Virginia DSS · Assisted Living Facility

Great Falls Memory Care by Artis

📍 1121 Reston Avenue, Herndon, VA, 20170

ID 37463One Year licenseActive
15
Inspections
On record
10
With violations
Visits that cited something
5
Clean visits
Nothing cited
22
Violations cited
Individual findings
20
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Great Falls Memory Care by Artis was inspected 15 times between April 5, 2021 and April 13, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 22 violations under 20 distinct standards. 4 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. 12 of these 15 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
04/30/2027
Administrator
Michelle Mceyeson
Licensing inspector
Jacquelyn Kabiri
Inspector phone
(703) 397-3017
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

15

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

April 13, 2026Inspection3 violations
Inspection dates
04/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 Complaint Investigation
Comments
Type of inspection: ¿Complaint¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/13/2026, 11:00 a.m. to 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 04/07/2026 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 partial reviews Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch and manicure/ nails day activity Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint(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. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on review of resident records, observation, and interview, the facility failed to implement its written medication management plan.
Evidence
  1. Section 3.2 of the facility’s medication management policy (under the “6 Rights”) states: when reading “The right time and the right label, compare the label against the MAR for the correct time. Medication may be given up to one hour before or after the scheduled time.”
  2. Resident 2 had a physician’s order dated 06/24/2025 for Losartan 100 mg tablet to be administered once daily at 8:30 a.m. Resident 2’s March 2026 MAR indicated that staff 3 administered this medication at 9:47 a.m., exceeding the allowable time frame outlined in the facility’s policy.
  3. Resident 2 had a physician’s order dated 06/24/2025 for Systane 0.3%–0.4% eye drops, one drop in each eye twice daily at 8:30 a.m. and 7:30 p.m. Resident 2’s March 2026 MAR documentation indicated: a. On 03/09/2026, the medication was administered at 9:39 a.m. by Staff 3. b. On 03/22/2026, the medication was administered at 9:47 a.m. by Staff 3. These administration times exceeded the allowable one-hour window before and after per facility policy.
  4. Section 3.2 of the facility’s medication management policy (under the “6 Rights”) states: “The right documentation, document that the medication was given immediately after administering.”
  5. According to the resident's progress notes, on 02/23/2026, resident 2 was transported to the hospital at approximately 6:13 p.m. However, the MAR documented that staff 2 administered the following medications after that time on 02/23/2026: a. At 7:30 p.m.: Atorvastatin 10 mg tablet, nasal spray 0.65% (two sprays), and Systane 0.3%–0.4% eye drops b. At 8:00 p.m.: Melatonin 10 mg and Memantine 5 mg tablet
  6. Based on the timeline, resident 2 was not present in the facility at the time these medications were documented as administered on 02/23/2026.
  7. Staff 1 acknowledged the LI’s findings.
Plan of correction
1.Steps to correct the non-compliance with the standards. -Community reviewed specific instances where the written medication management plan was not implemented 2.Measures to prevent the non-compliance of standard from occurring again. -Community reeducated Coordinators of Health and Wellness and Med Techs on the written medication management plan 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4. Date to be corrected: - May 31, 2026
22VAC40-73-680-C
Based on observations made during the review of resident's Medication Administration Records (MAR) and interview, the facility failed to administer medications no earlier than one hour before and not later than one hour after the facility's standard dosing schedule, expect those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The Licensing Inspector (LI) reviewed resident 2’s March 2026 Medication Administration Record (MAR). Documentation indicated the following: a. On 03/11/2026, Levothyroxine 125 mcg tablet, prescribed to be administered by mouth daily at 7:00 a.m., was not administered until 8:49 a.m. by staff 2. b. On 03/13/2026, Levothyroxine 125 mcg tablet, scheduled for 7:00 a.m., was not administered until 9:21 a.m. by staff 2. c. On 03/14/2026, Levothyroxine 125 mcg tablet, scheduled for 7:00 a.m., was not administered until 8:59 a.m. by staff 2. d. On 03/22/2026, Levothyroxine 125 mcg tablet, scheduled for 7:00 a.m., was not administered until 9:12 a.m. by staff 3.
  2. On 04/13/2026, the LI reviewed resident 2’s April 2026 MAR. Documentation indicated the following: a. On 04/05/2026, Levothyroxine 125 mcg tablet, scheduled for 7:00 a.m., was not administered until 8:48 a.m. by staff 3.
