Virginia DSS · Assisted Living Facility

The Crossings at Ironbridge

📍 6701 Ironbridge Parkway, Chester, VA, 23831

ID 36832One Year licenseActive
30
Inspections
On record
18
With violations
Visits that cited something
12
Clean visits
Nothing cited
55
Violations cited
Individual findings
37
Standards cited
Distinct rules
12
Complaint visits
Prompted by a complaint

The Crossings at Ironbridge was inspected 30 times between June 11, 2021 and May 12, 2026 by the Virginia Department of Social Services. 18 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 55 violations under 37 distinct standards. 12 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. 29 of these 30 are still on the state's site; the other 1 has since dropped off it and is 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
06/30/2026
Administrator
Melissa Freeman
Licensing inspector
Kimberly Davis
Inspector phone
(804) 356-3572
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

30

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

May 12, 2026Inspection7 violations
Inspection dates
05/12/2026,05/15/2026
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 PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-12-26 from 9:53 a.m.- 3:25 p.m. and 5-15-26 from 11:40 a.m.-3:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection -facility documentation, facility postings, first aid kit, medication pass, physician’s orders, and medication administration records. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-950-E
Based on a review of facility documentation the facility did not ensure that the facility shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services.
Evidence
  1. The facility’s most recent review of the emergency preparedness and response plan dated 4-30-26 was for staff only and did not include residents. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
22VAC40-73-720-A
Based on a review of resident records the facility did not ensure that the written Do Not Resuscitate (DNR) order is included in the individualized service plan (ISP).
Evidence
  1. The record for Resident # 1 contained a DNR order. However, the resident’s DNR was not included on the resident’s ISP dated 11-18-25. This was confirmed by Staff # 4.
  2. The record for Resident # 2 contained a DNR order. However, the resident’s DNR was not included on the resident’s ISP dated 4-16-26. This was confirmed by Staff # 4.
  3. The record for Resident # 3 contained a DNR order. However, the resident’s DNR was not included on the resident’s ISP dated 9-25-25. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observation during a tour of the facility the facility did not ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. A weekly menu was not posted. The menu for the current lunch meal was observed to be posted. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
22VAC40-73-250-C
Based on a review of staff records the facility did not ensure that each staff record contain verification that the staff person has received a copy of his/her current job description.
Evidence
  1. The record for Staff # 3 did not contain verification that the staff person had received a copy of his/her current job description. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
22VAC40-73-325-A
Based on a review of resident records the facility did not ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed.
Evidence
  1. The record for Resident # 1(admit date: 11-20-25), Resident # 2 (admit 3-2-26), Resident # 3 (admit date: 9-20-25), Resident # 4 (admit date: 3-26-25) and Resident # 6 (admit date: 2-6-25) did not contain a fall risk rating. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
22VAC40-73-970-A
Based on a review of facility documentation the facility did not ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code.
Evidence
  1. The facility did not have documentation of a fire and emergency evacuation drill for the month of March 2026. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on observation of a medication pass and a review of the resident’s record the facility did not ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The record for Resident # 2 contained a physician’s order for Acetaminophen 500 mg to be administered at 2:00 p.m. However, the medication was administered at 12:00 p.m. This was confirmed by Staff # 4.
Plan of correction
Not published by VDSS.
May 12, 2026Inspection1 violation
Inspection dates
05/12/2026
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: 5-12-26 from 10:20 a.m.- 11:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4-29-26 regarding allegations in the area(s) of: medication administration. Number of residents present at the facility at the beginning of the inspection: 70 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a self-report received from the facility on 4-29-26 the facility did not ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The facility reported to the licensing office that Staff # 1 administered the medication prescribed for Resident #1 to Resident # 2 in error on 4-28-26 at 6:00 p.m..
  2. The record for Resident # 2 indicated that the resident is allergic to the medication (Donepezil HCL 5 mg) that was administered in error. Progress notes for Resident # 2 documented that resident’s physician was notified and advised staff that the resident did not need to be sent to the emergency room. Progress notes also documented that staff monitored Resident # 2 and there were no signs of adverse effects or allergic reaction.
  3. The record for Resident # 1 contained a physician’s order for Donepezil HCL 5 mg at 7:00 p.m., however, the record for Resident # 2 did not contain an order for the medication.
