Virginia DSS · Assisted Living Facility

Bentley Commons at Lynchburg

📍 1604 Graves Mill Road, Lynchburg, VA, 24502

ID 37600Two Year licenseActive
44
Inspections
On record
31
With violations
Visits that cited something
13
Clean visits
Nothing cited
135
Violations cited
Individual findings
64
Standards cited
Distinct rules
18
Complaint visits
Prompted by a complaint

Bentley Commons at Lynchburg was inspected 44 times between January 25, 2021 and December 4, 2025 by the Virginia Department of Social Services. 31 of those visits ended with violations cited and 13 with none. Across that history VDSS cited 135 violations under 64 distinct standards. 18 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. 38 of these 44 are still on the state's site; the other 6 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
Two Year
License expires
06/19/2026
Administrator
Shannon Rudelis
Licensing inspector
Mari Gentry
Inspector phone
(804) 845-0851
Approved for
Non-Ambulatory · Assisted Living

Inspection History

44

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

December 4, 2025Inspection2 violations
Inspection dates
12/04/2025
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: 12/4/2025 10:00 to 14:27 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on 10/29/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; 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 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at an angela.swink@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on facility record review and resident record review, the facility failed to follow their medication management plan in regards to standard operating procedures, including the facility's standard dosing schedule and any general restrictions specific to the facility.
Evidence
  1. The licensing inspector (LI) received a self-reported incident on 10/29/2025 from the facility with documentation that Staff 1 had independently destroyed three separate pills, two hydrocodone and one gabapentin, for two separate residents, that were controlled narcotics on the PM shift.
  2. Resident 1 record contained an Individual Resident’s Controlled Substance Records with documentation on 10/27/2025 at 7pm that Gabapentin 300mg Capsule and Hydrocodone -Acetaminophen 5 – 325mg was discarded by Staff 1.
  3. The facility’s medication management plan, dated 3/1/2024, contained documentation that if the medication is a controlled medication, it will be disposed of by two people one being a licensed nurse or administrator.
  4. Interview with Staff 2 confirmed Staff 1 had independently destroyed the three separate pills that were controlled narcotics.
Plan of correction
All RMA’s will be in-serviced on the destruction of narcotic medications. This employee is no longer employed at our community per HR protocol.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained a signed physicians order, dated 9/30/2025, with documentation for Hydrocodone 5mg – Acetaminophen 325mg tablet Take 1 tablet by mouth every 6 hour. The record contained an Individual Resident’s Controlled Substance Record with documentation on 10/27/2025 that the medication was administered at 9:30pm and on 10/28/2025 at 12:15am.
  2. Interview with Staff 1 confirmed Resident 1 record to be current.
Plan of correction
This was part of the self-report the facility made. This staff person is no longer employed at the community per HR protocols. RMA’s will be in-serviced on following physician orders and proper sign-off in our EMAR system.
December 4, 2025Inspection4 violations
Inspection dates
12/04/2025
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: 12/4/2025 10:00 to 14:25 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 2 record contained a signed physicians order, dated 8/19/2025, with documentation to Check Blood Pressure and Pulse Once every other Wednesday for Hypertension. Resident record contained a November 2025 Medication Administration Record (MAR) with documentation for the treatment being completed on Friday 11/14/2025 and Friday 11/28/2025.
  2. Interview with Staff 1 confirmed Resident 2 Medication Administration Record for November 2025 to be current.
Plan of correction
Previous nursing management added the days for Fridays instead of Wednesdays. RMA’s will be in-serviced on following physician orders and the proper procedure for the input of new orders.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) shall include the dosage.
Evidence
  1. Resident 1 record contained a signed physicians order, dated 8/21/2025, with documentation for Humulog U-100 Insulin Subcutaneous solution 4 Times Daily Sliding Scale BS 0 – 200 Give 0 Units, BS 201 – 250 Give 2 U, 251- 300 Give 4 U, 301 – 350 Give 6 U, 351 – 400 Give 8 U, 401 – 450 Give 10 U, 451 – 500 Give 12 U, > 500 Call Hospice. Resident 1 record contained a November and December 2025 MAR with documentation at 9pm Blood Sugar 279 on 11/7/25, 271 on 11/14/2025, and 215 on 12/2/2025 at 9pm. The November and December 2025 MAR contained documentation on 11/7/2025, 11/14/2025, and 12/2/2025 that the medication was administered however the dosage amount was not included on the MAR.
  2. Interview with Staff 2 confirmed Resident 1 record to be current.
Plan of correction
Staff will be trained on the proper place to add the blood sugar readings.
22VAC40-73-680-A
Based on resident record review and staff interview, the facility failed to ensure that staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI.
Evidence
  1. Resident 1 record contained a Uniform Assessment Instrument (UAI), dated 11/27/2025, with documentation that the resident was dependent in medication administration. Resident record contained a History and Physical, dated 7/27/2025, with documentation that the resident was not capable of self administering medications and that the resident was not following orders for medications. Resident record contained a Hospice Certification and Plan of Care, dated 9/2/2025, with documentation that the resident’s spouse administers oral medications prepared by the residents daughter.
  2. Interview with Staff 1 confirmed Resident 1 record to be current. Staff 1 confirmed that the resident had the assistance of their spouse to administer their medications except for Lantus Solostar 100 Unit/ML and Insulin Lispro 100Unit/ML.
  3. Resident 1 record contained a November and December 2025 Medication Administration Record (MAR) with documentation that the resident self-administered their prescribed medications to include Asprin 81mg Tablet, Calcium 600mg Plus Vit D 400U, Culturelle Chewable Tablet 10B-200mg, Dicyclomine 20mg Tablet, Diphenoxylate- Atrop 2.5 – 0.025mg, Eliquis 2.5mg Tablet, Fish Oil 1000mg, Fureosemide 40mg Tablet, Lansoprazole Dr 15mg Capsule, Lorsartan Potassium 25mg TB, Metamucil Capsule, Metoprol Succ ER 25mg Tablet, Multivitamins Tablet, Sertraline HCL 50mg Tab, Vitamin B12 1000mcg, Vitamin C 500mg Tablet, and Vitamin D3 5000 Unit Tablet.
Plan of correction
RMA’s will be in-serviced on proper procedures for self-administer medications and following physician orders. A new DON has been hired and is now in place.
22VAC40-73-660-B
Based on resident record review, staff interview, and physical plant tour, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. This does not prohibit the facility from storing or administering all medication and dietary supplements.
Evidence
  1. Resident 1 record contained a Uniform Assessment Instrument (UAI), dated 11/27/2025, with documentation that the resident was dependent in medication administration.
  2. Interview with Staff 1 confirmed Resident 1 record to be current. Staff 1 confirmed that the resident kept their medication in their room except for Lantus Solostar 100 Unit/ML and Insulin Lispro 100Unit/ML.
  3. Licensing Inspectors (LIs) observed Resident 1 medications in daily pill containers located in and on their stove in the kitchen of their apartment.
Plan of correction
This resident had their independent living spouse administer medications. Medications will be administered by facility staff. Staff will be in-serviced on medication management of AL and IL spouses when a room is shared.
December 4, 2025Complaint survey2 violations
Inspection dates
12/04/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 12/4/2025 10:00 to 14:32 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/1/2025 regarding allegations in the area(s) of: Staffing and Supervision, Admission, Retention and Discharge of Residents, and 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 resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Staffing and Supervision, 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. 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-280-B
Based on facility record review and staff interview, the facility failed to ensure that they shall maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. The facility written staffing plan requires 6 direct care staff daily on the 7am to 3pm shift.
  2. Assignment Sheets for 7am to 3pm shift contained documentation on 10/20/25, 10/26/2025 and 10/17/2025 of 5 and 10/25/2025 and 11/1/2025 of 4 direct care staff providing care.
  3. Interview with Staff 1 confirmed the assignment sheets to be current.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on resident record review and staff interview, 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. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident 1 record, admission date 9/1/22, contained an ISP, dated 9/1/2023, as the most current ISP in the record.
  2. Interview with Staff 1 confirmed that Resident 1 record was current as provided to the licensing inspector.
Plan of correction
Not published by VDSS.
October 27, 2025Complaint survey1 violation
Inspection dates
10/27/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/27/2025 10:15 to 12:30 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 9/26/2025 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 interviews conducted with staff: 3 Observations by licensing inspector: Medication Cart Audit An exit meeting will be 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(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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on facility record review and staff interview, the facility failed to ensure to follow their medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s Medication Management Plan, dated 3/1/2024, contained documentation that all medications maintained in the facility that fall under DEA’s Schedule of II-V will be counted by RMA/Nurse from the off going shift and oncoming shift or anytime someone else is assigned to the medication care during the shift. Both staff members will sign the facility’s controlled medication inventory sheet.
  2. The Controlled Drug Content Count Signature form for October 2025 for medication Cart 2nd East did not contain a signature for the on coming 11pm to 7am shift on 10/15/2025 and the off coming shift for 11pm to 7am on 10/16/2025.
  3. Interview with Staff 1 confirmed that there was not a signature on those dates and times. S
Plan of correction
Not published by VDSS.
October 27, 2025Inspection0 violations
Inspection dates
10/27/2025
Areas reviewed
22VAC40-73 PERSONNEL
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: 10/27/2025 10:15 to 12:00 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 10/5/2025 regarding allegations in the area(s) of: Personnel The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 23, 2025Inspection1 violation
Inspection dates
09/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/23/2025 10:00 to 14:00 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: 67 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 interviews conducted with staff: 5 Observations by licensing inspector: Medication Cart Audit 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented and the documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident 2 contains a signed physician’s order, dated 9/16/2025, for BP BID – HTN (Blood Pressure Twice a Day – Hypertension).
  2. The September 2025 Medication Administration Record does not contain the blood pressure reading for 9/17/2025.
  3. Interview with Staff 1 and Staff 4 stated they were unable to provide the blood pressure reading for Resident 2 to the licensing inspector for 9/17/2025.
Plan of correction
ED or designee will conduct an in-service on the proper protocol for recording blood pressure readings in the EMAR system.
September 23, 2025Inspection0 violations
Inspection dates
09/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/23/2025 10:00 to 14:00 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 09/03/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Emergency Preparedness Number of residents present at the facility at the beginning of the inspection: 67 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 14, 2025Inspection1 violation
Inspection dates
08/14/2025
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: 8/14/2025 10:00 to 12:30 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 8/5/2025 regarding allegations in the area(s) of: Personnel and 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 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 will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s)/self-report); 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)/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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on resident record review and facility record review, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. The licensing inspector received an initial self report on 8/52025 with documentation that Resident 1 was administered Prozac, Ativan and Vitamin by Staff 1. Resident 1 was not prescribed these medications, and they were administered in error to the resident.
  2. Resident 1 record does not contain a signed physicians order for the medications Prozac, Ativan, or Vitamin.
  3. Resident 1 record contained a Progress Note, dated 8/5/2025, with documentation that the resident inadvertently received another resident’s medications this morning including 1mg of Ativan and Fluoxetine.
Plan of correction
Staff person 1 was immediately removed from the cart and underwent additional training on medication administration. Additionally, staff person 1 has weekly med pass observations by a licensed nurse. All RMA’s are to be in-serviced on the 5 rights of medication administration. Regional nurse and ED to assist with clinical oversight as it pertains to in-servicing and onboarding of our clinical staff.
August 14, 2025Inspection1 violation
Inspection dates
08/14/2025
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: 08/14/2025 10:00 to 12:30 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 4/28/2025 and 5/20/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Personnel 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on resident record review and facility record review, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. The licensing inspector received a final self report on 4/25/2025 with documentation that Resident 1 was administered 45 units of Lantus, a type of insulin that the resident is not prescribed, instead of 45 units of Humalog, a type of insulin the resident is prescribed, by Staff 3.
  2. Resident 1 record contained a signed physicians order dated, 4/16/2025, with documentation for Insulin Mixed Isophane – regular (Humulin 70/30) 45 Units Subcutaneous (under the skin) every morning.
  3. Resident 1 record does not contain a signed physicians order for the medication Lantus.
  4. The licensing inspector received a final self report on 5/20/2025 with documentation that Resident 2 was administered Humulin, a type of insulin the resident is not prescribed, instead of Basaglar, a medication the resident is prescribed, by Staff 1.
  5. Resident 2 record contained a signed physicians order dated, 5/20/2025, with documentation for Basaglar KwikPen U-100 Insulin 100 unit/30ml subcutaneous – Inject 20 unit subcutaneously once a day.
  6. Resident 2 record contained a Progress Note, dated 5/20/2025, with documentation that the resident was administered Humulin NPH 70/30 45 units instead of the residents prescribed Lantus 20 units.
  7. Resident 2 record contained a Progress Note, dated 5/20/2025, completed by Staff 3 with documentation that there was a “medication error administered the wrong insulin to the wrong resident.”
  8. Resident 2 record does not contain a signed physicians order for the medication Humulin.
Plan of correction
RMA’s will be in-serviced on the 5 rights of medication administration. Healthcare Director or designee and our Pharmacy Nurse Consultant are in process of conducting ongoing med pass reviews with all medication aides. New RMA’s will be observed by a licensed nurse, and skills must be signed off on by a licensed nurse before a new medication aide can independently pass medications. Staff members, one and three, were no longer employed at this community at time of inspection. All audits will be reviewed by ED.
June 5, 2025Inspection6 violations
Inspection dates
06/05/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
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: 06/05/2025 9:11AM to 1:44PM 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: 56 assisted living, 28 independent living The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) includes the date and time given and initials of direct care staff administering the medication.
Evidence
  1. The April 2025 MAR for resident 1 does not contain staff initials of which medication administration staff person administered the resident’s scheduled 9:00PM medications on 04/24/2025. Staff person 1 informed the licensing inspector (LI) that the medication was administered to the resident but it wasn’t documented on the MAR.
  2. The May 2025 MAR for resident 2 does not contain staff initials of which medication administration staff person that administered the resident’s 11:30AM scheduled medication on 05/25/2025. Staff person 1 informed the LI that the medication was administered to the resident but it wasn’t documented on the MAR.
Plan of correction
RCD or designee will review the medication administration policy with each RMA. RCD or designee will audit MARS daily to ensure compliance.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 2 contains a signed physician’s order, dated 04/22/2025, for Midodrine HCL 5MG tablet – take one tablet by mouth 3 times a day for hypotension – hold for systolic blood pressure greater than 115.
  2. The May 2025 medication administration record (MAR) for resident 2 contains the following blood pressure readings for the resident: 116/76 at 9:00PM on 05/02/2025; 118/76 at 3:00PM on 05/05/2025; 121/78 at 9:00PM on 05/18/2025; however, the May 2025 MAR contains staff initials as administering the medication when it should have been held because the systolic blood pressure was greater than 115. The June 2025 MAR for resident 2 contains the following blood pressure readings for the resident: 118/75 at 3:00PM on 06/01/2025; 120/83 at 9:00PM on 06/01/2025; and 118/65 at 9:00PM on 06/02/2025; however, the June 2025 MAR contains staff initials as administering the medication when it should have been held because the systolic blood pressure was greater than 115.
Plan of correction
RCD or designee will conduct med pass reviews with each RMA and will educate on following physician orders as it pertains to sliding scale insulin. RCD or designee will audit MARS daily to ensure compliance.
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative.
Evidence
  1. The ISP in the record for resident 3, updated on 04/18/2025 by staff person 3 to include that the resident is now receiving hospice care and wound care services, has not been signed and dated by the resident or the resident’s legal representative. Interview with staff person 1 confirmed this is accurate.
Plan of correction
All lSP's will be printed and singed at time of completion. All attempts to have POA or resident sign will be documented on the ISP. ISP coordinator will give all lSP's to RCD to review after completion and RCD or designee will follow up for appropriate signatures. ED will review all ISP's before filing to ensure compliance.
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented and the documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident 2 contains a signed physician’s order, dated 04/22/2025, to check the resident’s blood sugar and inject additional units of Novolog insulin 3 times a day with meals per sliding slide insulin: 70-180=0 units; 181-220=1 unit; 221-260=2 units; 261-300=3 units; 301-340=4 units; greater than 340=5 units.
  2. The May 2025 medication administration record (MAR) for resident 2 does not contain documentation of the resident’s blood sugar at 11:30AM on 05/22/2025 and 05/25/2025.
  3. During on-site inspection on 06/05/2025, staff person 1 was unable to provide documentation to the licensing inspector of what the resident’s blood sugar was on these dates/times.
