 09/06/2022.
Plan of correction
Staff 1 since then has been terminated.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior of the building was maintained in good repair and kept clean.
Evidence
  1. The ceiling in room E29 contained a large brown stain to the left of the entry door into the room.
  2. The floor around the toilet in resident 1’s bathroom contained a dark colored stain and was wet. This was observed by staff 2.
  3. On the floor in front of resident 2’s bed there was a pile of food crumbs and a plastic white fork. This was observed by staff 2.
  4. A bed side rolling table located in resident 3’s room contained a pair of black socks, a pair of pants and white napkins. When the licensing inspector got close to the items on the table, multiple small gnats started flying from the items which was also observed by staff 2.
Plan of correction
The ceiling in room E29 is currently being repaired and fixed by the maintenance director. The floor around the toilet in resident l's bathroom has been cleaned and fixed by housekeeping and maintenance and will be cleaned every day by housekeeping. The floor by resident 2's bed was cleaned up by housekeeping, we do a room sweep twice a week to maintain cleanliness. Resident 3's room was cleaned and sanitized and will be added one of the rooms they deep clean every day they come in.
September 2, 2022Complaint survey2 violations
Inspection dates
09/02/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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 (inspection was also performed in conjunction with local adult protective services): 09/02/2022 1:00PM until 2:00PM 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 08/18/2022 regarding allegations in the areas of: admission, retention and discharge of residents and resident care and related services. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the medicine container that is used for storage of medications and dietary supplements prescribed for residents was locked.
Evidence
  1. During on-site inspection on 09/02/2022 at approximately 1:01PM, the licensing inspector (LI) and Collateral 1 observed an unlocked medication cart located in the facility’s assisted living building in the dining room and no medication staff were observed near the cart. While the LI and Collateral 1 were standing near the unlocked medication cart, staff 1 walked into the dining room and stated that she was the staff who left the medication cart unlocked and unattended.
Plan of correction
Staff 1 written up and given a verbal warning and education about medication carts being locked and closed. Will be monitoring medication carts twice a week.
22VAC40-73-680-B
Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to a resident.
Evidence
  1. During on-site inspection on 09/02/2022 at approximately 1:01PM, the licensing inspector (LI) observed a white, paper pill cup sitting on top of a medication cart located in the facility’s assisted living building in the dining room with two pills (one white and oblong and one white and round). Staff 1 stated the two pills were for resident 2.
Plan of correction
Staff 1 written up and given a verbal warning and education for leaving 2 pills unsupervised on top of the medication cart. Will be monitoring twice a week.
July 26, 2022Complaint survey5 violations
Inspection dates
07/26/2022, 08/02/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: 07/26/2022 2:10AM through 3:00AM & 08/02/2022 9:40AM through 10:45AM 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 07/19/2022 regarding allegations in the areas of: staffing and supervision, resident care and related services, and additional requirements for facilities that care for adults with serious cognitive impairments. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1130-A
Based on staff interviews and a review of facility daily assignment sheets and employee time sheets, the facility failed to ensure that at least two direct care staff members were awake and on duty at all times in the special care unit when 20 or fewer residents are present.
Evidence
  1. In an interview conducted by two LI’s on 07/26/2022 with staff 3, it was expressed that staff 9 was the only direct care staff member on duty in the special care unit from 12:00pm until 3:00pm on 07/23/2022.
  2. On the day of inspection the licensing inspectors (LI’s) requested staff time sheets that included 07/23/2022. Documentation on the time sheets shows that staff 9 clocked in at 11:45am on 07/23/2022. Staff 2 clocked out at 12:15pm and staff 1 clocked out at 12:30pm on 07/23/2022. Staff 9 was the only direct care staff member on duty on the special care unit from 12:30pm until 4:00pm.
Plan of correction
Written disciplinary action for staff 1 and 2 completed as indicated. Facility meal program initiated free of charge for overnight personnel. Review of designated break and smoking areas that are within their assigned work areas. These policies will be reviewed by the HR Director for all new hires during orientation. Regional designees (staff 12 and 13) met with staff #4 to review responsibilities of the administrator of record. New executive director commences employment by October 1, 2022 and will monitor plan of correction to ensure ongoing compliance. Master schedule reviewed with staffing coordinator and administrator no less than weekly. Company approval for overtime and utilization of external agencies has been granted while recruitment efforts continue. Three current CNAs enrolled in RMA class in September. Five managers currently enrolled in DCA training that is scheduled to be completed no later than 9/30/2022. Utilization of managers for direct care will be an emergency contingency plan to maintain minimum staffing requirements. All staffing emergencies are to be reported to administrator and regional designees in real time. Staffing patterns reviewed no less than 5 times a week during morning stand up meeting. A minimum of one regional designee will participate in daily meetings. Administrator of record conducted meetings with management team, medication techs and care givers to review violation notices dated 7/26 and 8/2/2022.
22VAC40-73-1130-C
Based on observations made during an on-site visit and staff interviews, the facility failed to ensure that at least 2 direct care staff members were awake and on duty at all times in the special care unit when 22 or fewer residents are present.
Evidence
  1. At 2:15am on 07/26/2022, one licensing inspector (LI) entered the facility’s special care unit and observed that only one direct care staff member was present on the special care unit with 16 residents currently in care. Another LI observed that staff 1, who was scheduled to be on duty in the special care unit, was sitting in a car smoking across the street at the Morningside (assisted living) building.
  2. Interviews conducted by two LI’s with multiple staff on 07/26/2022 expressed that staff 1 has frequently left the special care unit during their scheduled 7pm to 7am shifts, leaving only one direct care staff member present to provide care to residents residing in the special care unit.
  3. In an interview conducted by two LI’s on 07/26/2022 with staff 3 it was expressed that they had been made aware sometime in the past several weeks of staff 1 leaving the special care unit during their shift. Staff 1 voiced that they had talked to staff 1 about not leaving the special care unit when only 2 direct care staff members are present but could not remember exactly when this conversation took place. Staff 1 also expressed that they had made the facility administrator aware.
  4. In an interview conducted by two LI’s on 07/26/2022 with staff 4, and in the presence of staff 5, it was expressed by staff 4 that they were aware of staff person 1 leaving the special care unit during their scheduled shifts, leaving only one direct care staff member on duty on the unit, but as of the date of this inspection they had not addressed it.
Plan of correction
Regional designees (staff 12 and 13) met with staff3 and 4 regarding minimum staffing requirements. Staff 3 and 4 understand the significance of their responsibilities with staffing coverage and escalating challenges to regional designees in real time. Master schedule reviewed no less than weekly in morning stand up meetings with the regional office. DCA and RMA classes are scheduled and in progress. Recruitment efforts continue with favorable results. Staff referral incentives initiated, salary adjustments for hourly employees completed to bring our wages above the fair market value. Company continues to approve overtime and external agency use. Monitoring systems and staff responsibility same as outlined above in 1130-C.
22VAC40-73-150-C
Based on observations made during an on-site visit and staff interviews, the administrator failed to be responsible for the general administration, management and oversight for the day-to-day operations of the facility to include implementing all policies, procedures and services as required.
Evidence
  1. At 2:15am on 07/26/2022, one licensing inspector (LI) observed staff 1 and 2 outside of the Morningside (assisted living) building. Staff 1 was supposed to be on duty in the facility’s Peaksview (special care unit) building and staff 2 was supposed to be on duty in the facility’s assisted living building.
  2. Interviews conducted by two LI’s with multiple staff on 07/26/2022 expressed that staff 1 frequently leaves the assisted living building and staff 2 frequently leaves the special care unit during their scheduled 7:00PM to 7:00AM shifts, leaving only one direct care staff member present to provide care to residents residing in the assisted living building and the special care unit building.
  3. In an interview with staff 4 on 07/26/2022 it was expressed that she was aware of the situation but was not aware of disciplinary actions that she could conduct with staff 1 and 2. When staff 4 was questioned if she had informed corporate of the situation she stated that she had not.
Plan of correction
Written disciplinary action completed for staff 1 and 2; counseling session included the responsibilities of direct care staff. Facility meal program initiated free of charge for overnight personnel. Review of designated break and smoking areas that are within their assigned work areas. These policies will be reviewed by the HR Director for all new hires during orientation. Regional designees (staff 12 and 13) met with staff #4 to review responsibilities of the administrator of record. New executive director commences employment by October 1, 2022 and will monitor plan of correction to ensure ongoing compliance. Administrator of record will submit written report to regional office no less than monthly confirming status of compliance. Any subsequent employee violations of this nature will be escalated to regional designees in real time for guidance with disciplinary action.
22VAC40-73-680-I
Based on a review of resident medication administration records (MARs), narcotic count logs and staff interviews, the facility failed to ensure that all required information was documented on resident MARs.
Evidence
  1. The June 2022 MAR for resident 1 contained documentation that staff 3 had administered the resident Hydrocodone at 8:00PM on 06/11/2022 and 06/12/2022. Interview with staff 3 revealed that she did not administer the medication because it was not available in the facility and that she was unable to circle or document the medication as not administered on resident 1’s MAR as required because the facility E-MAR system will not allow changes in the E-MAR system once a medication has been documented as administered.
Plan of correction
Counseling session with staff#3 conducted to review medication management standards as it relates to medication availability. Staff #3 did facilitate hard script for resident #l's controlled substance. Staff #3 in-serviced on the fact that a narrative entry in the resident's medical record is acceptable for supporting documentation. DON conducted in-service with all medication techs to review violation notice. Training provided to all med techs on standard of practice with narrative entry in medical records as it pertains to challenges with medication availability. Notation in medical record to include physician and responsible party notification as applicable. DON and/or designee will monitor pharmacy dashboard no less than weekly for oversight of any missed medication doses. Regional nurse will monitor for ongoing substantial compliance during on site and/or monthly remote visits. Nurse Consultant with preferred pharmacy provider will monitor no less than quarterly with health care oversight visits.
22VAC40-73-1020-A
Based on document review and staff interview, the facility, which consists of a mixed population of residents, failed to ensure that when residents are present, there are at least two direct care staff members awake and on duty at all times in each building who shall be responsible for the care and supervision of the residents.
Evidence
  1. At 2:15AM on 07/26/2022, one licensing inspector (LI) observed staff 2 outside of the Morningside (assisted living) building along with staff 1. Staff 2 was scheduled to be on duty in the assisted living building. Interviews conducted by two LI’s with multiple staff on 07/26/2022 expressed that staff 2 has frequently left the assisted living building during their scheduled 7:00PM to 7:00AM shifts, leaving only one direct care staff member present to provide care to residents residing in the assisted living building.
  2. During on-site visit on 07/26/2022, staff 10, who was on-duty in the assisted living building from 7:00PM to 7:00AM, revealed to two LIs that she was going across the road to the Peaksview (special care unit) building to administer resident 2’s scheduled morphine every two hours because she was the only registered medication aide (RMA) on duty therefore leaving only one direct care staff in the building if staff 2 was present and on-duty in the assisted living building at the time.
  3. Interview with staff 3 and 4 on 08/02/2022 revealed and confirmed that residents 3, 4 and 5 would not be able either physically and/or mentally to protect themselves from danger and/or be able to exit the facility on their own, either physically and/or mentally, in case of an emergency such as a fire. Therefore, the facility serves a mixed population of residents.
  4. The uniform assessment instrument (UAI) for resident 3, dated 05/11/2022, indicates that the resident is disoriented – some spheres, all the time to the following spheres: time, place and situation. The “Report of Resident Physical Examination” for resident 3, dated 06/04/2017, lists “Alzheimer’s Dementia” for “significant medical history” and “diagnosis or significant problems”.
  5. The UAI for resident 4, dated 10/28/2021, indicates that the resident is disoriented – some spheres, some of the time to place.
  6. The UAI for resident 5, dated 09/13/2021, indicates that the resident has a history of dementia. The “Report of Resident Physical Examination” for resident 5, dated 09/30/2016, lists “Dementia” for “significant medical history”. The individualized service plans (ISPs) for resident 3, dated 05/11/2022; resident 4, with a review date of 07/21/2022; and resident 5, with a review date of 06/05/2022, indicates that the orientation for residents 3, 4 and 5 is “Confusion/forgetfulness (short term/long term memory impairments) Resident will be redirected & reoriented with verbal, physical, &/or written reminders as needed & structure & supervision will be provided. Staff will re-direct and orient resident during periods of confusion.”
  7. Interview with staff 3 on 07/26/2022 revealed that she (staff 3) was the only direct care staff member in the assisted living on duty from 7:00AM until 7:00PM on 07/23/2022.
Plan of correction
Written disciplinary action completed for staff# 1 and 2; counseling session included the review of the responsibilities of direct care staff. Break times and location of designated break areas reviewed. Master schedule reviewed with staffing coordinator and administrator no less than weekly. Company approval for overtime and utilization of external agencies has been granted while recruitment efforts continue. Three current CNAs enrolled in RMA class in September. Five managers currently enrolled in DCA training that is scheduled to be completed no later than 9/30/2022. Utilization of managers for direct care will be an emergency contingency plan to maintain minimum staffing requirements. All staffing emergencies are to be reported to administrator and regional designees in real time. Staffing patterns reviewed no less than 5 times a week during morning stand up meeting. A minimum of one regional designee will participate in daily meetings.
July 15, 2022Complaint survey6 violations
Inspection dates
07/15/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: July 15, 2022 12:00PM until 2:00PM and July 19, 2022 10:30AM until 12:00PM 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 07/11/2022 regarding allegations in the area of resident care and related services. 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 resident care and related services. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-870-B
Based on observation of a resident’s room, the facility failed to ensure that all buildings were free from foul and stale odors.
Evidence
  1. On date of on-site inspection at approximately 12:20PM, the licensing inspector (LI) along with Collateral 1 and staff 1 noted a strong smell of urine upon entering resident 3’s room.
Plan of correction
Resident #3 room was disinfected; soiled linens removed, and laundry done. Odor subsided on completion. Housekeeping and laundry standards reviewed with housekeeping supervisor and memory care staff.
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required.
Evidence
  1. The UAI for resident 2, dated 10/13/2021, indicated that the resident does not require assistance with bathing; however, interview with staff 5 on 07/15/2022 revealed that the resident does require human assistance with bathing in the form of “cueing” to ensure that the resident has showered. This was also noted by Collateral 1 and staff 1.
Plan of correction
UAI’S and ISPs for residents #1, #2 & #3 were reviewed and updated according to resident need.
22VAC40-73-780-B
Based on observation of a resident’s room, the facility failed to ensure that bed linens were changed as needed.
Evidence
  1. At approximately 12:27PM on date of inspection, the licensing inspector along with Collateral 1 and staff 1, 6 and 7 noted that the fitted sheet on resident 3’s bed contained multiple stains and the resident’s pillow did not have a pillow case.
  2. Also, at approximately 12:57PM a balled up washcloth was observed by the LI, Collateral 1 and staff 1, 6 and 7 in resident 2’s shower that contained a brown substance.
Plan of correction
Residents bed for #2 and #3 were disinfected. Soiled linens were discarded. Laundry standards were reviewed with housekeeping supervisor and memory care staff. Carriage Hill Retirement will enter into an agreement with a third-party provider for linen services for sheets, pillowcases, towels, and washcloths before August 31, 2022.
22VAC40-73-460-H
Based upon resident record review and staff interview, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met including assistance with bathing at least twice a week.
Evidence
  1. The uniform assessment instrument (UAI), dated 03/25/2022, and the individualized service plan (ISP), dated 03/25/2022, for resident 1 indicate that the resident needs mechanical and human physical help and that “staff will provide (resident 1) complete assistance with bathing and getting in/out of shower safely”. The licensing inspector (LI) requested documentation of resident’s showers and was provided “Skin Monitoring: Comprehensive CNA Shower Review” sheets on 07/15/2022 and additional information provided to the LI by staff 4 on 07/19/2022 which indicated the following: during the week of 06/05/2022 through 06/11/2022 there was no documentation that the resident received any showers, during the time period of 06/19/2022 through 07/02/2022 there was no documentation that the resident received any showers and during the time period of 07/03/2022 through 07/19/2022 there was documentation that indicated the resident received only one shower.
  2. The UAI for resident 2, dated 10/13/2021, indicated that the resident does not require assistance with bathing; however, interview with staff 5 on 07/15/2022 revealed that the resident does require human assistance with bathing in the form of “cueing” to ensure that the resident has showered. The licensing inspector (LI) requested documentation of resident’s showers and was provided “Skin Monitoring: Comprehensive CNA Shower Review” sheets on 07/15/2022 which indicated the following: during the week of 06/12/2022 through 06/18/2022 there was no documentation to show that the resident had received any showers and during the time period 06/19/2022 through 07/02/2022 there was documentation that the resident only received two showers.
  3. The UAI for resident 3, dated 04/18/2022, indicated that the resident requires human physical help with bathing, and the ISP for the resident, dated 04/18/2022, indicated that “staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able.” The licensing inspector (LI) requested documentation of resident’s showers and was provided “Skin Monitoring: Comprehensive CNA Shower Review” sheets on 07/15/2022 which indicated the following: During the week of 06/19/2022 through 06/25/2022 there was documentation that the resident only received one shower and during the time period 07/03/2022 until 07/15/2022 the resident had only received one shower. During additional on-site visit on 07/19/2022, staff 4 did not provide additional documentation to the LI regarding showers/bathing for residents 2 and 3.
Plan of correction
Skin monitoring/ shower review forms will be submitted to the DON or med tech designee at the end of scheduled shift. DON or med tech will make an entry in 24-hour report confirming shower has been completed. Any refusal will be documented in the 24-hour report notation. DON met with nursing staff to review new process.
22VAC40-73-870-E
Based on observation of residents’ rooms, the facility failed to ensure that all furnishings, including furniture and toilets, were kept clean.
Evidence
  1. On date of on-site inspection at approximately 12:25PM, the licensing inspector (LI) along with Collateral 1 and staff 1 noted that the chair in resident’s 3 room contained a white sheet that had been folded up on top of the cushion. Upon removing the sheet from the chair’s cushion, it was noted that the cushion of the chair contained dried feces. This was observed by staff 1, 6 and 7 and Collateral 1.
  2. At approximately 12:57PM, the LI along with Collateral 1 and staff 1, 6 and 7 noted that the toilet in resident 2’s room contained a brown substance on the outside of the toilet.
Plan of correction
Staff #7 terminated 07/15/2022. Resident rooms for #2 and #3 were deep cleaned and properly disinfected. Routine wellness checks for memory care residents will include spot checking of the resident’s room and furnishings. Housekeeping standards reviewed with housekeeping supervisor and memory care staff.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contained the following physician’s order dated 05/12/2022: “start Novolog 10 units TID (three times daily) w/ meals. Hold Novolog if eats less than 50% of meals and hold Novolog if mealtime BS (blood sugar) less than 150”. The June 2022 medication administration record (MAR) for resident 1 indicated that on 06/23/2022 the resident’s blood sugar at 5:00PM was 124 and on 06/29/2022 the resident’s blood sugar at 5:00PM was 125; however, the June 2022 MAR indicated that the resident was administered Novolog by staff 3 on 06/23/2022 at 5:00PM and by staff 2 on 06/29/2022 at 5:00PM. Also, the June MAR indicated the resident’s blood sugar at 8:00AM on 06/07/2022 was 187 and there was no documentation to show the percentage the resident ate of his meal and staff 2 did not administer Novolog to the resident on 06/07/2022 at 9:00AM. The July 2022 MAR for resident 1 indicated that on 07/09/2022 the resident’s blood sugar at 12:00PM was 125 and on 07/14/2022 the resident’s blood sugar at 12:00PM was 125; however the resident was administered Novolog on both of these dates/times by staff 2. The July 2022 MAR for the resident indicated that on 07/01/2022 the resident’s blood sugar at 5:00PM was 380 and that the resident had eaten 100% of his meal; however, staff 4 did not administer the resident’s Novolog due to “Other: blood sugar <150” on 07/01/2022.