Plan of correction
Not published by VDSS.
March 3, 2026Complaint survey0 violations
Inspection dates
03/03/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-3-26 from 1:24 p.m.- 2:05 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-17-26 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 66 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 3, 2026Inspection0 violations
Inspection dates
03/03/2026
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: 3-3-26 from 12:28 p.m.-1:24 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1-17-26 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 66 Number of resident records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 3, 2026Inspection0 violations
Inspection dates
03/03/2026
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: 3-3-26 from 11:15 a.m.-12:28 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1-13-26 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 66 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 3, 2026Inspection0 violations
Inspection dates
03/03/2026
Areas reviewed
22VAC40-73 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: 3-3-26 from 9:58 a.m.- 11:15 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1-2-26 regarding allegations in the area(s) of: buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 An exit meeting was 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 22, 2025Inspection1 violation
Inspection dates
12/22/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12-22-25 from 12:30 p.m.-1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on regarding allegations in the area(s) of: the safe, secure unit and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-1150-A
Based on a self-report received from the facility on 10-22-25, the facility failed to ensure that doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates.
Evidence
  1. -According to a staff interview as well as a review of facility documentation, on 10-20-25 Resident # 1 (admit date: 10-6-25) was able to exit the memory care unit via the door leading to the stairwell and then exited the facility. -Per facility documentation, police and the resident’s family were contacted, the resident was found safe in the parking lot of the apartment complex beside the facility and returned to the facility unharmed.
Plan of correction
Not published by VDSS.
December 22, 2025Complaint survey1 violation
Inspection dates
12/22/2025
Areas reviewed
22VAC40-73 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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12-22-25 from 11:35 a.m.-12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care and staffing on the secure unit. Number of residents present at the facility at the beginning of the inspection: 64 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: provisions for signaling and call systems. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on a complaint received as well as in interview with staff the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: -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 often 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. Any agreement for a different frequency must be in writing, specify the frequency, be signed and dated by the resident and the facility, and be retained in the resident's record. If there is a change in the resident's condition or care needs, the agreement shall be reviewed and if necessary, the frequency of rounds shall be adjusted. If an adjustment is made, the former agreement shall be replaced with a new agreement or with compliance with the frequency specified in this subdivision. - 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. The documentation shall be retained for two years.
Evidence
  1. During an interview with Staff # 1 regarding the care of Resident # 1 on 8-29-25 and 8-30-25 on the safe, secure unit, Staff # 1 confirmed that the facility did not have documentation of rounds for the resident.
Plan of correction
Not published by VDSS.
July 10, 2025Complaint survey1 violation
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-10-25 from 10:27 a.m.- 12:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-10-25 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 67 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on a review of resident records the facility failed to ensure that the 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 record for Resident # 1 contained progress notes dated 5-27-25 that documented, “Resident was found on the floor by her bedside. It appears resident hit her head. Bleeding was noticed on the left side of resident’s head. 911 was called.” The notes document that the resident was transported to the hospital. However, the facility failed to notify the regional licensing office of the incident. This was confirmed by staff.
Plan of correction
Not published by VDSS.
July 10, 2025Complaint survey0 violations
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-10-25 from 12:50 p.m.-1:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-23-25 regarding allegations in the area(s) of: resident care and staffing. Number of residents present at the facility at the beginning of the inspection: 67 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Kimberly Davis, Licensing Inspector at (804) 356-3572or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 3, 2025Complaint survey3 violations
Inspection dates
07/03/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-3-25 from 1:10 p.m.- 3:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-9-25 regarding allegations in the area(s) of: resident care and staffing. Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that Individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. -The record for Resident # 1 contained an ISP dated 5-15-25 that indicated “Behaviors: Resident does not have current or history of disruptive, aggressive, verbal, or socially inappropriate behavior.” -Progress notes for the resident document behaviors on the following dates: 5-27-25, 5-28-25, 6-2-25, 6-16-25, 6-24-25, and 6-28-25. However, the resident’s ISP was not updated to indicate this change. This was confirmed by staff.
Plan of correction
Not published by VDSS.
22VAC40-73-460-E
Based on a review of resident records and an interview with staff, the facility failed to ensure that it shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. 1. Any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record.