  3. During an interview, staff 1 acknowledged the LI’s findings.
Plan of correction
1.Steps to correct the non-compliance with the standards. -Community reviewed specific instances where medications were administered outside the allowed time window 2.Measures to prevent the non-compliance of standard from occurring again. Community reeducated Coordinators of Health and Wellness and Med Techs to adhere to the allowed time window for med pass. Community evaluated the med pass schedule to reflect realistic timeframes for memory care residents who may require additional cueing or redirection during med pass. Director of Health and Wellness will conduct quarterly med pass observations for three quarters or until substantial compliance is achieved. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4. Date to be corrected: - May 31, 2026
22VAC40-73-680-H
Based on resident record review and staff interview, the facility failed to ensure that all medications administered to the residents were documented on the medication administration record (MAR).
Evidence
  1. According to the resident’s progress notes, on 02/23/2026 at approximately 5:20 p.m., staff observed resident 2 exhibiting signs of medical distress, and Emergency Medical Services (EMS) were contacted. Resident 2 was transported via EMS to the hospital around 6:13 p.m.
  2. The LI reviewed resident 2’s MAR for February 2026. Documentation indicated that the following medications were administered by staff 4 on 02/23/2026 at the times listed below: At 7:30 p.m.: Atorvastatin 10 mg tablet Nasal spray 0.65%, two sprays Systane 0.3%–0.4% eye drops At 8:00 p.m.: Melatonin 10 mg Memantine 5 mg tablet
  3. Hospital records verified that resident 2 was evaluated by a physician at 6:39 p.m. on 02/23/2026, admitted on 02/24/2026, and remained hospitalized until discharge on 02/26/2026 at approximately 6:30 p.m.
  4. Based on the hospital timeline, resident 2 was not present in the facility at the times the medications were documented as administered on the MAR on 02/23/2026.
  5. The LI discussed the discrepancies in the MAR documentation with staff 1, who acknowledged the LI’s findings.
Plan of correction
1.Steps to correct the non-compliance with the standards. Community reviewed specific instances of discrepancies on the MAR 2.Measures to prevent the non-compliance of standard from occurring again. Community reeducated Coordinators of Health and Wellness and Med Techs to ensure they timely document all medications administered on the MAR and accurately reflect any exceptions due to resident unavailability. Director of Health and Wellness will audit MARs monthly for three months or until substantial compliance is achieved to ensure all medications administered are documented on the MAR. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4. Date to be corrected: - May 31, 2026
March 18, 2026Inspection3 violations
Inspection dates
03/18/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 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 IMPAIRMENTS63.2- (18) Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
Type of inspection: ¿Renewal¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/18/2026, 10:45 a.m. to 5:33 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: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and activities Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn.Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on a review of resident records, the facility failed to 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.
Evidence
  1. Resident 5 was admitted to the facility on 02/12/2025.
  2. The record for resident 5 indicates the search of the Virginia State Police sex offender registry did not occur until 03/18/2026, on the day of inspection.
  3. Staff1 acknowledged the LI’s findings.
Plan of correction
1.Steps to correct the non-compliance with the standards. - A sex offender registry check was immediately conducted with no concerns noted. All other current resident files were audited to ensure compliance. 2.Measures to prevent the non-compliance of standard from occurring again. - The Director of Sales and Marketing will ensure that a sex offender registry check is completed prior to the day of move in. The Executive Director will audit resident business files for three months or until substantial compliance is achieved. 3.Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Sales and Marketing or designee 4.Date to be corrected: - April 30, 2026
22VAC40-73-490-D
Based on the review of resident records, the facility failed to have a list of specific residents for whom the health care oversight was provided.
Evidence
  1. The last health care oversight dated 04/01/2025 through 09/30/2025, did not include a list of specific residents for which the health care oversight was provided.
  2. Staff 1 confirmed that the information was not included.
Plan of correction
1.Steps to correct the non-compliance with the standards. The Director of Health and Wellness will include specific findings and recommendations in the Healthcare Oversight to be completed in April 2026. 2. Measures to prevent the non-compliance of standard from occurring again. The Director of Health and Wellness will ensure that specific findings and recommendations for individual residents will be included in the Healthcare Oversights completed from April 2026 forward. The Executive Director will review the Healthcare Oversights to ensure substantial compliance. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4. Date to be corrected: - April 30, 2026
22VAC40-73-700-1
Based on record review and staff interview, the facility failed to ensure oxygen orders contain all required information.