  2. The record for resident 1 contained the following physician’s order dated 05/12/2022: “start Lantus 66 unit every AM (morning). Hold Lantus if fasting (pre breakfast) BS (blood sugar) is < (less than) 150.” The June 2022 MAR for the resident indicated that on 06/13/2022 at 8:00AM the resident’s blood sugar was 125; however staff 2 administered the resident Lantus at 8:00AM on 06/13/2022. Also, on 06/03/2022 at 8:00AM the resident’s blood sugar was 170; however staff 4 did not administer the resident Lantus due to “other: bs <150” on 06/03/2022. The July 2022 MAR for the resident indicated that on 07/11/2022 at 8:00AM the resident’s blood sugar was 101; however staff 2 administered the resident Lantus at 8:00AM on 07/11/2022. Also, the on 07/14/2022 at 8:00AM the resident’s blood sugar was 127; however staff 2 administered the resident Lantus at 8:00AM on 07/14/2022.
Plan of correction
DON/Acting administrator and HR director met with staff #3 to review findings of 07/15/2022 violation notice. Written counseling completed and on file. Dr. Bell notified of errors with insulin administration and documentation of meal consumption.
June 24, 2022Complaint survey5 violations
Inspection dates
06/24/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 06/24/2022 through 06/30/2022 8:20AM through 12:30PM. 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 06/23/2022 regarding allegations in the areas of: staffing/personnel and resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on document review, resident record review, and staff interview the facility failed to implement their medication management plan.
Evidence
  1. The facility’s medication management plan provided to the licensing inspectors on the day of inspection indicated the following: “4. Methods to ensure that each resident’s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Daily procedures for refill request: refills need to be faxed to pharmacy daily. If refill is needed immediately, please call and fax the pharmacy with order so delivery can be made as soon as possible. All controlled medications, PRN medications or treatments should be re-ordered when there is a five (5) day supply left.” The May and June 2022 medication administration record (MAR) for resident 1 has a physician order for Morphine Sulf ER Tab 30mg, take one tablet by mouth three times a day for pain. Staff initials are circled as not administering this medication at 10pm on 05/23/2022 and at 6am on 05/24/2022 with documentation that it was not administered due to “doctor order”. Staff initials are circled as not administering this medication at 6am on 06/24/2022 with documentation that the medication was not administered due to “other ord”. In an interview with staff 1 in the presence of staff 2 this documentation indicates that the medication was unavailable and that they were waiting for the medication to be delivered from the pharmacy.
  2. The facility’s medication management plan also indicated the following: “No less than daily, the outgoing and incoming RN, LPN, or RMA authorized to administer medications will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate. DON and/or charge nurse will monitor daily.” During on-site inspection on 06/24/2022, staff 1 was the staff person who had possession of the keys to medication carts A, B, C, and D and had taken possession of the keys to all the medication carts from staff 5 at the end of staff 5’s shift. Interview with staff 1 revealed that she did not count the controlled narcotics with staff 5 and also did not sign the “Shift to Shift Narcotic Count Sign Off Sheet” for the medication carts. This was also noted by staff 2. The “Shift to Shift Narcotic Count Sign Off Sheet” for Cart A did not contain the signature of the staff for “7A-7P” off shift on 06/23/2022. The “Shift to Shift Narcotic Count Sign Off Sheet” for Cart B did not contain the signature of the staff for “7A-7P” off shift on 06/22/2022. The “Shift to Shift Narcotic Count Sign Off Sheet” for Cart C did not contain the signature of the staff for “7P-7A” on shift and “7P-7A” off shift for the dates of 06/20/2022 and 06/22-23/2022.
Plan of correction
DON will ensure RMAs are trained on proper documentation to identify when resident is out of the facility either for an extended pain management visit or being sent to the ER due to a fall or emergency. DON will monitor NARC sheet and EMAR to ensure dates when resident is out of the facility properly documented. DON or designee will conduct random audits throughout the week.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that all medications were administered in accordance with physician’s instructions.
Evidence
  1. The record for resident 1 has a physician order dated 05/09/2022 to “Please have Med Tech/LPN witnessed when administering controlled substances. Both Med Tech and witness need to sign”. On the day of inspection, it was noted that there is no documentation of a witness signing when a controlled substance was administered to resident 1. In an interview with staff 1 conducted in the presence of staff 2 it was expressed that the administration of controlled substances to resident 1 is not always being witnessed as per the physician order dated 05/09/2022.
Plan of correction
A tool for documenting two witness signatures was created and it's in use.
22VAC40-73-680-I
Based on resident record review, facility documentation, and staff interviews, the facility failed to ensure that all required information was documented on resident medication administration records (MARs).
Evidence
  1. The narcotic count log for resident 1’s prescribed Morphine Sulf ER 30mg tablets was reviewed on the day of inspection and a discrepancy was noted with the count of the medication. In a phone interview conducted in the presence of staff 1 and 2 with staff 3 ,it was explained that on 06/23/2022 at 2pm staff 3 signed resident 1’s June 2022 MAR for the administration of his prescribed Morphine Sulf ER 30mg. The medication was not administered because resident 1 was out of the building. Staff 3 expressed that they were unable to circle or document the medication as not administered on resident 1’s June 2022 MAR as required because the facility E-MAR (electronic medication administration record) system will not allow changes in the E-MAR system once a medication has been documented as administered.
Plan of correction
Staff on duty could not reverse documentation on EMAR. Inability to reverse EMAR activities is for accountability. Staff has been educated on the importance of notifying supervisor and properly documenting in nurses progress notes if such an incident reoccurs.
22VAC40-73-680-E
Based on observation, resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented.
Evidence
  1. The record for resident 1 contained a physician’s order, dated 06/23/2022, for the following: “Tubi grips RLE. Apply in AM and remove @ suppertime.” On day of inspection, one licensing inspector observed the resident not wearing Tubigrips throughout the morning. This was also observed by staff 6 at approximately 11:30AM.
Plan of correction
Physician order was written in less than 24 hours before inspection. Facility will continue to anticipate need when pharmacy is unable to make delivery. Facility will invest on emergency supplies.
22VAC40-73-200-C
Based on staff record review and staff interview, the facility failed to ensure that staff that provide direct care met one of the requirements.
Evidence
  1. During on-site inspection on 06/24/2022, a phone interview was conducted with staff 3 in the presence of staff 1 and 2. Staff 3 revealed that on 06/23/2022 during her shift staff 4 assisted her in transferring resident 1 off the toilet back into his motorized chair and that the resident is a two person assist. Interview with staff 1 and 2 confirmed that staff 4 does not have the required direct care training and staff 1 confirmed that the resident is a two person assist.
Plan of correction
Facility has employed staffing agency to support direct care staff. System and provisions have been put in place to train non-direct care staff in direct care training.
June 24, 2022Complaint survey0 violations
Inspection dates
06/24/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 06/24/2022 from 8:20 AM through 12:30 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 06/22/2022 regarding allegations in the area(s) of: resident care and related services. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 13, 2022Inspection11 violations
Inspection dates
06/13/2022
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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 06/13/2022 from 9:00AM until 5:30PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication passes, noon-time meal in the facility’s assisted living building, medication cart audits for four medication carts in the facility’s assisted living building and one medication cart in the facility’s safe, secure unit. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on resident record review, the facility failed to ensure that an annual fall risk rating was completed for residents who are assessed as assisted living level of care.
Evidence
  1. The uniform assessment instrument (UAI) dated 08/28/2021 in the record for resident 2 has documentation that the resident is assessed at an assisted living level of care. The record for resident 2 has documentation that the last annual fall risk rating was completed on 05/02/2021. An interview was conducted with staff 3 and 8 in which staff 8 expressed that they did not have any other place where fall risk ratings are kept and that all fall risk ratings are placed in resident records. As of the end of the exit meeting conducted on the day of inspection, a current fall risk rating for resident 2 was not made available for the LI to review.
Plan of correction
Resident 2 fall ratings was done on January 6th 2022, and it’s now on file. Director of nursing will ensure chronological arrangement of documents. Facility will keep a separate record to track fall risk ratings to minimize reoccurrence.
22VAC40-73-150-C
Based on resident record review and observations of the facility physical plant, the administrator failed to be responsible for the general administration, management and oversight for the day-to-day operations of the facility to include implementing all policies, procedures and services as required.
Evidence
  1. The record for resident 6 contained documentation in progress notes of the resident smoking in the building on 03/13/2022, 03/14/2022, 03/19/2022, 04/27/2022, 06/09/2022 and 06/12/2022.
  2. Observations made by 2 LI’s on the day of inspection of the room for resident 6 noted cigarette ashes on the window sill and cigarette ashes on the bathroom floor. The room was noted to smell of cigarette smoke.
  3. The record for resident 6 has documentation of a” Rental Agreement Assisted Living/Memory Care” that was signed by resident 6 and the facility administrator on 03/10/2022. Documentation on page 12 of this agreement indicates “The residents/responsible party acknowledges and agrees “The Company” has a smoke and drug free environment policy (this includes but is not limited to e-cigarettes, vaporizers, pipes or other assistive smoking devices), which includes all interior areas. “The Company” vehicles. Smoking shall only be permitted in designated exterior areas. The Resident/Responsible Party agrees to make arrangements to vacate the resident’s apartment upon notification if the smoke environment policy has been violated by Resident/Responsible Party, members of their family, guests, agents and or employees of the Resident/Responsible Party. If the smoke environment policy is violated by Resident/Responsible Party or Resident/Responsible Party’s family, guests, agents or employees, the Company may terminate this agreement and require Resident to vacate the Premises.”
  4. A renewal study completed at the facility on 11/30/2021 and resulted in 31 violations in the areas of administration and administrative services, personnel, admission, retention and discharge of residents, resident care and related services, resident accommodations and related provisions, buildings and grounds, criminal background checks and sworn disclosure and a provisional license was issued effective 01/01/2022. Repeat violations have been cited in the areas of resident care and related services and building and grounds from complaint investigations, monitoring visits and a renewal study completed during this current licensure period.
Plan of correction
An unbiased analysis of the facility has been made which shows that there is need for repairs, renovation, upgrade of appliances and furniture, HVAC replacement, and sprinkler flushing which commensurate with the needs of a 35 years old building as opposed to attributing such needs to the failure of the administrator or personnel’s responsibility. Resident 6 smoking assessment has been done and her discharge process has been initiated per facility rental agreement. The 11/30/21 annual inspection has a record number of violations cited overturned in the history of Carriage Hill after first and second desk review due to those violations nor correctly cited. With the help of corporate office all the needs and projects required for upgrade of the physical plant has been approved. The facility is recovering from the impact of COVID-19 shutdown on staff shortage, staff burn out, and residents’ well-being. The company has approved and scheduled capital expenditure. Additionally, a team of regional directors will be providing support for operation, clinical reviews, human resources, business office oversight. Regional human resource department has trained facility human resources on how to tidy staff record. A director of nursing, and a unit coordinator and compliance has been employed to provide support to the administrator. Weekend incentives has been introduced by the administrator which has boosted staff renumeration and morale for work. A psych practitioner has been hired by the administrator to support facility physician and to also provide services for facility psych population. Areas of repeat violations has been aggressively addressed and staff educated on severity and consequences that entails violating company policies. Educational consultant and other healthcare consultants have been employed by the facility for support.
22VAC40-73-860-I
Based on observation during tour of the physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 9:56 AM, one licensing inspector (LI) found the door unlocked to room 38 that contained three cleaning carts. The following chemicals were found in the room: 401K organic acid bowl cleaner, Great Value Linen Fresh Odor Eliminator, Conqueror Odor Counteractant cleaner, and two clear, plastic spray bottles with an unknown substance.
  2. At 9:34AM one LI observed that the door to the housekeeping closet on the memory care unit was not locked. Various cleaning agents including Great Value Bleach, Multi-Surface and Glass Cleaner, Monogram Stainless Steel Cleaner, LaBamba Multipurpose Cleaner, Lysol Power Toilet Bowl Cleaner and Clorox Scentiva Disinfecting Cleaner were observed sitting out on shelfs in the housekeeping closet.
Plan of correction
The facility has relocated cleaning materials in the memory care unit and other units properly secured. All unit have been properly secured. Housekeeping and maintenance directors will routinely monitor chats, materials, and staff diligence on all shifts.
22VAC40-73-880-C
Based on observation during tour of the physical plant, the facility failed to ensure that temperatures in all areas used by resident did not exceed 80 degrees Fahrenheit.
Evidence
  1. At approximately 4:08PM through 4:13PM during on-site inspection on 06/13/2022, it was noted by one licensing inspector (LI) and staff 7 and 8 the following in the facility’s assisted living building: in the lobby of the facility a clock that was located on the wall behind the receptionist’s desk displayed the temperature as 81.5 degrees Fahrenheit, the thermostat located outside the kitchen door in the dining room displayed the temperature as 82 degrees Fahrenheit and the thermostat located on C hall of the facility displayed the temperature as 81 degrees Fahrenheit.
Plan of correction
Facility procured two units of HVAC to common areas. Maintenance department has a service plan to monitor common areas and rooms which ensures areas used by residents does not exceed 80F. Witt Mechanical has been working with the facility and quotation was made available to license inspector during inspection and completion of work that was delayed due to parts late delivery has been completed once parts was delivered. Witt Mechanical confirmed parts delivered, and work completion date confirmed. Temperature log for common areas has been put in place to monitor and ensure compliance.
22VAC40-73-870-E
Based on observations made of the facility physical plant, the facility failed to keep all furnishings, fixtures and equipment clean and in good repair.
Evidence
  1. A dried brown substance was noted on the toilet in room 12 on the memory care unit.
  2. The mattress and box springs on the bed in room 22 of the memory care unit were noted to be soiled.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on observation during tour of the physical plant, resident interview and resident record review, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The record for resident 12 contained a uniform assessment instrument (UAI), dated 06/04/2022, which indicated the resident needs his medication administered/monitored by lay person (RMA/Nurse). The UAI also indicated that the resident is orientated to all spheres at all times.
  2. Regarding the duties of registered medication aides (RMAs) when providing assistance with oral medication administration, section 4.2 of the Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, revised 05/21/2021, pages 122-123 state the following: “11. Stay with the client until he/she has swallowed the medications (check mouth PRN).”
  3. At approximately 9:47AM during on-site inspection on 06/13/2022, one licensing inspector (LI) observed a plastic medication cup with applesauce and seven pills (one brown/dark colored pill, one red pill and five white pills) sitting on the bed in resident 12’s room. Interview with resident 12 revealed that the pills were his morning medications and that staff 3 had brought him the pills earlier on date of on-site inspection on 06/13/2022 and left them in his room. The medications were also observed by staff 8. The June 2022 medication administration record (MAR) for resident 12 indicates that staff 3 was the registered medication aide (RMA) that administered the medications to resident 12 on 06/13/2022 at 8:00AM.
Plan of correction
Facility notified resident physician who reviewed and made recommendations. Staff involved was counselled on the severity of her action and went through facility counselling and write up protocol. The director of nursing and administrator will continue to educate staff on compliance and conduct random room check after med pass.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair and kept clean and free of rubbish.
Evidence
  1. At approximately 10:06AM during on-site inspection on 06/13/2022, one licensing inspector (LI) observed room 21 with multiple Equal packets, multiple empty Oreo packages beside the resident’s bed, plastic cups containing water on the floor, the trash can overflowing with incontinence supplies and the sheets on the resident’s bed contained multiple small spots of a brown substance. At approximately 11:29AM when the LI went back into room 21, the resident’s sheet were still dirty and the LI observed the plastic mattress cover has having a multiple brown substances as the flat sheet on the bed had been pulled back.
  2. Stains were noted on the carpet in room 12 on the memory care unit.
  3. The plastic strip on the floor between the dining room and sitting room in the memory care unit was noted to be loose and coming up from the floor on both ends of the strip.
  4. The light switch plate in the bathroom of room 15 on the memory care unit was noted to be missing all screws and the electrical wiring was visible behind the switch plate. Also, the light switch plate in the bathroom of resident 6’s room was noted to be missing.
  5. A large area of water, food and other debris was observed on the floor around the drain in the kitchen on the memory care unit. Interviews with staff expressed that when the dishwasher is used water and food flow up from the drain.
  6. The LI observed at 9:25am multiple areas of food, liquid spills, and other dried substances on the dining room floor and dining tables. Interviews with staff expressed that breakfast was served at 8:00am and that at the time of observation, the dining room had not been cleaned.
  7. The ceiling in the hallway by the exit doors on the right side of the Mountainside dining room was noted to have an area of peeling paint/tape.
Plan of correction
Facility wide renovation and refurbishment of old structure, parts, and HVAC system is on-going. Housekeeping and maintenance department were educated on the severity of compliance. A systemic twice-daily routine rounds by housekeeping staff was put in place to monitor and keep troubled rooms or rooms suspected to have hoarding features for regular upkeeping. An expedited plan was coordinated with regional director of operations and maintenance director to facilitate the completion of painting, repairs, and HVAC system replacement.
22VAC40-73-870-B
Based on observation during a tour of the physical plant, the facility failed to ensure the building was free from foul and stale odors.
Evidence
  1. At approximately 10:11AM during on-site inspection on 06/13/2022, one licensing inspector (LI) entered resident 13’s room and there was a strong odor of urine present in the resident’s bathroom. This was also noted by staff 8.
  2. A foul odor was noted coming from the kitchen and into the dining room area in the memory care unit at 9:10am on the day of inspection.
Plan of correction
Renovation of troubled rooms and old rooms are on-going. While this reconstruction and renovation are on-going, residents are being relocated. Resident 13 was relocated to a new room immediately. Toilet and bathroom flooring will be replaced, and room painted before the room is available. Facility has a room availability template to monitor rooms that are due for renovation.
22VAC40-73-430-H-1
Based on resident record review, the facility failed to ensure that a discharge statement was retained in resident records.
Evidence
  1. The record for resident 8, who has been discharged from the facility, did not contain documentation of a discharge statement. Interviews with staff 8 and 10 expressed that a discharge statement had not been completed at the time of resident 8’s discharge.
Plan of correction
Staff responsible for keeping discharge information and creating final statement was using a different form for discharge. Staff has been educated on the right form to use. A discharge notice will be sent to the discharged resident.
22VAC40-73-100-C-2
Based on observation during medication cart audit, the facility failed to ensure that infection control policies that are consistent with the Centers for Disease Control and Prevention (CDC) recommendations were followed.
Evidence
  1. The facility’s infection control policy provided during on-site inspection on 06/13/2022 included the following statement: “11. Ensure the blood glucose meter is cleaned and disinfected after use according to manufacturer’s recommendations and stored appropriately (i.e., in a storage case, labeled with the patient’s name if dedicated for individual use).”
  2. The glucometer for resident 10 was observed in the storage case for resident 11’s glucometer and the glucometer for resident 11 was observed in the storage case for resident 10’s glucometer during audit of medication cart B. This was also observed by staff 4.
Plan of correction
The facility ensured glucometers where correctly stored. Facility will continue to observe chart audit and educate RMAs on maintaining all facility’s medication management policy. Facility did inservices on recent violations and medication management policy.
22VAC40-73-680-M
Based on observation during medication cart audit, the facility failed to ensure that medications ordered for PRN (as needed) administration were available at the facility.