Evidence
  1. The record for Resident # 1 contained progress notes dated 5-27-25, 6-24-25, 6-28-25, that documented that resident was “inappropriately touching” Resident # 2. Although the corresponding action taken was documented in the record of Resident # 1, there was no documentation in the record of Resident # 2. Staff stated that Resident # 2’s son was notified, but it was not documented.
Plan of correction
Not published by VDSS.
22VAC40-73-440-A
Based on a review of resident records the facility failed to ensure that 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 record for Resident # 1 contained a UAI dated 5-15-25 that checked “Appropriate” for Behavior and was not updated to indicate the change in the resident’s behavior.
Plan of correction
Not published by VDSS.
July 3, 2025Complaint survey2 violations
Inspection dates
07/03/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-3-25 from 11:50 a.m.- 1:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5-19-25 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting was 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: A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-460-E
Based on a review of resident records and staff interviews the facility failed to ensure that any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record.
Evidence
  1. The record for Resident # 1 contained progress notes dated 5-8-25 which documented that staff was informed that the “resident has skin tears on left arm.” However, there was no documentation to indicate corresponding action taken such as an updated skin assessment. The facility provided documentation of skin assessments for Resident # 1 dated 5-4-25 and 5-5-25, but not for 5-8-25. This was confirmed by staff.
Plan of correction
Not published by VDSS.
22VAC40-73-325-B
Based on a review of the resident’s record and staff interviews the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall.
Evidence
  1. The record for Resident # 1 contained progress notes dated 5-9-25 which documented that “resident was found on the floor by staff”, indicating a fall. However, the resident’s record did not contain documentation of a fall risk assessment after the fall. This was confirmed by staff.
Plan of correction
Not published by VDSS.
July 3, 2025Inspection2 violations
Inspection dates
07/03/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-3-25 from 10:05 a.m.- 11:50 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 5-5-25 regarding allegations in the area(s) of: personnel and resident care. Number of residents present at the facility at the beginning of the inspection: 68 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: 2 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on a self-report submitted to the licensing office as well as staff interviews, the facility failed to ensure that all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities.
Evidence
  1. According to a self-report submitted to the licensing office by the facility as well as staff interviews, on 5-4-25 Staff #1 who was assisting Resident # 1 with repositioning in her wheelchair, was “observed pulling the resident’s hair” and the “resident yelled out.”
Plan of correction
Not published by VDSS.
22VAC40-73-460-E
Based on a review of the resident’s record as well as an interview with staff, the facility failed to ensure that any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record.
Evidence
  1. The record for Resident # 1 did not contain documentation of the incident on 5-4-25 during which the resident’s hair was pulled by a staff member, or any corresponding action taken by the facility.
Plan of correction
Not published by VDSS.
May 7, 2025Inspection10 violations
Inspection dates
05/07/2025,05/23/2025
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 INVESTIGATION
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: 5-7-25 from 10:40 a.m.- 4:10 p.m. and 5-23-25 from 10:00 a.m.- 3:55 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, first aid kit, medication pass, physician’s orders, medication administration records, lunch meal/menu. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on a review of resident records the facility failed to ensure that 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 conducted by a licensed healthcare provider (MD, PA, NP, RN, LPN). Evidence: The record for Resident # 6 contained a risk assessment form dated 2-14-25 that was completed by an MSW and not a licensed healthcare provider.
Plan of correction
Not published by VDSS.
22VAC40-73-870-B
Based on observation during a tour of the facility with the administrator the facility failed to ensure that all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During a tour of the facility with the administrator the licensing inspector observed a foul odor in Room # 202 and a strong urine odor in Room # 235.
Plan of correction
Not published by VDSS.
22VAC40-73-1110-B
Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.
Evidence
  1. The record for Resident # 2 (admit date to memory care: 3-15-24) contained a Review of Appropriateness of Continued Residence in Special Care Unit form that was dated 10-2-24.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observation the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. During a tour of the facility with the administrator the licensing inspector observed that there was no menu posted in the memory care unit.
Plan of correction
Not published by VDSS.
22VAC40-73-620-A
Based on a review of facility documentation 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. The facility provided documentation of a dietician report last dated 10-7-24.
Plan of correction
Not published by VDSS.
22VAC40-73-350-B
Based on a review of resident records the facility failed to ensure that the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. The record for Resident # 6 (admit date: 2-24-25) contained a sex offender search dated 5-7-25.