Evidence
  1. Resident 7 has an oxygen order dated 03/04/2026 that states oxygen 2L per NC as needed for SOB. The order does not contain the source or the delivery of the oxygen gas or concentrators.
  2. Staff 1 confirmed that the order is missing the delivery method for the oxygen order.
Plan of correction
1.Steps to correct the non-compliance with the standards. - The Community obtained updated physician orders for residents on oxygen to include the oxygen source on the order. 2. Measures to prevent the non-compliance of standard from occurring again. - Coordinators of Health and Wellness were reeducated on the components needed in an order for oxygen. The Director of Health and Wellness or designee will audit oxygen orders for a period of three months or until substantial compliance is achieved to ensure all include the source of the oxygen on the order. 3 Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4 Date to be corrected: April 30, 2026
July 30, 2025Complaint survey1 violation
Inspection dates
07/30/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 Complaint Investigation
Comments
Type of inspection: ¿Complaint¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: July 30, 2025, 1:45 p.m. to 5:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on July 08,2025, 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: 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 staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: None. 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: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-680-C
Based on record review and staff interview, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. During the onsite inspection on 07/30/2025, Staff 1 provided the facility's medication management plan, which states in 3.2, "The right time, when reading the label, compare the label against the MAR for the right time. Medication may be given up to an hour before or after the scheduled time (follow State/Local regulations for your specific medication administration timeframe )".
  2. The May 2025 MAR audit report for resident 1 indicates that the following medications were not administered according to policy: a. Memantine, 5mg, was administered late 11 times in May 2025. b. Escitalopram, 10mg, was administered late 9 times in May 2025. 3.Staff 1 and 2 acknowledged the LI's findings.
Plan of correction
1.Steps to correct the non-compliance with the standards. -The Community reeducated the Coordinator of Health and Wellness regarding the company policy related to timing of medication administration. 2. Measures to prevent the non-compliance of standard from occurring again. -The Community reeducated all Med Techs and Coordinators of Health and Wellness regarding the company policy related to timing of medication administration. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee
July 30, 2025Complaint survey0 violations
Inspection dates
07/30/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-80 Complaint Investigation
Comments
Type of inspection: ¿Complaint¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/30/2025, 12:45 p.m. to 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 07/10/2025 regarding allegations in the area(s) of: Administration and Administrative Services. 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2025Inspection2 violations
Inspection dates
05/05/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 IMPAIRMENTS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
Type of inspection: ¿Monitoring¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/05/2025, 9:45 a.m. to 3:05 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: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed 3, plus 27 partial for new hires. Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: lunch Additional Comments/Discussion: none An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on observation, and staff interviews, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. On 05/05/2025, at 11:40 a.m., staff 3 was observed conducting a blood glucose monitoring at the dining table while in the presence of one resident and a collateral contact.
  2. Facility’s medication management policy 3.10, Blood Glucose Monitoring, procedures 3. “Identify the resident, provide privacy, and explain the procedure”. 3.Staff 1 and 2 acknowledged the medication management policy and procedures.
Plan of correction
1.Steps to correct the non-compliance with the standards. -The Community reeducated the Med Tech regarding the company policy related to resident privacy. 2.Measures to prevent the non-compliance of standard from occurring again. -The Community reeducated all Med Techs and Coordinators of Health and Wellness regarding the company policy related to resident privacy. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4. Date to be corrected: - June 30, 2025
22VAC40-73-860-I
Based on observation and staff interviews, the facility failed to ensure cleaning supplies and other hazardous materials were in a locked area.
Evidence
  1. During the facility tour on 05/05/2025, the licensing inspector (LI) observed the kitchenette in the Elkins hallway with two bottom cabinets unlocked. The cabinet contained one bottle of Vital Oxide disinfectant cleaner. The second cabinet contained three spray bottles of multi-surface disinfectant cleaner, and one can of Pledge polish and shine cleaner.
  2. LI observed an unlocked bottom cabinet in the Washington Way hallway kitchenette. The LI opened the unlocked cabinet door and saw what is determined to be a staff tote bag of personal items. A prescription bottle of Chlorthalidon, 25mg pills was observed on the top of the tote bag.