Evidence
  1. The record for resident 9 contained a physician’s order, dated 05/12/2022, for Cepacol Extra Strength Lozenges. During medication cart audit, staff 4 revealed that the aforementioned medication was not available at the facility during on-site inspection on 06/13/2022.
Plan of correction
Facility pharmacy sent resident medication to the facility. Resident Care Coordinator will audit PRN orders and medications periodically to ensure Pharmacy’s failure to complete orders is identified at the right time. The DON and administrator will provide layers of supervision to ensure that PRN medication is refilled in a timely manner.
April 29, 2022Inspection0 violations
Inspection dates
04/29/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection: 04/28/2022. This inspection also included a joint investigation with local adult protective services. 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 04/22/2022 regarding allegations in the area(s) of: resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2022Complaint survey4 violations
Inspection dates
04/28/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) for Carriage Hill Retirement, under the supervision of the licensing administrator (LA) and in conjunction with another LI, conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 04/28/2022. The LIs and the LA reviewed one full resident record pertaining to an allegation that the resident needed a higher level of care, a partial record for one resident pertaining to an allegation of a prohibited condition, three residents’ accounting information pertaining to allegations that these residents are not receiving their funds, one previous staff record pertaining to an allegation that one staff was hired that should not have been due to having a criminal record and one LI observed an activity being conducted by staff in regards to an allegation that activities are not being done at the facility. Findings were reviewed with facility staff during the inspection. A preliminary exit interview was conducted with the Administrator, the Director of Nursing and the Regional Director 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. A final exit interview was conducted with the Administrator via phone on 04/29/2022. The information gathered during the investigation does not support the allegation, so the complaint is determined to be “not valid”; however, please review the violation notice to see violations that were cited as a result of the complaint inspection. Please sign, date, and return this notice to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-325-C
Based on resident record review, the facility failed to show documentation of an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls after a resident has a fall.
Evidence
  1. The record for resident 1 contained two “Falls Risk Rating” documents, completed by staff 2, due to the resident having a fall on 02/06/2022 and on 03/23/2022; however, both documents did not show documentation of an analysis of the circumstances of the falls or interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of correction
Appropriate procedures for falls were reviewed with our healthcare team. DON was educated on appropriate documentation and oversight of resident falls as well as appropriate reporting requirements. Fall interventions were reviewed with the team as well. Moving forward, our DON will evaluate each fall, ensure proper documentation and that appropriate interventions are in place.
22VAC40-73-700-1
Based on resident record review, the facility failed to have a valid physician’s or other prescriber’s order that includes the oxygen source such as compressed gas or concentrators.
Evidence
  1. The record for resident 1 contained a physician’s order, dated 01/23/2022, for oxygen; however, the order did not contain the oxygen source.
Plan of correction
The oxygen source was clarified on the physician’s order. Our DON is reviewing physician orders, and overseeing the documentation of them, to ensure the residents chart and all order are complete. Our healthcare team is auditing charts ongoing to ensure full compliance with residents orders.
22VAC40-73-350-B
Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 1 was admitted to the facility on 08/19/2021; however, the record for resident 1 contained documentation that a sex offender screening was not completed for the resident until 08/20/2021.
Plan of correction
Our Regional Marketing Director as well as Administrator, and consultants reviewed the appropriate documentation that is to be completed and the appropriate time frames for which it should be completed with our admissions team. Our Regional Marketing Representative is working with our Admissions team to ensure ongoing compliance with admission documents. New admissions paperwork is being audited by our internal team prior to admission to ensure we are compliant with applicable paperwork needed.
22VAC40-73-650-C
Based on resident record review, the facility failed to ensure physician’s or other prescriber’s orders were reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. The record for resident 1 contained the following document dated 03/29/2022: “Physician orders – Flagyl 250mg tablet. Crush and apply to R (right) thigh wound twice weekly per Hospice SN.” The document did not contain a signature of a physician or other prescriber and this was also noted by staff 2 during the on-site inspection.
Plan of correction
The appropriate signature was obtained on the resident order. All physician orders will contain appropriate documentation to ensure that they are complete. Our healthcare team is auditing charts to ensure full compliance with resident orders. Our DON will oversee physician orders, and documentation in the residents chart to ensure orders are complete.
April 28, 2022Inspection4 violations
Inspection dates
04/28/2022
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Criminal History Record Report
Comments
The licensing inspector (LI) for Carriage Hill Retirement, along with another LI and under the supervision of the licensing administrator (LA), conducted an unannounced, non-mandated inspection on 04/28/2022 from 9:00AM until 2:30PM, finding 60 residents in care. This inspection is the first of two inspections for the facility’s Provisional license. The LIs and the LA reviewed high risk violations that were cited at the facility’s renewal inspection on 11/30/2021 as well as any high risk violations that have been cited this licensure year. A tour of the physical plant for both the assisted living building and the safe, secure building were conducted, four medication carts were audited, resident records were reviewed, four staff trainings were reviewed, criminal record checks for staff hired and staff employed since 12/01/2021 were reviewed and staff and resident interviews were conducted. Findings were reviewed with facility staff during the inspection. A preliminary exit interview was conducted with the Administrator, the Director of Nursing and the Regional Director 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. A final exit interview was held with the Administrator on 04/29/2022 via phone. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-640-A
Based on document review, the facility failed to implement their medication management plan.
Evidence
  1. The facility’s medication management plan states “at the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.”
  2. At approximately 9:23AM on 04/28/2022 during on-site inspection, the “Shift to Shift Narcotic Count Sign Off Sheet” for medication cart A for April 2022 did not contain the signature of the medication staff coming on duty (11p-7a) for 04/27/2022 and (7a-3P) for 04/28/2022 and did not contain the signature of the medication staff going off duty (11p-7a) for 04/28/2022.
  3. At approximately 9:22AM on 04/28/2022 during on-site inspection, the “Shift to Shift Narcotic Count Sign Off Sheet” for medication cart B for April 2022 did not contain the signature of the medication staff coming on duty (11p-7a) for 04/27/2022.
  4. At approximately 9:38AM on 04/28/2022 during on-site inspection, the “Shift to Shift Narcotic Count Sign Off Sheet” for medication cart C for April 2022 did not contain the signature of the medication staff coming on duty (7p-3p) for 04/28/2022.
  5. At approximately 10:11AM on 04/28/2022 during on-site inspection, the “Shift to Shift Narcotic Count Sign Off Sheet” for medication cart E for April 2022 did not contain the signature of the medication staff coming on duty (11p-7a) for 04/27/2022.
Plan of correction
Our medication management plan has been updated to reflect the oversight and management by our DON that is being completed. We have reviewed the policy with our medication technicians and nurses, and they are aware of our standard as it relates to narcotic logs. Ongoing, our DON and staff will be checking narcotic counts daily, and will be counting off daily to ensure that the narcotic counts for our residents are accurate and accounted for. We will perform random spot checks to ensure this is being completed accurately and according to our medication management policy.
22VAC40-73-680-B
Based on observation during a tour of the facility’s memory care building, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to residents.
Evidence
  1. During on-site inspection on 04/28/2022, two licensing inspectors observed two round, white pills in resident 6’s room. These pills were also observed by staff 1 in the resident's room.
Plan of correction
Medication technicians have been educated on the medication management policy and appropriate storage and distribution of medications. DON is making daily rounds during and after med pass times to ensure that meds are administered and stored properly.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that physical examination reports for residents contained all required components.
Evidence
  1. The “Report of Resident Physical Examination” for resident 1, dated 08/18/2021, did not contain the resident’s height. The examination also indicated that the resident has an allergy to Voltoren; however, there is no description of the resident’s reactions.
  2. The “Report of Resident Physical Examination” for resident 2, dated 03/11/2022, did not contain information on whether or not the resident is capable of self-administering medication and it also did not contain the resident’s address and telephone number.
  3. The “Report of Resident Physical Examination” for resident 3, dated 11/05/2021, and resident 4, dated 01/25/2022, did not contain the address and telephone number of the residents.
Plan of correction
The residents height has been added to the Physical, and reactions to the medication have been updated as well. The appropriate residents telephone number and address have been updated. The appropriate physical form has been updated in all resident charts. An audit has been performed to ensure that all physical’s have been filled out completely. DON and resident care coordinator in addition to our compliance consultants will be auditing routinely to ensure compliance.
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure that resident personal and social information contained all required components.
Evidence
  1. The “Resident – Personal/Social Data” document for resident 1, admission date 08/19/2021, did not indicate if the resident had served in Armed Forces and did not include documentation of the resident’s strengths.
  2. The “Resident – Personal/Social Data” document for resident 2, admission date 03/16/2022, did not include documentation regarding the resident’s current behavioral and social functioning.
  3. The “Resident – Personal/Social Date” document for resident 3, admission date 11/18/2021, did not indicate if the resident had served in Armed Forces and did not include documentation of the resident’s current behavioral and social functioning.
Plan of correction
The resident’s personal social data forms have been updated to reflect all required and appropriate information. Our Admissions department has been educated and taught about the proper completion of Admission documents including the personal social data form. Our Regional Marketing Director in addition to our resident care coordinator and compliance consultants have audited resident charts to ensure this form has been completed appropriately for all current residents. Moving forward our team has been trained to appropriately fill out this form to ensure compliance.
March 18, 2022Complaint survey5 violations
Inspection dates
03/18/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) for Carriage Hill Retirement conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 03/18/2022 in conjunction with the local long-term care ombudsman. The LI reviewed documentation and conducted interviews with staff and one resident relating to allegations of an inappropriate discharge notice and a staff member identified as in charge not being trained on their duties while in charge. The LI had a preliminary exit interview with the Administrator during the on-site inspection on 03/18/2022 and a final exit interview via phone on 03/28/2022 where an opportunity was given to ask questions regarding the violations. The information gathered during the investigation supports the allegations. Based on the preponderance of evidence the complaint is determined to be valid. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-560-F
Based on observation, the facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents.
Evidence
  1. During on-site inspection on 03/18/2022 at approximately 1:00PM, the licensing inspector (LI) observed that the computer located on top of medication cart B was left unlocked allowing any individual to access information regarding residents and their medications. The LI noted that there were no staff members around the medication cart. The LI informed staff 1 of this observation and staff 1 confirmed this was accurate and proceeded to lock the information on the computer. Staff 1 stated that staff 2 was the registered medication aide (RMA) that currently had possession of the keys to medication Cart B and also noted that staff 2 nor any other staff were located near the medication cart. Also, the LI noted that the small trash container located on the side of medication cart B contained an empty blister pack for resident 2 for methotrexate 2.5MG and resident 3 for true metrix glucose strips. The resident information had not been marked out by staff prior to being placed in the trash container. This was also observed by staff 1.
Plan of correction
Computer screen was immediately locked and name on the empty medicine container was scratched. Staff member was educated with medication management standards. DON had an in-service with staff on medication management plan. DON or designee will conduct medication cart rounds to ensure compliance and privacy. Education consultant will also routinely aduit when visiting.
22VAC40-73-680-B
Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to residents.
Evidence
  1. During on-site inspection on 03/18/2022, the licensing inspector (LI) observed two small, round pills with an inscription of HH210 lying on the floor outside of room 23 on B hall of the facility. The pills were also observed by staff 1 and Collateral 1.
Plan of correction
Loose pills were properly disposed per facility policy. Nursing and housekeeping staff were instructed to monitor and conduct inspection daily and be vigilant to any possible loose pills and report to Resident Care Coordinator and DON.
22VAC40-73-660-A
Based on observation, the facility failed to ensure that when medications and dietary supplements are administered by the facility, the medicine container that is used for storage of medications and dietary supplements prescribed for residents was locked.
Evidence
  1. During on-site inspection on 03/18/2022 at approximately 1:00PM, the licensing inspector (LI) observed medication cart B located on B hall outside of staff 1’s office to be unlocked and no staff were observed near the cart by the LI. When staff 1 was alerted of this, the LI observed staff 1 lock the cart by pushing in the lock and staff 1 revealed to the LI that the cart was unlocked and unattended. Staff 1 stated that staff 2 was the registered medication aide (RMA) that currently had possession of the keys to medication Cart B; however, the LI and staff 1 observed that staff 2 was not located near medication cart B and had left the cart unlocked and unattended.
Plan of correction
Medication cart was locked immediately. Staff member was educated with medication management standards. DON had an in-service with staff on medication management plan. DON or designee will conduct medication cart rounds to ensure compliance and privacy. Education consultant will also routinely audit when visiting.
22VAC40-73-430-B
Based on document review, the facility failed to ensure that as soon as discharge planning beings, the resident was notified of the reason for the discharge.
Evidence
  1. The discharge notice, dated 03/02/2022, for resident 1 contained the following: “The facility has activated its 30 days discharge notice policy for (resident 1) on 03/02/22 due to facility’s inability to meet resident’s needs.” The notice did not identify which needs of the resident that the facility cannot meet.
Plan of correction
Facility will no longer use ‘unable to meet resident needs’ as the reason for discharge. Moving forward, facility will ensure that reason(s) for discharge is specifically described.
22VAC40-73-190-C
Based on staff record review, the facility failed to ensure that the staff member, prior to being placed in charge, was informed of and received training on his duties and responsibilities and provided written documentation of such duties and responsibilities.
Evidence
  1. The licensing inspector (LI) was informed by Collateral 2 that on 03/16/2022 she visited the facility to speak with staff 1. Collateral 2 was informed by facility staff that staff 1 was not present and that staff 3 was in charge. Interview with staff 1 confirmed that staff 3 was in charge on 03/16/2022 during his absence from the facility.
  2. Staff 1 provided the LI the record for staff 3 during on-site inspection on 03/18/2022. The record for staff 3 did not contain written documentation that staff 3 had been informed of and received training on her duties and responsibilities prior to being placed in charge.
Plan of correction
Staff was trained to be supervisor-in-charge, but no credit hours was assigned to the training. Facility will ensure credit due to this training is allotted to it per first desk reviewer’s suggestions.
February 28, 2022Complaint survey2 violations
Inspection dates
02/28/2022, 03/02/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 02/28/2022 in conjunction with the local long-term care ombudsman. The LI interviewed the resident the complaint was regarding, reviewed documentation for the resident, toured the resident's room, and conducted one staff interview on 02/28/2022 and one staff interview via phone on 03/02/2022 relating to allegations of the resident's diet not being served correctly, not receiving medication and the cleanliness of the resident's room. The LI held a preliminary exit interview with the administrator on 02/28/2022 while the LI was at the facility and an exit interview was also held with the administrator via phone call on 03/04/2022 where the violations were discussed and an opportunity was given to ask questions. The information gathered during the investigation supports one of the allegations. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-870-E
Based on observation, the facility failed to ensure all furnishings, fixtures, and equipment, including showers, were kept clean.
Evidence
  1. During on-site inspection on 02/28/2022, resident 1 informed the licensing inspector (LI) and Collateral 1 that there was a coating of dust on the top of the walk-in shower in the bathroom of resident 1’s room. The LI, along with Collateral 1 and staff 3, observed that there was a coating of dust along the top of the shower resident 1’s room.
Plan of correction
Resident 1’s bathroom has been deep cleaned. All resident rooms are on a routine deep cleaning schedule that rotates several times throughout the week. All rooms are cleaned daily, and are rotated on a deep clean schedule daily.
22VAC40-73-650-A
Based on resident record review and resident and staff interviews, the facility failed to ensure that medications that were started by the facility had a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. During an interview with resident 1, resident 1 informed the licensing inspector (LI) and Collateral 1 that she had been given Tylenol by staff 1 on 02/26/2022 at 2:00PM. The record for resident 1 did not contain a valid order from a physician or other prescriber for the resident to have Tylenol.
  2. During interview with staff 1, staff 1 confirmed to the LI that she did administer resident 1 Tylenol on 02/26/2022 at 2:00PM, that the Tylenol was staff 1’s personal Tylenol and confirmed that the resident does not have a valid order from a physician or other prescriber for Tylenol. LI asked staff 1 if this was documented on a medication administrator record (MAR) for resident 1 and staff 1 stated it was not documented on a MAR.
Plan of correction
A Tylenol PRN order was established for Resident 1. Staff 1 was counseled on the need to have and if pending, wait for a valid order from a physician or other prescriber before administering any medication including over the counter medications.
February 28, 2022Complaint survey1 violation
Inspection dates
02/28/2022
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) for Carriage Hill Retirement conducted an unannounced complaint inspection in conjunction with local adult protective services in response to a complaint that was received by the licensing office on 02/28/2022. The LI and adult protective services reviewed documentation and conducted interviews regarding allegations of a resident to resident altercation and if one resident was receiving appropriate care and if the other resident was safe in the facility. The Administrator had also informed the LI of two additional resident to resident altercations. The LI and the Administrator had a discussion regarding standard 1080-A. The LI held an exit interview via phone with the Administrator on 03/09/2022 where an opportunity was given to ask questions and review the violation(s). The information gathered during the investigation determined one of the allegations to be valid and violations can be found on the violation notice. Please sign, date, and return this notice to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-1080-A
Based on resident record review and collateral interview, the facility failed to ensure that a resident had a serious cognitive impairment due to a primary psychiatric diagnosis of dementia prior to being admitted to the safe, secure environment as defined in 22VAC40-73-10.
Evidence
  1. According to the State Board of Social Services Standards for Licensing Assisted Living Facilities in Virginia, a safe, secure environment is defined as a self-contained special care unit for residents with serious cognitive impairments due to primary psychiatric diagnosis of dementia who cannot recognize danger or protect their own safety and welfare.
  2. Resident 1 was admitted to the facility’s safe, secure unit (special care unit) on 01/28/2022.
  3. The report of resident physical examination, dated 12/27/2021, and the assessment of serious cognitive impairment, dated 01/26/2022, for resident 1 do not contain information that the resident has a diagnosis of dementia.
  4. Interview with Collateral 1 via phone on 03/03/2022 confirmed that resident 1 does not have a diagnosis of dementia.
  5. Considering the aforementioned information, resident 1 was not appropriate to be admitted to the facility's safe, secure unit due to not having a primary diagnosis of dementia.
Plan of correction
Facility has updated its admission requirement into the secured unit environment or memory care unit to include primary psychiatric diagnosis of dementia. Potential resident with a serious cognitive impairment who cannot recognize danger or take of themselves due to TBI or other impairments without a diagnosis of dementia will not be admitted.
January 31, 2022Complaint survey14 violations
Inspection dates
01/31/2022, 02/09/2022, 03/18/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) for Carriage Hill Retirement, in conjunction with another LI conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 01/31/2022. The LI also conducted two additional on-site inspections; on 02/09/2022 with local adult protective services and on 03/18/2022 with the local long-term care ombudsman. The LIs, adult protective services and the local long-term care ombudsman reviewed resident records, toured the facility, and conducted staff and resident interviews relating to allegations of resident files not being treated confidentiality, multiple resident deaths, resident care and related services, lack of direct care staff, a resident that had an overdose, special diets not being served, lack of housekeeping throughout the facility that included residents' rooms, and staff scheduled to work on 12/24-25/2021 who were not direct care staff trained but were scheduled to provide care to residents. The two licensing inspectors had a preliminary exit interview with the Administrator on 01/31/2022 and the inspector of record for the facility conducted a final exit interview with the Administrator via phone on 04/11/2022 where the violations were reviewed and an opportunity was given to ask questions and provide any additional information. The information gathered during the investigation supports four of the allegations. Additional violations were cited that were not related to the allegations that were reported and can be found on the violation notice. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-930-D
Based on document review, the facility failed to document that rounds were made for each resident with an inability to use a signaling device which included the date, time, and staff member who made the rounds.