Plan of correction
Not published by VDSS.
22VAC40-73-380-A
Based on a review of resident records the facility failed to ensure that prior to or at the time of admission to an assisted living facility, the following personal and social information on a person shall be obtained: 1. Name; 2. Last home address, and address from which resident was received, if different; 3. Date of admission; 4. Birth date or if unknown, estimated age; 5. Birthplace, if known; 6. Marital status, if known; 7. Name, address, and telephone number of all legal representatives, if any; 8. If there is a legal representative, copies of current legal documents that show proof of each legal representative's authority to act on behalf of the resident and that specify the scope of the representative's authority to make decisions and to perform other functions; 9. Name, address, and telephone number of next of kin, if known (two preferred); 10. Name, address, and telephone number of designated contact person authorized by the resident or legal representative, if appropriate, for notification purposes, including emergency notification and notification of the need for mental health, intellectual disability, substance abuse, or behavioral disorder services - if the resident or legal representative is willing to designate an authorized contact person. There may be more than one designated contact person. The designated contact person may also be listed under another category, such as next of kin or legal representative; 11. Name, address, and telephone number of the responsible individual stipulated in 22VAC40-73-550 H, if needed; 12. Name, address, and telephone number of personal physician, if known; 13. Name, address, and telephone number of personal dentist, if known; 14. Name, address, and telephone number of clergyman and place of worship, if applicable; 15. Name, address, and telephone number of local department of social services or any other agency, if applicable, and the name of the assigned case manager or caseworker; 16. Service in the armed forces, if applicable; 17. Lifetime vocation, career, or primary role; 18. Special interests and hobbies; 19. Known allergies, if any; 20. Information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable; 21. Previous mental health or intellectual disability services history, if any, and if applicable for care or services; 22. Current behavioral and social functioning including strengths and problems; and 23. Any substance abuse history if applicable for care or services.
Evidence
  1. -The record for Resident # 4 (admit date: 10-4-24) contained a Resident Personal/Social Data form that was incomplete and did not address all required items. -The record for Resident # 6 (admit date: 2-24-25) contained a Resident Personal/Social Data form that was incomplete and did not address all required items.
Plan of correction
Not published by VDSS.
22VAC40-73-460-B
Based on a review of resident records the facility failed to ensure that it provide prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The call bell response log dated 2-27-25 for Resident # 2 indicated a response time by staff of 11minutes and 17 seconds.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on a review of resident records the facility failed to ensure that 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), and by the resident or his legal representative.
Evidence
  1. -The record for Resident # 2 contained an ISP dated 4-21-25 that was not signed or dated by the resident or his/her legal representative. -The record for Resident # 6 contained an ISP dated 2-8-25 that was not signed or dated by the resident or his/her legal representative.
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.
Evidence
  1. The record for Staff # 2 (date of hire: 3-7-25) did not contain documentation of first aid certification.
Plan of correction
Not published by VDSS.
January 29, 2025Inspection3 violations
Inspection dates
01/29/2025
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: 1-29-25 from 9:55 a.m. – 11:34 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 59 Number of resident records reviewed: 2 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a self-report from the facility as well as an interview with staff, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. According to an interview with Staff # 1 as well as a review of facility documentation, on 9-29-24 the PRN medication (Morphine 100MG/5ML) for Resident # 1 had not arrived to the facility yet and staff administered the PRN Morphine 100MG/5ML of Resident # 2 to Resident # 1.
Plan of correction
Not published by VDSS.
22VAC40-73-680-H
Based on a review of resident records the facility failed to ensure that 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 self-report received from the facility noted that on 9-29-24, the PRN medication of Resident # 2 (Morphine 100MG/5ML) was administered to Resident # 1 whose PRN Morphine of the same dosage had not yet arrived at the facility. However, the MAR for Resident # 1 was blank with no staff initials for Morphine 100MG/5ML on 9-29-24 to indicate that the medication was administered. This was confirmed by staff.
Plan of correction
Not published by VDSS.
22VAC40-73-650-E
Based on a review of resident records as the result of a self-reported incident from the facility regarding medication administration, the facility failed to ensure that 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.