Plan of correction
RCD or designee will in-service all medication aides as to where to document blood sugars in our EMAR system and each RMA will be required to a perform a return demonstration once in-serviced to ensure understanding.
22VAC40-73-660-B
Based on observation during a tour of the facility and resident record review, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. At approximately 9:29AM during on-site inspection on 06/05/2025, the licensing inspector (LI) observed a spray bottle of McKesson dermal wound cleanser sitting on top of the microwave in the resident 3’s kitchenette. During an interview with the LI and resident 3, the resident stated that it was being used for a wound that she has on her leg. The record for resident 3 contains documentation that the resident had been receiving wound care from a hospice agency.
  2. The UAI in the record for resident 3, dated 06/17/2024, indicates on page 2 that their medication is administered/monitored by lay person – licensed practical nurse or registered medication aide.
  3. The record for resident 3 does not contain an order that the resident may have and is capable of self-administering the dermal wound cleanser that was in her room. Interview with staff person 1 confirmed this is accurate.
Plan of correction
Resident Care Director (RCD) or designee will in-service staff, families and outside providers reiterating our medication self-administration policy and the correct storage of medications. Rooms will be audited weekly by RCD or designee and audit sheets will be turned into ED with correct signatures and kept in ED's office.
22VAC40-73-1070-B
Based on observation during a tour of the facility, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. The facility has in care residents with serious cognitive impairments.
  2. At approximately 9:27AM during on-site inspection on 06/05/2025, the licensing inspector (LI) noted that the door to the second-floor laundry room across from rooms 231 and 232 was unlocked and unattended. The LI observed 5 packets of XPLO Gentle Clean laundry detergent in the first top drawer of the cabinets to the left of the door and a box that contained bottles of Clean on the Go Smoke & Odor Eliminator located in the second to last cabinet on the bottom of the cabinets that line the wall across from the washers and dryers.
  3. At approximately 9:34AM, the LI noted that the door to the third-floor laundry room across from rooms 333 and 334 was unlocked and unattended. Inside of the laundry room was a gray laundry basket that contained a bottle of Arm & Hammmer sensitive skin laundry detergent.
Plan of correction
Staff and residents will be educated ED or designee regarding this regulation. Laundry rooms will be checked daily to ensure compliance. Audit tool will be turned into ED weekly with appropriate signatures and will be kept in ED's office. A sign will be placed in the laundry room reminding residents and staff that laundry detergent may not be left our unattended.
June 5, 2025Complaint survey0 violations
Inspection dates
06/05/2025
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: 06/05/2025 9:11AM to 1:44PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/09/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 56 assisted living, 28 independent living Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 5, 2025Complaint survey0 violations
Inspection dates
06/05/2025
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: 06/05/2025 9:11AM to 1:44PM 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 04/10/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 56 assisted living, 28 independent living Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 19, 2025Inspection13 violations
Inspection dates
03/19/2025
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 3/19/2025 08:15 to 16:40 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspectors 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:3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: Observations by licensing inspectors: Medication Cart Audits, Medication Pass Observations, Breakfast Meal, Lunch Meal, and Morning and Afternoon Activities. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observation during a tour of the facility and resident record review, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. At approximately 8:46AM, one licensing inspector (LI) observed a spray bottle of McKesson dermal wound cleanser sitting on top of the microwave in the resident 9’s kitchenette. During an interview with the LI and resident 9, the resident stated that it was being used for a wound that she has on her leg. The record for resident 9 contains documentation that the resident had been receiving wound care from an outside agency and the agency was using dermal wound cleanser.
  2. The UAI in the record for resident 9, dated 06/17/2024, indicates on page 2 that their medicine is administered/monitored by lay person – licensed practical nurse or registered medication aide.
  3. The record for resident 9 does not contain an order that the resident may have and is capable of self-administering the dermal wound cleanser that was in her room.
Plan of correction
ED and HCD has educated residents, family and staff on self admin medications in rooms. A letter will be resent to all families reiterating our medication self-administration policy as it pertains to needing self-administration orders and the storage of medications. Rooms will be audited on a rotating basis to ensure compliance with this policy.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician.
Evidence
  1. The record for resident 1 contains a resident-personal/social data sheet that indicates on page 1 of 2 that the resident’s admission date was 02/21/2025.
  2. The report of resident physical examination in the record for resident 1 indicates that the date of the examination by the physician was 12/26/2024 and the same physician signed the report of resident physical examination on 01/07/2024. Both dates are longer than 30 days preceding resident 1’s admission to the facility.
Plan of correction
The date was based off of the date resident signed lease and took possession of the apartment, which was within 30 days. Moving forward, ED or designee will ensure the physical exam is within the 30 days of a resident physically moving into the community. ED in-serviced appropriate staff regarding this regulation.
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure 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 to include information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable.
Evidence
  1. The record for resident 1 contains a resident – personal/social data sheet that indicates on page 1 of 2 that the resident “Have Advance Directive & DDNR”; however, the record for the resident contains a document that the resident is Full Code and the spine of the resident’s medical record contains a statement that the resident is Full Code. The record for the resident does not contain a DDNR.
Plan of correction
Healthcare Director did not have an order for a DNR but will ensure the information she has matches the social data sheet. If it does not match, HCD will call POA to clarify and to request the correct forms. Resident records will be audited to ensure we have correct code status on each resident.
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Resident 9 record contained a signed physicians order, dated 2/4/2025, with documentation for SN performed admission to HH services for wound care to LLE. Cleanse with wound cleanser, cover with dry dressing until verify order with Dermatology. 2x/week and prn for soiled or dislodged dressing.
  2. Resident 9 record contained Coordination Progress Notes with documentation, dated 2/20/2025, from the home health nurse that the patient is to be discharged from skilled nursing with the home health company and that the home health nurse had contacted the physician regarding Resident 9 plan of care/goal/treatments however there is no signed order from the physician discontinuing physician’s order.
  3. During an interview on the day of inspection with two licensing inspectors and staff 5, staff 5 confirmed the facility did not have a signed physicians order to discontinue the order and that home health was no longer providing services or care to Resident 9.
Plan of correction
HCD will ensure all orders received from outside providers have a physician signature. If order has a nurse signature, HCD or designee will contact the provider for correction. HCD will in-service appropriate staff to review the appropriate steps when receiving orders and ensuring orders are properly signed.
22VAC40-73-50-B
Based on resident record review and staff interview, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or his legal representative shall be retained in the resident’s record.
Evidence
  1. The record for resident 1 does not contain written acknowledgement that the resident or their legal representative received the facility’s disclosure statement. Interview with staff person 4 confirmed this is accurate.
Plan of correction
ED in-serviced appropriate staff regarding the paperwork needed upon admission. ED or designee will audit new resident records at time of admission to ensure compliance.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan was completed within 30 days after admission and include a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
  1. Resident 1 record contained a Comprehensive Individualized Service Plan, dated 2/21/2025, with documentation of description of needs were PT/OT and Safety Check (Q 2 Hour Check).
  2. During an interview on the day of inspection with two licensing inspector (LI) and staff 3 and staff 5, staff 3 and staff 5 confirmed that Resident 1 did not have a need for PT/OT or Safety Check (Q 2 Hour Check) therefore the ISP was not accurate.
Plan of correction
Healthcare Director will ensure all comprehensive ISP’s are completed and accurately reflect the resident’s needs within 30 days of admission. HCD or designee will audit new resident records to ensure ISP’s are current and accurately reflect resident needs as it specifically pertains to therapy orders and 2-hour checks.
22VAC40-90-40-H
Based on staff record review and staff interview, the facility failed to ensure to not continue to employ any person who has a conviction of any of the barrier crimes.
Evidence
  1. The document, “Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs”, dated October 2023, states that an assisted living facility cannot hire anyone who has a conviction for an offense in clause (i) of the barrier crime definition in 19.2-392.02 in the Code of Virginia and that a licensed assisted living facility or adult day care center may hire an applicant convicted of one misdemeanor barrier crime not involving abuse or neglect, or any substantially similar offense under the laws of another jurisdiction, if five years have elapsed following the conviction.
  2. The record for staff person 7, date of hire 01/13/2025, contained a Virginia Criminal Record Report, dated 01/15/2025, that staff person 7 has been found guilty of two misdemeanor barrier crimes, on 03/31/2008 and 02/25/2019, that are both listed on the document “Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs”. During an interview with staff person 3, staff person 3 confirmed that staff person 7 is a current employee at the facility.
Plan of correction
Business office manager completed an audit of all employee records to ensure compliance. Business Office Manager will compare all background checks to the barrier crime list and will give to ED for review before orientation of a new employee.
22VAC40-73-1070-B
Based on observation during a tour of the facility, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. The facility has in care residents with serious cognitive impairments.
  2. At approximately 8:27AM, one licensing inspector (LI) noted that the door to the second-floor laundry room was unlocked and unattended. The LI observed a contained of Clorox healthcare hydrogen peroxide cleaner disinfectant wipes located in the lower cabinet behind the entrance to the laundry room.
  3. At approximately 8:49AM, one LI noted that the door to the staff lounge on the second floor was propped open by a chair and was unattended. The LI observed inside the staff lounge there was a black spray can of Real-Kill ant and roach killer sitting on top of the refrigerator. Also, the LI observed that the door to the room located within the staff lounge near the lockers and drink machine was open. Inside of the room, the LI observed a container of Reown 3000 refill orange citrus air freshener on the floor.
  4. At approximately 8:56AM, one LI noted the door to room 332 was unlocked and unattended. The LI noted inside the room multiple items that included The Works toilet bowl cleaner, SSE Carpet pre-spray and spotter cleaner, clear spray bottle that contained a yellow liquid with HDX sprayer on the bottle, Resolve stain remover carpet cleaner, multiple hand tools and multiple In addition, in room 332 the LI observed a medication cart located in the back of the bedroom that contained 2 Hydralazine 25MG tablets and contained a pharmacy label with resident 10’s name and 4 Albuterol Sulfate unopened vials.
Plan of correction
ED in-serviced all managers to review this regulation and to ensure all their areas are compliant. Each department manager will in-service their staff on this regulation. Additionally, the department managers will inspect their space daily to ensure compliance and that work areas are locked. Laundry room and employee breakroom to be checked daily to ensure chemicals are not accessible to residents.
22VAC40-73-550-G
Based on resident record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. EVIDENCE:
  2. Resident 9 record contained Rights and Responsibilities of Residents of Assisted Living Facilities form, signed and dated 2/26/2024, as the most current signature and date.
  3. Resident 8 record contained Rights and Responsibilities of Residents of Assisted Living Facilities form, signed and dated 1/29/2024, as the most current signature and date.
  4. Resident 4 record contained Rights and Responsibilities of Residents of Assisted Living Facilities form, signed and dated 1/30/2024, as the most current signature and date.
  5. During an interview with two licensing inspectors and staff 3, staff 3 revealed that the facility had reviewed resident 9, resident 8, and resident 4 of their rights and responsibilities in December 2024, however, did not provide documentation of the review on the day of inspection. On the day after inspection, 3/20/2025, staff 3 provided the licensing inspector with documentation that resident 9, resident 8, and resident 4 signed and dated that they had reviewed the resident rights and responsibilities in December 2024.
Plan of correction
Resident rights are performed annually, but staff person provided the wrong documents to inspector. The appropriate forms where provided the next morning. ED educated appropriate staff person on the importance of providing correct information when items are requested from our licensing inspectors.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff person 8 was hired at the facility on 01/08/2025. The Virginia Criminal Record Report in the record for staff person 8 during the on-site inspection was dated 03/19/2025. Interview with staff person 4 revealed that she did not obtain the Virginia Criminal Record Report for staff person 8 until the day of the on-site inspection.
Plan of correction
Business Office Manager will not proceed with orientation of any employee until the background check has been received and reviewed by the ED. All new hire records have been audited to ensure compliance.
22VAC40-73-100-C-1
Based on medication pass observation and facility record review, the facility failed to follow their Infection Control Program in regard to ensuring that there are procedures for the implementation of infection prevention measures by staff and volunteers to include use of personal protective equipment.
Evidence
  1. The facility’s Infection Control Guide/Infection Control Program contained documentation that Personal Protective Equipment (PPE), specifically gloves, were to be worn when there is potential contact with blood, body fluids, mucous membranes, non – intact skin, or contained equipment.
  2. During a medication pass observation with the licensing inspector (LI) and staff 1, the LI observed staff 1 administer the medication Refresh Classic Eye drop, 1 drop both eyes 3 times a day to resident 6 without any gloves on staff 1 hands during the administration even though there is potential contact with body fluids and mucous membranes.
Plan of correction
Healthcare Director will in-service all care staff regarding our infection control program and specifically the use of PPE when administering eye drops. Staff person 1 was re-educated same day as inspection.
22VAC40-73-410-A
Based on resident record review and staff interview, the facility failed to ensure upon admission to provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system and, if needed, the orientation shall be modified as appropriate for residents with cognitive impairments and acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident’s record.
Evidence
  1. The record for resident 1 contains a resident-personal/social data sheet that indicates on page 1 of 2 that the resident’s admission date was 02/21/2025.
  2. The record for resident 1 does not contain any documentation that the resident or their legal representative received orientation upon admission to the facility. Interview with staff person 4 confirmed this is accurate.
Plan of correction
ED in-serviced all managers regarding new resident orientation. New admissions will be oriented using an orientation checklist that was given out during the in-service and will be initialed by each manager. After it is completed it will be given to ED to review to ensure compliance
22VAC40-73-450-H
Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. Resident 4 record contained an ISP, dated 3/1/2025, with documentation of description of needs being Safety Check ( Q 2 Hour Check) daily at facility by direct care staff.
  2. Resident 4 record contained Resident Rounding Log for Every 2 hour Rounding dated 3/17/2025 with no documentation for rounds being completed between 7am to 11pm, and no rounds completed on 3/8/2025 and 3/12/2025.
  3. During an interview on the day of inspection with two licensing inspectors and staff 5, staff 5 confirmed Resident 4 record to be current.
  4. Resident 7 record contained an ISP, dated 2/22/2025, with documentation of description of needs being Safety Check ( Q 2 Hour Check) daily at facility by direct care staff.
  5. Resident 7 record contained no documentation for rounds being completed daily from 3/1/2025 through 3/19/2025.
  6. During an interview on the day of inspection with two licensing inspectors and staff 5, staff 5 confirmed resident 7 did need the safety checks however they were not being completed by staff and the resident 7 record was current.
Plan of correction
HCD to in-service staff on q2 hour checks and the log that is to be filled out. HCD and/or designee will audit the log after each shift to ensure compliance.
March 19, 2025Inspection3 violations
Inspection dates
03/19/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS
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: 3/19/2025 8:15 to 16:25 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 11/27/2024, for Midodrine 5MG tablet 1 tablet 3 times daily and hold if systolic pressure greater than 115. The February and March 2025 MARs for resident 1 contain documentation that Midodrine is administered to the resident daily at 9:00AM, 3:00PM, and 9:00PM. The February 2025 MAR contains documentation that the resident’s systolic pressure was greater than 115 at 9:00AM on 02/06/2025, 02/20/2025, 02/26/2025 and 02/27/2025; at 3:00PM on 02/01/2025, 02/21/2025, and 02/25/2025; and at 9:00PM on 02/01/2025, 02/02/2025, and 02/17/2025; however, the MAR contains staff initials that the resident was administered Midodrine 5MG. The February 2025 MAR contains staff initials and documentation drug not given (DNG) at 9:00AM on 02/15/2025 and 02/21/2025; however, the resident’s blood pressure was 115/89 at 9:00AM on 02/15/2025 and 115/84 at 9:00AM on 02/21/2025 and the medication should have been administered to the resident. The March 2025 MAR contains documentation that the resident’s systolic pressure was greater than 115 at 9:00AM on 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/11/2025, and 03/12/2025 and at 9:00PM on 03/08/2025 and 03/12/2025; however, the March 2025 MAR contains staff initials that the resident was administered Midodrine 5MG. The March 2025 MAR contains staff initials that the resident was administered Midodrine 5MG at 3:00PM on 03/07/2025; however, the documented blood pressure for the resident was 0/0 mmHG.
  2. The record for resident 2 contains a signed physician’s order, dated 10/01/2024, for Metoprolol TRAT 25MG take one tablet by mouth two times daily for hypertension and hold for systolic pressure < 120. The March 2025 MAR contains documentation that the resident’s blood pressure was 119/97 at 9:00PM on 03/04/2025 and staff initials that the medication was administered; however, the medication should have been held.