  3. During an interview on 05/05/2025, staff 1 and 2 acknowledged the cabinets were unlocked and contained cleaning supplies.
  4. Photo Evidence taken.
Plan of correction
1. Steps to correct the non-compliance with the standards. - The Community immediately removed and secured the items and reeducated staff regarding the importance of properly securing those items. 2. Measures to prevent the non-compliance of standard from occurring again. - The Community reeducated staff on the importance of properly securing chemicals and associate personal items and took disciplinary action as appropriate. Coordinators of Health and Wellness will spot check cabinets when doing rounds and/or shift huddles to ensure all items are properly secured. 3.Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness or designee 4. Date to be corrected: - June 30, 2025
May 7, 2024Inspection3 violations
Inspection dates
05/07/2024,05/08/2024
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 IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 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 PROCESSInspection Type: Renewal Unannounced MandatedAreas of Standards Reviewed:REVIEWED AREAS OF STANDARDS22VAC40-73 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 IMPAIRMENTS32.1 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: 05/07/2024 05/08/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 19 Number of interviews conducted with residents: 2 and (2-Collateral) Number of interviews conducted with staff: 3 Observations by licensing inspector: Toured the facility, observed medication administration, and checked the medication cart for prescribed medications. LI also observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact ,Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.kabiri@dss.virginia.gov
Violations
22VAC40-73-220-B
Based on record review, the facility failed to ensure that private duty personnel are qualified for the types of direct care or companion services they are responsible for providing to residents and maintain documentation of the qualifications.
Evidence
  1. Staff #18’s record did not contain a copy of certification for direct care credentials.
  2. Interview with Staff #4 confirmed the credentials were not in Staff #18’s record.
Plan of correction
1. Steps to correct the non-compliance with the standards. - The Community obtained a copy of the private duty personnel’s certificate of completion of nurse aide education and placed in the private duty personnel’s credentialing file. 2. Measures to prevent the non-compliance of standard from occurring again. - The Director of Health and Wellness will ensure any private duty personnel have evidence of certification of direct care credentials on file at the Community. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness
22VAC40-73-350-A
Based on the record review and staff interview, the facility failed to ensure that the assisted living facility registered with the Department of State Police to receive notice of the registration or registration of any sex offender within the same or contiguous zip code area in which the facility is located.
Evidence
  1. Staff 1 provided a copy of the Department of State Police registration dated May 2, 2024.
  2. Staff 1 stated they were unaware that the facility had not registered. Staff 1 registered the facility when it was determined it had not been done.
Plan of correction
1. Steps to correct the non-compliance with the standards. -The Community registered with the Department of State Police on May 2, 2024 following an internal audit and was in compliance prior to the licensing inspection. 2. Measures to prevent the non-compliance of standard from occurring again. -The Community is registered through the Executive Director and will ensure that it updates the registered email address as needed to remain in compliance. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Executive Director
22VAC40-73-210-D
Based on record review, the facility failed to ensure that the annual training for medication aides shall include continuing education as required by the Virginia Board of Nursing.
Evidence
  1. Five of the six registered medication aids, did not complete a four-hour refresher training course.
  2. Staff 12, 13, 15, 16, 17’s record had medication refresher training dated 3/30/23.
Plan of correction
1. Steps to correct the non-compliance with the standards. - The Director of Health and Wellness arranged for a medication refresher training on 6/13/24 which was completed by six medication aides. All other medication aides are likewise arranging to take the refresher course. 2. Measures to prevent the non-compliance of standard from occurring again. - The Director of Health and Wellness will ensure all medication aides provide annual proof of medication refresher training. A copy will be maintained in their Associate file and the license tracking binder which will be audited by the Director of Health and Wellness to ensure sustained compliance. 3. Person responsible for implementing each step and/or monitoring any prevention measures. - The Director of Health and Wellness
February 13, 2024Inspection0 violations
Inspection dates
02/13/2024
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: 2/13/24 (4:55 PM – 5: 45 PM). An incident report was received by VDSS Division of Licensing on 2/7/24 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: Two Number of interviews conducted with residents: One Number of interviews conducted with staff: Two Observations by licensing inspector: Meal 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 Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 30, 2023Inspection2 violations
Inspection dates
03/30/2023
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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
Technical assistance
Documentation was discussed with the provider.