Evidence
  1. The record for Resident # 1 contained a physician’s order form for Lorazepam .5mg and Morphine Sulfate 20MG/MLthat was not signed or dated. This was confirmed by staff.
Plan of correction
Not published by VDSS.
January 29, 2025Inspection1 violation
Inspection dates
01/29/2025
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-29-25 from 11:30 a.m.- 12:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on regarding allegations in the area(s) of: the secure environment. Number of residents present at the facility at the beginning of the inspection: 59 Number of resident records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-1150-A
Based on a self-report received from the facility on 8-2-24, the facility failed to ensure that doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates.
Evidence
  1. According to a staff interview as well as a review of facility documentation, Resident # 1 was able to exit the memory care unit via the door leading to the stairwell on 8-2-24. -Per facility documentation, the resident was observed by staff to be sitting on the bottom of the staircase and “resident states that she got up out of wheelchair at the top of the stairs and slid down each step until reaching the bottom. Resident was sent to the ER and returned with no injuries.” -According to Staff # 1, staff on the memory care unit were unable to hear the door alarm at the time of the incident.
Plan of correction
Not published by VDSS.
January 29, 2025Complaint survey0 violations
Inspection dates
01/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-29-25 from 12:00 p.m.- 12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 59 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 1, 2024Inspection4 violations
Inspection dates
05/01/2024,05/08/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE 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 PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-1-24 from 9:36 a.m. – 2:00 p.m. and 5-8-24 from 10:33 a.m.-2:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed: facility documentation, facility postings, first aid kit, lunch meal/menu, med pass, physician’s orders, and medication administration records (MARs). An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on a review of resident records the facility failed to ensure that it shall ascertain, prior to admission, whether a potential resident is a registered sex offender with the Department of State Police.
Evidence
  1. The record for Resident # 1 and Resident # 10 contained a sex offender screening from Dru Sjodin National Sex Offender Public Website.
Plan of correction
All admissions will have a sex offender registry check completed before admission with the Virginia Department of State Police. The Administrator or her designee will ascertain that all future referrals have the sex offender registry check completed before or at the time the referral assessment is scheduled.
22VAC40-73-870-B
Based on observation during a tour of the facility, the facility failed to ensure that all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During a tour of the facility with Staff # 1, the licensing inspector observed a strong odor of urine upon entering the first-floor hallway.
Plan of correction
Additional housekeeping services are in place to ensure all floors are free of odor. A daily community walk-through will be completed by the housekeeping supervisor to ensure the building is free of odor. The Executive director/designee will ensure compliance.
22VAC40-73-210-F
Based on a review of staff records the facility failed to ensure that at least two of the required hours of training for direct care staff shall focus on infection control and prevention.
Evidence
  1. The record for Staff # 5 (date of hire: 12-3-18) did not contain documentation of 2 hours of annual infection control and prevention training.
Plan of correction
The Administrator/designee will ensure that all staff will have 2 hours of infection control and prevention training within the training year. One hour of infection control training will be scheduled at least 2x annually.
22VAC40-73-210-B
Based on a review of staff records the facility failed to ensure that all direct care staff shall attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides (CNA) shall attend at least 12 hours of annual training.
Evidence
  1. The record for Staff # 5 who is a CNA (date of hire: 12-3-18) did not contain documentation of 12 hours of annual training.
Plan of correction
The Administrator/designee will follow the in-service calendar to ensure that all staff is compliant with 12 hours of annual in-service training.
March 26, 2024Inspection2 violations
Inspection dates
03/26/2024
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: 3-26-24 from 9:40 a.m.-11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing 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: 65 Number of resident records reviewed: 1 Number of staff records reviewed:1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on a self-reported incident received from the facility on 12-1-23, as well as a staff interview, the facility failed to ensure that 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. Medications shall be stored in a manner consistent with current standards of practice. Schedule II drugs and any other drugs subject to abuse must be kept in a separate locked storage compartment (e.g., a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart).
Evidence
  1. -The narcotic medication (Oxycodone 5mg) for Resident # 1 was discovered to be missing from the medication cart on 11-29-23 and according to Staff # 1 the med tech on duty did not store the medication properly and was unable to locate the medication.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on a review of the facility’s medication management plan the facility failed to ensure that it keep current and implement a written plan for medication management.