Plan of correction
RMAs and LPNs will be educated and in-serviced on the Five Rights of Medication Administration. The HCD or their designee will conduct med pass reviews with each RMA/LPN, placing additional emphasis on medications with specific parameters.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) includes the dosage.
Evidence
  1. The record for resident 1 contains a signed physician’s order, dated 11/27/2024, for Novolog FlexPen 100units/ml injectable solution insulin – 3 units with meals, sliding scale in addition to the 3 units with meals: 70-180 = 0 units, 181-220 = 1 unit, 221-260 = 2 units, 261-300 = 3 units, 301-340 = 4 units, > 340= 5 units. The February and March 2025 MARs for resident 1 contain documentation that Novolog is administered daily at 8:30AM, 11:30AM and 5:00PM.
  2. The February 2025 MAR contains documentation that the resident’s blood sugar was 181 or greater at 8:30AM on 02/07/2025, 02/15/2025 and 02/23/2025; at 11:30AM on 02/01/2025, 02/03/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/09/2025, 02/15/2025, 02/20/2025, 02/22/2025, 02/24/2025, and 02/26/2025; and at 5:00PM on 02/01/2025, 02/02/2025, 02/04/2025, 02/06/2025, 02/08/2025, 02/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/18/2025, 02/21/2025, 02/22/2025, 02/26/2025, and 02/28/2025. The March 2025 MAR contains documentation that the resident’s blood sugar was 181 or greater at 11:30AM on 03/01/2025 and 03/03-17/2025 and at 5:00PM on 03/01/2025, 03/03/2025, 03/04/2025, 03/06/2025 03/15/2025 and 03/18/2025.
  3. The aforementioned dates and times of the resident’s blood sugar being 181 or greater on the February and March 2025 MARs indicate, according to the physician’s order, the resident was to be administered additional units of insulin based on the sliding scale instructions. The February and March 2025 MARs for the resident do not contain the dosage of insulin the resident was administered on the aforementioned dates and times.
  4. Interview with staff person 1 and two licensing inspectors (LIs) during on-site inspection on 03/19/2025 revealed that when the staff person enters the resident’s blood sugar on the electronic medication administration record (EMAR), the EMAR system populates how many units are to be administered to the resident; however, the units are not recorded on the MAR. Staff person 1 was unable to produce documentation to the LIs of how many units of insulin was administered to the resident during February and March 2025.
Plan of correction
Our system automatically calculates the number of additional units needed when blood sugar is entered. While this resident did receive the additional units on the days noted, we discovered during the inspection that the system was not saving this information. We are currently working with our EMAR system to resolve this issue. In the meantime, RMAs and LPNs are being educated on where to properly document this information to ensure compliance.
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented and the documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident 2 contains a signed physician’s order, dated 10/01/2024, for Metoprolol TRAT 25MG take one tablet by mouth two times daily for hypertension and hold for systolic pressure < 120. The February and March 2025 medication administration records (MARs) contains documentation that the resident is administered this medication daily at 9:00AM and 9:00PM.
  2. The February 2025 MAR for the resident only contains blood pressure readings for the resident at 9:00AM on 02/01/2025, 02/03/205, and 02/06/2025 and at 9:00PM on 02/08/2025, 02/14/2025, 02/18/2025, 02/19/2025, 02/22/2025, 02/25/2025, and 02/28/2025. The March 2025 MAR for the resident only contains blood pressure readings for the resident at 9:00AM on 03/05/2025 and 03/08/2025 and at 9:00PM on 03/04/2025, 03/05/2025, 03/07/2025, 03/09/2025, 03/11/2025, 03/14/2025, and 03/18/2025.
  3. During on-site inspection, staff person 1 was unable to provide any additional blood pressure readings for resident 2 to the licensing inspectors (LIs) for February and March 2025.
Plan of correction
RMAs and LPNs have been educated by our Health Care Director and Regional Nurse on where to enter BP readings in our EMAR system. This process is being audited daily by the HCD or their designee to ensure compliance.
February 18, 2025Complaint survey2 violations
Inspection dates
02/18/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/18/2025 10:15 to 12:45 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 2/6/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication Cart An exit meeting will be 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(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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review, facility record review, pharmacy record review, and medication cart audit, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained a signed physician’s order dated 7/8/2024 with documentation for Revlimid 5mg capsule, take one capsule by mouth every day for multiple myeloma – family provides – indicated for multiple myeloma.
  2. A pharmacy delivery ticket for resident 1 contained documentation for the delivery of Revlimid 5mg capsule, 11 doses on 12/24/2024. A pharmacy delivery ticket for resident 1 contained documentation for the delivery of Revlimid 5mg capsule, 28 doses on 1/3/2025. The blister pack on the medication cart for Revlimid 5mg capsule for resident 1 is dated 1/29/2025 with 28 doses.
  3. Resident 1 record contained a progress note dated 12/26/2024 that the facility received the medication Revlimid 5mg, 11 doses on that date.
  4. Resident 1 record contained no documentation on the December 2024, January 2025 or February 2025 that the resident was not in the building to receive their medication or refused the medication.
  5. During a medication cart audit on the day of inspection on 2/18/2025, the licensing inspector observed medication for resident 1 of 15 doses of the medication Revlimid 5mg Capsule, Take one capsule by mouth every day for multiple myeloma -family provides- on the medication cart. Staff 5 observed this medication cart audit and confirmed there were 15 doses on the medication cart for this medication. According to the doses received by the facility beginning on 12/26/24 and the physician’s order, there should have been 12 doses remaining in the blister pack on the medication cart on this date (12/26/2024 to 1/5/2025 (11 doses), 1/6/2025 to 2/2/2025 (28 doses) and 2/3/2025 to 2/18/2025 (16 doses)).
  6. On the day of inspection during an interview with the licensing inspector and staff 4, staff 4 revealed that they had not notified the prescribing doctor of the missed medications as the facility could not confirm that the resident had not been administered all doses, even with 3 doses extra remaining on the blister pack.
Plan of correction
The Healthcare Director or designee will review all new orders to ensure accuracy and that medications are administered per physician orders. The Healthcare Director or designee will audit medication carts weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit.
22VAC40-73-640-A
Based on facility record review and staff interview, the facility failed to follow their medication management plan in regard to ensuring there are methods for monitoring medication administration and the effective use of the MARs for documentation.
Evidence
  1. The facility’s medication administration plan/medication management plan (MMP) contained documentation that quarterly observation of medication administration will be performed by the Resident Care Director (RCD)/designee or pharmacy consultant. The observation record will be maintained in a binder in the RCD office.
  2. Facility records contained Medication Observation Clinical Competency forms located in the Med Tech Audit Binder with documentation for staff 1 to be observed on 9/15/2024, staff 2 to be observed on 9/5/2024, and staff 3 to be observed on 9/14/2024 for quarterly clinical competency. These observations were the most recent observations in the binder.
  3. During an interview on the day of inspection with the licensing inspector and staff 4, staff 4 confirmed the Med Tech Audit Binder to be current, and the most recent observations were completed in September 2024. Staff 4 confirmed that an observation should have been completed on staff during the months of October 2024, November 2024, or December 2024 to follow their MMP.
Plan of correction
Audits were conducted by the nurse consultant in October, November, and December. Going forward, a medication pass review will be added to these visits. Additionally, the Healthcare Director or their designee will conduct quarterly reviews to ensure adherence to our medication management plan. The Healthcare Director or designee will verify and confirm completion of these reviews each quarter with the Executive Director.
January 8, 2025Complaint survey3 violations
Inspection dates
01/08/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 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: 1/8/25 10:45 to 16:06 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/25/24 regarding allegations in the area(s) of: General Procedures, Emergency Preparedness, Resident Care and Related Services, Admission, Retention, and Discharge of Residents 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: 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 A Marie Swink, Licensing Inspector at 265-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-80-120-E-2
Based on physical plant observation and staff interview, the facility failed to ensure that certain documents related to the terms of the license are posted on the premises of each facility including the findings of the most recent inspection of the facility.
Evidence
  1. On the day of the on-site inspection, the most recent inspection of the facility, dated 10/22/2024, was not posted on the premise of the facility.
  2. Staff person 1 signed, dated, and returned via email the completed 10/22/2024 inspection documents on 10/28/2024 to the licensing inspector.
  3. On the day of the on-site inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed they had not posted the most recent inspection of the facility dated 10/22/2024.
Plan of correction
The Executive Director is ordering a locked shadow box so the most recent inspections can be displayed in a manner that will allow the inspection reports to remain displayed and not be taken down. 02/01/25
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained signed physicians order, dated 10/29/2024, with documentation for tramadol 50mg tablet, take 1 tablet every 6 hours by oral route for 7 days and baclofen 10mg tablet, take 1 tablet 3 times a day by oral route for 15 days.
  2. Resident 1 record contained an October 2024 Medication Administration Record with documentation that Baclofen 10mg tablet, take 1 tablet by mouth 3 times a day for 15 days was not administered on 10/30/2024, as the MAR is empty on this date and times for this medication, and tramadol 50mg tablet, take 1 tablet by mouth every 6 hours for 7 days was not administered on 10/30/2024 at 12am, 6am, 12pm or 6pm, and 12am on 10/31/2024, as the MAR is empty on this date and times for this medication. 3.Resident 1 record contained signed physician’s order, dated 11/4/2024, with documentation to discontinue baclofen 10mg oral tablet, 1 tab oral 3 times a day and tramadol 50mg 1 tab oral every 6 hours interval.
  3. Resident 1 record contained a November 2024 Medication Administration Record (MAR) with documentation of the administration of Baclofen 10mg Tablet, take 1 tablet by mouth 3 times a day on 11/4/2024 at 8pm and 11/5/2024 at 8am and Tramadol 50 mg Tablet, take 1 tablet by mouth every 6 hours on 11/4/2024 at 8pm and 11/5/2024 at 8am.
Plan of correction
The Executive Director has scheduled a medication refresher course for the medication aides to attend on 2/5/25. The Healthcare Director or designee will review all new orders to ensure accuracy and that medications are administered per physician orders. The Healthcare Director or designee will audit medication carts weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit. 03/01/25
22VAC40-73-990-A
Based on facility record review, resident record review, and staff interview, the facility failed to follow their written plan for resident emergencies that includes procedures for making pertinent medical information and history available to the rescue squad and hospital, including a copy of the current medication administration record and advance directives.
Evidence
  1. Facility records contained an Emergency Preparedness and Response Plan Resident Medical Emergency policy with documentation that when a resident is hospitalized or transported by emergency medical personnel, information necessary to the care of the resident shall be furnished by the community to the hospital or emergency medical personnel. Examples of such information include a copy of the current medication administration record (MAR), a DO Not Resuscitate (DNR) Order, advance directives, and organ donation information. 2.Resident 1 record contained documentation that the resident was taken to the emergency department by ambulance on 10/31/2024. 3.On the day of the on-site inspection during an interview with the licensing inspector and staff 1, staff 1 revealed that the facility does not include the current Medication Administration Record as part of the documents for the rescue squad or hospital when a resident is in need of emergency medical care. Staff 1 revealed the facility will send a medication list.
Plan of correction
Staff has been in-serviced regarding the fact that the medication administration record (MAR) is to be provided to EMS when EMS transports a resident to the ED, instead of a physician order sheet listing medications. The Healthcare Director or designee will schedule an in-service on emergency preparedness as it relates to resident emergencies, and staff will sign off expressing understanding. The Healthcare Director or designee will follow up after each resident emergency to ensure proper procedures are followed. 03/01/25
January 8, 2025Complaint survey2 violations
Inspection dates
01/08/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/8/25 10:45 to 16:10 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/18/24 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services Number of resident records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s of non-compliance with standard(s) or law, and violation(s) were 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained a physicians order, dated 10/28/2024 with documentation for Tresiba Flexitouch 100 Units, Inject 10 Units Subcutaneously every day for diabetes.
  2. Resident 1 record contained a November 2024 Medication Administration Record with documentation that Tresiba Flexitouch 100 Units, Inject 10 Units Subcutaneously every day for diabetes was not administered on 11/1/24, 11/4/24 to 11/6/24, 11/11/24, 11/13/24, 11/15/24, and 11/27/24.
Plan of correction
The Executive Director has scheduled a medication refresher course for the medication aides to attend on 2/5/25. The Healthcare Director or designee will review all new orders to ensure accuracy and that medications are administered per physician orders. The Healthcare Director or designee will audit medication carts weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit. 03/01/25
22VAC40-73-280-B
Based on facility record review and staff interview, the facility failed to implement their written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care.
Evidence
  1. The facility’s written plan, provided by staff person 1, that specifics the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care, showed that the facility will have 3 staff providing direct care from 11pm – 7am daily.
  2. The facility Assignment Sheets for the 11pm -7am shift for direct care staff had documentation that there were only two staff providing direct care on 11/9/24, 11/10/24, 11/13/24 to 11/19/24, 11/22/24 to 11/29/24.
  3. On the day of the on-site inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed the assignment sheets to be current.
Plan of correction
The Executive Director reviewed the community staffing plan with the Healthcare Director and the direct care staff to ensure understanding of this policy. The Community Healthcare Director or designee will oversee the schedule and assignment sheets daily to ensure we always have the appropriate staffing numbers in the community. 03/01/25
January 8, 2025Inspection2 violations
Inspection dates
01/08/2025
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: 1/8/25 10:45 to 16:11 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 12/30/24 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and facility record review, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The licensing inspector received a final self-report on 12/30/2024 from the facility which contained documentation that resident 1 was not administered their “cancer medication” from 12/20/2024 through12/25/2024. The medication was reported to be not on the medication cart on 12/21/2024, however the medication changeover from the pharmacy occurred on 12/19/2024. The facility attempted to locate the medication within the facility with no success. The facility began to attempt to receive the medication from the pharmacy beginning on 12/21/2024, however, was not able to secure the medicine in the building until 12/26/2024 due to the closing of outside vendors (manufacturer of the medication and delivery). Staff 2 documented on the December 2024 Medication Administration Record that they had administered the medication on 12/20/2024.
  2. Resident 1 record contained a physician’s order dated 10/28/2024 for Revlimid 5mg Capsule (Lenalidomide) – Take one capsule by mouth every day for multiple myeloma. -Family Provides.
  3. Resident 1 record contained a December 2024 Medication Administration Record with documentation that the medication was not administered on 12/21/2024, 12/22/2024, 12/23/2024, and 12/25/2024.
Plan of correction
22VAC40-73-680D The Executive Director has scheduled a medication refresher course for medication aides to attend on February 5, 2025. The Healthcare Director or their designee will provide training to staff on the proper procedure for conducting the monthly medication change-over. This process will now be monitored by a community Licensed Practical Nurse on a monthly basis. Additionally, the Healthcare Director or designee will conduct weekly audits of medication carts to ensure medications are properly stocked, with reports submitted to the Executive Director following each audit. The Executive Director, in collaboration with the community Human Resources department, investigated the incident, which resulted in the employees involved no longer being with the community, in accordance with HR policies. 03/01/25
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included any medication errors or omissions;
Evidence
  1. Resident 1 record contained a December 2024 MAR with documentation for Revlimid 5mg Capsule being administered on 12/20/2024 and 12/25/2024.
  2. On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed the resident did not receive their Revlimid 5mg capsule on 12/20/2024 and 12/25/2024 because it was not able to be located in the facility to administer to the resident.
Plan of correction
22VAC40-73-680I The Executive Director has scheduled a medication refresher course for the medication aides to attend on 2/5/25. The Healthcare Director or designee will audit MARs daily to ensure medications are given per physician orders. Medication carts will be audited weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit. The Executive Director, in collaboration with the community Human Resources department, investigated the incident, which resulted in employees that were involved no longer being associated with the community, in accordance with HR policies. 03/01/25
January 8, 2025Inspection4 violations
Inspection dates
01/08/2025
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: 1/8/2025 10:45 to 16:00 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 12/10/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on resident record review, staff interview, and facility record review, the facility failed to ensure that they assumed general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. Resident 1 record contained a signed physician’s order dated 10/31/2024 for Torsemide 20mg Oral Tablet, 2.5 Tab BID for 30 days and a subsequent signed physician’s order dated 12/5/2024 to increase torsemide 20mg Tab 2.5 tab BID to torsemide 20mg tab 3.5 tablets BID for 5 days for fluid retention.