Comments
An unannounced renewal inspection was conducted on 3/30/23 (8:10 AM - 5:20 PM). At the time of entrance, 56 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on documentation, the facility failed to implement the medication management plan: verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in order.
Evidence
  1. Resident #1 was prescribed PRN Tums and PRN Acetaminophen on 2/1/23. Resident #1's PRN medications (ordered on 2/1/23) were not included on his MAR, at the time of the medication cart inspection.
Plan of correction
The Director of Health and Wellness will ensure an audit is conducted of all current physician order sheets as compared to the medication administration records (MARs) to ensure all current physician orders are present on the MARs. Any discrepancies identified will be corrected. The Director of Health and Wellness will ensure re-education is conducted with Coordinators of Health and Wellness regarding the process of transcribing physicians’ verbal orders. All physician orders will be faxed to the pharmacy, stamped “faxed” on physician order with date and initial, and the physician order will be flagged for 24-hour chart check to be conducted by the Assistant Director of Health and Wellness or designee. The Coordinator of Health and Wellness will ensure that the medication is delivered and placed into the correct medication cart. The Director of Health and Wellness will conduct a random audit of 10% of the residents’ medical records to compare the physician orders to the MARs for three months or until substantial compliance is achieved. The Director of Health and Wellness, Assistant Director of Health and Wellness and Coordinators of Health and Wellness.
22VAC40-73-650-C
Based on record review, the facility failed to ensure that physician's oral orders are reviewed and signed by the physician within 14 days.
Evidence
  1. Resident #7's record was reviewed during the inspection. The record contained Bacitracin orders (12/1/22 and 12/7/22) that were not signed by the physician, within 14 days of the order date.
Plan of correction
The Director of Health and Wellness will ensure an audit of all physician orders is conducted to verify all orders have been signed by the physician. Any discrepancies noted will be corrected. The Director of Health and Wellness will ensure re-education is conducted with Coordinators of Health and Wellness regarding the requirement for all telephone orders to be reviewed and signed by the physician within 14 days. Each physician has a folder for documents to be signed. The telephone order will be carried out as ordered, placed in folder, signed by Physician within 14 days, and then filed in the resident medical record. An audit of all medical records will be conducted monthly for three months or until substantial compliance is achieved to ensure all physician orders are timely signed.
August 31, 2022Inspection0 violations
Inspection dates
08/31/2022, 01/12/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Unannounced monitoring inspections were conducted on 8/31/22 and 1/12/23, in response to facility-reported incidents. Resident records and staff records were observed. Interviews were conducted. No violations were cited as a result of the inspections. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 10, 2022Inspection0 violations
Inspection dates
05/10/2022
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT
Comments
An unannounced focused inspection was conducted on 5/10/22 to follow-up on a violation that was cited on 3/15/22. Staff schedules and facility documentation was reviewed. No violations were cited and an exit meeting was held. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 15, 2022Inspection4 violations
Inspection dates
03/15/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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
An unannounced renewal inspection was conducted on 3/15/22 (8:30 AM - 5:00 PM). At the time of entrance, 45 residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-1130-C
Based on documentation, the facility failed to ensure that there were enough direct care staff members, awake and on duty, during night hours.
Evidence
  1. Facility staffing schedules and census documents were reviewed during the inspection. The resident census was between 41 and 50, from 3/6/22 until 3/14/22. The staffing schedule indicates that the facility did not have at least five staff members, awake and on duty, on the following night shifts: 3/6/22 (four staff members), 3/8/22 (four staff members), 3/10/22 (four staff members), and 3/13/22 (four staff members).
Plan of correction
The Director of Health & Wellness has reviewed the staffing schedule and ensured five direct care staff members are scheduled on night shift when there are between 41 and 50 residents present. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding staffing. The Director of Health & Wellness or designee will review the staffing schedule daily to ensure that the appropriate number of direct care staff members are scheduled on night shift and make any adjustments necessary. The Director of Health & Wellness is responsible for implementing each step and/or monitoring any preventative measures
22VAC40-73-440-B
Based on record review, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee.
Evidence
  1. The record for Resident #3 was reviewed during the inspection. The UAI located in the resident's chart was dated 1/22/21. Facility staff reported that the resident's UAI had been updated in January 2022. That UAI, dated 1/20/22, was not signed by the administrator. Resident #5's UAI, dated 10/29/21, was not signed by the administrator. Resident #6's UAI, dated 3/10/22, was not signed by the administrator.