Evidence
  1. The "Memory Care Rounding Log" documents for November and December 2021 and January 2022 for the hours of 12AM through 6AM provided to the licensing inspector (LI) by staff 2 on 01/31/2022 for the facility's safe, secure building residents who have an inability to use a signaling device contained multiple dates and times that did not contain the signature of a staff member that rounds were made for multiple residents.
Plan of correction
The Memory care rounds are documented in two locations: EMAR and paper documentation. The facility will transition completely into two-hour rounds on EMAR for its 24 hours round documentation. The DON will monitor compliance in this regard.
22VAC40-73-610-B
Based on observation and staff interviews, the facility failed to ensure that the current week’s menu was posted in an area conspicuous to residents.
Evidence
  1. At 7:39am on 01/31/2022 it was observed that the current week’s menu was not posted on the facilities memory care unit. An interview with staff 3 and 4 it was expressed that the menu is usually posted in the enclosed board beside the kitchen window but it was not posted at the time of this inspection.
  2. At 8:26am 0n 01/31/2022 it was observed that the menu that was posted in the dining room of the Assisted Living building was dated 01/23/2022 through 01/29/2022. The current week’s menu was not posted. During the preliminary exit with staff 1 on 01/31/2022 it was expressed that the current menu was posted in the kitchen. This posting is not conspicuous to residents as the doors to the kitchen are locked and residents to not have access into the kitchen.
Plan of correction
The menu for the appropriate week was posted immediately. A new dining services director was hired and has been trained on compliance and the weekly posting of the menus.
22VAC40-73-1020-A
Based on staff interview and facility document review, the facility failed to ensure that when residents are present, there are at least two direct care staff members awake and on duty at all times in each building who are responsible for the care and supervision of the residents.
Evidence
  1. The facility serves a mixed population in the assisted living building of the facility based on document review meaning that there would be to be at least two direct care staff on duty at all times.
  2. Interview with staff 2 revealed that staff 6 worked from 9:00pm until 11:00pm and staff 7 worked from 11:00pm until 5:00am; however, neither staff 6 or 7 are trained or certified in providing direct care to residents. Staff 2 confirmed that during the night shift on 12/24/2021 from 9:00pm until 5:00am on 12/25/2021 that there was only one direct care staff member, staff 8, on duty in the facility’s assisted living building.
Plan of correction
There was a COVID outbreak among staff around this time and management staff members stepped up during this time frame to assist in covering the building. The licensing inspector is aware of COVID outbreak during this time. Moving forward, we have communicated with external agencies so that in the event that we have another outbreak, or instance where we are short on staffing, we have appropriate care staff available to assist us. We have also hired additional staff members and DON. The DON and administrator will ensure the facility is within limit of compliance moving forward.
22VAC40-73-870-B
Based on observation, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. Between 8:29am and 8:47am during on-site inspection on 01/31/2022, there was a strong scent of urine in rooms A1, A3 and C52.
Plan of correction
Residents had just woken up this morning. They were changed and cleaned before breakfast and housekeeping was present per normal schedule to evaluate laundry, and linens and transfer appropriate clothing and linens to be washed. This was noted within an 18 minute time period, and while residents were waking up.
22VAC40-73-560-E
Based on observation and staff interview, the facility failed to keep all resident records in a locked area.
Evidence
  1. At approximately 9:09 AM during on-site inspection on 01/31/2022, two licensing inspectors observed the door to the outside white shed by the kitchen loading dock to be unlocked. Inside the unlocked white shed, there were multiple bankers’ boxes that contained resident information. Interview with staff 1 confirmed that the boxes did contain resident records.
Plan of correction
The shed was secured with a new lock. Maintenance and administration will ensure these records are kept locked to maintain confidentiality of applicable information.
22VAC40-73-680-D
Based on resident interview, staff interviews and photo
Evidence
  1. , the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE:
  2. The record for resident 5 contained a public pay uniform assessment instrument (UAI), dated 09/14/2021, that indicated the resident can take medications without assistance; however, the individualized service plan (ISP) dated 09/22/2021, indicated that for medication administration the resident’s medications will be “administered by lay person: med tech – a registered medication aide/nurse will administer medications per MD orders to resident. RMA/Nurse will ensure all meds were taken and swallowed before exiting room.” Phone interview with staff 2 on 03/28/2022, revealed that the resident does need assistance with medication administration and that the UAI is incorrect.
  3. The UAI for the resident indicates that the resident is oriented and the two ISPs, dated 09/22/2021 and 10/22/2021, indicate that the resident is oriented x4 and alert and oriented to all spheres.
  4. Regarding the duties of registered medication aides (RMAs) when providing assistance with oral medication administration, section 4.2 of the Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, revised 05/21/2013, pages 122-123 state the following: “11. Stay with the client until he/she has swallowed the medications (check mouth PRN).”
  5. The record for resident 5 contained a physician’s order, dated 10/04/2021, for the following scheduled 8:00PM medications: Amitiza, Ibuprofen, Pregabalin, Prazosin, Topiramate and Trazodone. During interview with resident 5 on 03/18/2022, resident 5 revealed that the 7PM-7AM registered medications aides (RMAs) would bring him his scheduled 8:00PM medications (pills) in a soufflé cup prior to his hospitalization on 01/10/2022; however, the medication staff would leave the pills with him and would leave the room without observing him taking the medications (pills). Resident 5 stated specifically that he did not wish to take the whole schedule 8PM trazodone pill and he would cut the whole pill into four pieces and take one piece at a time prior to going to sleep.
  6. The licensing inspector (LI) was provided photo evidence by Collateral 1 of pills that were found in the resident’s room on 01/07/2022 by Collateral 1. Resident 5 confirmed during interview on 03/18/2022 that the pills in the two photos were the pills that were found in his room by Collateral 1 on 01/07/2022. Resident 5 verified that the medications in the two pictures included multiple Trazadones, two Acetaminophen (physician’s order dated 10/29/2021 for APAP 500 mg every 12 hours PRN (as needed), two Dilaudid (physician’s order dated 10/04/2021 for Hydromorphone/Dilaudid 2 MG one tablet four times a day), one Baclofen (physician’s order dated 09/23/2021 Baclofen 20MG take one tablet twice daily PRN (as needed) for muscle spasms), one Synthroid (physician’s order dated 10/04/2021 take one tablet every morning), and one Iron (physician’s order dated 10/04/2021 for Ferrous Sulfate take one tablet every Monday, Wednesday and Friday for supplement) and were his prescribed medications. Phone interview with staff 10 revealed that the resident did have an issue with “hoarding medications” and that she had found medications in the resident’s room prior to Collateral 1’s findings on 01/07/2022. Staff 10 stated that she sent pictures of the pills to staff 1 that she found in the resident’s room and was instructed by staff 1 to dispose of the pills. (violation notice continued on separate document)
Plan of correction
Resident UAI and ISP were audited and corrected to reflect the same information RMS’s were educated on Section 4 of the medication aide curriculum and were educated on appropriate practices for administering medications. DON was hired and is reviewing medication management system in the building. She provides on the job training to med techs and is spot checking med passes to ensure proper compliance.
22VAC40-73-780-B
Based on observation, the facility failed to ensure that bed linens were changed at least every seven days and more often if needed.
Evidence
  1. At approximately 8:47am during on-site inspection, two licensing inspectors observed the flat sheet on the bed in resident 6’s room to be saturated with a yellow substance.
Plan of correction
The residents’ sheets were changed. Housekeeping schedules are formatted so that all residents’ linens are checked daily and are changed as needed, no less than multiple times a week. Our housekeeping director and care team are checking rooms several times a day to ensure compliance with this.
22VAC40-73-700-2
Based on observation, the facility failed to post “No Smoking-Oxygen in Use” signs when oxygen therapy is provided.
Evidence
  1. Room B20 contained an oxygen concentrator and a portable oxygen tank, room C52 contained an oxygen concentrator, and room D68 contained multiple portable oxygen tanks in the closet. These rooms did have residents residing in them during the on-site inspection on 01/31/2022. These rooms did not contain a “No Smoking-Oxygen in Use” sign.
Plan of correction
No smoking oxygen in use signs have been placed on all applicable resident rooms. Newly hired DON will ensure anyone using oxygen has appropriate signage to ensure compliance.
22VAC40-73-860-I
Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. At approximately 8:24 AM during on-site inspection on 01/31/2022, the door to room 56 (employee lounge) in the facility’s assisted living building was found by two licensing inspectors to be unlocked. A container of sani-cloth germicidal disposable wipes and a spray bottle of liquid performance sanitizing spray was found sitting on the table in the employee lounge.
  2. At approximately 8:52 AM, the door to room A16 which is also located in the facility’s assisted living building was found to be unlocked and contained an unlocked housekeeping rolling cart that contained a bottle of 401 K organic acid bowl cleaner, a spray bottle of preservation furniture polish and an unmarked clear spray bottle with a light yellow substance.
Plan of correction
Both doors were secured while inspectors were on site. Staff has been educated that no chemicals of any kind should be left unattended in an unsecured environment. Housekeeping has been notified of this and does audits daily to ensure compliance.
22VAC40-73-670-1
Based on review, the facility failed to ensure that a staff person who administers medications is authorized by 54.1-3408 of the Virginia Control Act.
Evidence
  1. During on-site inspection on 01/31/2022, staff 3 confirmed that she is a licensed registered medication aide and the staff member administering medications in the facility’s safe, secure unit on this date. According to the Virginia Department of Health Profession License Lookup website, staff 3’s license as a registered medication aide expired on 12/31/2021.
  2. The January 2022 medication administration record (MAR) for resident 10 contained initials that staff 5 administered medications to the resident at 8AM on 01/06/2022, 01/08-09/2022, 01/14/2022, 01/19-20/2022, and 01/22-23/2022. According to the Virginia Department of Health Profession License Lookup website, staff 5’s license as a registered medication aide expired on 12/31/2021.
Plan of correction
Staff #3’s license has been updated and reinstated. HR has been educated on auditing this timely and new procedures have been put in place to ensure compliance with this.
22VAC40-73-650-F
Based on resident record review and collateral interview, when a resident was admitted to a hospital for treatment of any condition the facility failed to ensure that the primary physician was aware of any new medication orders and treatments and had documented any contact with the physician regarding the new orders that were obtained at the time of the resident’s return to the facility.
Evidence
  1. “History and Physical” document for resident 5, dated 10/04/2021, by Collateral 2 indicated the following: “Pain management: I have told him that all pain prescriptions and directions for pain medications through [sic] (Collateral 3). He will be seen a minimum of every 3 months. His reservoir for the morphine pump will need to be refilled. I have deferred changing his Dilaudid to (Collateral 3).”
  2. Phone interview with a representative from Collateral 3’s office on 03/30/2022 revealed that they did not receive information from Carriage Hill Retirement regarding the resident’s hospitalization on 01/10/2022 and discharge from the hospital on 01/11/2022 in regards to the new medication orders from the hospital.
Plan of correction
Staff has been educated on the importance of notifying all appropriate agencies and parties when a resident goes to the hospital. A DON was hired in an effort to evaluate our nursing team and provide leadership to our healthcare staff. She will oversee documentation and communication related to all incidents and hospitalizations.
22VAC40-73-870-A
Based on observation and staff interviews, the facility failed to keep the interior of the building clean.
Evidence
  1. Between 8:15am and 8:58am during on-site inspection on 01/31/2022 multiple dried stains and drag marks were observed down the hallways of the A, B, C and D units. Spots that were wet with a brown substance were observed in the hallway outside of rooms A2, B27 and C48. Interviews with staff expressed that the stains and drag marks were caused by some employees dragging bags of trash down the hallways.
  2. At approximately 8:29am, two licensing inspectors observed a large spill of liquid beside the resident’s bed in room C52.
  3. The floor around the toilets in the bathrooms of rooms C52 and A3 contained a sticky substance around the bottom of the toilets.
Plan of correction
Hallways have been touched up with paint and have been patched and repaired. Staff has been educated on proper trash removal and housekeeping procedures verified to enter compliance with keeping rooms clean.
22VAC40-73-70-A
Based on review, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident 5 contained hospital discharge documentation, dated 01/11/2022, that the resident had been admitted to the hospital on 01/10/2022 and was being discharged back to the facility. The hospital discharge documentation stated that the resident had “been evaluated and treated for accidentally taking too much of a medicine, using someone else’s medicine by mistake, or swallowing a chemical product.”
  2. Also, a staff progress note for resident 5 written by staff 2, dated 01/29/2022 at 10:34AM, stated that the resident had asked to be sent out to the hospital around 2:30AM and that the hospital had reported to staff 2 that the resident had “to [sic] much Hydromophone [sic] in his system.”
  3. The aforementioned information regarding resident 5 was not reported to the regional licensing office for either instance.
Plan of correction
The incident involving residents was reported to licensing. Our administrator is aware of the regulations regarding reportable incidents and will continue to report what meets criteria to report to appropriate licensing agencies.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) included all required components.
Evidence
  1. Resident 5 was admitted to the facility on 09/23/2021 per staff 1. The record for resident 5 contained a “Resident-Personal/Social Data” sheet. Interview with staff 7 revealed that the document “Resident-Personal/Social Data” for resident 5 was completed by Collateral 1 on the resident’s date of admission. On page 2 of 2, Collateral 1 had indicated that the resident did have a substance abuse history and documented the following: “Overdosed on own meds 4+ times alcohol abuse (stole alcohol from me) cigarette smoking napping (chain smoking)”
  2. Documentation from Collateral 7, dated 05/05/2020, included the following information: “Problem list/past medical history – ongoing – overdose and substance abuse”.
  3. The aforementioned information listed on the resident’s “Resident-Personal/Social Data” sheet was not documented on either of the resident’s comprehensive ISPs dated 09/22/2021 and 10/22/2021. Interview with staff 2 on 02/09/2022 revealed that she completes the ISPs it was the first time that she had seen the “Resident-Personal/Social Date” sheet that was in the resident’s record.
Plan of correction
The resident ISP was updated to reflect appropriate resident history. A care plan coordinator consultant was hired to audit the care plans and assist us with compliance ongoing to ensure better documentation, consistency and compliance.
January 31, 2022Complaint survey0 violations
Inspection dates
01/31/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) for Carriage Hill Retirement, in conjunction with another LI, conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 01/31/2022. The LIs reviewed documentation, toured the facility, and conducted staff interviews relating to allegations of infection control procedures and housekeeping staff administering Covid-19 tests to residents. The LIs held a preliminary exit interview with the Administrator while on-site on 01/31/2022 and the inspector of record held a final exit interview via phone with the Administrator on 03/28/2020 to give an opportunity to ask questions about the violation. Based on a review requested by the facility that was completed by the department on 06/15/2022, there are no violations regarding the inspection and the complaint is not valid. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 12, 2022Complaint survey3 violations
Inspection dates
01/12/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 01/12/2022 and 06/13/2022 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 01/09/2022 regarding allegations in the area of resident care and related services. The evidence gathered during the investigation supported some, but not all of the allegations. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-470-A
Based on resident record review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident were met.
Evidence
  1. The record for resident 1 contained a progress note written by Collateral 3, dated 12/17/2021, with the following statement: “The skin tears need closer attention and care than the med techs can provide. I am going to order ongoing wound cleaning and light dressings until home health can see the resident. I am going to consult home health for wound management.”
  2. The record for resident 1 contained a “visit note report” from Collateral 4, dated 12/30/2021, with the following statement: “Spoke to med tech at length that pt (patient) has no need for nursing from home health , as there is no skill. Suggested he be evaluated by hospice.” Licensing inspector spoke with Collateral 4 on 01/27/2022 and Collateral 4 stated that the resident was not picked up for skilled nursing and wound care was not performed by Collateral 4.
  3. Resident was admitted to the hospital from the facility on 01/09/2022 and the following consultation note was documented by the hospital dated 01/09/2022: “He was sent to the emergency department and a very disheveled and poor hygiene condition. He had multiple ulcerations ranging from his scalp all the way down to his lower legs in varying stages of healing both pressure and non-pressure. He also had cellulitis of the right elbow following a abrasion and laceration of the right elbow which required 5 stitches. Apparently the sutures were still in place upon evaluation and admission on 9 January of this year. It was found to have red swollen area around it with purulent drainage. Due to the history of multiple falls and his current condition he was admitted. Wound care was asked to see today in regards to the multiple wounds in varying locations.” and did not return to the facility. During interview with staff 1 during on-site inspection on 06/13/2022, staff 1 confirmed that the record for resident 1 did not contain documentation that the resident had received any “ongoing wound cleaning and light dressings until home health can see the resident” and also that there was no documentation of any wound cleansing or dressings after the resident was not picked up for skilled nursing on 12/30/2021.
Plan of correction
Facility physician provided an order that did not capture his progress note description. Director of nursing and administrator will ensure that physician progress note is reconciled with orders and demand clarifications on vague orders received from any provider when applicable.
22VAC40-73-650-C
Based on resident record review and staff interview, the facility failed to ensure a physician’s or other prescriber’s oral order was reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. The record for resident 1 contained an oral (voice order) by staff 2, dated 08/31/2021 at 1:15PM for the following: “D/C (discontinue) Lovenox sub-q injections. Start Eliquis 2.5mg tablet PO BID for 7 days for anticoagulant therapy”; however, the order was not signed by a physician or other prescriber. Interview with staff 1 confirmed this was accurate.
Plan of correction
Facility has educated licensed nurse that receives voice order on the need to ensure providers/physician/hospice providers signs voice order within 14 days. Director of nursing and administrator will ensure voice orders are signed within 14 days. Resident chats will be flagged until voice orders are signed by physician.
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to obtain a valid order from a physician or other prescriber prior to discontinuing a medication, dietary supplement, diet, medical procedure, or treatment.
Evidence
  1. Resident 1 was admitted to the facility on 07/15/2021. The record for resident 1 contained an order, dated 07/15/2021, for “Ensure Plus (chocolate) liquid 240ML drink or give contents of 1 can (240ML) by mouth daily” that was signed by Collateral 2.
  2. The July 2021 medication administration record (MAR) for resident 1 from 07/15/2021 through 07/31/2021, the August, September, October 2021 MARs for the resident and the November 2021 MAR from 11/01/2021 through 11/18/2021 did not include documentation that resident 1 had been given Ensure. Interview with staff 1 during on-site inspection on 06/13/2022 confirmed that there was no discontinue order for Ensure for the resident and that there was no documentation that the resident had been given Ensure during the aforementioned time period.
Plan of correction
At admission facility received a medication record and H&P that did not have Ensure Plus Liquid order in it, but this medication could be found in resident 1’s separate discharge note. Moving forward, the director of nursing will reconcile all documents including hospital notes, discharge notes, and progress note and send to pharmacy to avoid reoccurrence.
December 13, 2021Inspection3 violations
Inspection dates
12/13/2021, 01/31/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
The licensing inspector (LI) for Carriage Hill Retirement initiated an unannounced focused monitoring inspection via phone on 12/13/2021 and an on-site inspection on 01/31/2022 in conjunction with another LI to follow-up on a facility reported incident of an elopement of a resident who resides in the facility's safe, secure unit that occurred on 12/06/2021. Findings were reviewed with facility staff during the on-site portion of the inspection on 01/31/2022. An exit interview was conducted with the Administrator on 02/09/2022, 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. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. The “Report of Resident Physical Examination” for resident 1, dated 11/05/2021, showed that the resident is “nonambulatory (by reason of physical or mental impairment is not capable of self-preservation without the assistance of another person).” and the “Assessment of Serious Cognitive Impairment” for the resident, dated 11/05/2021, showed that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and is unable to recognize danger or protect his/her own safety and welfare.”