  2. Resident 1 record contained a November 2024 and December 2024 Medication Administration Record (MAR) that had documentation that the resident did not receive approximately 24 doses of the prescribed medication for Torsemide 20mg Tab, 2.5 Tab BID for 30 days. The MARs state the medication is a loop diuretic. The December 2024 MAR contained documentation that Torsemide 20mg Tablet 2.5 Tab BID was administered at the AM schedule on 12/5/2024, 12/6/2024, 12/7/2024, and 12/9/2024, and at the PM schedule on 12/5/2024 even though a new order was written on 12/5/2024 to increase the dose of the medication. The physician’s order dated for 12/5/2024 for this medication and dose was not administered to the resident until 12/10/2024. The November and December 2024 MAR contained documentation that at least 8 direct care staff members observed resident 1 between 11/25/2024 – 12/9/2024.
  3. During the on-site inspection during an interview with the LI and staff 1, staff 1 revealed through facility investigation that the prescribed medication of Torsemide 20mg Tab, 2.5 tab BID was not available on the medication cart to administer beginning on 11/23/2024.
  4. Resident 1 record contained a signed physician’s order dated 10/31/2024 that has documentation that the resident’s weight was 64.3 kg (141 pounds).
  5. Resident 1 record contained hospice clinical notes that had documentation that the resident’s weight in pounds was 156.7 on 11/25/2024, 156.2 on 11/27/2024, 160.7 on 12/2/2024, 167.1 on 12/9/2024, 154 on 12/11/2024, and 147 on 12/16/2024.
  6. Resident 1 record contained hospice clinical notes that had documentation that the resident had swelling around toes and tops of feet on 11/15/2024, pitting edema to BLE +1, +2 on 11/30/2024, pitting edema present to BUE on 12/2/2024, pitting edema present to BLE on 12/6/2024, a swollen right cheek on their face and “both eyes look like the skin is about to burst from fluid” on 12/9/2024, edema decrease on 12/13/2024, and edema decrease on 12/16/2024.
  7. Resident 1 record contained Progress Notes for December 2024 that contained no documentation regarding the resident’s edema or weight gain.
  8. Facility records contained a signed statement from staff 3 with documentation that staff 3 had notified staff 4 that Torsemide 20mg tablet for resident 1 was not available on the medication cart on 11/23/2024 and staff 3 notified the hospice provider and staff 5, the health care director, on 12/9/2024 regarding the resident appearing “puffy”. Facility records contained a signed statement from staff 2 with documentation that staff 4, shift supervisor was notified on 12/2/2024 that Torsemide 20mg tablet for resident 1 was not available on the medication cart.
Plan of correction
The Executive Director has scheduled a medication refresher course for the medication aides to attend on 2/5/25. The Healthcare Director or designee will review all new orders to ensure accuracy and that medications are administered per physician orders. The Healthcare Director or designee will audit medication carts weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit. The Executive Director, in collaboration with the community Human Resources department, investigated the incident, which resulted in the employees involved no longer being with the community, in accordance with HR policies. 03/01/25
22VAC40-73-640-A
Based on facility record review, the facility failed to follow their medication management plan in regard to ensuring each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s medication administration plan/medication management plan contained documentation that if a medication is not available at the scheduled time of administration, responsible staff with notify RCD or designee for further instructions and the entry will be made in the pharmacy communication notebook. Charting “med not available” on the MAR alone, does not fulfill this requirement.
  2. Facility records contained a signed statement from staff 3 with documentation that staff 3 had notified staff 4 that Torsemide 20mg tablet for resident 1 was not available on the medication cart on 11/23/2024. Facility records contained a signed statement from staff 2 with documentation that staff 4, shift supervisor was notified on 12/2/2024 that Torsemide 20mg tablet for resident 1 was not available on the medication cart.
  3. The facility’s pharmacy communication notebook contained no documentation from any staff member regarding resident 1 medication for Torsemide 20mg Tablet on 11/23/2024 or 12/2/2024. The pharmacy communication notebook contained documentation on 12/9/2024 that the medication had arrived at the facility.
Plan of correction
22VAC40-73-640A The Healthcare Director or designee will review the facility’s medication plan with the community registered medication aides on the proper procedure for documenting when a medication is not available. The RMA will notify the Healthcare Director or designee and will make a note in the pharmacy communication notebook. The Healthcare Director or designee will review the communication notebook daily to ensure compliance. The Executive Director, in collaboration with the community Human Resources department, investigated the incident, which resulted in the employees involved no longer being with the community, in accordance with HR policies. 03/01/25
22VAC40-73-680-I
Based on resident record review and facility record review, the facility failed to ensure that the Medication Administration Record (MAR) included date and time given and initials of direct care staff administering the medication and any medication errors or omissions.
Evidence
  1. Resident 1 record contained a signed physician’s order dated 10/31/2024 for Torsemide 20mg Oral Tablet, 2.5 tab Oral BID for 30 days.
  2. Resident 1 record contained November and December Medication Administration Record (MAR) with documentation of Torsemide 20mg Oral Tablet, 2.5 tab Oral BID not being administered on 11/17/2024 by staff 2, and being administered on 11/30/2024, 12/1/2024, and 12/9/2024 by staff 3.
  3. Facility record contained a statement from staff 2 that had documentation that staff 2 did administer the medication as prescribed on 11/17/2024 however was not able to acknowledge that the medication was administered due to issues with the new electronic MAR system. A statement from staff 3 had documentation that staff 3 did not administer the medication on 11/30/2024, 12/1/2024, and 12/9/2024 as indicated on the MAR that it had been administered.
Plan of correction
22VAC40-73-680I The Executive Director has scheduled a medication refresher course for the medication aides to attend on 2/5/25. The Healthcare Director or designee will audit MARs daily to ensure medications are given per physician orders. Medication carts will be audited weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit. The Executive Director, in collaboration with the community Human Resources department, investigated the incident, which resulted in employees 1 and 2 no longer being with the community, in accordance with HR policies. 03/01/25
22VAC40-73-680-D
Based on resident record review and facility record review, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The licensing inspector (LI) received an incident report from the facility on 12/10/2024 that contained documentation that resident 1 was not consistently receiving their Torsemide 50mg BID from 11/7/2024 to 12/9/2024 and confirmed that some doses were missed. The incident report contained documentation that resident 1 had swelling on 12/9/2024 to the hands and face.
  2. Resident 1 record contained a signed physician’s order dated 10/31/2024 for Torsemide 20mg Oral Tablet, 2.5 tab Oral BID for 30 days. This order was written as part of the discharge from the local hospital.
  3. Resident 1 record contained documentation that the resident returned to the facility from a hospital admission on 11/1/2024.
  4. Facility records contained a Consolidated Delivery Sheet for 11/4/2024 at 18:08 from the pharmacy for delivery of the medication to the facility for resident 1.
  5. Resident 1 record contained the November and December 2024 Medication Administration Record (MAR) that had documentation that the resident was not administered Torsemide 20mg Tablet, 2.5 Tab (50mg) at the scheduled morning (AM) time on 11/13/2024, 11/14/2024, 11/15/2024, 11/19/2024, 11/22/2024, 11/23/2024, 11/25/2024, 11/27/2024, 11/28/2024, 12/2/2024, 12/3/2024 and at the scheduled afternoon time (PM) on 11/7/2024, 11/8/2024, 11/9/2024, 11/15/2024, 11/17/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/27/2024, 11/28/2024, 12/2/2024, and 12/4/2204. There is documentation on the MAR that the resident was out of the facility in the AM on 11/19/2024, the drug was not available in the PM on 11/23/2024 and 11/25/2024 in the AM on 12/3/2024, and Other, as the reason for not administering, in the PM on 11/28/2024 and the AM on 12/2/2024, and drug was not given on 12/2/2024 and 12/4/2024.
  6. Resident 1 record contained a signed physician’s order dated 12/5/2024 to increase torsemide 20mg Tab 2.5 tab BID to Torsemide 20mg tab 3.5 tablets BID for 5 days for fluid retention.
  7. Resident 1 record contained the December 2024 MAR that had documentation that the resident was administered Torsemide 20mg Tablet, 2.5 Tab BID at the AM schedule on 12/5/2024, 12/6/2024, 12/7/2024, and 12/9/2024, and at the PM schedule on 12/5/24. The MAR contained documentation that this medication at this dose was not administered at the AM schedule on 12/8/2024 and PM schedule on 12/6/2024, 12/7/2024, 12/8/2024, and 12/9/2024.
  8. Resident 1 record contained December 2024 MAR that had documentation that the Torsemide 20mg tab 3.5 tablets BID for 5 days for fluid retention was first administered on 12/10/2024.
Plan of correction
22VAC40-73-680-D The Executive Director has scheduled a medication refresher course for the medication aides to attend on 2/5/25. The Healthcare Director or designee will review all new orders to ensure accuracy and that medications are administered per physician orders. The Healthcare Director or designee will audit medication carts weekly to ensure medications are available, and reports must be submitted to the Executive Director after each audit. The Executive Director, in collaboration with the community Human Resources department, investigated the incident, which resulted in the employees involved no longer being with the community, in accordance with HR policies. 03/01/25
October 22, 2024Inspection0 violations
Inspection dates
10/22/2024
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: 10/22/2024 13:00 to 13:50 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication Cart Audit 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 21, 2024Inspection1 violation
Inspection dates
08/21/2024
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: 08/21/2024 10:50 to 12:00 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 8/13/2024 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: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review, staff record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the date and time given and initials of direct care staff administering the medication.
Evidence
  1. The licensing inspector received a self-report of noncompliance on 08/13/2024 from the facility which contained documentation that resident 1 was not administered their medication Clonazepam 0.5mg on 8/9/24 and 8/11/24. The medication was signed off on in the Electronic Medication Administration System (EMAR) by staff 2 but was not signed off on in the Narcotic book by staff 2, however, Narcotic count was correct. Staff 2 was interviewed by facility staff, and staff 2 stated that they did not give it and that they had signed off in error on the EMAR. 2.Resident 1 record contained an August 2024 MAR with documentation for the scheduled 9pm Clonazepam .5mg Tablet being administered on 8/9 and 8/11 by staff 2.
  2. Staff 2 record contained an Employee Counseling Record dated 8/12/2024 with documentation that staff 2 signed off on 8/9 and 8/11 that they had administered resident 1 scheduled 9pm Clonazepam .5mg Tablet, and the medication was found in the back of the narcotic drawer by staff 4.
  3. On the day of inspection during interviews with one licensing inspector and staff 1 and then staff 5, staff 1 and then staff 4 confirmed the resident did not receive their scheduled 9pm Clonazepam .5mg Tablet. Staff 1 and Staff 4 confirmed the medication was on the cart, however, staff 2 did not administer it to the resident according to the narcotic log sheet and staff 2 interview.
Plan of correction
A mandatory in-service was held for RMAs to review the correct procedures for administering and documenting medications. RMA involved was required to complete a medication refresher course. Following this, the Healthcare Director or designee conducted individual medication pass reviews with the RMA.
August 5, 2024Inspection2 violations
Inspection dates
08/05/2024
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: 8/5/2024 09:45am to 12:25pm 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 7/30/2024 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 97 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: 4 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review, staff record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident 1 record contained a July 2024 MAR with documentation for Revlimid 5mg Capsule being administered on 7/20, 7/21, 7/24, and 7/25 by staff 3, on 7/23 by staff 4, 7/22, 7/27, and 7/28 by staff 5, and on 7/26 by staff 6.
  2. Staff 3 record contained an Employee Counseling Record dated 7/31/2024 with documentation that the staff 3 signed off on 7/20, 7/21, 7/24, and 7/25 that they had administered resident 1 Revlimid medication, and the medication was found in a desk drawer and had not been given in 10 days.
  3. Staff 4 record contained an Employee Counseling Record dated 7/31/2024 with documentation that the staff 4 signed off on 7/23 that they had administered resident 1 Revlimid medication, and the medication was found in a desk drawer and had not been given in 10 days.
  4. Staff 5 record contained an Employee Counseling Record dated 7/31/2024 with documentation that the staff 5 signed off on 7/23, 7/27, and 7/28 that they had administered resident 1 Revlimid medication, and the medication was found in a desk drawer and had not been given in 10 days.
  5. Staff 6 record contained an Employee Counseling Record dated 7/31/2024 with documentation that the staff 6 signed off on 7/26 that they had administered resident 1 Revlimid medication, and the medication was found in a desk drawer and had not been given in 10 days.
  6. On the day of inspection during interviews with one licensing inspector and staff 1 and then staff 2, staff 1 and then staff 2 confirmed the resident did not receive their Revlimid 5mg capsule from 7/20/2024 through 7/29/2024. Staff 1 and Staff 2 confirmed the medication was not on the cart to be provided to the resident.
Plan of correction
A mandatory in-service was held for RMAs to review the correct procedures for administering and documenting medications. All RMAs involved were required to complete a medication refresher course. Following this, the Healthcare Director or designee conducted individual medication pass reviews with each RMA.
22VAC40-73-680-D
Based on resident record review, staff record review, and staff interview, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The licensing inspector received a self-report of noncompliance on 7/30/2024 from the facility which contained documentation that resident 1 was not administered their medication Revlimid 5mg capsule from 7/19/2024 until 7/29/2024.
  2. Resident 1 record contained a signed physician’s order dated 7/8/2024 for Revlimid 5mg Capsule (Lenalidomide) – Take one capsule by mouth every day for multiple myeloma. -Family Provides- Indicated for Multiple Myeloma.
  3. On the day of inspection during an interview with one licensing inspector and staff 2, staff 2 revealed that on 7/29/2024 the medication Revlimid for resident 1 was found in a drawer in the nurse’s station at their desk. Staff 2 revealed that staff 3 had removed the medication from the medication cart on the evening of 7/19/2024 during the monthly change over for medication refill from the pharmacy. Staff 2 did not know the reason the medication was in the drawer at their desk in the nurse’s station.
  4. On the day of inspection during an interview with one licensing inspector and staff 1, staff 1 confirmed the resident did not receive their Revlimid 5mg capsule from 7/20/2024 through 7/29/2024. Staff 1 confirmed the medication was not on the cart to be provided to the resident.
Plan of correction
RMA's involved were sent to a medication refresher class on 8/14/24. The Nursing Supervisor, or their designee, will oversee the monthly pharmacy medication change-over. They will audit all medication cards against the EMAR to verify that all cards are present on the cart. Staff assigned to this task will receive proper training. Carts will be audited weekly by the Healthcare Director or designee to ensure all medications are on the cart and are being given appropriately.
May 15, 2024Complaint survey1 violation
Inspection dates
05/15/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/15/2024 10:30am to 12:08pm 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 5/7/2024 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: 95 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 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-470-B
Based on resident record review and staff interview, the facility failed to ensure a resident's need for skilled nursing treatments within the facility was met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.
Evidence
  1. The record for resident 1 has a physicians order dated 5/3/2024 with documentation for Wound Care due to a procedure performed on 5/3/2024 that requires follow up wound care. Keep the bandage on the wound for 24 hours. Keep bandage dry and clean. Do not get it wet while bathing. After 24 hours, remove the bandage. Clean the wound gently while bathing with soap and water. Then, apply a small amount of Vaseline and recover it with a Band Aid or other clean bandages. Repeat this once/day until the scab has fallen off or for 4 weeks.
  2. The record for resident 1 has a subsequent physicans order dated 5/3/2024, with clarification made on 5/8/2024, with documentation for Bandage Care due to a procedure performed that requires bandage care. Keep the bandage on the site left forearm for 24 hours. Keep bandage dry and clean. Do not get it wet while bathing. After 24 hours, remove the bandage. Clean the site daily gently while bathing with soap and water. Then, apply a small amount of Vaseline and recover it with a Band Aid or other clean bandages. Repeat this once/day until 4 weeks.
  3. The May 2024 Medication Passing Detail has documentation of staff person’s 3 initials on 5/4, 5/5, 5/6, 5/8, 5/9, 5/10, 5/13, and 5/14, staff person’s 4 initials on 5/7, and staff person’s 5 initials on 5/11 and 5/12 for completion of these treatments. The May 2024 Medication Administration Record has documentation that staff person 3,4, and 5 are Registered Medication Aides (RMA) however this treatment should have been completed by a licensed healthcare provider.
  4. During an interview with one licensing inspector and staff person 1 on 5/15/2024, staff person 1 disclosed they requested clarification from the prescriber for the order to be changed to bandage care due to RMA not having the skill set to assess wounds.