Evidence
  1. The facility’s medication management plan was not current as it was dated 12/2014 at the bottom of each page.
Plan of correction
Not published by VDSS.
March 26, 2024Inspection0 violations
Inspection dates
03/26/2024
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 3-26-24 from 11:30 a.m.-12:25 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 2-16-24 regarding allegations in the area(s) of: resident accommodations. Number of residents present at the facility at the beginning of the inspection: 65 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 12, 2024Complaint survey3 violations
Inspection dates
03/12/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-12-24 from 10:02 a.m.-2:25 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-14-24 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: 66 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-460-I
Based on a review of the resident’s record the facility failed to ensure that each resident shall be dressed in clean clothing and be free of odors related to hygiene.
Evidence
  1. -Hospice documentation for Resident # 1 dated 2-12-24 noted, “He is noted to be unkempt with food on shirt, face, and wheelchair.” -Hospice documentation dated 2-14-24 noted, “changed clothing and provided nail care as patient was disheveled and malodorous.”
Plan of correction
Effective immediately, HCD/HSD or designee to in-service all care staff on harmony policy and procedures on providing basic care to residents in the community.
22VAC40-73-460-H
Based on a review of the facility’s shower log for Resident # 1, 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 and hygiene and grooming to include skin care at least twice daily for those with limited mobility.
Evidence
  1. -The facility’s shower log for January and February 2024 for Resident # 1 indicated that the resident only received a shower or bath on 1-1-24, 1-8-24, 1-15-24, and 1-29-24, 2-5-24, and 2-14-24. The shower log indicates that the resident refused a shower/bath on 1-10-24, 1-17-24, 1-22-24, and 2-7-24. -The facility’s Skin Integrity Monitoring sheet for February 2024 for Resident # 1 only indicated skin care monitoring on 2-5-24, 2-7-24, 2-12-24, and 2-14-24.
Plan of correction
Effective immediately, at least 1x per week, HCD/HSD or designee shall review the daily shower sheets to ensure all residents are receiving showers per his/her care plan/at least 2x weekly. In the event that a resident refuses, two additional attempts shall be made on the same day to offer a shower. If the resident continues to refuse, it will be documented on the shower sheet and another attempt will be made on the following day. Responsible Party to be notified of refusal and documented. Any alteration of the number of weekly showers are requested by the resident or his/her legal guardian, such request shall be indicated on the resident’s ISP/Care Plan.
22VAC40-73-680-D
Based on a review of the resident’s record the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The physician’s order for Resident # 1 dated 2-1-24 noted “D/C Metoprolol Succ 50 mg”. However, the resident’s Medication Administration Record (MAR) for February 2024 indicates that the facility continued to administer Metoprolol Succ 50 mg to the resident on February 2,3,7,10,11,12,13, and indicated D/C on 2-16-24.
Plan of correction
HCD or designee will continue weekly med cart checks to ensure removal of all discontinued medications. ALL RMA’s or nurses to be in serviced to remove all discontinued medication upon receipt of orders from physician.
August 23, 2023Complaint survey0 violations
Inspection dates
08/23/2023
Areas reviewed
22VAC40-80 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: 8-23-23 from 9:31 a.m.-1:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on July 24, 2023 regarding allegations in the area(s) of: resident care and personnel. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:15 Number of staff records reviewed: 4 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 1 Additional Comments/Discussion: The lunch meal/menu were also observed. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 8, 2023Inspection6 violations
Inspection dates
06/08/2023
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 PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-8-23 from 10:55 a.m.- 7:05 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit, emergency food supply, medication pass, physician’s orders, medication administration records. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-980-H
Based on observation the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water and that at least 48 hours of the supply must be on site at any given time, of which the facility's rotating stock may be used.
Evidence
  1. The facility did not have an emergency water supply on site.
Plan of correction
Emergency Water was ordered and delivered on 6/14/2023. Administrator met with Director of Food and Beverage on 6/9/2023 to retrain on providing the emergency supply to always include food and water on site in case of an emergency.
22VAC40-73-940-A
Based on a review of facility documentation the facility failed to ensure that it shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. The facility’s last fire inspection was dated 2-17-22.
Plan of correction
The Fire Inspection was completed on 6/13/2023 with no violations. Moving forward Plant Operation Director will ensure that the inspection has been scheduled in a timely manner and the Administrator will follow up. On 6/13/2023 The Fire Marshall gave his direct contact information to ensure the date is locked in and so the administrator can reach out directly.