  2. The public pay uniform assessment instrument (UAI), dated 10/13/2021, for the resident showed the following information: “Prior to admission (resident) was discharge [sic] to an AFL (assisted living facility) where he eloped from to go drinking with a friend” and “Family and AR reported that patient stays Drunk. Patient eloped from ALF to go Drinking with friends and refused to return”. This individualized service plan (ISP) for resident 1, dated 11/17/2021, does not address the identified information from the UAI that the resident left the previous assisted living facility he resided at.
  3. Resident 1 was admitted to the facility’s safe, secure unit on 11/18/2021.
  4. Incident report from staff 1 emailed to the licensing inspector (LI) on 12/07/2021, stated that on “12/06/21, between 8 and 9am” the following occurred: “Resident was present during night shift morning round. During Day shift morning round staff noticed resident had left his room through the window. Administrator was notified and the facility staff started looking for resident. After a thorough search of both buildings, the administrator called the police. Administrator continued search until he found resident around 10am. The administrator found resident at Huddleshouse [sic] in front of Walmart. Administrator stayed with resident until police officer arrived and resident was taken back to the facility.” Google maps shows that it is at least a 4.2 mile walking distance from the facility to the Huddle House, located at 1138 E Lynchburg Turnpike Bedford, Virginia 24523, where the resident was found by the administrator.
  5. According to timeanddate.com, the temperature for 12/06/2021 from 7:54 AM to 10:54 AM was between 50 degrees Fahrenheit and 65 degrees Fahrenheit.
Plan of correction
In our memory care, and as reflected in our rental agreement, Carriage Hill Retirement does not provide one on one care to our residents. Carriage Hill was in compliance with routine evening, night shift, and morning shift rounds on residents, including resident 1, which was submitted to the department for review and consideration. This elopement was not as a result of lack of supervision for what is required of a special care unit not requiring one on one supervision or care, but rather was an isolated incident invoke by the individual alone in between rounds. There were no indicative precursors or warning signs showing escalation or any reason for enhanced supervision to be implemented at all in our rounds. The evidence provided in number one is not relevant to what is being stated as the violation. The individual was placed in our special care unit as a result of formal recognition from professional health care providers, and nothing listed in evidence one relates to a violation. The evidence listed in number 2 related to the UAI stating historical information on the resident also doesn’t directly relate to anything Carriage Hill did to violate this listed regulation. The issue of the UAI and ISP not matching is not accurately cited in this regulation, as this regulation relates to 460-D, involving adequate care and supervision not UAI and ISPs. This is addressed in the appropriate violation of the listed regulation. Number three is also just a point of reference. Number four is a summary of the report that we submitted to the state as a result of this elopement. It also references the distance from the community to where the resident was located insinuating a long walking distance. We have no proof that the resident walked to the location where he was found. Number five references a third-party website that states what the approximate temperature was on the day of the elopement which also seems irrelevant as evidence to how Carriage Hill violated this regulation. The resident was found, was unharmed, did not require hospitalization or further evaluation, and no new order were initiated as a result of this elopement. Moving forward, Carriage Hill will continue to follow the regulations, and care outlined for this resident by their medical providers to ensure his well-being and safety to the best of our ability.
22VAC40-73-680-K
Based on resident record review and staff interview, the facility failed to ensure that licensed health care professionals administer PRN medications and when medication aides administer PRN (as needed) medications when the facility has obtained from the resident’s physician or other prescriber orders that include symptoms that indicate the use of the medication and a detailed medication order that includes directions as to what to do if symptoms persist.
Evidence
  1. Physician’s order for resident 1, dated 12/10/2021, includes the following PRN medications: Acetaminophen 325 MG – take two tablets by mouth every 4 hours as needed for pain, Banophen 50 MG (Benadryl) – take one capsule by mouth every 6 hours as needed for allergies, Bisacodyl 5 MG tablet – take 2 tablets by mouth every day as needed for constipation, Geri-Lanta Liquid – take 30 MLs by mouth every 4 hours as needed for indigestion, Haloperidol 5 MG tab – take one tablet by mouth every 6 hours as needed for agitation, Lorazepam 2 MG tablet – take one tablet by mouth every 6 hours as needed for agitation and Nicotine 2 MG chewing gun – chew one piece of gum every 4 hours as needed for nicotine withdrawl [sic]. The physician’s order also states “Use PRN’s for agitation/behaviors before it escalates.” The aforementioned physician’s orders do not include descriptive symptoms or directions as to what to do if symptoms persist.
  2. The order for the resident also includes the following: “Diphenhydramine 50MG/ML Vial – inject 1ML (50MG) intramuscularly every 6 hours as needed for muscle spasms.” Interview with staff 1 on 01/31/2022 revealed that the facility currently only employs registered medication aides (RMAs) and does not employ a licensed health care professional. The registered medication aide curriculum does not include training on administering intramuscular injections.
Plan of correction
The physician was consulted and the PRN orders were updated to include what to do if symptoms persist. Staff procedure in this instance is to call the medical provider to report for further instructions, and that has been reflected in writing on the order in the resident MAR. The order for the IM Diphenhydramine has been removed. This PRN order has never been exercised or administrated. Staff is aware to not accept any pending orders or enter them in our EMAR system if they exceed the capacity for the skillset of our RMA’s. Moving forward our NP will review and evaluate all orders to ensure they are appropriately within our scope of practice prior to them being accepted by the pharmacy for the property EMAR.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure residents’ individualized service plans (ISP) included all required components.
Evidence
  1. Resident 1 was admitted to the facility’s safe, secure unit on 11/18/2021.
  2. The record for resident 1 contains the document “Regional Discharge Assistance Program Provider Agreement” (DAP Agreement), signed by staff 1 on 11/25/2021, that indicates the following information: “Due to (resident’s) overt opposition both verbally and non-verbally (elopement) and aggressive behaviors surrounding his ability to do so (Verbally aggressive with yelling, slapping tables, and modeling delusions with reenactments) (resident) is approved for Tier 1 supports at Carriage Hill Retirement. These supports include additional resident assistance surrounding time related to escorting, reminders, and overall staff support, as needed. Tier 1 supports also provides support around activities of daily living that will help create meaningful daily activities, which will help provide coping strategies for his depression. Although (resident) can perform his ADL’s he needs supervision and prompts in order to do so. Tier 1 level of care provides these supports in order for him to maintain consistency and ensure cleanliness for overall general health.” and “Because (resident) experiences baseline delusional and paranoid thinking, especially surrounding his family, it is important to redirect him to preferred topics in an effort [sic] avoid escalation. These baseline behaviors consist of ‘suing’ his family and homicidal statements and ideation surrounding them. (Resident) enjoys talking about hunting and reading hunting magazines. He also enjoys trout fishing and can be verbally redirected with this topic. If escalation should occur, the DAP Specialist (name below) should be contacted immediately, as well as any Horizon CSB Case Management Services (if applicable).” The aforementioned information was not included on the resident’s comprehensive ISP dated 11/17/2021.
  3. The public pay uniform assessment instrument (UAI), dated 10/13/2021, for the resident showed the following information: “Prior to admission (resident) was discharge [sic] to an AFL (assisted living facility) where he eloped from to go drinking with a friend” and “Family and AR reported that patient stays Drunk. Patient eloped from ALF to go Drinking with friends and refused to return”. This information was not included on the resident’s individualized service plan (ISP) dated 11/17/2021.
Plan of correction
The DAP Agreement listed in the evidence is not a medical tool that is required to be used in developing an Individualized Service Plan as it is essentially a financial agreement between a government agency and our property for purposes of designated how an individual will be paying the community for its services. As this is not a legitimate medical document, we do not use this for historical documentation purposes for translating information to our ISP’s and UAIs. We use H&P’s hospital notes, social assessments, and other clinical documents to formulate these important documents. As it relates to Evidence number 2, we have updated the ISP to reflect the consistent information noted in the UAI so that both documents match and are reflective of the same information.
November 30, 2021Inspection32 violations
Inspection dates
11/30/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
To ensure the facility had a thorough understanding of the standards, the licensing inspector and the Administrator had a discussion regarding standard 980-A.
Comments
The licensing inspector (LI) for Carriage Hill Retirement, under the supervisor of the licensing administrator and along with two additional LIs, conducted an unannounced renewal study on 11/30/2021 from 8:26 am until 6:22pm, finding 63 residents in care. The inspection included a tour of the physical plant of both the facility's assisted living building and the safe, secure unit, observation of medication passes, review of the medication storage carts, staff/resident interviews, and observation of the noon-meal. Eight resident records and four staff records were thoroughly reviewed. Sworn disclosure statements and criminal record checks were examined for all newly hired staff still employed since the facility's last mandated inspection. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. Documents were requested throughout the day giving facility staff multiple opportunities to provide documentation needed for the inspection and in addition the facility was given until 5:00pm on 12/01/2021 to get additional documentation to the licensing representatives. A preliminary exit interview was conducted with the Administrator on 11/30/2021 as well as an additional conference via Google Meets on 12/09/2021 with the Administrator, Regional Director of Operations and legal representation, 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. The facility was given until the end of the day on 12/10/2021 to provide additional documentation. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216. This inspection was amended on 03/09/2022 by the licensing inspector to reflect the results of two reviews that occurred on 01/13/2022 and 03/01/2022.
Violations
22VAC40-73-70-A
Based on resident record review and document review, the facility failed to ensure that a major incident that threatens that life, health, safety or welfare of a resident was reported to the regional office within 24 hours.
Evidence
  1. The record for resident 8 has documentation in progress notes dated 09/20/2021 at 9:34am that “Rsd began choking while eating breakfast this am. Staff tried assisting him in coughing up whatever was making him choke. Rsd then began spitting up thick mucus but was stating something was still stuck in his throat. Hospice was notified of this situation and ordered that we call 911 due to them not being able to respond quick enough. Rsd was sent to the hospital and we are awaiting results.” As of the day of inspection, this incident has not been reported to the regional licensing office.
Plan of correction
Staff was educated on documentation, and the importance of notification to Administrator of any incidents. Incidents that meet criteria to be reported to the licensing department will be and within the required timeframe.
22VAC40-73-680-B
Based on observations made of the facility medications carts, the facility failed to ensure that all medications remained in pharmacy issued containers until administered to residents.
Evidence
  1. The second drawer of the medication cart located on the safe, secure unit was observed to have a white pill with the number F84 and a white pill with the number 337 lying loose in the bottom of the drawer on the day of inspection.
  2. A plastic medication cup that contained a white cream was noted to be sitting out on the bathroom sink in room 9 on the safe, secure unit. In an interview with staff person 4, it was unclear what the cream in the plastic medication cup was.
Plan of correction
Uncontained medications were immediately discarded. Staff was verbally educated and reminded about proper storage of medications. Routine med cart audits have been put in place, along with room sweeps to ensure proper storage of medications. New DON will monitor this and Administrator will spot check to ensure compliance.
22VAC40-73-870-B
Based on observations, the facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During on-site inspection on 11/30/2021 of the facility's assisted living building at 10:08AM and 11:12AM, a trashcan in the bathroom of room 15 was observed to be full and overflowing with gloves that contained a brown substance and tissues. The odor was strong and foul. Also, the hallway outside of the conference room 67 had a cigarette smoke smell throughout the day during the on-site inspection.
Plan of correction
LI did not receive a plan of correction for this violation.
22VAC40-73-270-4
Based on staff record review, the facility failed to ensure that direct care staff training for residents with aggressive behaviors occurred at least annually.
Evidence
  1. The record for staff 5, hired 07/01/2009, has documentation that the last training for residents with aggressive behaviors was completed on 06/05/2020.
Plan of correction
Staff has obtained training for aggressive and abusive behaviors. We will set a continuous schedule for staff ongoing to receive this training through an educational consultant. Human Resources will monitor staff files to ensure all staff members are in compliance with required trainings, and Administrator will periodically review.
22VAC40-73-660-A
Based on observation, the facility failed to ensure when required medications shall be refrigerated.
Evidence
  1. At approximately 9:36AM on 11/30/2021 during audit of medication cart A, the licensing inspector (LI) observed a Humalog KwikPen insulin pen that had been unopened for resident 17. Interview with staff 11 confirmed that the insulin pen had been unopened and should be in the refrigerator instead of in the medication cart since the insulin pen had not yet been opened.
Plan of correction
The insulin pens proper storage has been restored. Staff was verbally educated and reminded about proper storage of medications. Routine med cart audits have been put in place to ensure proper storage of medications. New DON will monitor this, and Administrator will spot check carts to ensure compliance.
22VAC40-73-860-I
Based on observation, the facility failed to ensure that hazardous materials were stored in a locked area.
Evidence
  1. Based on document review of residents in the facility's assisted living building, the facility does have residents that have serious cognitive impairments. During the morning tour of the assisted living building on 11/30/2021, a door off of the dining room marked "Danger - No Smoking - Biohazard" was observed to be unlocked. The unlocked closet contained a box marked biohazard with a red biohazard lining bag holding a partially full sharps container.
  2. During the morning tour of the facility's safe, secure unit on 11/30/2021, the laundry room door was unlocked and inside of the laundry room was a laundry detergent container of "all free and clear mighty pacs" that contained a label stating "harmful if swallowed" on a shelf that was easily accessible by residents.
Plan of correction
On the day of the inspection, maintenance staff was making repairs in the hazard room which is why the door was left unlocked. Maintenance and all staff have been educated on the importance of keeping the door closed at all times even when repair is on-going to ensure the safety of our residents.
22VAC40-73-270-3
Based on a staff record review, the facility failed to ensure that staff training in methods of dealing with residents who have a history of agitated behaviors to include information, demonstration, and practical experience in self-protection and de-escalation of aggressive behavior was conducted by a qualified health professional.
Evidence
  1. The records for staff 2, hired 10/29/2020; staff 3, hired 10/22/2020 and staff 4, hired 10/15/2020, have documentation that the only aggressive behavior training completed was from an on-line video based “Relias” program and does not include the name of a health professional who is qualified to teach this training.
Plan of correction
Staff has obtained training for aggressive and abusive behaviors. We will set a continuous schedule for staff ongoing to receive this training through an educational consultant. Human Resources will monitor staff files to ensure all staff members are in compliance with required trainings, and Administrator will periodically review.
22VAC40-90-40-B
Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Documentation provided by staff 7 showed the date of hire for staff 8 as 07/16/2021, staff 9 as 07/27/2021 and staff 10 as 09/04/2021.
  2. All three staff records contained documentation, "Virginia State Police Detail Report Central Criminal Records Exchange", that a criminal record history report was not obtained for staff 8 until 09/13/2021, staff 9 until 10/20/2021 and staff 10 until 11/01/2021 meaning the reports were not obtained on or prior to the 30th day of employment for each employee.
Plan of correction
A criminal record is placed in the employees file. HR was educated on the importance of ensuring that no one is permitted to work without a background check in place within the required timeframe. Administrator will oversee this process by spot checking staff files quarterly to ensure they are kept in compliance.
22VAC40-73-380-A
Based on document review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information on a person was obtained.
Evidence
  1. Resident 15 was admitted to the facility on 09/10/2021. The "Resident - Personal/Social Data" for resident 15 did not contain the resident's birth place, advance directive, local department of social services, previous mental health or intellectual disability and current behavioral and social functioning. "Substance abuse history if applicable for care or services:" was selected as "Not Applicable"; however, a physician's progress note for the resident, dated 10/17/2021, showed the resident has end-stage alcohol related Cirrhosis.
  2. Resident 4 was admitted to the facility on 09/23/2021. The "Resident - Personal/Social Data" for the resident did not contain documentation for "current behavioral and social functioning".
Plan of correction
Form was updated to reflect “unknown” instead of blank. Admissions office was notified that it is the preference of the licensing office that on admission forms there should not be blanks, and to ensure “unknown” is listed where applicable.
22VAC40-73-680-M
Based on resident record review, observation, and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration were available.
Evidence
  1. The record for resident 5 contains a physician's order, dated 11/09/2021, for "Artificial tears 1 drop eyes-both, twice daily as needed" and the record for resident 15 contains a physician’s order for "Bisolax 10 mg suppository insert 1 unwrapped suppository into the rectum every 3 days as needed for bowel movement". During the medication cart audit on 11/30/2021, this medication could not be located. Interview with staff determined that these medications were not available for residents 5 and 15.
Plan of correction
Resident 5’s eye drops were present. Resident 15 suppository was not sent by pharmacy. All appropriate treatments have been secured in the med cart at this time. We hired a new DON who is assisting our staff in following all medications management policies and practices and who is overseeing this process to ensure compliance. CPC will follow up to ensure Pharmacy makes all delivery in due time, and concerns will be brought to our Administrator.
22VAC40-73-610-B
Based on observation, the facility failed to ensure that menus for meals for the current week were dated and posted in an area conspicuous to residents.
Evidence
  1. During on-site inspection on 11/30/2021, the menu that was posted was for 12/01-07/2021. There was no menu posted for 11/30/2021.
Plan of correction
Current Kitchen menu was immediately placed on the wall. Kitchen supervisor will do rounds daily in the kitchen and environment to ensure compliance with signs, and make sure the appropriate menu is hanging on the wall. Administrator will spot check this process as well.
22VAC40-73-210-F
Based on staff record review, the facility failed to ensure staff received at least 2 hours of training in infection control annually.
Evidence
  1. The record for staff 3, hired on 10/22/2020, has documentation that the employee has only received 1.5 hours of annual training in infection control.
Plan of correction
Staff 3 has received 2 hours of additional training in infection control. A new business office manager was hired who oversees the staff training logs and records for staff training, and she has been educated on the importance of staying on top of making sure all staff have the appropriate number of hours necessary to stay withing compliance of state standards.
22VAC40-73-660-B
Based on observation, the facility failed to ensure that residents maintaining self-administer medications in their rooms were keeping the medications in an out-of-site place.
Evidence
  1. Resident 5 was observed asleep in his room with the room door standing open. Bio-freeze and Antifungal Powder were observed on a bedside table in full view and accessible to other residents. Resident 5 does have a self-administer order for these medications; however, they were not being maintained in an out-of-site place.
Plan of correction
Powder was removed from resident room. Facility will ensure RCC and CPC do room sweep. Resident has order for Bio-Freeze. Resident had bought antifungal powder from the store. It is within his right to buy whatever he wants. Facility will ensure it is stored appropriately even if resident has order for self-administration. Resident has been educated on proper storage as well.
22VAC40-73-710-C
Based on observation and staff interviews, the facility failed to ensure, if a restrain is used, it must be imposed in accordance with a physician’s written order that specifies the condition, circumstances, and duration under which the restraint is to be used.
Evidence
  1. During on-site inspection on 11/30/2021, resident 13’s bed was observed with half bed rails in the up position. The record for resident 13 has a physician’s note, dated 11/12/2021, stating that the resident has progressive Alzheimer’s. The Uniform Assessment Instrument (UAI), dated 9/13/2021, states that the resident is Disoriented to time and situation some of the time, has short and long term memory problems and judgment problems. A Hospice nurse in the facility reported that resident 13 does not know what the half bed rail is on his bed for or how to use it.
  2. Resident 3 was observed in bed with one half rail in the up position. When one licensing representative questioned resident 3 about the bed rail, the resident reported that the rail had “something to do with smoking”. The same Hospice nurse reported during an interview that resident 3 is "cognitively impaired and doesn’t know what the half rail is on his bed for or how to use it".