Plan of correction
ED, RCD, and or/Designees will partner with outside agency to ensure all wound care and treatments outside of scope of practice is performed in accordance with physician's orders. Ongoing.
April 18, 2024Inspection4 violations
Inspection dates
04/18/2024
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 PREPAREDNESS22VAC40-90 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: 4/18/2024 07:50 to 3:50pm 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: 90 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 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the dosage.
Evidence
  1. The record for resident 7 has a physician’s order dated 1/2/2024 for Novolog 100 Unit/ML solution pen injector, inject as per sliding scale; if 0 – 149 = 0, 150 – 200 = 2; 201- 250 = 4; 251 – 300 = 6; 301 – 350 = 8; greater than 400 notify MD; 351 – 400 = 10 subcutaneously after meals and at bedtime for DM.
  2. The April 2024 MAR in the record for resident 7 has documentation that the resident’s blood sugar was 155 on 4/2, 161 on 4/3, 165 on 4/4 at 12:30pm, 166 on 4/2, 180 on 4/7, 176 on 4/9 at 5:30pm, and 151 on 4/2, 196 on 4/9 at bedtime of which the residents blood sugar fell within parameter to receive sliding scale insulin coverage. The MAR does not have documentation that units were given for the Novolog 100Unit/ml for any of these blood sugars or of any injection sites.
  3. During an interview on 4/18/2024 with the licensing inspector (LI) and staff person 6, staff person 6 confirmed the MAR did not have documentation of the units given.
Plan of correction
RCD and/or Designee will audit and review medication dashboard weekly. Staff educated on proper documentation for insulin administration. Ongoing
22VAC40-73-680-M
Based on resident record review and staff interview, the facility failed to ensure the medications ordered for PRN administration shall be available for a resident.
Evidence
  1. The record for resident 1 has a physician’s order dated 4/2/2024 for Anti-Diarrheal 2mg Caplet – Take 1 tablet by mouth as needed after each loose stool – DNE 8tabs/24hrs and Benzonatate 100 mg capsule – take one capsule by mouth 3 times a day as needed for cough.
  2. During a medication cart review on 4/18/2024 with the licensing inspector and staff person 3, staff person 3 confirmed the medications were not in the cart and available for the resident.
Plan of correction
RCD and/or Designee will ensure all PRN medications are available, properly labeled for the specific resident, and properly stored at the facility. Ongoing
22VAC40-73-310-B
Based on resident record review and staff interview, the facility failed to ensure that a documented interview was completed between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any.
Evidence
  1. The record for resident 5, admission date 4/15/2024, did not contain a documented interview.
  2. During an interview on 4/18/2024 with the licensing inspector (LI) and staff person 4, staff person 4 confirmed the record that a documented interview was not completed.
Plan of correction
RCD/ISP Coordinator and/or Designee will complete note describing interview of prospective resident at time of Uniform Assessment Instrument (UAI) completion prior to admission. Note will be located in EMAR system and/or physical copy attached to physical copy of Uniform Assessment Instrument. Ongoing
22VAC40-73-950-E
Based on facility record review and staff interview, the facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all residents, with emphasis placed on an individual's respective responsibilities.
Evidence
  1. On 4/18/2024, The licensing inspector (LI) requested to review documentation of the semi-annual review on the emergency preparedness and response plan with all residents. The facility binder that was identified as the survey readiness book did not have documentation that a semi-annual review was completed with all residents.
  2. During an interview on 4/18/2024 with the LI and staff person 4, staff person 4 confirmed that the semi-annual review on the emergency preparedness and response plan with all residents had not been completed.
Plan of correction
ED and/or Designee will ensure that a written record of biannual emergency preparedness review for all residents be completed and filed in state survey readiness file
April 18, 2024Inspection0 violations
Inspection dates
04/18/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 4/10/2024 07:50am to 03:40pm 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 4/3/2024 regarding allegations in the area(s) of: Administration and Administrative Services, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 90 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: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 16, 2024Inspection0 violations
Inspection dates
02/16/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2.16.2024 9:30am to 10:35am 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 2.9.2024 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 97 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: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink, Licensing Inspector at 276.623.6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 25, 2023Complaint survey0 violations
Inspection dates
04/25/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
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: 04/25/2023 9am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/11/2023 regarding allegations in the area(s) of: Staffing, Resident care and related services and building and grounds Number of residents present at the facility at the beginning of the inspection: 82 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 interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 25, 2023Inspection10 violations
Inspection dates
04/25/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/25/2023 9:00am until 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 82 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: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that within the 30 days preceding admission, a person had a physical examination by an independent physician that contained all required components.
Evidence
  1. Resident 5 was admitted to the facility on 12/19/2022. The report of resident physical examination in the record for the resident did not include the following information on page 1: the date of examination and the resident’s height weight and blood pressure. Page 3 of the examination was dated 12/20/2022 and the Virginia Tuberculosis (TB) risk assessment was dated 12/20/2022. There was no documentation provided during on-site inspection that the physical examination for the resident was conducted within 30 days preceding the admission of the resident.
Plan of correction
Director of Community Relations will ensure that all resident physical examinations and screening and/or testing for tuberculosis are complete prior to admission into the facility. Resident physical examinations will be audited by RCD and/or ED prior to admission into the facility. Ongoing.
22VAC40-73-560-E
Based on resident record review, the facility failed to ensure that resident records were kept current.
Evidence
  1. The record for resident 6 has documentation that the resident is receiving regular routine wound care from a home health agency. The last documentation of home health notes to include documentation of wound care being completed in the record for resident 6 was dated 03/26/2023.
Plan of correction
RCD and/or Designee will ensure that any Home Health Agency providing care to residents in the facility provide documentation and updates from their visit/services provided. Resident/Responsible Parties will be notified by staff for non-compliance with the recommendation that services be performed by a Home Health Agency that will ensure compliance with Department of Social Services Regulations. Ongoing.
22VAC40-73-660-B
Based on observation during a tour of the physical plant and resident record review, the facility failed to ensure that for a resident that is capable of self-administering medication that the resident’s medication is kept in an out-of-sight place in the resident’s room and stored so that the medication and any dietary supplements are not accessible to other residents.
Evidence
  1. The report of resident physical examination in the record for resident 9, dated 08/01/2022, and the uniform assessment instrument (UAI), dated 08/11/2022, both indicate that resident 9 is capable of self-administering medications. Interview with staff 5 and 7 indicated that this is accurate.
  2. At approximately 10:06AM during on-site inspection, it was noted by two licensing inspectors (LIs) that the door to resident 9’s room was unlocked, and the resident was not present in the room. The LIs observed that medications in resident 9’s room were not stored in an out-of-sight place as a small plastic cup with two loose pills and a bottle of Ciprofloxacin Ophthalmic solution 0.3% eye drops were observed sitting out on the kitchen counter. Also, the two LIs observed a pill box with multiple pills in the Wednesday and Thursday sections of the pill box sitting out on the bed.
Plan of correction
All Residents will be encouraged to keep entry doors to their apartments locked when not in their residences. Residents that have orders for self-administration of medications that choose not to keep their residence entry doors secured will be instructed in writing that all medications must be stored in an out-of-sight location and not accessible to other residents. Ongoing.
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure that all direct care staff attended at least 18 hours of training annually.
Evidence
  1. The record for staff person 1, hired on 02/17/2017, did not include documentation that the staff person had at least 18 hours of annual training from 02/17/2022 through 02/17/2023.
  2. The record for staff person 3, hired on 01/17/2019, did not include documentation that the staff person had at least 18 hours of annual training from 01/17/2022 through 01/17/2023.
  3. Interviews with staff persons 5 and 7 confirmed that this is accurate.
Plan of correction
Director of Business Administration will audit training records for all staff monthly, utilizing online training interface. In-Person Trainings, led by qualified individuals and/or licensed health care professionals will be scheduled by DBA, Resident Care Director, or Designee, throughout the year to ensure compliance with regulations in which virtual training does not meet training requirements. Ongoing.
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility all required resident personal and social information was obtained.
Evidence
  1. The resident-personal/social data sheet for resident 3, admitted 02/07/2023, did not contain the following information for the resident: admission date, allergies, and interests/hobbies.
  2. The resident-personal/social data sheet for resident 4, admitted 03/07/2023, did not contain information on resident allergies, lifetime vocation/career and current behavioral and social functioning including strength and problems.
  3. The resident-personal/social data sheet for resident 6, admitted 02/14/2023, did not contain information on resident allergies, interest/hobbies, lifetime vocation/career, information on advance directives, DNR or organ donation if applicable.
Plan of correction
DCR and/or ED will ensure that all fields of resident personal/social data sheet are fully completed prior to or at date of admission. Ongoing.
22VAC40-73-260-A
Based on staff record review, the facility failed to ensure that all direct care staff received certification in first aid within 60 days of employment.
Evidence
  1. The record for staff person 4, hired on 10/13/2022, has documentation that this employee did not receive certification in first aid until 04/03/2023.
Plan of correction
DBA, RCD, and/or Executive Director will ensure documentation of first aid certification of all direct care staff is current and up to date at time of hire. If first aid certification has lapsed prior to date of hire, first aid training will be scheduled and completed within first 60 days of employment. Ongoing.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were completed as required.
Evidence
  1. The uniform assessment instrument (UAI) for resident 1, dated 04/10/2023, indicates that the resident requires supervision human help and mechanical help with transferring; however, the ISP for the resident, dated 04/10/2023, indicates that the resident requires physical assistance human help of one nursing staff and mechanical help with transferring. Interview with staff 7 revealed that the UAI is correct, and the ISP is incorrect.
  2. The most recent fall risk tool, dated 01/22/2023, in the record for resident 8 indicates that the resident has had 10 falls in the last six months and has a total score of 13. During interview with staff 7, staff 7 confirmed that this would identify the resident as a high fall risk; however, the resident’s ISP, recently updated 02/06/2023, does not indicate that the resident is a high fall risk.
  3. The ISP for resident 8, recently updated 02/06/2023, indicates that the resident started receiving wound care two times weekly to treat open areas on the resident’s left buttock on 01/19/2023. When staff 7 was asked for wound care notes during the on-site inspection regarding this service, staff 7 revealed that the resident is no longer receiving wound care and indicated that the resident’s ISP needs to be updated to reflect that wound care has been discontinued for the resident.
  4. The record for resident 6, admitted on 02/14/2023, has documentation of the resident falling on 03/14/2023, 03/26/2023 and 04/12/2023. A physician order dated 04/18/2023 was noted for a physical and occupational therapy evaluation. The ISP dated 04/13/2023 in the record for resident 6 does not address these identified needs.
Plan of correction
Individualized Service Plan Coordinator and/or ISP Certified Designee as assigned by RCD will ensure all Individualized Service Plans reflect accurate information as provided by Uniform Assessment Instrument, completed by UAI-certified personnel. Ongoing.
22VAC40-73-680-D
Based on observations of the facility medication carts and resident medication administration records (MARs), the facility failed to ensure that medications administered were consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The record for resident 10 has a physician order for the administration of Victoza 1.8ml sub-q at bedtime for DM. This medication is a non-insulin injection.
  2. The record for resident 11 has a physician order for Ozempic 0.5mg sub-q every Saturday for DM. This medication is a non-insulin injection.
  3. The April 2023 MARs for residents 10 and 11 have documentation of staff initials who are RMA’s for the administration of these medications.
  4. Page 53 of the current 68 hour registered medication aide curriculum revised in 2022 has documentation that “Non-insulin injections a. Medication aides may not administer pursuant to 18VAC90-60-110(B)(5)”.
Plan of correction
RCD and/or Designee will contact Resident’s Prescribing Physicians for new orders to ensure compliance with regulation 18VAC90-60-110(B)(5) on Non-Insulin Injections. I Ongoing.
22VAC40-73-250-D
Based of staff record review, the facility failed to ensure that staff received a screening for tuberculosis on or within 7 days prior to the first day of work.
Evidence
  1. The record for staff person 2, whose first day of work was 10/25/2022, has documentation that a screening for tuberculosis for not completed until 10/27/2022.
Plan of correction
DBA will ensure all new hires are in compliance with screenings for tuberculosis on or within 7 days prior to the first day of work. Ongoing
22VAC40-73-270-4
Based on staff record review and staff interview, the facility failed to ensure a refresher training for all direct care staff was provided at least annually or more often as needed for facilities that accept, or have in care, residents who are or who may be aggressive.
Evidence
  1. The record for resident 5 contained a staff note, dated 02/14/2023, that the resident was very agitated and confused the whole day, and an additional staff note, dated 02/22/2023, stated that the resident was agitated. Also, the record for resident 8 contained a staff note, dated 01/11/2023, that the resident was very combative with staff on the 11:00PM – 7:00AM shift and staff had difficulty changing the resident’s soiled brief and the resident was calling out the name of staff and kicking.
  2. The records for staff persons 1 and 2 do not have documentation that these individuals have had annual training for residents with aggressive behaviors. Interview with staff 5 and 7 confirmed that this is accurate.
Plan of correction
ED, RCD, and DBA will establish training schedule for face to face annual training for all direct care staff led by licensed health professional for compliance with state regulations on aggressive behaviors. Ongoing.
January 12, 2023Complaint survey0 violations
Inspection dates
01/12/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/12/2023 11:00am until 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the areas of: resident care and related services and building and grounds 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: Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 12, 2023Complaint survey0 violations
Inspection dates
01/12/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/12/2023 11:00am until 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the areas of: resident care and related services and building and grounds 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 26, 2022Inspection6 violations
Inspection dates
05/26/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/26/2022 8:45am until 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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. An exit meeting will be conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-50-A
Based on review of resident records, the facility failed to ensure that the current disclosure state form was used for prospective residents.
Evidence
  1. The disclosure statement in the records for residents 1, 5 and 6 were noted to lack information on the facility emergency power source as required by this standard.
Plan of correction
Facility will begin using the VDSS disclosure form. ED will ensure that emergency power is listed on the disclosure form and not just in the contract.
22VAC40-73-250-D
Based on a review of staff records, the facility failed to ensure that staff screenings for tuberculosis were completed in entirety on or within 7 days prior to the first day of work.
Evidence
  1. The record for staff person 2, hired on 04/20/2022 has documentation of a screening for tuberculosis that is lacking the date of the screening making it unclear if the screening was completed on or within 7 days prior to the first day of work at the facility.
Plan of correction
The Business Office Manager or designee will ensure dates are on all TB screening forms and will check for this before filing the screening in the employee record.
22VAC40-73-210-G
Based on review of staff records, the facility failed to ensure documentation of the number of hours of training for staff.
Evidence
  1. The record for staff 3, date of hire 04/08/2021, did not contain documentation of the number of hours for all the training that the staff member had completed for the training year 04/08/2021 through 04/07/2022.
Plan of correction
The Business Office Manager or designee will ensure that training hours are listed on all future in-services. BOM will now add that to her auditing tool for future use.
22VAC40-73-310-D
Based on review of resident records, the facility to insure that written assurance was provided to a resident at the time of their admission.
Evidence
  1. The record for resident 1, admitted on 03/14/2022, did not contain documentation that written assurance was provided to this resident at the time of their admission to the facility.
Plan of correction
The written assurance was completed before admission and was found after the inspection. The ED will ensure that all papers are filed in the record at time of admission. Facility does have a letter of written assurance that is used for each admission. An audit of resident records confirmed that written assurance was in each record.
22VAC40-73-440-A
Based on review of resident records and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) was updated when there was a significant change in the resident’s condition.
Evidence
  1. The individualized service plan (ISP) for resident 7, with an update of 05/03/2022, indicated that staff are to complete routine two hour checks on the resident due to disorientation. The UAI for resident 7, dated 02/15/2022, indicated that the resident is oriented. Interview with staff person 4 revealed that the resident is disoriented some spheres, some of the time to place and time meaning that the ISP is correct and the UAI was not updated as required.
Plan of correction
The Director of Nursing or designee will ensure that all changes in conditions will be updated on both the ISP and UAI. A chart review of all records will be performed to ensure compliance to this standard. Additionally, the ISP coordinator will be in-serviced and re-educated on this standard.
22VAC40-73-310-B
Based on review of resident records, the facility failed to ensure a documented interview occurred between the administrator or designee and the resident and their legal representative prior to or on the date of admission.
Evidence
  1. The record for resident 1, 5 and 6 did not contain documentation of an interview conducted with the resident and their legal representative prior to or on the date of these residents admission.
Plan of correction
The facility will begin using an interview form for each new admission. This will be added to the auditing tool used for all new admissions.