22VAC40-73-950-E
Based on a review of facility documentation the facility failed to ensure the semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating.
Evidence
  1. The facility did not have documentation that the emergency preparedness and response plan (dated 1-14-23 by the administrator) was reviewed with all staff, residents, and volunteers.
Plan of correction
The administrator will ensure that the Emergency Preparedness and response plan is reviewed by all staff, residents, and volunteers semi-annually and documented. The start date of the training will be 6/14/2023 and will be completed by 6/30/2023 for all staff, residents, and volunteers.
22VAC40-73-970-A
Based on a review of facility documentation the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. The facility had no documented fire and emergency evacuation drills from 12-30-22 until 4-20-23.
Plan of correction
Fire Drill is scheduled for 6/15/2023 for night shift and 6/16/2023 for day shift and maintenance assistant has been retrained on fire drills, regarding they are to be conducted monthly, on alternating shifts to ensure all shifts are participating in the fire drills.
22VAC40-73-260-A
Based on a review of staff records the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for Staff # 2 (date of hire: 3-27-23) did not contain first aid certification.
Plan of correction
A first aid and CPR training has been scheduled for 6/22/2023 for all staff who has expired first aid or CPR training. On 6/9/2023 the Administrator retrained the Director of Wellness on all Nursing team members are to at least be First Aid Trained within 60 days of start date of employment.
22VAC40-90-40-B
Based on a review of staff records the facility failed to ensure that a criminal history record report from the State Police shall be obtained prior to the 30th day of employment.
Evidence
  1. -The record for Staff # 2 (date of hire: 3-27-23) contained a criminal history record report that was not from the Virginia State Police, but from a source called JDP. -The record for Staff # 1 (date of hire: 4-20-23) did not contain the results of a criminal history record report. -The record for Staff # 5 (date of hire: 3-7-23) reviewed with all new hires did not contain the results of a criminal history record report.
Plan of correction
Going forward as of 6/8/2023 the administrator will ensure that all background checks are obtained from the Virginia State Police department and that all background reports are printed/placed in the staff member’s file.
April 18, 2023Complaint survey5 violations
Inspection dates
04/18/2023
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-18-23 from 10:30 a.m.- 2:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on March 17, 2023 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 66 Number of resident records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-430-H-2
Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record.
Evidence
  1. The record for Resident # 1 (discharge date: 1-30-23) did not contain a written discharge statement.
Plan of correction
Administrator will ensure all discharge statements reflect the initial date that a resident is no longer in the community.
22VAC40-73-460-E
Based on a review of resident records the facility failed to ensure that any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record.
Evidence
  1. The record for Resident # 2 (admit date: 2-27-21) contained a hospital discharge summary dated 2-14-23 that noted that the resident was admitted to the hospital due to a fall with a hematoma on 2-12-23. However, there was no documentation in the resident’s charting notes regarding the resident’s fall, injury, hospitalization, and any corresponding action taken. There were no charting notes in the resident’s record after 2-10-23 until 2-15-23.
Plan of correction
Staff will be retrained on proper documentation of all falls, change in conditions, and follow up documentation when residents are sent to the hospital.
22VAC40-73-70-A
Based on a review of resident records the facility failed to ensure that it 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 record for Resident # 2 (admit date: 2-27-21) contained a hospital discharge summary dated 2-14-23 that noted that the resident was admitted to the hospital due to a fall with a hematoma on 2-12-23. However, the facility did not notify the licensing office of the incident.
Plan of correction
Staff will be educated on ensuring they are reporting the reportable incidents to the administrator in a timely manner so that all incidents will be reported in the proper time allotted by the state regulations.
22VAC40-73-460-H
Based on a review of the facility’s shower logs 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. There was no documentation in the “Comments”, “Initials”, or “Refusal Reported” sections on the facility’s shower log sheets for Resident # 4- Resident # 8 during the month of December 2022 for the following dates: December 5, 7, 12, 14, 19, 21, 26, and 28.
Plan of correction
Staff will be retrained on the proper way to document all refusals of showers and all showers given on the shower log sheet.
22VAC40-73-450-E
Based on a review of resident records the facility failed to ensure that 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), and by the resident or his legal representative.