  3. Resident 15 was observed asleep in her bed with two half rails in the up position. The UAI for resident 15, dated 08/25/2021, states that she is disoriented to place & time all the time, has short and long term memory problems, and judgment problems. A hospital discharge note, dated 9/28/2021, states that the resident has end-stage Cirrhosis, Major Depressive disorder and Dementia. Staff reported to a licensing representative that “some days the resident is totally out of it and can’t follow instructions”.
Plan of correction
Carriage Hill is not a facility that uses restraints in any fashion, and does not operate as a restraining facility. The half bed rails for resident #3, #13, and #15 were removed from the residents’ rooms. Moving forward all residents that receive orders for anything that could be considered a restraint will be evaluated by our Administrator and nursing staff and will be replaced if necessary to ensure compliance.
22VAC40-73-610-C
Based on observation, the facility failed to ensure the minimum daily dietary requirement based on current U.S. Department of Agriculture (USDA) food guidance or dietary allowances.
Evidence
  1. The posted menu dated December 1-7, 2021 shows on 12/01-03/2021 no serving of dairy is offered. The menu shows that on 12/04-07/2021 one serving of dairy is offered. The menu shows that on 12/07/2021 no fruit is shown on the menu and one serving of dairy is offered.
  2. The USDA my plate guidance recommends for adults at least 1-2 cups of fruit daily, 2-3 cups of vegetables daily and 3 cups of dairy are recommended daily.
Plan of correction
A new dietician was hired companywide to review menus. Kitchen manager will ensure facility dietitian reviews and approves all menus to meet USDA my plate guidance. Administrator will review no less than quarterly to ensure compliance.
22VAC40-73-100-C-2
Based on observations made of the facility medication carts, the facility failed to ensure that infection control policies that are consistent with CDC recommendations were followed.
Evidence
  1. The medication cart located on the facility's safe, secure unit contained a glucometer bag that was labeled for resident 7 on the day of inspection. The meter that was located inside of the bag was not labeled with the resident's name per CDC recommendations.
  2. Medication cart B, located in the facility's assisted living building, contained a glucometer bag that was labeled for resident 18 on the day of inspection. The meter that was located inside of the bag was not labeled with the resident's name per CDC recommendations.
Plan of correction
The glucometers were labeled with resident’s name. Staff was verbally educated on the importance of appropriate labeling of medications pursuant to our medication management policy. We hired a new DON who will have direct oversight and involvement in audits and medication management practices.
22VAC40-73-520-I
Based on observation, the facility failed to ensure if one activity is substituted for another, the change is noted on the written schedule of activities.
Evidence
  1. The posted activity calendar in the facility's assisted living building showed that for 11/30/2021 the following activities would be available: 10:00AM Sit and Fit; 11:00AM Walk and Daily Bread and 2:00PM a birthday party.
  2. The only activity that was observed during the on-site inspection on 11/30/2021 was Bingo at 10:00AM.
Plan of correction
Activities were present during the day the licensing inspectors were present. There was an emergency for a staff member that caused our primary activities director to have to leave the building which altered the course of activities in the building for the day. The Administrator will ensure in the absence of the activities director that activities are carried out.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that the physical examination report contained a description of the person’s reactions to known allergies.
Evidence
  1. The physical examination form for resident 7, dated 9/10/2021, indicated that the resident has allergies to Aspirin, Carbamazepine, and Zolpidem; however, the form did not indicate a description of the resident’s allergic reactions.
Plan of correction
The resident record has been updated to reflect unknown under potential reaction to allergies. The allergy was written; however, the physician did not know what a reaction might be to the allergy because it hasn’t occurred. We educated the physician that they need to write unknown if the allergy reaction is unknown.
22VAC40-73-440-F
Based on resident record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed within 90 days prior to admission to the assisted living facility.
Evidence
  1. Resident 4 was admitted to the facility on 09/23/2021. The public pay UAI provided by staff 6 for the resident shows an assessment date of 06/10/2021 which is more than 90 days prior to the admission of the resident.
Plan of correction
An updated UAI has been placed in resident chart to ensure compliance. The regulation with standard code 440 F and G permits a resident’s UAI up to 90 days prior to admission and up to 12 months if the resident is coming from another assisted living facility settings respectively. Resident’s admission process started from an assisted living facility but she was later admitted to the hospital before admission was concluded. There was no significant change in resident’s care plan as a result of going to the hospital. Facility admission team has been counseled to pay attention to these standard codes to keep facility in compliance with subsequent admissions.
22VAC40-73-650-C
Based on resident record review, the facility failed to ensure physician's or other prescriber's orders were reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. The record for resident 3 contained the following document dated 10/15/2021: "Physician orders - honey consistency liquids VO". The document did not contain the signature of a physician or other prescriber.
Plan of correction
The doctors order has the appropriate signature. All doctor’s order will be sent by resident care coordinator to physician to ensure they are signed within appropriate time frame immediately after Doctor’s visit. A new DON was hired and will assist in overseeing this process to ensure proper signatures are present for doctors orders.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure for private pay individuals the uniform assessment instrument (UAI) was completed as required by 22VAC30-110.
Evidence
  1. The UAI for resident 3, dated 10/15/2021, does not contain the signature of the administrator or designee.
Plan of correction
The UAI has been updated and signed. The Care Plan Coordinator will bring forms during normal routine audits to Administrator for oversight and to sign. We hired a new DON as well who will assist in organization and auditing of healthcare documents to ensure we maintain compliance.
22VAC40-73-650-A
Based on observation, resident record review and resident interview, the facility failed to ensure that no medication was changed by the facility without a valid order from a physician or other prescriber.
Evidence
  1. Interview with resident 2 revealed that the resident has Diclofenac sodium 1% gel (Voltaren 1% Gel) that she self-administers and keeps in a lock box in her room. The record for resident 2 contains a physician's order, dated 08/04/2021, for Diclofenac sodium 1% gel (Voltaren 1% Gel); however the order does not state that the resident can self administer and keep this medication in a lock box in her room.
  2. During tour of the facility's assisted living building, one licensing inspector observed azelastine nasal spray in resident 14's room. The record for resident 14 did not contain a physician's order for the resident to self-administer this medication. The resident's uniform assessment instrument (UAI), dated 10/05/2021, states that she is dependent in medication administration and that medications are to be administered/monitored by professional nursing staff.
Plan of correction
A new DON was hired and will oversee all physicians orders. In communication with CPC, and DON, Administrator will ensure all physician orders are followed. Resident has order to self-administer but facility will ensure facility physician gives detail about keeping in the room or in the med cart.
22VAC40-73-270-2
Based on observation and staff interview, the facility failed to ensure training for staff in assisted living facilities that accept, or have in care, residents who are or who may be restrained.
Evidence
  1. Residents 3, 13, and 15 were observed by the licensing representative using half bed rails.
  2. A nurse in the facility reported that resident 3 is cognitively impaired and does not know what the half rail is for or how to use it.
  3. The record for resident 13 contains a physician's date, dated 11/12/2021, that states the resident has a diagnosis of progressive Alzheimer's.
  4. The record for resident 15 contains a hospital discharge summary, dated 09/28/2021, that states the resident has a diagnosis of major depressive disorder and dementia. Staff reported that "some days she (the resident) is so out of it she can't follow instructions or understand instructions."
  5. Interview with staff 6 confirmed that staff have not had training in restraints.
Plan of correction
Carriage Hill is not a facility that uses restraints in any fashion, and does not operate as a restraining facility. The half bed rails for resident #3, #13, and #15 were removed from the residents’ rooms. Moving forward all residents that receive orders for anything that could be considered a restraint will be evaluated by our Administrator and nursing staff and will be replaced if necessary to ensure compliance.
22VAC40-73-560-F
Based on observation, the facility failed to ensure that all records are treated confidentially.
Evidence
  1. During tour of the assisted living building on 11/30/2021, narcotic medication administration records containing confidential resident specific information was observed on top of the unattended medication carts A, B, C, and D.
Plan of correction
The narcotic book was locked in the cart immediately. Staff was verbally educated on the importance of making sure there isn’t sensitive information available to the public or place in an unsecured place on the med cart. A new DON was hired who is working with staff to improve processes, and who is routinely auditing med carts to ensure compliance.
22VAC40-73-550-G
Based on record review, the facility failed to ensure that the rights and responsibilities of residents shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person and
Evidence
  1. of this review shall be filed in the resident’s or staff person’s record. EVIDENCE:
  2. The sign in sheet dated 06/30/2021 for a review of resident rights does not have the signatures of staff 4 and 5 on the form to determine attendance with the review.
Plan of correction
All staff has received the appropriate training. Facility had the training. There was a secondary training used as a make up for staff unable to attend the first training. Few staff had the training on the alternate day. Facility will ensure all training is documented and written in a document for licensing inspector, and that the licensing inspector gets a comprehensive list of trainings to ensure all staff are present and we are in compliance.
22VAC40-73-640-A
Based on document review, observation, and staff interviews, the facility failed to implement their medication management plan.
Evidence
  1. The facility's medication management plan states "Daily procedures for refill request: refills need to be faxed to pharmacy daily. If refill is needed immediately, please call and fax the pharmacy with order so delivery can be made as soon as possible" and "Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate."
  2. The record for resident 3 contains a physician's order, dated 08/27/2021, for Lactulose Solution 10GM/15 take 15MLs by mouth every day for constipation. The November 2021 medication administration record (MAR) for the resident states "other: awaiting on pharmacy" or "other: waiting on pharmacy" for the dates of 11/20-23/2021, 11/28/2021 and 11/30/2021 and "other: waiting on delivery" for 11/29/2021. Interview with staff 2 revealed that the medication was not available in facility on date of inspection.
  3. Resident 5 has a physician’s order for Ibuprofen 600 mg take one tablet by mouth every 8 hours for pain. The MAR shows that this medication was not administered two times during the month of November due to “Ordered”.
  4. The record for resident 15 has a physician’s order for Ensure drink the contents of 1 bottle with each meal that patient does not eat. The MAR shows that the Ensure was not given eleven times in the month of November due to “Waiting on pharmacy”. Resident 15 has a physician’s order for Enulose 10 gm/15 mg Solution give 30 mls by mouth four times a day for constipation hold if more than 5 bowel movements in 24 hours. The MAR shows that the resident did not receive this medication eight times in November due to “Awaiting Pharmacy”. Resident 15’s Ensure was not available on November 30, 2021 during the inspection.
  5. There was no documentation to show that staff had been implementing the facility's medication management plan regarding refilling medications.
  6. At approximately 9:07AM during on-site inspection on 11/30/2021, The "Shift to Shift Narcotic Count Sign Off Sheet" for medication cart B did not contain the signature of the medication staff coming on duty (7a-3p) for 11/30/2021. Interview with staff 2 revealed that she was the medication staff that took possession of the keys for medication cart B; however, she did not sign the "Shift to Shift Narcotic Count Sheet Off Sheet".
  7. The "Shift to Shift Narcotic Count Sign Off Sheet" for medication cart A for November 2021 did not contain the signature of the medication staff going off duty (7a-3p) and coming on duty (3p-11p) on 11/19/2021.
Plan of correction
Staff is scheduled for a medication management in service for 01/05/2022. A new DON was hired and will have direct oversight and involvement in medication management, procedures, and practices. Staff will receive refresher training on medication management practices periodically, and DON will ensure compliance.
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) included a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. The ISP for resident 3, dated 10/16/2021, stated that the resident needs mechanical assistance only with mobility. The uniform assessment instrument (UAI) for the resident, dated 10/15/2021, stated that the resident needs mechanical assistance and human physical assistance with mobility. Interview with staff 6 revealed that the UAI is correct and the ISP is incorrect.
  2. The UAI for resident 5, dated 7/21/2021, stated that the resident needs assistance with money management. The ISP for the resident, dated 9/23/2021, stated the resident manages all financial matters himself or asks facility for assistance if needed.
  3. The ISP for resident 7, dated 9/10/2021, indicated that the resident is unable to use the call bell and has a need for two hour nightly rounding by staff; however, the same ISP also indicated that the resident is a fall risk and as a fall intervention, staff will remind the resident to use the call bell.
  4. The record for resident 8 contains a physician progress note, dated 03/19/2021, that the resident is a DNR/no CPR. The ISP in the record for resident 8 signed 06/07/2021 is inconsistent as it has that the resident is a full code and does not address resident 8’s DNR status.
Plan of correction
The residents UAI and ISP have been updated so that they are consistent. We have communicated with DSS assessors to update their documents. UAI for Auxiliary Grant is written by DSS assessor. The facility does not write it nor have control over it. The facility keeps reminding assessors. Assessors make corrections per their own schedule. Facility will continue to work with DSS and document attempts to communicate with them in order to keep updated UAI’s in place on property and to keep them consistent with our ISPs, especially when changes or updates occur.
22VAC40-73-750-B
Based on observations made of the facility's physical plant, the facility failed to ensure all required items were in resident rooms.
Evidence
  1. The following are located in the facility's assisted living building: in room 47 there were no chairs available for resident use, the bedside lamp was sitting in the floor with no blub and the shade was off. One resident resides in this room.
  2. In room 52 there was no sturdy chair only a wheelchair. One resident resides in this room.
  3. In room 21 there was only one chair available, the lamp by the bed closest to the door was wedged between the wall and the bed in the floor and the lampshade was missing and there was no bedside lamp accessible to the bed by the window. Two residents reside in this room.
  4. Rooms 4, 7, 9, 14, 15 and 20 located in facility's safe, secure unit did not contain bedside lamps on the day of inspection.
Plan of correction
Each resident has the appropriate furnishings in their rooms to meet compliance. Private pay residents bring furniture to their rooms. Our facility provides furniture for AG residents. Administrator will ensure all private pay resident family bring residents furniture if they have promised to provide them to meet requirements and ask that the furniture brought in is in good repair. Administrator will ensure all AG residents have their rooms fully furnished before moving into the facility. Administrator will ensure to document whenever a family has ordered furniture and its taking weeks to deliver or is not yet in the building.
22VAC40-90-30-B
Based on staff record review, the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment.
Evidence
  1. Documentation provided by staff 7 showed that staff 8's date of hire was 07/16/2021. The record for staff 8 contained documentation that the sworn statement or affirmation was completed after the date of hire on 07/19/2021.
Plan of correction
The appropriate staff hire date has been reflected in the staff file. HR department has been educated on the importance of proper documentation, and making sure all documentation matches for staff files. Business office will routinely audit employee files to ensure compliance with hire dates, and Administrator will periodically spot check for compliance.
22VAC40-73-870-E
Based on observation, the facility failed to ensure that all fixtures shall be kept clean and in good repair.
Evidence
  1. At 11:15am on the day of inspection, 2 licensing inspectors (LI’s) observed that the lunch meal for the residents residing on the facility safe, secure unit had been delivered from the facility’s main kitchen and placed on the warming/serving table located in the safe, secure units kitchen. The table was noted to be dirty, had dried food stains from a previous meal and still contained a platter of cold scrambled eggs from the previous breakfast meal.
  2. The ceiling light in the hallways on the safe, secure unit between rooms 4 an 7 and outside of room 28 and outside of the room labeled housekeeping were noted to have bulbs that were burnt out/ inoperable on the day of inspection. Also, two dust-covered vents were observed on the ceiling in the common area on the safe, secure unit.
Plan of correction
The kitchen area was immediately wiped down and cleaned off. Maintenance department has replaced all bulbs. Kitchen manager will ensure dietary aide serves and completes side work for clean after each meal.
22VAC40-73-610-E
Based on observation and staff interview, the facility failed to ensure to have a current and readily available to food preparation personnel a dietary manual containing acceptable practices and standards for nutrition.
Evidence
  1. During tour of the facility's assisted living building, one licensing inspector requested a dietary manual from kitchen staff and a manual could not be located. One kitchen staff reported that she "made up a lot of her recipes" and that she "might have a manual at home.".
Plan of correction
Kitchen manuals were located and kitchen staff was educated on where to find these manuals in case anyone asks to see them. Kitchen manager will ensure kitchen manual is shown to any inspector or party interested.
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form.
Evidence
  1. The record for staff 2 contained an initial TB assessment dated 10/29/2020; however, the record did not contain an annual TB assessment for 2021.
  2. The record for staff person 3, hired on 10/22/2020, has documentation that the last screening for tuberculosis was completed on 10/16/2020.
  3. The record for staff person 4, hired on 10/15/2020, has documentation that the last screening for tuberculosis was completed on 10/15/2020.
Plan of correction
Updated TB screenings have been obtained for all staff members in need. HR was educated on the importance of ensuring compliance by accurately tracking due dates for TB expirations. TB assessments will be monitored by the ED and his designee to ensure all staff have TB assessments upon hire and annually.
October 12, 2021Complaint survey2 violations
Inspection dates
10/12/2021,11/30/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
Comments
The licensing inspector (LI) for Carriage Hill Retirement conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 10/12/2021. The LI reviewed documentation submitted by the facility and additional documentation provided by the Administrator to the LI on 11/30/2021 regarding allegations of resident care and related services and buildings and grounds. Based on the preponderance of evidence, one of the allegations is valid regarding buildings and grounds. Other violations cited can be found on the violation notice. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-870-A
Based on document review, the facility failed to ensure that the interior of all buildings were kept clean.
Evidence
  1. Documentation in the record for resident 1 by Collateral 2, dated 09/06/2021, stated the following: "PT is found in his room, wheeling himself out of bathroom, DSG intact to left foot and PT has a R AKA.There is a strong urine odor noted in the room and the floor is sticky as this writer makes her way to a chair.".
  2. A photograph, provided by Collateral 3, dated 09/30/2021 at 12:51PM, showed multiple marks of a brown substance located on the wall that the resident's bed is beside. See (ALF11041416 09-30-2021 P1) attached.
Plan of correction
Resident room was cleaned per regular cleaning schedule on 9/6/2021. The room was not reported by other staff, or individuals to have a urine odor, or a sticky floor. The room was renovated and repainted on 10/11/2021.
22VAC40-73-470-A
Based on resident record review and staff interview, the facility failed to ensure that, either directly or indirectly, that the health care service needs of residents were met by assisting residents in making appropriate arrangements for health care services.
Evidence
  1. The record for resident 1 contained a progress note from Collateral 1, dated 04/09/2021, that stated, “I had also ordered podiatric consultation. It is not clear to me whether he has yet seen the podiatrist but he does have a follow-up appointment in the next couple of weeks.” Collateral 1 also stated in the same progress note “He is to keep his appointment with podiatrist.”
  2. Facility staff progress notes for resident 1 stated the following: “04/09/2021 – Resident has an appointment to Podiatry in Bedford to see (doctor) on 4-14-21 @ 2:00 p.m.”; “04/14/2021 – Transportation has a vehicle down and can’t transport resident today. His new appointment to Podiatry is 5-18-21 @9:00 A.M.”. The record for the resident did not contain information that the resident went to either of the scheduled podiatry appointments on 04/14/2021 or 05/18/2021. Interview with staff 1 confirmed that the resident did not go to the scheduled podiatry appointment on 04/14/2021 and also the resident did not go to the scheduled podiatry appointment on 05/18/2021.
Plan of correction
Resident was scheduled with an external transportation company for his appointments. The external transportation company failed to have vehicles that were in appropriate working order to service the resident twice. Our company does not have transportation services or a driver to accommodate individual resident appointments. Carriage Hill has created a list of alternative transportation services that can potentially assist residents in the event their primary transportation services are unavailable. Our staff will review resident appointments and attempt to ensure they have transportation. If a resident needs assistance with additional transportation options, staff will consult Administrator for assistance and the team will work to schedule transportation to the best of their ability.