April 14, 2022Complaint survey0 violations
Inspection dates
04/14/2022, 05/26/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION
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: 04/14/2022 and 05/25/2022 9am until 3pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/30/2022 regarding allegations in the area of: Staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standards 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 14, 2022Inspection5 violations
Inspection dates
04/14/2022
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 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
The LI for Bentley Commons conducted a monitoring visit at the facility on 04/14/2022 from 8:45am until 1:30pm in conjunction with another LI and the LA. A tour of the facility physical plant was conducted and required posting were noted. The morning exercise activity and mid day meal were observed. The morning medication pass was observed and medication carts were audited. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. An exit interview was conducted with the facility Administrator and Director of Nursing on the day of inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.
Violations
22VAC40-73-680-E
Based on observation, resident interview and resident record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented.
Evidence
  1. The record for resident 4 contained a physician’s order, dated 04/11/2022, for Knee High Ted Hose apply in the morning and remove in the evening for edema to both legs.
  2. The individualized service plan (ISP) for resident 4, dated 03/17/2022, indicates that the resident will receive physical assistance to include application and removal of Ted Hose daily and as needed to promote healthy circulation and prevent edema in the legs and this service is to be provided by LPNs and RMAs at the facility.
  3. The LI observed staff person 2 administer resident 4’s scheduled 9AM oral medications; however, the LI did not observe staff person 2 apply resident 4’s Ted Hose. The LI interviewed resident 4 and the resident indicated that he did not have his Ted Hose on. The LI observed that the resident had on long, black socks and his Ted Hose were located on the chair in his bedroom. Staff person 2 documented on the medication administration record (MAR) on this date with her initials that the resident did have on his Ted Hose.
  4. The licensing administrator, two licensing inspectors and staff person 3 observed resident 4 later during the inspection in his room and staff person 3 agreed that the resident did not have on Ted Hose and that he was wearing black socks. Staff person 3 proceeded with putting on the resident’s Ted Hose.
Plan of correction
ED and DON counseled staff person two regarding the proper use of ted hose and how to differentiate between ted hose and socks. 4/22/22
22VAC40-73-560-F
Based on observation during medication pass, the facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents.
Evidence
  1. The LI noted that the small trash container located on the side of the third floor medication cart contained an empty blister pack for resident 9 for Potassium CL ER. The trash can did not have a lid and content inside the trash can were visible to anyone. The resident information had not been marked out by staff prior to being placed in the trash container.
Plan of correction
ED and DON had a staff meeting and in-service on how to ensure resident records are treated confidentially and how resident information is made available only when needed for the care of the resident. Additionally, ED and DON discussed with the RMA’s how to properly dispose of medication cards that have resident information located on them. 4/22/22
22VAC40-73-680-D
Based on observation during medication pass, the facility failed to ensure that a registered medication aide (RMA) administered medications consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. During the morning medication pass observation conducted on 04/14/2022, the LI observed staff person 2 passing medications at approximately 9:22AM on the third floor of the facility. Staff person 2 was not wearing identification as required by the Board of Nursing Regulations Governing Medication Aides, which is covered in Chapter 1, Objective 1.3 of the current RMA curriculum approved by the Virginia Board of Nursing. Staff person 2 confirmed with the LI that she was not wearing her name tag.
Plan of correction
ED and DON counseled staff person two regarding her not wearing her name tag, per the Virginia Board of Nursing regulations. 4/19/22 ED and DON in serviced staff regarding always wearing name tags while in the facility. 4/22/22
22VAC40-73-660-B
Based on observations made of the facility’s physical plant and resident record review, the facility failed to ensure that medications kept in residents’ rooms were stored in an out of sight place in the residents’ rooms and for only residents who have been assessed as capable of self-administering their own medications.
Evidence
  1. At approximately 9:30AM, the LI observed an Albuterol HFA inhaler on the table beside the bed in resident 5’s bedroom. The uniform assessment instrument (UAI) for resident 5, dated 03/07/2022, has documentation that the resident requires medications to be administered by facility staff. There was not a physician’s order for this medication in the record for resident 5.
  2. At approximately 10:01AM, the LI observed the following on the table beside the bed in resident 6’s bedroom: Systane eye drops, a bag of Honey Lemon Cough Drops, Saline Nasal spray, Vaporizing Rub, and Cortizone-10. The UAI for resident 6, dated 03/10/2022, has documentation that the resident requires medications to be administered by facility staff. There were not physician’s orders for these medications in the record for resident 6.
Plan of correction
facility policy on medication administration as it pertains to self-administering of medications and storage of medications in their rooms. 4/22/22. ED will send out a letter to residents and POA’s reminding them of the facility policy on medication administration as it pertains to self-administering of medications and storage of medications in their rooms. 4/29/22. DON or designee will check rooms weekly for compliance regarding the storage of medications and the self-administering of medications. 5/30/22
22VAC40-73-680-H
Based on a review of resident medication administration records (MARs) and interviews with staff and resident, the facility failed to ensure that only medications that were administered to residents were documented on on resident MARs.
Evidence
  1. The LI observed staff person 1 administering medications at 9:23am on 04/14/2022. When staff person 1 opened the April 2022 MAR for resident 2 it was noted that staff person 2's initials were present for administering the following morning medications; Lisinopril 10mg, MVI, Senna 8.6mg, Pantoprazole 40mg, Ensure Liquid, Polyethylene Glycol 17 grams in water. Several of these medications were noted to still be in the bubble pack on the medication cart for the 04/14/2022 dose. Staff person 1 and the LI interviewed resident 2 who expressed that no morning medications had been brought in or administered to her as of the time of the interview. An interview was conducted with staff person 2 in the presence of staff persons 3 and 4 on the day of inspection. Staff person 2 expressed that she had signed off the morning medications for resident 2 but had not administered them. Staff person 1 was made aware of this and all morning medications were then administered to resident 2.
Plan of correction
ED and DON counseled staff person two regarding proper documentation of medications being administered. 4/19/22. Staff person two will be going through a medication refresher course on 4/28/22 . DON and ED in-serviced RMA’s regarding proper documentation of medications being administered. 4/22/22
February 15, 2022Inspection1 violation
Inspection dates
02/15/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
The LI for Bentley Commons began a self reported incident investigation on 02/15/2022. An email was sent to the facility Administrator on 02/15/2022 requesting resident record and documentation information to be sent tot he LI. A on-site follow up visit was conducted on 04/14/2022. A tour of the facility physical plant was conducted and interviews were held with staff. An exit interview was conducted with the facility Administrator on the day of the on-site inspection in which all violations were discussed and opportunities were given for the facility to provide any additional information. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.
Violations
22VAC40-73-450-H
Based on a review of resident records, facility documentation and interviews with staff, the facility failed to ensure that services specified in a residents individualized service plan (ISP) was provided.
Evidence
  1. The uniform assessment instrument (UAI) dated 01/13/2022 in the record for resident 1 has documentation that the resident is disoriented to some spheres some of the time with time, place and situation being the spheres affected. The UAI also has documentation that resident 1 requires mechanical and human help supervision with mobility.
  2. The ISP dated 01/13/2022 in the record for resident 1 has documentation that the resident is disoriented to time, place and situation some of the time and is to be redirected/reoriented by staff as needed. The ISP also has documentation that resident 1 requires mechanical and supervision with mobility to go outside of the community.
  3. A facility self reported incident was received by the LI on 02/12/2022. The incident report has documentation that on 02/11/2022 resident 1 " stated to the concierge at 5:55pm that she was going to sit on the front porch. Concierge states she does this most evening after dinner and that concierge "peaks in on her every few minutes while outside". The concierge went to check on her after 5minutesand saw her in the parking lot walking towards another building. Concierge immediately walked over to her and asked her where she was going. Resident stated she was going to her room. The concierge then re-directed her and brought her inside and immediately called the Executive Director at 6:06pm once resident was safely inside." The record for resident 1 does not have documentation that the supervision required for resident 1's mobility outside of the community was continuously provided while resident 1 was sitting outside on the front porch.
Plan of correction
ED self-reported this incident to licensing after concierge stated to ED that the resident went outside to sit on the porch with another resident. After five minutes concierge checked on this resident to find her in the parking lot. Resident was immediately brought inside, ED and POA was immediately called, and 24/7 sitters were put in place. Resident was discharged to a secure unit four days later. ED coached staff and concierge regarding residents that have supervision checked on their UAI for mobility and how staff must always supervise these residents while out of the facility. The resident binder will be updated to include all residents that are not permitted to sit on the porch unattended, per their UAI/ ISP. This will be left at the concierge desk. ED/ DON will in-service staff regarding the meaning of mobility and supervision as it pertains to our residents. Completed by 5/4/2022
November 15, 2021Inspection26 violations
Inspection dates
11/15/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
An on-site renewal inspection was conducted from 8:20am until 5:00pm on 11/15/2021 in conjunction with another LI and a Home Office consultant. A tour of the facility physical plant was conducted and the morning medication pass was observed. Resident and staff records as well as other forms of facility documentation were reviewed. The mid day meal and activities were observed. A meeting was held with facility staff at the end of the inspections to go over violations founds and opportunities were given to to ask questions and provide clarifications or additional information on violations cited. Please respond back to your LI with a plan of correction. If you have any questions please feel free to contact your LI at 540-309-2968.
Violations
22VAC40-73-660-B
Based on observations made of the facility physical plant, the facility failed to ensure that medications kept in residents rooms were stored in an out of sight place in the resident rooms and for only residents who have been assessed as capable of self administering their own medications.
Evidence
  1. The room for resident 7 was noted to contain a bottle of Gentle Lax and a container of Metamucil on the kitchen counter. The uniform assessment instrument (UAI) dated 09/12/2021 in the record for resident 7 has documentation that the resident requires medications to be administered by facility staff. There was not a physician order for these medications in the record for resident 7.
  2. The room for resident 10 was noted to have a bottle of Equate Pain Reliever and Tums Smoothies on the kitchen table. The UAI dated 10/20/2021 in the record for resident 7 has documentation that the resident requires medications to be administered by facility staff. There was not a physician order for these medications in the record for resident 10.
  3. Residents 1 and 16 share a room at the facility. At approximately 11:58 AM, while both residents were observed eating lunch in the facility dining room, the door to the residents’ room was noted to be unlocked. Medications for both residents were sitting in plain sight on a table in the living room.
Plan of correction
All items were immediately removed from the resident rooms, or was moved to an out of sight place when appropriate. Staff have been trained on this standard and ongoing monitoring of resident rooms is being performed. Additionally, we have discussed with the residents and families the proper procedures for bringing in over the counter medications.
22VAC40-73-950-E
Based on a review of facility documentation, the facility failed to ensure that a review of the facility emergency preparedness and response plan was completed semi-annually.
Evidence
  1. Documentation of the last facility review of the their emergency preparedness and response plan with all staff was dated for 04/19/2021, which would require a review to have been completed in October 2021.
Plan of correction
Facility is in the process of reviewing Emergency Preparedness with all staff. ED or designee will schedule and monitor to ensure this occurs semi-annually
22VAC40-73-100-C-1
Based on observations made of the morning medication pass and interviews with staff, the facility failed to ensure implementation of the facility infection control policy.
Evidence
  1. During observations made of the morning medication pass conducted on 11/15/2021, a blood pressure cuff was used on resident 7 to check their blood pressure prior to administering medication to the resident. The same blood pressure cuff was then used to check resident 4's blood pressure without being cleaned/sanitized first. Staff person 1 was unsure of any cleaning instructions for the blood pressure cuff. The facility infection control policy indicates that responsibilities for cleaning and disinfection of medical equipment are assigned to specific personnel.
  2. The glucometer bags labeled for residents 8 and 9 had glucometers that were not labeled on the day of inspection. The facility infection control policy indicates that each device will have the residents name clearly written on the carrying case, which is inconsistent with CDC recommendations to label each individual glucometer with the residents name.
Plan of correction
All glucometers in use have been labeled. RMA’s have been in-serviced on the infection control policy and that resident specific names must be on each glucometer. DON or designee will observe RMA’s at scheduled times during their medication pass to ensure compliance and understanding of this standard.
22VAC40-73-50-B
Based on resident record review and staff interview, the facility failed to ensure a written acknowledgment of the receipt of the disclosure by the resident or his legal representative was retained in the resident’s record.
Evidence
  1. The records for resident 1, admitted 10/29/21, and resident 2, admitted 10/25/21, did not contain a written acknowledgment of the receipt of the disclosure by the residents or their legal representative. Interview with staff person 12 confirmed this was accurate.
Plan of correction
Marketing Director will ensure this is included in each contract. Marketing Director and ED will review and initial each new admission to ensure compliance with this standard. All records are in the process of being audited.
22VAC40-73-690-G
Based on resident record review and staff interview, the facility failed to ensure that the action taken in response to the recommendations noted in the resident’s medication review were documented in the resident’s record.
Evidence
  1. The facility’s most recent medication review, dated 10/07/2021, showed the following recommendation for resident 3: “GDR (gradual dose reduction) Seroquel”.
  2. The record for resident 3 did not contain documentation of the action taken in response to these recommendations. Interview with staff person 5 confirmed this was accurate.
Plan of correction
DON or Designee will follow up on recommendations made during med review. Nurse consultant and DON and/ or designee will audit resident records to ensure compliance
22VAC40-90-40-B
Based on a review of staff record records, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for staff.
Evidence
  1. The record for staff person 2, hired on 8/30/21 contained documentation that the criminal record report was not obtained until 10/4/21.
  2. The record for staff person 12, hired on 08/24/21, contained documentation that a criminal record history report was not obtained until 10/03/21.
  3. The record for staff person 9, hired on 08/23/21, contained documentation that a criminal record history report was not obtained until 10/02/21.
  4. The record for staff person 11hired on 07/15/21, contained documentation that a criminal record history report was not obtained until 10/04/21.
Plan of correction
Business Office Manager has been trained on employee records and specifically the criminal record report. Business Office Manager and ED is auditing all records to ensure compliance in this area. BOM is working to ensure all current records contain a background check and that all new hires will be in compliance with this standard. Business office manager will use the auditing tool that has been implemented with all new hires.
22VAC40-73-610-B
Based on observation, the facility failed to ensure that menus for meals posted in the facility were for the current week.
Evidence
  1. The menu posted in the facility during inspection on 11/15/2021 was for the week 11/07/2021 through 11/13/2021.
Plan of correction
The menu was immediately posted. ED met with dietary staff to train on this standard. The new dietary Director will monitor to ensure compliance moving forward.
22VAC40-73-1040-B
Based on observations made of the facility physical plant, resident record reviews and interviews with staff, the facility failed to ensure that protective devices are on windows in common areas accessible to residents with cognitive impairments to prevent the windows from being opened wide enough for a resident to crawl through.
Evidence
  1. The window in the facility dining room were noted to completely open on the day of inspection. In an interview with staff person 5, it was expressed that the facility several residents with cognitive impairments residing within the facility including resident 6, who has a diagnosis of dementia.
Plan of correction
Facility will ensure a protective device will be placed on all windows to ensure that no resident can climb through.
22VAC40-73-1030-B
Based on a review of staff records, the facility failed to ensure that direct care staff received six hours of training in working with individuals who have a cognitive impairment within the first four months of employment.
Evidence
  1. The record for staff person 1, hired on 4/8/21, does not have documentation that this employee received 6 hours of training on individuals with cognitive impairment within the first four months of their employment at the facility.
Plan of correction
We are in the process of training on cognitive impairments with all staff. ED has implemented a training schedule for the business office to use. Business office and ED will track and monitor to ensure all employees have the appropriate training and is in compliance with this standard.
22VAC40-73-430-H-2
Based on a review of resident records, the facility failed to ensure that a copy of a written discharge statement was retained in resident records.
Evidence
  1. The record for resident 12, discharged from the facility in August 2021, did not contain a copy of the residents written discharge statement.
Plan of correction
ED has trained the Business Office Manager on this standard. ED will audit and sign each discharge statement and will ensure it is retained in the resident record.
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ensure, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. The records for resident 1, admitted 10/29/21, and resident 2, admitted 10/25/21, did not contain documentation to determine whether the residents were a registered sex offender. Interview with staff person 12 confirmed this was accurate.
Plan of correction
Marketing Director has been trained on the proper procedure regarding running sex offenders on residents prior to admission. The Marketing Assistant will ensure these are in place prior to admission on each resident. ED or designee will review each new admission record to ensure compliance with this standard.
22VAC40-73-870-A
Based on observation of the facility physical plant, the facility failed to ensure that the interior of the building is maintained in good repair and kept clean.