Evidence
  1. The record for Resident # 2 (admit date: 2-27-21) contained an ISP with an expected outcome date of 2-27-23 that was not signed or dated at all.
Plan of correction
The administrator will reinforce that the Director of Wellness understands the importance of signing all ISPs once completed and to provide the POA and resident will a copy to look over and have the POA sign the original document in a timely manner before filing in resident's chart.
April 18, 2023Inspection0 violations
Inspection dates
04/18/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-18-23 from 10:00 a.m.-10:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 Additional Comments/Discussion: The licensing inspector toured the facility’s converted memory care rooms and measurements were taken. The facility is not requesting a change in their licensed capacity. An exit meeting was conducted to review the inspection findings. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 13, 2022Inspection1 violation
Inspection dates
10/13/2022
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 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 LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-13-22 from 9:30 a.m.- 3:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, emergency food and water supplies, medication pass observation, physician’s orders/Medication Administration Records (MARs), lunch meal/menu, and resident and staff interviews. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and a violation is 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual.
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individual's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's record. Evidence: -The record for Resident # 8 (admit date: 10-4-2020) contained an acknowledgment of the annual review of resident rights last dated 10-2-2020. -The record for Resident # 9 (admit date: 7-10-2020) contained an acknowledgment of the annual review of resident rights last dated 6-30-2020. -The record for Resident # 10 (admit date: 9-26-19) contained an acknowledgment of the annual review of resident rights last dated 9-26-19. -The administrator stated that she would ensure that the resident rights were reviewed with the residents with updated written acknowledgment.
Plan of correction
Resident # 8 resident’s rights acknowledgement was signed on 10/13/2022 Resident #9 resident’s rights acknowledgement was signed on 12/12/2022 Resident #10 resident’s rights acknowledgement was signed on 12/11/2022 Going forward the Director of Nursing and the Executive Director will ensure all residents rights are annually acknowledged and signed.
February 8, 2022Complaint survey2 violations
Inspection dates
02/08/2022
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2-8-22 from 10:27 a.m.- 12:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on regarding allegations in the area(s) of: administration and resident care. Number of residents present at the facility at the beginning of the inspection: 61 Number of resident records reviewed: 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 allegation(s); area(s) of non-compliance with standard(s) or law were: administration and resident care A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (name), Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
22VAC40-73-430-H-2
Based on a review of resident records the facility failed to ensure that at the time of discharge a copy of the discharge statement shall be retained in the resident’s record.
Evidence
  1. The record for Resident # 1 (discharge date: 1-8-22) did not contain a discharge statement. The administrator stated that staff forgot to complete the discharge statement.
Plan of correction
The correction was made on March 21, 2022, and a discharge statement was placed with the records of resident #1. Moving forward the completion of all discharge statements will be completed by the Business office manager or his/her designee.
22VAC40-73-70-A
Based on a complaint received and interviews with facility staff the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The facility failed to report to the regional licensing office an allegation of physical abuse of a resident by a staff member. The licensing inspector learned of the allegation when the complainant reported it to the licensing office.
Plan of correction
Staff was educated on self-reporting regarding all allegations of abuse and moving forward the Executive Director or her/his designee will report within the state regulations time frame of 24 hours from incident.
February 8, 2022Inspection0 violations
Inspection dates
02/08/2022
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: 2-8-22 from 12:20 p.m.- 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on January 7, 2022 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 61 Number of resident records reviewed: 1 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 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 (name), Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2021Complaint survey0 violations
Inspection dates
11/05/2021,11/12/2021,12/15/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated complaint inspection was initiated on November 5, 2021 and concluded on December 15, 2021. A complaint was received by the department regarding allegations in the areas of resident food. The nurse supervisor was contacted by telephone to conduct the investigation. The licensing inspector emailed the nurse supervisor a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on November 12, 2021. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 11, 2021Inspection0 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 Protection of adults and reporting22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Technical assistance
Standard 22VAC40-73-440: Recommendation to review private pay Uniform Assessment Instrument (UAI) to ensure assessment selections are documented appropriately.
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/11/2020 and concluded on 6/23/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 60. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, required facility documentation, medication administration records and physician orders and criminal history records submitted by the facility to ensure documentation was complete. An exit meeting was held with the administrator. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.