Plan of correction
The Executive Director and Director of Artis Way Experience audited all UAIs. Any UAIs lacking signature have been signed by the Executive Director. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding UAIs. The Director of Health & Wellness will ensure that each time a UAI is completed, it is timely presented to the Executive Director for review and signature. For all new residents, the UAI will be completed on or before move-in and presented to the Executive Director for review and signature. For all existing residents, the Director of Health and Wellness will track when reviews are due and ensure that the updated UAI is timely presented to the Executive Director for review and signature. UAIs will be reviewed at care conferences to ensure all required signatures are present. The Director of Health & Wellness is responsible for implementing each step and/or monitoring any preventative measures.
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. The record for Staff #1, hired 7/13/11, was reviewed during the inspection. The first aid certification in Resident #1's record expired in February 2022. No additional documentation was provided, to verify that Staff #1 had current certification in first aid.
Plan of correction
The Executive Director audited all direct care staff member files for current certifications in First Aid and CPR. Any direct care staff member lacking First Aid/CPR certification was notified via email and phone call. The community has arranged for a First Aid/CPR class to be offered to direct care staff. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding First Aid/CPR certifications. The Executive Director has compiled copies of all First Aid/CPR certifications by expiration date to ensure that direct care staff remain current with their certifications. The Director of Artis Way Experience will review the certifications monthly and arrange periodic First Aid/CPR classes to enable direct care staff to keep their First Aid/CPR certifications current. The Director of Artis Way Experience and the Director of Health & Wellness will ensure that all direct care staff members have current certification in First Aid/CPR.
22VAC40-73-450-E
Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the resident or his legal representative.
Evidence
  1. The record for Resident #4, admitted 8/4/21, was reviewed during the inspection. Resident #4's ISP, dated 8/4/21, was not signed by the resident or his legal representative.
Plan of correction
The Executive Director and Director of Artis Way Experience audited all ISPs for signatures. The Director of Health & Wellness was advised of any ISPs missing signatures. The Director of Health & Wellness will contact any responsible parties whose signatures are missing to request they sign the ISP. The Executive Director completed education with the Director of Health & Wellness and the Director of Artis Way Experience regarding ISPs. The Director of Health & Wellness will ensure that the ISP is signed by the responsible party during care conferences. If the responsible party is unable to sign at the time of the care conference, a copy of the ISP will be provided to the responsible party and signature requested. The Director of Health & Wellness or designee will document efforts to obtain the responsible party’s signature on the ISP. The Director of Artis Way Experience will conduct a random audit of 10% of the residents’ ISPs monthly for three months or until substantial compliance is achieved. The Director of Health & Wellness is responsible for implementing each step and/or monitoring any preventative measures.
November 29, 2021Complaint survey0 violations
Inspection dates
11/29/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 11/29/21 and concluded on 11/29/21. A complaint was received by the department regarding allegations in the areas of: Administration and Administrative Services and Resident Care and Related Services. The licensing inspector conducted an on-site observation at the facility on 11/29/21. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 29, 2021Inspection1 violation
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Documentation was discussed with the provider
Comments
A non-mandated monitoring inspection was initiated on 6/29/21 and concluded on 7/14/21. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The licensing inspector conducted an on-site observation of the facility on 6/29/21. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-325-C
Based on record review and interview, the facility failed to document an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. Resident #1 was admitted to the facility on 4/2/21. On 4/4/21, Resident #1 fell in the facility’s secure outdoor area and he was taken to the hospital for evaluation. Resident notes state that Resident #1 was diagnosed with abrasions and facial bruising. Resident #1 was noted to have three stiches on his chin, when he returned to the facility. No information was included in the resident record, to document the interventions that were initiated to prevent or reduce the risk of subsequent falls after Resident #1’s fall on 4/4/21. On 6/14/21, Resident #1 was found face down in the facility’s secure outdoor area. Resident #1 was noted to be bleeding from the chin, he had a deep cut/laceration, and a possible tooth injury.