October 12, 2021Inspection1 violation
Inspection dates
10/12/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
To ensure that the facility had a thorough understanding of standards, the licensing inspector and the Administrator had a discussion regarding standard 680-D.
Comments
A non-mandated monitoring inspection regarding an intensive plan of correction (IPOC) was initiated on 10/12/2021 and concluded on 10/13/2021. The licensing inspector conducted an on-site observation at the facility on 10/12/2021 and the Administrator emailed the licensing inspector items requested by the licensing inspector to conduct the follow-up on 10/12/2021. There were no repeat violations from the non-mandated monitoring inspection regarding the IPOC; however, any violations not related to the non-mandated monitoring inspection but identified during the course of the inspection can be found on the violation notice.
Violations
22VAC40-73-640-A
Based on observation and document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of all controlled substances.
Evidence
  1. The facility’s current medication management plan states that “Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.”
  2. The record for resident 1 contains a physician’s order, dated 05/05/2021, for “morphine concentrate 100 mg/5mL (20 mg/mL) oral solution take ¼ ml by mouth every three hours as needed for pain”.
  3. At approximately 10:29AM during on-site inspection on 10/12/2021, the most recent log entry, dated 08/17/2021, on the “Controlled Drug Record” indicated that there were 26.75 mL of morphine; however, the bottle of morphine for resident 1 showed that there were 24 mL of morphine. Staff 1, 2 and 3 confirmed that the bottle contained 24 mL of morphine.
Plan of correction
The bottle of morphine was removed from the cart and sent to the pharmacy. Pharmacy confirmed morphine bottle leaked. To prevent the potential of this occurring again, moving forward, facility will distribute morphine in prefilled syringes. Facility will not accept a morphine bottle without a bung or stopper. Prefilled syringe and a bottle stopper will prevent leaking.
August 4, 2021Inspection1 violation
Inspection dates
Aug. 4, 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 08/04/2021 and concluded on 08/11/2021. A self-report was received by the department regarding allegations in the areas of staff and resident care and related services regarding medication management. 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 one standard of non-compliance, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-680-H
Based on document, resident record review and staff interview, the facility failed to ensure that at the time a medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents.
Evidence
  1. The record for resident 1 contained a physician’s order, dated 04/12/2021, for ?Hydrocodone-Acetamin 10-325MG (Norco 10/325 Tablet) “ Take One Tablet By Mouth At Bedtime As Needed for Pain ” PRN Indicated For Pain?. The “Controlled Drug Record” for this medication for resident 1 showed that a quantity of 30 of this medication was received by the facility on 07/26/2021 and “signature of nurse receiving medication” was staff 1. At the time of receipt the medication card contained 30 tablets labeled 1 through 30 and contained one tablet per blister. The “Controlled Drug Record” for this medication for resident 1 contained staff 1’s signature that she had removed tablet 30 on 07/26/2021 at 9:00PM and tablet 29 at 7:00PM and tablet 28 at a time that was not legible on 07/27/2021. Picture evidence of the medication card provided to the licensing inspector (LI) by staff 2 on 08/04/2021 of this medication for resident 1 showed that tablets 30, 29, and 28 were missing from the card. See (ALF1104146 07-28-21 P1) attached. The July 2021 MAR for resident 1 showed during the time period of 07/26-27/2021 that this medication was administered only on 07/27/2021 at 8:14PM by staff 1. There was no documentation on the MAR that the medication was administered on two other occasions by staff 1 during this time period.
  2. The record for resident 2 contained a physician’s order, dated 07/23/2021, for “Oxycodone 5mg tab ” tab (2.5mg) PO q 4 hrs. PRN breakthrough pain. #30 (thirty).? The “Controlled Drug Record” for this medication for resident 2 showed that “No. of Doses Received: 60” of this medication was received by the facility on 07/24/2021 and “signature of nurse receiving medication” was staff 1. At the time of receipt the medication card contained 60 tablets labeled 1 through 60 and contained half a tablet per blister. The “Controlled Drug Record” for this medication for resident 2 contained staff 1’s signature that she had removed tablet 60 on 07/26/2021 at 7:00PM, tablet 59 on 07/27/2021 at 12:00AM, tablet 58 on 07/27/2021 at a time that was not legible, tablet 57 on 07/27/2021 at 7:00AM, tablet 56 on 07/27/2021 at 7:00PM and tablet 55 on 07/27/2021; however, there was no time documented of when staff 1 removed tablet 55. On 07/28/2021 tablets 54 and 53 were removed by staff 1 but there was no time indicated when these two tablets were removed. Picture evidence of the medication card provided to the LI by staff 2 on 08/04/2021 of this medication for resident 2 showed that tablets 60 through 53 were missing from the medication card. See (ALF1104146 07-28-2021 P2) attached. The July 2021 MAR for resident 2 showed during the time period of 07/26/2021 through 07/28/2021 showed this medication was only administered to resident 2 on 07/27/2021 at 7:48PM and 07/28/2021 at 12:42AM by staff 1. There was no documentation on the MAR that the medication was administered on the six other occasions by staff 1 during this time period.
  3. The record for resident 3 contained a physician’s order, dated 07/23/2021, for ?Tramadol 50 mg PO TID PRN Pain #90 (ninety).? The “Controlled Drug Record” for this medication for resident 3 showed that a quantity of 90 tablets of this medication was received by the facility on 07/23/2021. Interview with staff 4 confirmed this was accurate. The “Controlled Drug Record” for this medication for resident 3 contained staff 1’s signature that she had removed tablet 30 on 07/23/2021 at a time that was not legible, tablet 29 on 07/24/2021 at 7:00PM, tablet 28 on 07/25/2021 at 5:00AM, tablet 27 on 07/25/2021 at 7:00PM, tablet 26 on 07/25/2021 at 8:00AM
Plan of correction
Please see Intensive Plan of Correction
May 6, 2021Complaint survey2 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 The Criminal History Record Report22VAC40-80 COMPLAINT INVESTIGATION
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 05/06/2021 and concluded on 05/12/2021. A complaint was received by the department regarding allegations in the areas of infection control, resident care and related services, staffing and supervision and the criminal history record report. 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. To ensure that the facility had an thorough understanding of standards, the licensing inspector, the Vice President and the Administrator had a discussion regarding standard 100 A. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-100-A
Based on document review, the facility failed to ensure that the infection control program included all required components.
Plan of correction
1. The facility will update the Infection Control Program to include sanitation of rooms, including cleaning and disinfecting
22VAC40-73-640-A
Based on document review, the facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan states ?Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies At the end Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.?
  2. The “Shift to Shift Narcotic Count Sign off Sheet” for medication cart “D” for May 2021, does not contain the signature of the registered medication aide (RMA) going off duty (11p-7a Leaving) for the dates of 05/04/2021 and 05/06/2021, the RMA going off duty (3p-11p Leaving) for 05/03/2021 and the on-coming RMA (11p-7a Coming) for the dates 05/03/2021 and 05/05/2021.
Plan of correction
1. Director of Nursing / Administrator will ensure Medication Log is signed off by each shift.
March 25, 2021Complaint survey11 violations
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-80 COMPLAINT INVESTIGATION
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 03/25/2021 and concluded on 05/13/2021. A complaint was received by the department regarding allegations in the areas of personnel, admission, retention and discharge of residents, 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. To ensure that the facility had a thorough understanding of standards, the licensing inspector, Vice President and Administrator had a discussion regarding 440 A, 440 D and 640 A. The evidence gathered during the investigation supported one 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
22VAC40-73-290-A
Based on document review and staff interview, the facility failed to maintain a written work schedule with an indication of whomever is in charge at any given time.
Evidence
  1. The work schedule provided to the licensing inspector for the time period 03/14/2021 through 03/26/2021 does not indicate which direct care staff was in charge during each shift for this time period. Interview with staff 1 confirmed this information.
Plan of correction
1. Facility will indicate on staffing schedule staff member in charge for each shift.
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure that the uniform assessment instrument was completed as required.
Evidence
  1. The UAI for resident 9, dated 03/11/2021, showed that the resident is “disoriented ” some spheres, all the time?; however, the UAI does not indicate which spheres are affected. Interview with staff 1 revealed that the spheres affected are time and place.
Plan of correction
1. Facility will ensure UAI indicates spheres affected and documented accordingly.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plans (ISP) included all required components.
Evidence
  1. The uniform assessment instrument (UAI) for resident 5, dated 03/19/2021, stated that the resident needs physical assistance with bathing and supervision with toileting. The ISP for resident 5, with an identified need date of 03/19/2021, showed the resident needs supervision with bathing and does not need any assistance with toileting. Interview with staff 1 revealed that the UAI is incorrect and the ISP is correct.
  2. The UAI for resident 6, dated 03/15/2021, stated on page 7 that resident is allergic to influenza vaccine and pneumococcal vaccine. This is not documented on the resident’s ISP.
  3. The UAI for resident 9, dated 03/11/2021, stated that the resident needs physical assistance only with stairclimbing. The ISP for resident 9, dated 03/12/2021, showed that the resident needs physical assistance and mechanical assistance (hand rails) with stairclimbing. Interview with staff 1 revealed that the UAI is incorrect and the ISP is correct.
Plan of correction
1. Care Plan Coordinator and or Director of Nursing will ensure initial UAI /ISP needs align and is documented.
22VAC40-73-460-I
Based on document review, the facility failed to ensure that all residents are dressed in clean clothing.
Evidence
  1. Two photographs, provided by Collateral 2, dated 03/19/2021 at 1:14 PM, showed resident 1 wearing a stained shirt. There was also food on his shirt and pants. See (ALF11041416 03-19-21 P2) and (ALF11041416 03-19-21 P3) attached.
  2. Interview with staff 1 on 05/13/2021 confirmed that resident 1 needs assistance with changing his clothes.
Plan of correction
1. Resident physician was notified of needed order for bibs. Staff instructed to provide resident with bibs during meals.
22VAC40-73-460-J
Based on documentation review, the facility failed to ensure that all residents who are incontinent have clean clothing and linens each time their clothing or bed linen is soiled or wet.
Evidence
  1. The individualized service plan (ISP) for resident 2, dated 02/11/2021, stated that the resident has bladder incontinence, with expected outcomes/goals ?Resident will be clean, dry & free of odor and Skin integrity will be maintained?. The ISP also states that the resident needs physical assistance with dressing.
  2. Interview with Collateral 4 on 03/24/2021 revealed when Collateral 4 came to the facility on 03/18/2021 to visit with resident 2 that the resident’s clothing and linens were soaked with urine; however, the resident’s brief had been changed.
  3. Interview with staff 1 confirmed that staff 2 was terminated by the facility because staff 2 admitted to not changing the resident’s clothes and linens when she changed the resident’s brief. Staff 1 confirmed that resident 2 needs staff assistance with changing her clothes and linens.
Plan of correction
1. Staff member was terminated, hospice provider was contacted and requested for additional service days, and Administrator reviewed with staff changing of briefs and linens when soiled.
22VAC40-73-480-E
Based on resident record review and staff interview, the facility failed to ensure that the evaluations of progress and other pertinent information regarding rehabilitative services shall be recorded in the resident’s record.
Evidence
  1. The licensing inspector (LI) requested home health notes from November 2020 until present for resident 8 on 04/13/2021. Staff 1 informed the LI that the home health notes had to be requested from the home health agency on 04/13/2021 as the notes were not in the facility.
Plan of correction
1. Facility requested home health deliver notes after visits and check out with Director of Nursing post visit.
22VAC40-73-580-F
Based on resident record review, the facility failed to notify resident’s attending physician when a significate weight loss of 5.0% in one month was identified.
Evidence
  1. The record for resident 7 contained documentation that the resident weighed 242 lbs. on 07/05/2020 and 228 lbs. on 08/05/2020 which is greater than a 5% weight loss in one month.
  2. The record for resident 7 did not contain documentation that the resident’s attending physician was notified of the weight loss.
Plan of correction
1. Director of Nursing will oversee resident weights and ensure changes over 5% are reported to the resident’s physician and documented in the resident’s chart.
22VAC40-73-650-A
Based on resident record review, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was discontinued without a valid order from a physician of other prescriber.
Evidence
  1. The uniform assessment instrument completed by Collateral 6, dated 03/15/2021, included current physician’s orders that included “diphenhydramine (Benadryl) 25 mg = 1 cap, Oral, Tab, every 6 hr for 365 days, PRN pain”.
  2. The March 2021 medication administration record (MAR) for resident 6 did not contain this medication and the resident’s record did not contain a discontinued order for this medication.
Plan of correction
1. Facility contacted pharmacy and clarified current prescribed medications. Medications discontinued were documented in the MAR and an order placed in chart.
22VAC40-73-870-A
Based on document review, the facility failed to ensure that the interior of all buildings are maintained in good repair and kept clean.
Evidence
  1. A photograph, provided by Collateral 1, dated 04/28/2021, showed two cracked floor tiles at the entry way of C hallway. See (ALF11041416 04-28-2021 P1) attached.
  2. Video with audio, provided by Collateral 1, dated 04/28/2021, showed Collateral 1 walking down the hallway on C Wing. The audio supported Collateral 1's report that the floor was sticky "all the way down the hall beside the kitchen".
Plan of correction
1. Facility replaced tiles and changed moping solution from hospital grade disinfectant (COVID-19) to all-purpose moping solution.
22VAC40-73-870-E
Based on document review, the facility failed to ensure that all furnishing were kept clean and in good repair and condition.
Evidence
  1. Two photographs provided by Collateral 1 showed that on 04/28/2021 the floor around the toilet in resident 3's room had not been cleaned. See (ALF11041416 04-28-21 P4) and (ALF11041416 04-28-21 P5) attached.
  2. Photograph provided by Collateral 1, dated 03/26/2021, of the toilet in resident 4's room showed a brown substance, that appeared to be feces on the toilet. See (ALF11041416 03-26-21 P6) attached. Photograph provided by Collateral 1, dated 04/28/2021, showed the toilet in resident 4's room had a brown substance that appeared to be feces on the seat and what appeared to be urine in the toilet where the toilet had not been flushed. See (ALF11041416 04-28-21 P7) attached.
  3. Photograph provided by Collateral 1, dated 03/26/2021 at 12:17 PM, showed three lines of a brown substance, that appeared to be feces on the side of the box spring for the mattress for resident 4 that had not been cleaned. See (ALF11041416 03-26-21 P8) attached. Additional photographs from 03/29/2021 at 1:19 PM from Collateral 1 showed that the three lines of brown substance had not been completely cleaned from the box spring. See (ALF11041416 03-26- 21 P9) and (ALF11041416 03-26-21 P10) attached.
Plan of correction
1. Incontinent needs addressed with nursing staff / housekeeping, box spring replaced, and waterproof cover installed.
22VAC40-73-930-D
Based on resident record review, the facility failed to ensure that for each resident with an inability to use a signaling ilit device, the facility shall document rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. Resident 5 was admitted to the facility on 03/15/2021. The individualized service plan (ISP) for resident 5, with an identified need date of 03/15/2021, showed “CALL BELLS Resident is not able to alert staff when assistance is needed” and ?Resident is unable to use call bell to alert staff when assistance is needed, and staff will check on and document a minimum of every 1 hour while asleep and every 2 hours while awake. Staff will assess a minimum of annually and/or if a significant change or as needed.? The record for resident 5 did not contain documentation of the times rounds were made on the resident from 03/15/2021 through 03/30/2021. The record for resident 5 only includes that rounds were made at 4PM, 6PM, 8PM and 10PM on 03/31/2021.
  2. Resident 6 was admitted to the facility on 03/18/2021. The ISP for resident 6, with an identified need date of 03/18/2021, showed “CALL BELLS Resident is not able to alert staff when assistance is needed” and ?Resident is unable to use call bell to alert staff when assistance is needed, and staff will check on and document a minimum of every 1 hour while asleep and every 2 hours while awake. Staff will assess a minimum of annually and/or if a significant change or as needed.? The record for resident 6 does not contain documentation of the times rounds were made on the resident from 03/18/2021 through 03/30/2021. The record for resident 6 only includes that rounds were made at 4PM, 6PM, 8PM and 10PM on 03/31/2021.
Plan of correction
1. Director of Nursing will ensure staff complete rounds and document accordingly.
March 25, 2021Inspection1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
To ensure that the facility had a thorough understanding of standards; the LI and the Administrator had a discussion regarding standard 440
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 monitoring inspection was initiated on 03/25/2021 and concluded on 05/04/2021. A self-reported 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 did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed at least once every 12 months.
Evidence
  1. The most current ISP for resident 1 contains identified needs for the resident with a begin date of 02/27/2020 and that the expected outcomes/goals of these identified needs would be reviewed by 02/26/2021; however, the ISP does not contain documentation that these identified needs had been reviewed by 02/26/2021.
Plan of correction
Care Plan Coordinator will take part in an in-person training course for Individualized Service Plans. Administrator and/or Director of Nursing will review training with Care Plan Coordinator and provide oversight of Individualized Service Plans.
March 15, 2021Complaint survey7 violations
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
To ensure that the facility had a thorough understanding of standards, the licensing inspection and the administrator had a discussion regarding standards 650 A and 650 F.
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 virtual complaint inspection was initiated on 03/15/2021 and concluded on 04/12/2021. A complaint was received by the department regarding allegations in the areas of personnel, resident care and related services, buildings and grounds and emergency preparedness. 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 four 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. Based on a requested review of violations by the facility, this violation notice has been amended due to a review by the department that occurred on 01/06/2022.
Violations
22VAC40-73-200-B
Based on resident record review and staff interview, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training.
Evidence
  1. The record for resident 1 contained a physician’s order, dated 02/19/2021, that stated ?Fleets enema rectally once may use one more time if no results in one hour“ and ”Indication - DX constipation?. The February 2021 medication administration record (MAR) for resident 1 contained documentation that the following registered medication aides (RMAs) administered the enemas on the following dates at 5:00 PM: staff 1 on 02/21/2021; staff 2 on 02/22/2021 and 02/24/2021; and staff 3 on 02/23/2021 and 02/26/2021. The March 2021 MAR for resident 1 contained documentation that the following registered medication aides (RMAs) administered the medication enemas on the following dates at 5:00 PM: staff 1 on 03/07/2021; staff 2 on 03/01/2021; and staff 3 on 03/05/2021, 03/08/2021, and 03/13-14/2021. The “Commonwealth of Virginia Board of Nursing Medication Aide Curriculum For Registered Medication Aides” states The “Commonwealth of Virginia Board of Nursing Medication Aide Curriculum For Registered Medication Aides” states on page 136 ?NOTE: The administration of enemas requires additional knowledge, skills, and clinical practice that are not addressed in this curriculum.? The records for staff 1, 2 and 3 did not contain documentation that these staff had additional knowledge, skills, and clinical practice or additional training related to administering enemas and staff 4 confirmed that staff 1, 2 and 3 did not have this additional training.
Plan of correction
Director of Nursing, Administrator, and/or designee will ensure direct care staff provide services within their scope of practice.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were reviewed and updated as the condition of a resident changes.
Evidence
  1. The January 2021 medication administration record (MAR) for resident 2 showed that starting on 01/16/2021 the resident started refusing multiple medications daily during the month of January 2021. The February 2021 MAR for resident 2 showed that during the month of February 2021 resident 2 refused multiple medications daily during the month of February 2021. The March 2021 MAR for resident 2 showed the resident refused all medications daily from 03/01/2021 through 03/14/2021 and refused all morning medications on 03/15/2021.
  2. The ISP for resident 2, dated 01/04/2021, was not updated to reflect this significant change in resident 2’s condition.
Plan of correction
Director of Nursing and/or Administrator will review and update ISPs to reflect significant changes.