Evidence
  1. Multiple stains were observed on the carpet in Room 108 and the hallway carpet outside room 231 had a long, thin line of a stain.
  2. Red and black marks were observed across the bottom of the doors to rooms 304, 322 and 300.
Plan of correction
Maintenance Director cleaned the carpets and made repairs to doors 304, 322, and 300. Carpets are on a rotating schedule to be cleaned with an outside vendor. Maintenance Director will use the carpet cleaner that is on site when needed. Facility is in the process of hiring a Maintenance Assistant to help with maintaining the physical plant.
22VAC40-90-30-B
Based on a review of staff records, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment.
Evidence
  1. The record for staff person 2, hired on 8/30/21, has a sworn statement or affirmation that does not have a date that the form was completed.
  2. The record for staff person 7, hired on 09/13/21, contained documentation that the sworn statement or affirmation was completed after the date of hire on 09/20/21.
  3. The record for staff person 8, hired on 09/22/21, contained documentation that the sworn statement or affirmation was completed after the date of hire on 10/05/21.
  4. The record for staff person 9, hired on 08/23/21, contained documentation that the sworn statement or affirmation was completed after the date of hire on 08/24/21.
  5. The record for staff person 10, hired on 09/20/21, contained documentation that the sworn statement or affirmation was completed after the date of hire on 09/28/21.
  6. The record for staff person 11, hired on 07/15/21, did not contain documentation that a sworn statement or affirmation was completed. Interview with staff person 12 revealed this was accurate.
Plan of correction
Business Office Manager has been trained on employee records and specifically the sworn disclosures. Business Office Manager and ED is auditing all records to ensure compliance in this area. BOM has added the disclosure statements to these records and an auditing tool has been implemented and will be used with all new hires.
22VAC40-73-640-A
Based on observations of the facility medication carts, the facility failed to ensure implementation of the facility medication management plan.
Evidence
  1. The controlled drug content count signature sheet for the 2nd and 3rd floor medication carts is missing staff signatures for several shifts on several days. The count sheet has documentation that "signing this form verifies that the medications count is correct at the change of shift.
  2. A Basaglar Kwik pen was noted to be open and in use on the 3 West medication cart. The pen did not have an open date to ensure that it is discarded within 28 of opening per manufactures instructions.
Plan of correction
DON met with nursing staff to discuss and train in this area. Additionally, DON or designee conducts daily audits of the controlled drug log. Scheduled audits of all medication carts are being performed by the DON or designee to ensure all items are being labeled correctly and that the carts are in compliance with this standard.
22VAC40-73-680-D
Based on a review of resident records, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The November 2021 medication administration record (MAR) has a physician order for Metoprolol Tart 25mg, 1/4 tablet twice a day for hypertension, hold if systolic blood pressure is less than 100 or heart rate less than 60. On 11/6/2021 staff initials are present for the administration of this medication at 8pm but the residents heart rate was documented at 59, which would have required the medication to be held.
  2. The record for resident 13 has a physician order for Repatha 140mg/ml, inject 1ml subcutaneously once a month for hyperlipidemia on the 15th off the month. The September 2021 MAR for resident 13 has documentation of staff initials for the administration of this medication on 9/1/21 and 9/3/2021 through 9/8/2021. The October MAR 2021 for resident 13 has staff initials for the administration of this medication on the 1st of the month and not on the 15th.
Plan of correction
DON trained and counseled in this area. Additional training is being scheduled with all RMA’s to ensure understanding and compliance with this standard. DON or designee is checking each new order to ensure it has been added to the MAR correctly.
22VAC40-73-860-I
Based on observations made during an on-site inspection conducted at the facility on 10/18/2021, the facility failed to ensure that all cleaning supplies were stored in a locked area.
Evidence
  1. The storage closet in the kitchen where cleaning supplies are stored was noted to be unlocked as the lock on the door was inoperable on the day of inspection. The storage closet is located by a door that leads directly to a hallway frequented by residents and this door into the kitchen was also noted to be unlocked.
  2. The door to the second floor laundry room was observed to be unlocked on the day of inspection. A bottle of “Clean on the Go – Clean by Peroxy” and a container of disinfecting wipes were noted in the unlocked cabinets in the laundry room.
  3. The door to the third floor laundry room was observed to be unlocked. A container of “Clorox Healthcare Hydrogen Peroxide” disinfecting wipes were noted in the unlocked cabinets in the laundry room.
Plan of correction
A new lock has been placed on the kitchen closet door . Maintenance repaired this door immediately to ensure it shuts properly. Kitchen staff have been trained on the importance of keeping chemicals stored in a locked area. The new Dietary Director will monitor. Laundry room cabinet doors have locks placed on them and staff have been trained on the importance of chemicals being stored in a locked area. DON, ED or designee will perform scheduled checks of the laundry room to ensure compliance with this standard.
22VAC40-73-250-D
Based on a review of staff records, the facility failed to ensure that all required health information was maintained in staff records as required.
Evidence
  1. The screening for tuberculosis in the records for staff persons 1, hired 4/8/21, staff person 2, hired 8/30/21, staff person 8, hired 9/22/21, staff person 9, hired 8/23/21, and staff person 7 hired 09/13/2021, do not include the date that the screenings were completed to ensure that the screenings were conducted on or within seven days prior to the first day of work at the facility for these employees.
  2. The record for staff person 4 has documentation that the last screening for tuberculosis for this employee was completed on 10/19/20.
Plan of correction
Business office manager has been in-serviced on employee records and specifically as it pertains to employee health and tuberculosis screening. Business Office Manager will work with the DON to ensure this standard is being met. Business office will use the auditing tool for each new employee record. ED or designee will review and monitor to ensure compliance with this standard.
22VAC40-73-990-B
Based on a review of facility documentation and staff interviews, the facility to ensure that a review of resident emergencies with all staff was completed at least every six months.
Evidence
  1. In an interview with staff person 6 on the day of inspections it was expressed that facility did not have documentation to show that a review of resident emergencies was completed within the past six months with all staff.
Plan of correction
Facility is in the process of reviewing resident emergencies with all staff. ED and Business office manager will manage the employee training schedule to ensure it is completed at least every six months.
22VAC40-73-120-A
Based on a review of staff records, the facility failed to ensure that orientation and required training occurred within the first seven working days for staff.
Evidence
  1. The record for staff person 2, hired on 8/30/21 and staff person 3, hired on 9/28/21 and staff person 8, hired on 9/22/21 has documentation that their orientation and required training were not completed until 10/14/21.
Plan of correction
All staff training will be completed within 7 working days. Business Office Manager will follow the procedure put in place by ED regarding new hires and staff training. Business Office Manager will sign off on each new staff record stating that it meets this standard. ED reviewed with all Departments and each department manager expressed understanding of this standard.
22VAC40-73-270-1
Based on a review of staff records, the facility to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Evidence
  1. The records for staff persons 2 and 4 do not contain documentation that these employees received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. The facility houses a mixed population of residents including residents who have a history of aggressive behaviors, including residents 3 and 5.
Plan of correction
A departmental training for all care staff is scheduled with our nurse consultant to ensure compliance with this standard. Staff person 2 and 4 have been trained on caring for residents with aggressive behaviors and agitated states. ED or designee will ensure a training log is current for each employee and will be monitored and maintained by ED or designee.
22VAC40-73-550-G
Based on a review of resident and staff records, the facility failed to ensure that a review of resident rights and responsibilities was conducted annually with residents and staff.
Evidence
  1. The record for residents 3, 4 and 5 has documentation that the last annual review of resident rights and responsibilities for this resident was completed on 10/8/20.
  2. The record for staff person 4 has documentation that the last annual review of resident rights and responsibilities for this employee was completed in October 2020.
Plan of correction
Facility has reviewed resident rights with all residents and staff. A training log has been implemented. The Business Office Manager will track and monitor to ensure all trainings are current. ED is working with the business office to ensure understanding of this standard.
22VAC40-73-440-D
Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required.
Evidence
  1. The individualized service plan (ISP) dated 7/14/21 in the record for resident 6 has documentation that the resident requires mechanical and physical assistance with bathing. The UAI dated 7/14/21 for resident 6 has that the resident only requires mechanical assistance with bathing. Per an interview with staff person 5, the UAI is incorrect and that resident 6 does require mechanical and physical assistance with bathing.
Plan of correction
DON or designee, along with the nurse consultant will audit all ISP’s to ensure needs match the UAI. DON or designee will train on ISP’s and UAI’s. ED or designee will audit each ISP before it is finalized.
22VAC40-73-450-C
Based on a review of resident records, the facility to ensure that identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. On day of inspection at approximately 11:21 AM, one licensing inspector observed staff pushing resident 1 in a wheelchair to the dining room. Interview with staff revealed that the resident does use a wheelchair and that staff have push him in the wheelchair as the resident is unable to do this himself. The ISP for resident 1, dated 10/28/2021, does not address this identified need.
  2. The Uniform Assessment Instrument (UAI) for resident 1, dated 10/28/2021, showed that the resident “ambulates w/ walker, needs gait belt” and the “Care plan check sheet” for resident 1, dated 10/28/2021 showed that the assistance the resident needs with his walker is “guidance gait belt”. Interview with staff person 5 revealed that when the resident uses his walker, a gait belt needs to be used by staff. The ISP for resident 1 does not address this identified need.
  3. The ISP for resident 3, with an onset date of 06/11/2021, contained documentation of “Anticoagulant Therapy Eliquis”. The record for resident 3 does not contain documentation that the resident has a physician’s order for Eliquis.
  4. The ISP for resident 3, with an onset date of 09/21/2021, contained documentation that the resident is receiving physical therapy from Select Therapy. Interview with staff person 5 revealed that the ISP is incorrect because the resident is not currently receiving physical therapy.
Plan of correction
DON or designee, along with the nurse consultant will audit all ISP’s to ensure needs match the UAI. Nurse consultant will help audit and train on ISP’s and UAI’s. ED or designee will audit each ISP before it is finalized. ED has put in place an auditing tool to assess all identified needs for each resident to ensure all needs are identified and are on the service plan.
22VAC40-73-610-D
Based on observation and resident record review, the facility failed to ensure that diets prescribed for residents by a physician were prepared and served according to physician orders.
Evidence
  1. The record for resident 14 contained a physician’s order, dated 9/24/21, for a mechanical soft, nectar thick liquids diet.
  2. The record for resident 15 contained a physician’s order, dated 10/12/21, for a mechanical soft, regular liquids diet.
  3. At approximately 11:40 AM, two licensing inspectors and staff person 6 observed residents 14 and 15 eating in the dining room during lunch. Both residents had not been served their prescribed diets and were eating a regular meal that had been served to most residents in the dining room.
Plan of correction
ED was new to the building and only had been in the building for five days, but immediately met with the Dietary Director and all dining staff to implement proper procedures to ensure residents with special diets were receiving the correct plate. Speech therapy was arranged and met with the dietary department to give a training on special diets and best practices. A new dietary director was hired and is offering ongoing training to ensure compliance in this area, along with the ED or designee. Additionally, new Dietary Director and ED will walk the dining room at different time intervals to ensure residents are receiving their special diets.
22VAC40-73-680-B
Based on observations made of the facility medication carts, the facility failed to ensure that all medications remained in the pharmacy issued container with prescription label until administered.
Evidence
  1. The 3 west medication cart contained a Basaglar Kwik pen that did not have a pharmacy label or residents name on the day of inspection.
Plan of correction
RMA’s have been in-serviced on this standard. DON or designee will conduct weekly audits of all carts to ensure compliance.
22VAC40-73-970-A
Based on a review of facility documentation and staff interviews, the facility failed to ensure that a fire and emergency evacuation drill was conducted for each shift in a quarter.
Evidence
  1. In an interview with staff person 6 on the day of inspections it was expressed that facility does not have documentation to show that a fire drill has been completed since 07/31/2021.
Plan of correction
ED and Maintenance Director are conducting fire and emergency evacuation drills on each shift. ED will manage the scheduling of drills to ensure facility is in compliance with this standard.
October 18, 2021Complaint survey4 violations
Inspection dates
10/18/2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
A non-mandated complaint inspection was initiated on 10/18/2021 and concluded on 11/03/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, building and grounds and emergency preparedness. The licensing inspector conducted an on-site observation at the facility on 10/18/2021 and documentation was requested to be emailed to the LI during the on-site inspection. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations issued can be found on the violation notice.
Violations
22VAC40-73-980-H
Based on observations made of the facility emergency food supply during an on-site inspection conducted on 10/18/2021, the facility failed to ensure that a 48 hour supply of emergency food was on-site at the facility.
Evidence
  1. The facility was noted to have a total of 64 residents in care on the day of inspection with 44 of those residents being assisted living level of care. The facility 48 hour on-site emergency food supply was observed in the presence of staff persons 2, 3 and collateral witness 1. The supply was noted to lack enough items to provide breakfast, lunch and dinner as well as snacks to 64 residents for the required 48 hours. Staff were unable to determine what appliances (refrigerator or freezers) is run by the facility generator in the event of a power outage to be able to consider food being stored in these appliances.
Plan of correction
Emergency food supply was ordered on 10/18/2021 and delivered by 10/22/21. Supply is in stock room and labeled as designated emergency supply.
22VAC40-73-860-I
Based on observations made during an on-site inspection conducted at the facility on 10/18/2021, the facility failed to ensure that all cleaning supplies were stored in a locked area.
Evidence
  1. The storage closet in the kitchen where cleaning supplies are stored was noted to be unlocked as the lock on the door was broken on the day of inspection. The storage closet is located by a door that leads directly to a hallway frequented by residents and this door into the kitchen was also noted to be unlocked.
Plan of correction
A new keyed/lockable handle set was placed on this door. Staff have been in-services on keeping this locked at all times, if there is not a staff member in the closet accessing supplies.
22VAC40-73-610-B
Based on observations made during an on-site inspection conducted on 10/18/2021, the facility failed to ensure that substitutions made to the lunch meal on 10/18/2021 was recorded on the posted menu.
Evidence
  1. The facility posted menu has documentation that grilled Italian subs with florentine soup or tomato an bacon sandwich and curry soup would be served as the lunch meal on10/18/2021. The lunch meal that was observed being served to residents in the dining room consisted of tomato soup, clam chowder, grilled cheese sandwich and salad.
Plan of correction
Dining Service Director will provide a staff in-service to re-educate dining service associates as to protocol for recording substitutions on the posted menu. DSD will create a binder to file menus with substitutions after the menu cycle is complete.
22VAC40-73-290-B
Based on observations made during an on-site inspection conducted on 10/18/2021, the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. The facility current person in charge posting was noted to lack the name of the current on-site person in charge on the day of inspection.
Plan of correction
Posting of staff member in charge will be updated daily by our concierge team for both 7am -7pm and 7pm-7am shifts. The posting will be displayed on the concierge counter at the front of the community.
October 18, 2021Complaint survey2 violations
Inspection dates
10/18/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 10/18/2021 and concluded on 11/03/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The licensing inspector conducted an on-site observation at the facility on 10/18/2021 and documentation was requested to be emailed to the LI during the on-site inspection. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations issued can be found on the violation notice.
Violations
22VAC40-73-130-A
Based on review of resident records, facility documentation and interviews with staff, the facility failed to ensure that mandated reporting occurred as per 63.2-1606 of the Code of Virginia.
Evidence
  1. Documentation in a written warning dated 9/21/2021 and several staff written interviews expressed that residents 1 through 5 had made complaints in regards to staff person 1's treatment towards them between 9/5/2021 and 9/21/2021. An incident report dated 9/21/2021 for resident 3 has documentation of alleged abuse and that resident 3 indicated that staff was rough when caring for her. Bruising was noted on resident 3's bilateral arms and right hand. In a phone interview with collateral witness 1 it was expressed that these complaints of suspected abuse or neglect were not reported to the local Adult Protective Agency as required by 63.2-1606 of the Code of Virginia.
Plan of correction
Review of 63.2-1606 of the code of Virginia and 22VAC40-73-130-A will be completed by the Executive Director and Resident Care Director. Executive Director and Resident Care Director will hold in-service to review with all department managers and care supervisors to ensure they understand incidents that require mandated reporting and that they must notify a supervisor of any such incident at time of incident, or at time they learn of incident.