Plan of correction
Interventions to prevent or reduce risk of subsequent falls are documented for Resident #1 related to his fall on 6/14/21. Director of Health and Wellness and/or designee will audit records for all residents who have had a fall in the past 30 days to ensure interventions to prevent or reduce risk of subsequent falls are documented. The Vice President of Health and Wellness re-educated the Director of Health and Wellness regarding fall risk assessments and appropriate interventions. The Director of Health and Wellness and/or designee will provide education to all Coordinators of Health and Wellness regarding the requirement to document interventions to prevent or reduce risk of subsequent falls. Director of Health and Wellness and/or designee will review resident records for the next 60 days or until the community deems substantial compliance for all new move ins and all residents who have a fall and ensure interventions to prevent or reduce risk of subsequent falls are documented.
April 6, 2021Complaint survey2 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 4/6/21 and concluded on 4/29/21. A complaint was received by the department regarding an allegation in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-560-F
Based on documentation and interview, the facility failed to ensure that information be made available only when needed for care of the resident.
Evidence
  1. Progress notes for Resident #1 indicate that the resident was transported to the hospital via ambulance on 12/25/20. Facility policy states that a resident summary/transfer referral form, resident data sheet, a functional status form, current MARs (medication administration records), and advanced directives are to be sent with the resident when they are transported. A facility incident report states that an incorrect face sheet was furnished, when Resident #1 was sent to the hospital on 12/25/20. Facility staff reported that Resident #2’s face sheet was furnished instead of Resident #1’s, and that Resident #1’s husband corrected the issue at the hospital. Resident #2 was not hospitalized or transported by emergency medical professionals on 12/25/20. Hospital staff were in receipt of Resident #2’s medical history and diagnoses. Resident #2's face sheet was observed during the inspection, and the face sheet does not include information about the resident's medical history or diagnoses. A page from Resident #2's physical examination, completed in 2017, had been furnished when Resident #1 was transported to the hospital.
Plan of correction
Resident #1 and #2's medication orders were reviewed. Both residents were shown to the HWC to ensure knowledge of who the residents were. Director meeting was held by the temporary ED to ensure all protocols and policies are understood. DHW and/or designee will ensure that HWC and licensed staff are aware of the residents that are being transported out on an on-going basis. DHW and/or designee will in-service all licensed nursing staff on the importance of knowing the policy on which information is needed to give to the transportation services when transferring residents to a hospital setting. DHW and/or designee will have random checks on the residents that are transported out to ensure the policy is being followed on proper documentation being given to emergency services personnel. The ED and/or designee will complete random checks as well.
22VAC40-73-650-F
Based on documentation, the facility failed to obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility, whenever a resident is admitted to a hospital for treatment. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.
Evidence
  1. Progress notes report that Resident #1 was transported to the hospital on 12/25/20 and returned on 12/26/20. The hospital discharge medication list indicated an adjustment to Resident #1's Donepezil, Doxycycline, Levetiracetam, and Vitamin D. Resident #1's MAR does not indicate any changes to the resident's Donepezil, Doxycycline, Levetiracetam, or Vitamin D. No documentation was found in Resident #1's progress notes regarding the changes to her Donepezil, Doxycycline, Levetiracetam, or Vitamin D.
Plan of correction
Resident #1's medication orders were reviewed, however they were moved to another community prior to the physician coming in to sign the new orders. DHW and/or designee will audit all current physician orders to ensure that all medication orders are reviewed and appropriate to the orders given. DHW and/or designee will in-service all licensed nursing staff on the physician order process. All residents that are admitted into a hospital for treatment will have orders reviewed upon return to ensure proper physician orders are in place and documented. DHW and/or designee will check all resident's orders once they are back in the community and make physicians aware if need be for any order changes. The ED and/or designee will complete random checks on orders.
April 5, 2021Inspection1 violation
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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
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 4/5/21 and concluded on 4/13/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 37. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-90-40-B
Based on record review, the facility failed to obtain a criminal history record report, from the Department of State Police, within 30 days of hiring an employee.
Evidence
  1. The criminal history record reports, of new staff members, were reviewed during the inspection. The criminal history report for Staff #4, hired 11/1/20, was dated 4/5/21.
Plan of correction
The record for Staff #4 was done through the state police and filed. DBS and/or designee will audit the charts to make sure no other staff are out of time frame of employment sure no other staff are out of time frame of employment. DBS and/or designee created a checklist of needed items prior to employment to ensure all documents are in the charts. Background check consent will be given during the time of interview and application process. DBS and/or designee will review quarterly and pull random charts to audit to make sure all staff charts are in order with the background checks.