22VAC40-73-460-H
Based on resident record review, the facility failed to ensure that all residents received personal assistance and care with bathing at least twice a week, but more often if needed or desired.
Evidence
  1. The Individualized Service Plan (ISP) for resident 1, dated 04/22/2020, showed the following: ?BATHING: Mechanical/Physical Assistance Staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able while using the following DME equipment: shower bench/seat, grab bars“; ”Person who will provide services: Direct Care Staff, Resident“ and ”When & where services will be provided: Minimum of twice weekly & as needed in bathroom at Carriage Hill?. The record for resident 1 did not contain documentation that the resident had received any showers during the weeks of 01/24/2021 through 01/30/2021, 01/31/2021 through 02/06/2021, 02/14/2021 through 02/20/2021, 02/21/2021 through 02/27/2021, 02/28/2021 through 03/06/2021 and 03/07/2021 through 03/13/2021.
  2. The ISP for resident 2, dated 01/04/2021, showed the following: ?BATHING: Supervision Staff will supervise resident while bathing and cue resident as needed. Staff will ensure resident is able to get in/out of shower safely with a gently [sic] hand.“; ”Person who will provide services: Direct Care Staff, Resident“ and ”When & where services will be provided: Minimum of twice weekly & as needed in bathroom at Carriage Hill? The record for resident 2 did not contain documentation that the resident had received any showers during the time period of 01/24/2021 through 03/13/2021.
  3. The ISP for resident 3, dated 10/08/2020, showed the following: ?BATHING: Mechanical/Physical Assistance Staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able while using the following DME equipment: shower bench/seat, grab bars“; ”Person who will provide services: Direct Care Staff, Resident“ and ”When & where services will be provided: Minimum of twice weekly & as needed in bathroom at Carriage Hill?. The record for resident 3 did not contain documentation that the resident had received any showers during the weeks of 01/24/2021 through 01/30/2021 and 01/31/2021 through 02/06/2021. The record for resident 3 contained documentation that the resident had only received three showers from 02/07/2021 through 02/27/2021 and that the resident had only received one shower from 02/28/2021 through 03/13/2021.
Plan of correction
Director Nursing, Administrator, and/or designee will ensure proper documentation of showers to include refusals.
22VAC40-73-640-A
Based on resident record review, the facility failed to ensure that the medication aide or the person licensed to administer drugs routinely communicated issues or observations related to medication administration to the prescribing physician or other prescriber.
Evidence
  1. Document “Medication Management Plan” states on page 8 the following: ?13. All staff is responsible for communicating daily, per shift, to the SIC (supervisor in charge), Administrator/DON any change in condition, problems, concerns, falls or other issues of a Resident that could have a negative effect on their medical status. The SIC is ibl f responsible for communication problems, concerns or changes in condition with the assigned physician either fax or phone.?
  2. The March 2021 medication administration record (MAR) for resident 2 showed the resident refused all medications daily from 03/01/2021 through 03/14/2021 and refused all morning medications on 03/15/2021.
  3. The facility failed to communicate the resident 2’s refusals of prescribed medications as evidenced by ?Progress Note“ by Collateral 1, dated 03/15/2021, which showed on page 1 of 2 that ”Nursing relates that he (resident 2) has been much more cooperative. He is eating better. He is taking his medications.?
Plan of correction
The providers response for the "plan of correction" was not received as of 04/23/2021 and will not appear on this Violation Notice
22VAC40-73-650-B
Based on resident record review, the facility failed to ensure that physicians or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, conditions or specific indications for administering each drug and how often the medication is to be given.
Evidence
  1. The record for resident 1 contained a physician’s order, dated 02/25/2021, for ?Rx: Keflex 500 mg oral capsule SIG: 1 cap oral every 12 hr for 7 days?. The order did not contain the diagnosis or conditions or specific indications for administering the drug.
  2. The record for resident 2 contained a physician’s order, dated 01/14/2021, for ?Rx: silver sulfadiazine (SILVADENE, SSD) 1 % cream Sig: Apply by topical route to the affected area (s).? The order did not contain the diagnosis, conditions or specific indications for administering the drug and how often the medication is to be given.
Plan of correction
Director of Nursing and/or Administrator will educate Physician to include diagnosis, condition, and specific indications for administration on orders.
22VAC40-73-680-D
Based on resident record review and staff record review, the facility failed to ensure that medications were administered in accordance with physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 2 contained a physician’s order, dated 01/22/2021, for “NOVOLOG 100 UNIT/ML SOLN ” CHECK FSBS FOUR TIMES A DAY AND INJECT SSI AS FOLLOWS 150-199 = 1U, 200-249 = 2U, 250 – 299 = 3U, 300-349 = 4U, >350 = 5U FOR DIABETES “ 8AM, 12PM, 4PM, 8PM Indicated for DIABETES”. The January 2021 Medication Administration Record (MAR) for resident 2 showed that on 01/09/2021 at 8AM the resident’s glucose reading was 305 and 5 units of Novolog were administered; however, according to the physician’s orders 4 units should have been administered. On this same date, at 8PM the resident’s glucose reading was 189 and Novolog was not administered to the resident; however, 1 unit should have been administered. On 01/10/2021 at 12PM the resident’s glucose reading was 222 and 3 units of Novolog were administered; however, 2 units should have been administered. On 01/14/2021 at 12PM the resident’s glucose reading was 274 and 4 units of Novolog were administered; however, 3 units should have been administered. The January 2021 MAR showed that on 01/01/2021 at 12PM, the resident’s glucose reading was 233; on 01/02/2021 at 12PM, the resident’s glucose reading was 247, at 4PM was 248 and at 8PM was 178; on 01/03/2021 at 12PM, the resident’s glucose reading was 164, and at 8PM was 218. The MAR does not contain documentation of how many units of Novolog were administered to resident 2 for these dates and times. The February 2021 MAR for resident 2 showed that on 02/20/2021 at 8AM the resident’s glucose reading was 220 and 4 units of Novolog were administered; however, 2 units of Novolog should have been administered.
Plan of correction
Director of Nursing and /or Administrator will educate Medication Aids on the dosing scale for insulin.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that all residents? medication administration records (MARs) included the initials of the direct care staff administering medications.
Evidence
  1. The February and March 2021 MARs for resident 1 showed ?Enema (Fleet Enema) Insert and empty contents of 1 enema into rectum once for constipation for: constipation?. The MARs contained “Medication Notes” by registered medication aide; staff 3, on 02/19/2021 and 03/03/2021 at 5:00 PM that “Nurse Give”.
  2. The MARs do not contain the initials of the direct care staff that administered the enema.
Plan of correction
Director of Nursing and/or Administrator will educate Medication Aids on proper documentation on MAR.
March 1, 2021Complaint survey4 violations
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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 03/01/2021 and concluded on 03/17/2021. A complaint was received by the department regarding allegations in the areas of admission, retention and discharge of residents. 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 allegation of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-320-A
Based on resident record review and staff interview, the facility failed to ensure that within 30 days preceding admission, all residents had a physical examination by an independent physician.
Evidence
  1. The record for resident 1, admitted 07/30/2020, did not contain documentation of a physical examination by an independent physician.
  2. Interview with staff 1 confirmed that the resident did not have a physical examination by an independent physician preceding admission to the facility.
Plan of correction
Admission staff were provided with a copy of State Model Form 032-05-0007-09-eng (02/18) and were educated on the importance of gathering preadmission medical information prior to admission of a resident. Staff were educated on the information gathered on State Model Form and its importance to the admission of prospective residents. State Model Form has been provided to staff in digital and physical format to ensure availability.
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care.
Evidence
  1. The record for resident 1 showed that the most recent fall risk rating for the resident was dated 07/24/2020; however, a progress note for resident 1 stated, ?Late Entry for 12/4/2020 5:00 PM: PT returned to facility via transport. Pt returned from hospital with c/o pains in her left jaw, right leg and her left elbow. Pt stated that the fall hurt her pretty bad and that she will be in her room until tomorrow getting some rest.? 2 Interview with staff 1 confirmed that the fall risk rating had not been updated
  2. Interview with staff 1 confirmed that the fall risk rating had not been updated.
Plan of correction
Administrator and/or designee will ensure fall risk ratings are completed on each fall and filed accordingly in Resident’s chart.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed and updated as the condition of a resident changes.
Evidence
  1. The ISP for resident 1, dated 07/29/2020, showed that the resident was “Abusive/Aggressive/Disruptive ” Less than weekly“ and the type of inappropriate behavior was ”Recent ECO to hospital for agitated behavior related to UTI.? The uniform assessment instrument (UAI), dated 07/24/2020, showed that the resident was ? Abusive/Aggressive/Disruptive “ Less than weekly” and the type of inappropriate behavior was ?Recent ECO to hospital for agitation that may be related to UTI.?
  2. The most recent UAI for resident 1, dated 09/24/2020 and completed by the local department of social services, showed on page 8 that resident 1 is “Abusive/Aggressive/Disruptive ” Weekly or more? and the type of inappropriate behavior is “agitated easily, refuses meds at times” and “source of information: (staff 2)”.
  3. The ISP was not updated to reflect this change in resident 1’s condition.
Plan of correction
Community will audit resident charts to ensure ISPs are in line with UAIs and are up to date. Discrepancies will be adjusted to reflect resident’s current needs.
22VAC40-73-460-B
Based on resident record review, the facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The record for resident 1 contained a “psychiatric periodic evaluation”, dated 01/12/2021 and completed by Collateral 1, that stated, “Patient today is continued to have irritability and refuse medication at times.” and ?Follow-up: Monitor for changes in mood or behaviors. Please contact (Collateral 2) as needed for concerns and consultation.?
  2. Resident 1 continued to refuse medications as indicated by progress notes dated 01/22/2021 that resident ?refused all AM and PM medications?; progress notes dated 01/19/2021, 01/23/2021 and 01/26/2021 that resident refused all AM (morning) medications; and progress note dated 01/28/2021 that resident refused all PM (evening) medications.
  3. Progress note for resident 1, dated 01/19/2021, stated “resident was put on the docs list to be seen” and progress note, dated 01/28/2021, stated “doctor notified”; however, there was no documentation that resident had been seen by a physician or that the facility contacted Collateral 2 as instructed by Collateral 1.
  4. The February 2021 medication administration record (MAR) for resident 1 shows that the resident refused to take multiple medications daily from 02/01/2021 through 02/14/2021. A progress note for resident 1, dated 02/15/2021, showed the resident was agitated and pulled out a pair of scissors in a threatening manner on 02/11/2021. A progress note for resident 1, dated 02/15/2021, stated the following, ?Resident has become a danger to herself and others currently that has had escalating behavior for one week.? Hospital documentation, dated 02/15/2021, stated the following, “Chief Complaint ” (Facility) called us for an ECO because she keeps calling 911 & saying we’re starving her cats & has been threatening to stab us with scissors. She’s refusing all medications.?
  5. Resident returned to the facility from the hospital on 02/16/2021 and the February 2021 MAR showed from 02/16/2021 through 02/28/2021 showed that the resident continued to refuse multiple medications on numerous days.
  6. Progress note, dated 02/18/2021, showed that staff 3 reached out to Collateral 1 and Collateral 1 refused to see resident and that ?another practitioner would be assuming a new role with the facility and would be there in a few weeks.? Also, the progress note showed that staff 3 reached out to local adult protective services (APS) and APS (Collateral 3) “agreed Resident was a danger to herself and `especially others” in the facility and agreed Resident `needed to be TDO’d“ for stabilization of meds and mental health issues. Instructed to `call 911 immediately when she acts up” and file ECO papers and notify on-call APS worker?.
  7. Progress note, dated 02/28/2021 at 1:48 AM, stated that resident 1 had called 911 and spoke with officer alone in her room and ?resident still refusing all meds. resident seems to be seeing things that are not there as she reported to staff there were two people outside window near front of building when nothing nor anyone was there.?
  8. Progress note, dated 03/01/2021 at 7:41 AM, stated that ?resident came to staff and told staff that `the man with one leg came in my room with a weapon and said he was going to kill me and my cat??. Additional progress note on 03/01/2021 at 12:39 PM stated that ?staff reported to (Staff 1) that resident accused a resident of coming into her room with a weapon and threatening her. Also progress note on 03/01/2021 at 1:46 PM stated that resident 1 had thrown a glass of water on another resident.
  9. Interview with staff 1 revealed that the facility had requested an ECO for resident 1 on 03/01/2021 and resident was sent out of facility on an ECO. Staff 1 stated that resident 1 is currently in an inpatient psychiatric facility.
Plan of correction
Facility has trained nursing staff through In-service on: 1. Refusal of Medication 2. Reporting Refusal 3. Follow-up to Refusal
January 19, 2021Inspection1 violation
Inspection dates
Jan. 19, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 01/19/2021 and concluded on 02/02/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services regarding medication administration. The acting administrator/assisted living facility administrator-in-training was contacted by telephone to conduct the investigation. The licensing inspector emailed the acting administrator/assisted living facility administrator-in-training 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 violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-680-B
Based on resident record review, document review and staff interview, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. The facility submitted a written report regarding an incident that occurred on 01/17/2021. The report revealed that staff 1 observed a medication sitting on resident 1’s shirt and assisted resident 1 in taking the medication.
Plan of correction
Plan of correction: 1.Our Administrator self-reported this incident, including the medication error to the state. The resident was sent out to the hospital for further evaluation. 2.Staff member involved in the incident was counseled appropriately for behavior. Appropriate action was taken in reporting this incident and the staff involved, to the appropriate regulatory agencies. An in-service was conducted with all staff regarding appropriate medication management practices, including but not limited to observation of the med pass, and appropriate action and documentation associated with a med pass. Mandatory additional training through our company training program was also initiated for all medication technicians to complete. 3.Our Director of Nursing is providing on the job training and is observing med passes at random with staff to ensure ongoing compliance. She is also spot-checking documentation in the EMAR system to ensure we are documenting med passes appropriately. 4.Weekly our Administrator and DON will meet to discuss nursing functions and med passes will be discussed to ensure we are operating within compliance ongoing.
December 29, 2020Complaint survey1 violation
Inspection dates
12/29/2020
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
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 12/29/2020 and concluded on 2/5/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services and building and grounds. 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.
Violations
22VAC40-73-870-A
Based on documentation review and interviews, the facility failed to keep the interior of the building clean.
Evidence
  1. On 12/24/2020 the local emergency management services (EMS) responded to the facility for reports of resident 1 not feeling well. Interviews with EMS personnel expressed that urine was observed on the floor in resident 1's room, that the floor was very sticky and the bathroom toilet and floor were dirty. Documentation in the emergency room notes dated 12/24/2020 states that EMS found resident 1's room in disarray upon arrival.
Plan of correction
1. Resident room was cleaned, picked up and repaired to appropriate standards. 2. New staff were hired in the housekeeping department to assume duties of ensuring appropriate cleanliness of resident rooms. Cleaning protocols and maintaining appropriate room standards for residents are a part of their standard job duties. Housekeeping schedules and duties have assumed roles that were previously filled by nursing staff, and housekeeping personnel are focused on maintaining appropriate infection control, and environment cleanliness. 3. Our Director of Nursing is monitoring the timeliness of patient care and is simultaneously checking resident rooms at random to ensure proper order and infection control is maintained in their personal environments ongoing. 4. Administrator is overseeing the operations of the housekeeping department and is spot checking rooms at random daily to ensure these measures are being reviewed and maintained.
December 23, 2020Complaint survey1 violation
Inspection dates
Dec. 23, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
To ensure the facility had a thorough understanding of standards, the licensing inspector and the acting administrator had a discussion regarding standard 40 A.
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 12/23/2020 and concluded on 02/02/2021. A complaint was received by the department regarding allegations in the area of administration and administrative services in regards to infection control. The executive administrative assistant was contacted by telephone to conduct the investigation. The licensing inspector emailed the executive administrative assistant and the business office manager a list of documentation required to complete the investigation. To ensure that the facility had a thorough understanding of standards, the licensing inspector and the acting administrator had a discussion regarding standard 100 A and 100 F. 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
22VAC40-73-100-A
Based on observation during a virtual inspection and, documentation, and interviews, the facility failed to implement their infection control policy.
Evidence
  1. “Infection Control ” VAC 40-73-100 C&D“, the facility’s infection control policy, states on page 1, ”Carriage Hill promotes a safe and healthy environment for residents, staff, and visitors where the acquisition of infection is minimized by adhering to Centers for Disease Control AND OSHA guidelines and precautionary measures.?
  2. “Considerations for Preventing Spread of COVID-19 in Assisted Living Facilities”, published by the CDC on 05/29/2020, includes the following excerpts: ?Everyone in the facility should practice source control. Personnel should wear a facemask (or cloth face covering if facemasks are not available or only source control is required) at all times while they are in the facility? ?Encourage residents to wear a cloth face covering (if tolerated) whenever they are around others, including when they leave their rooms and when they leave the facility.? “Encourage social (physical) distancing ” instead of communal dining, consider delivering meals to rooms, or staggering mealtimes to accommodate social distancing while dining (e.g., a single person per table).? ?Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic“ published by the CDC on 12/14/2020 showed ”Because of the potential for asymptomatic 2019 (COVID 19) Pandemic“, published by the CDC on 12/14/2020, showed ”Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.?
  3. During an interview, Collateral 1 reported that she had been informed by multiple staff at the facility that no one (staff) wears masks in the facility because no one in the facility has COVID-19. Collateral 1 also reported that she observed the executive director, the nurses and staff not wearing masks.
  4. Interview conducted on 12/28/2020 with staff 3 indicated ?wearing masks was just made mandatory last week due to a complaint“ and ”no one was wearing masks prior to one week ago.?
  5. Interview conducted on 12/28/2020 with staff 4 indicated “wearing masks was just enforced in the last week.” And ? no one had been wearing masks until then.?
  6. Interviews with staff 3 and 4 revealed that the facility did not have enough masks to provide to staff prior to masks being made mandatory but the facility has a good supply presently.
  7. During virtual inspection on 12/23/2020, staff 5 was observed in the memory care building conducting an activity with residents and was not wearing a mask. Interview with staff 1 and 2 revealed that staff 5 does not wear a mask due to asthma. Interview with staff 6 also revealed that staff 5 does not wear a mask due to asthma but administrative staff is working on a solution to this issue.
  8. During a virtual inspection conducted by another LI on 12/30/2020, 10 to 15 residents were noted to be sitting at several tables in the dining room near the kitchen door. Some of the tables had 2 to 3 residents each and several residents were noted without masks and were not socially distanced. Lunch had not yet been served.
Plan of correction
Plan of correction: 1. Staff were individually contacted and communicated with about the importance of maintaining infection control, including appropriate mask wearing procedures. Tables were added in the dining room to ensure social distancing. Staff was educated by our Resident Care Coordinator on the importance of proper mask wearing, and all PPE, and the risks associated with non-compliance related to this. It is our internal policy that all staff (medically appropriate) wear appropriate PPE while at work. 2. Notices have been posted on the entrances to our buildings advising staff of appropriate PPE guidelines for entering the community. Our break rooms have been set up to accommodate appropriate social distancing. We have ample available PPE for all staff and residents which they can request at any time. 3. Management staff have been educated and tasked to ensure they are watching staff to ensure they are consistently wearing appropriate PPE.
November 23, 2020Complaint survey0 violations
Inspection dates
Nov. 23, 2020
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
To ensure that the facility had a thorough understanding of standards, the LI had a discussion with the Administrator regarding standards 450 C and 570 D.
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 11/23/2020 and concluded on 12/03/2020. 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 did not support the allegations of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.