22VAC40-73-70-A
Based on a review of facility documentation, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. A facility incident report dated 9/21/2021 for resident 3 has documentation of alleged abuse and that resident 3 indicated that staff was rough when caring for her. Bruising was noted on resident 3's bilateral arms and right hand. The facility did not notify the regional licensing office of this incident until 10/8/2021,17 days after the incident occurred.
Plan of correction
Review of 22VAC40-73-70 regarding incident reporting and items that require reporting to DSS within 24 hours will be completed by the Executive Director and Resident Care Director. Executive Director and Resident Care Director will hold in-service to review with all department managers and care supervisors to ensure they understand reportable incidents and that they must notify a supervisor of any such incident at time of incident, or at time they learn of incident.
September 14, 2021Inspection2 violations
Inspection dates
09/14/2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A non-mandated monitoring inspection was initiated on 09/10/2021 and concluded on 09/14/2021. 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 licensing inspector conducted remote observations at the facility on 09/14/2021.The evidence gathered during the investigation supported the non-compliance with standards or law, and violations were issued.
Violations
22VAC40-90-40-B
Based on a review of staff records, the facility failed to ensure that a criminal history report from the Virginia State Police was obtained on new staff on or prior to their 30th day of employment.
Evidence
  1. The records for staff persons 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 all of whom have been employed at the facility for longer than 30 days, does not contain documentation that the facility has obtained a criminal history record report from the Virginia State Police for these employees.
Plan of correction
Director of Business Administration and Operations Specialist will conduct an audit of all current associate files. Any file found not to have criminal history record report from the Virginia State Police will be completed and put in the file. DBA will ensure documentation in place for all new hires ongoing.
22VAC40-73-270-1
Based on a review of staff records, the facility failed to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Evidence
  1. The records for staff person 16, hired on 4/18/2019, does not have documentation that they have received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states. The facility currently serves a mixed population of residents, of which some resident have a diagnosis of dementia/cognitive impairments and have a history of aggressive behaviors.
Plan of correction
Director of Business Administration and Operations Specialist will conduct an audit of all current associate files to verify completion of training modules. Understanding Alzheimer's Disease and working with difficult and combative residents. Training modules will be completed by any associate who is found to not have this on file. DBA will ensure training completed for all new hires.
June 14, 2021Inspection15 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 6/14/2021 and concluded on 6/16/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 52. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, health care oversight, medication management plan and infection control, fire and health inspections, fire drill logs, and dietician oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non- compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-1030-B
Based on a review of staff records, the facility to ensure that training in working with individuals who have cognitive impairments was completed within four months of the start date of employment for all direct care staff.
Evidence
  1. The record for staff person 1, hired on 10/19/2020, does not contain any documentation that the employee has received any training for individuals with cognitive impairments.
Plan of correction
Staff training records will be audited and all staff that have not received the cognitive impairment training requirements will be given any and all necessary cognitive impairment training as required to be within compliance. Training will continue to be ongoing continue to be ongoing.
22VAC40-73-120-A
Based on a review of staff records, the facility failed to ensure that required orientation and training occurred within the first seven working days of employment.
Evidence
  1. The record for staff person 1, hired on 10/19/2020, has documentation that the required orientation and training was not completed until 11/30/2020.
  2. The record for staff person 4, hired on 3/3/2021 has documentation that the required orientation and training was not completed until 5/21/2021.
Plan of correction
Staff training records will be audited and all staff that have not received the orientation and training requirements will be given all necessary orientation training as required to be within compliance. All new employees will be provided the new orientation training within 7 days of employment
22VAC40-73-250-D
Based on a review of staff records, the facility failed to ensure that all staff received a screening for tuberculosis on or within seven days prior to the first day of work at the facility.
Evidence
  1. The record for staff person 3, hired on 4/18/2019, has documentation that a screening for tuberculosis was not completed until 10/16/2019.
  2. The record for staff person 4, hired on 3/3/2021 does not have documentation that a screening for tuberculosis has been completed for this employee.
Plan of correction
Staff records will be audited and TB screenings will be conducted for current staff. Going forward, TB screenings will be conducted on or within 7 days prior to first day of work.
22VAC40-73-260-A
Based on a review of staff records, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment.
Evidence
  1. The record for staff person 4, hired on 3/3/2021, does not have documentation that this employee has received certification in first aid.
Plan of correction
Staff records will be audited and CPR/First Aid Training will be conducted for current staff. Going forward, CPR/First Aid Training will be conducted within 60 days of employment.
22VAC40-73-270-1
Based on a review of staff records, the facility failed to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Evidence
  1. The records for staff persons 1, 2, 3 and 4 does not have documentation that they have received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states. The facility currently serves a mixed population of residents, of which some resident have a diagnosis of dementia/cognitive impairments. An interview with staff person 5 expressed that the facility does house a residents with agitation/aggressive behaviors.
Plan of correction
Staff training records will be audited and all staff that have not received the aggressive training requirements will be given any and all necessary aggressive behavior training as required to be within compliance. Training will continue to be ongoing.
22VAC40-73-450-C
Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs).
Evidence
  1. The record for resident 1 has documentation in resident notes dated 5/28/2021 of the resident receiving a chopped meats diet. A fall risk tool completed 9/12/2020 has that resident 1 is a risk for falls. These identified needs are not addressed on the ISP dated 9/12/2020. Also the record for resident 1 has a physician order dated 5/28/2021 for meds to be placed whole in applesauce, pudding or yogurt. The uniform assessment instrument (UAI) dated 5/19/2021 for resident 1 has documentation that the resident requires supervision with walking and physical assistance with wheeling. The ISP dated 9/12/2020 is inconsistent as it has that resident 1's medications are to be crushed and that the resident The ISP dated 9/12/2020 is inconsistent as it has that resident 1s medications are to be crushed and that the resident requires mechanical assistance only with walking and wheeling.
  2. The record for resident 2 has documentation in resident notes of the resident refusing showers and medications. The UAI dated 5/11/2021 also has documentation of medication and shower refusals as well as that resident 2 requires physical assistance with dressing and physical and mechanical assistance with walking. The ISP dated 5/11/2021 in the record for resident 2 does not address these identified needs.
  3. The record for resident 3 has documentation on a fall risk tool dated 3/19/2021 that the resident is a fall risk. The ISP dated 6/5/2021 in the record for resident 3 does not address this identified need.
  4. The record for resident 4 has a physician order dated 6/1/2021 for an Aspen collar to be worn PRN (as needed). The ISP dated 3/30/2021 in the record for residnet 4 is inconsistent as it has documetatio that the collar is to be worn daily.
Plan of correction
1.Director of Nursing will conduct chart audits, UAI and ISP audits and make corrections to UAI and ISPs of all current residents. Director of Nursing and Executive Director will ensure that all needed services are identified and UAI and ISPs match for both current and new residents. 2. Any services that residents refuse will be documented on the ISPs. Staff will be trained and informed to document refusals. Resident’s physicians will be notified of any services that are refused. 3. During chart audits, any resident who has been identified as a fall risk, will have risk documented on ISP. Fall risks will be updated annually and as needed and reflected on the ISP. 4. During audit of UAIs and ISPs, treatment orders will be identified and corrected and documented correctly on ISPs. Going forward, any changes in treatment orders will be reflected on ISP
22VAC40-73-550-G
Based on a review of staff records, the facility failed to ensure that a review of resident rights and responsibilities was conducted annually with all staff.
Evidence
  1. The record for staff person 2 hired on 5/3/2016 does not contain documentation of an annual review of resident rights.
  2. The record for staff person 3 hired on 4/18/2019 does not contain documentation of an annual review of resident rights.
Plan of correction
Staff records will be audited and resident rights will be reviewed for current staff. Going forward, all new hires will receive resident rights review upon employment and all staff will review annually
22VAC40-73-640-A
Based on a review of the facility medication managment plan, the facility failed to ensure all required procedures were addressed in the plan.
Evidence
  1. The facility medication management plan that was submitted for review does not address all required procedures per this standards requirement.
Plan of correction
Executive Director will review current Medication Management Plan and re-write plan to include all required procedures per standards requirements to be within compliance.
22VAC40-73-650-F
Based on a review of resident records, the facility failed to ensure that that a residents primary care physician was made aware of all new/changes in medication orders when a resident returned to the facility from a hospital admission.
Evidence
  1. The record for resident 3 has documentation of an orders reconciliation report from a local hospital signed by the hospital physician on 6/7/2021 when resident 3 was discharged and returned to the facility. There are discrepancies noted between the medications listed on the Orders reconciliation report and the residents current June 2021 MARs from which medications are being administered. The record for resident 3 does not have documentation that resident 3's primary care physician was notified and made aware of the discrepancies or of any further physicians order since the 6/7/2021 reconciliation report.
Plan of correction
Nurses or Director of Nursing will notify residents? Primary Care Physicians of any changes in orders immediately. PCP outside of facility will be notified immediately on physician order sheet by fax and phone. House physician will be called immediately for notification and will review/sign physician order sheets during next clinical visit.
22VAC40-73-680-D
Based on a review of resident records and medication administration records (MARs), the facility failed to administer medications i accordance with physician instructions.
Evidence
  1. The record for resident 3 has a physician order dated 6/7/2021 for Ferrous Sulfate (Ferosul 325mg (65mg elemental iron) 1 tablet every other day. The June 2021 MAR for resident 3 has Ferrous Gluconate 324mg , 1 tablet every 2 days o ) tab 3 as e ous G uco ate 3 g , tab et e e y days listed and this was the medication noted to be on the medication cart for administration.
  2. The May 2021 MAR for resident 4 has a physician order dated 2/26/2021 for Furosemide 20mg daily as needed for CHF if weight goes up 2 pounds from 120.2. The MAR has documentation of the residents weight being above the 2 pound weight parameter and requiring the administration of the Furosemide on 5/1/2021, 5/8/2021, 5/9/2021 and 5/12/2021 but there is no documentation that it was administered on these days. Also there are staff initials documentation for the administration of this medication twice on 5/5/2021 but the physician order is for daily admiistration.
Plan of correction
1. Nurses or Director of Nursing will notify residents? Primary Care Physicians of any changes in orders immediately. PCP outside of facility will be notified immediately on physician order sheet by fax and phone. House physician will be called immediately for notification and will review/sign physician order sheets during next clinical visit. 2. Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
22VAC40-73-680-E
Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that all medical procedures were documented as required.
Evidence
  1. The May 2021 MAR for resident 1 has a physician order for daily weights to be recorded. The MAR does not have staff initials or the record weight on 5/16/2021 or 5/24/2021.
  2. The May 2021 MAR for resident 2 has a physician order for wound treatment to the residents left thigh on Mondays, Wednesdays and Fridays to be completed by Hospice nurse. The MAR does not have any initials for the completion of this treatment on 5/3/2021, 5/5/2021, 5/7/201, 5/10/2021, 5/12/2021 or 5/14/2021.
  3. The May 2021 MAR for resident 3 has a physician order for daily weight checks for monitoring and PRN medication if needed. The MAR does not have documentation of the residents weight on 5/20/2021.
Plan of correction
1.Director of Nursing and/or LPNs will be conducting daily MAR checks. 2. Medication Aides and Nurses will sign off that Home Health or Hospice Nurses have completed treatments and document on MAR. Executive Director and/or Director of Nursing will notify Home Health and Hospice Agencies that their nurses will be required to document in resident’s charts that treatments have been conducted and completed.
22VAC40-73-680-I
Based o a review of resident medication administration records (MARs), the facility failed to ensure that all required documentation was included on resident MARs.
Evidence
  1. The May and June 2021 MAR for resident 1 does not have staff initials for the administration of the prescribed medications Acetaminophen 325mg 2 tablets at 9 pm on 5/21/2021, Diclofenac Sodium 1% at 9pm on 5/7/2021 and 5/8/2021, Guaifenesin ER 600mg at 9pm on 5/21/2021, Latanoprost 0.005% eye drops at 9pm on 5/21/2021,Metoprolol 50mg at 6am on 5/9/2021, 5/10/2021, 5/14/2021, 5/19/2021, 5/24/2021, at 2pm on 5/26/2021, and at 10pm on 5/11/2021, 5/21/2021, 5/30/2021, 6/3/2021 and 6/4/2021, Zinc Sulfate 220mg at 6pm on 5/7/2021, 5/8/2021 and 5/21/2021.
  2. The May and June 2021 MAR for resident 2 does not have staff initials for the administration of the prescribed medications Levothyroxine 112mcg at 6am on 5/8/2021 through 5/10/2021, 5/14/2021, 5/19/2021, 5/25/2021 and 6/2/2021, Voltaren 1% gel at 9pm on 5/7/2021, 5/8/2021 and 5/21/2021, Docusate Sodium 100mg at 9pm on 5/21/2021.
  3. The May 2021 MAR for resident 3 does not have staff initials for the administration of the prescribed medications Levothyroxine 88mcg at 6am on 5/9/2021 and 5/10/2021.
  4. The May and June 2021 MAR for resident 4 does not have staff initials for the administration of the prescribed medications Buspirone 5mg at 2pm on 5/17/2021 and 5/22/2021, Levothyroxine 75mcg at 6am on 5/6/2021, 5/9/2021, 5/10/2021 and 6/6/2021.
Plan of correction
Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
22VAC40-73-970-A
Based on a review of facility documentation, the facility failed to conduct fire drills on each shift quarterly.
Evidence
  1. The facility fire drill log does not have documentation of a fire drill being conducted from February 2020 through April 2021.
Plan of correction
Fire drill reviews with staff restarted in April 2021 and conducted monthly. Going forward, fire drill reviews will continue to be conducted and documented monthly.
22VAC40-90-30-B
Based on a review of staff records, the facility failed to ensure that a sworn statement or affirmation was completed for applicants of employment.
Evidence
  1. The records for staff persons 4, 15, 16, 17, 18, 19, 20, 21 and 22, all of whom are current employees at the facility, does not contain documentation that a sworn statement or affirmation was completed prior to their employment.
Plan of correction
Executive Director and/or Business Office Manager will audit employee charts and have current employees sign a sworn statement to keep within records. Going forward, all new employees will sign a sworn statement prior to or no later than first day of work.
22VAC40-90-40-B
Based on a review of staff records, the facility failed to ensure that a criminal history report was obtain on new staff on or prior to their 30th day of employment.
Evidence
  1. The records for staff persons 1, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20 and 21, all of whom have been employed at the facility for longer than 30 days, does not contain documentation that the facility has obtained a criminal history record report for these employees.
Plan of correction
Executive Director and/or Business Office Manager will audit employee charts and have criminal history reports obtained for all current employees lacking this document to keep within records. Going forward, all new employees will have a criminal history report conducted prior to and/or no later than 30 days after first day of work.
April 28, 2021Complaint survey0 violations
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 04/28/2021 and concluded on 06/28/2021. A complaint was received by the department regarding allegations in the areas of Personnel and resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 22, 2021Complaint survey3 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 4/22/2021and concluded on 6/18/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-640-A
Based on a review of resident medication administration records (MARs) and the facility medication management plan, the facility failed to ensure that medications were reordered in a timely manner to avoid missed doses.
Evidence
  1. The April 2021 MAR for resident 1 has a physician order for Refresh Plus 0.5% eye drops, 1 drop into both eyes 3 times a day for dry eyes. The MAR has staff initials that are signed and circled as not administering the medication on 4/13/21 through 4/15/21 and 4/19/21 through 4/22/21. The medication notes page has documentation that the medication was not administered because it was unavailable, not in the cart, family to provide, refill reordered and waiting on pharmacy.
  2. The March 2021 MARs for resident 4 has a physician order for Primidone 50mg, half a tablet at bedtime for 1 week on 3/4/21 through 3/10/2021. The MAR has staff initials that are circled as not administering the medication at 9pm on 3/9/21 and 3/10/21 with documentation on the medication notes that the medication refill was pending. The March 2021 MAR also has a physician order for Primidone 50 mg,1 tablet at bedtime for 1 week on 3/11/21 through 3/17/21. Staff initials on the MAR are circled on 3/11/21, 3/12/21 and 3/13/21 as not administering the medication with documentation on the medication notes that unable to locate med, refill pending and waiting on pharmacy.
Plan of correction
Executive Director will review current Medication Management Plan and re-write plan to include all required procedures per standards requirements to be within compliance.
22VAC40-73-680-D
Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions.
Evidence
  1. The record for resident 3 has a physician order dated for 8/27/20 for Hydralazine 25mg twice a day for Hypertension, hold for systolic blood pressure less than 100 and a physician order dated 8/28/20 for Benazepril HCL 10mg every hold for systolic blood pressure less than 100 and a physician order dated 8/28/20 for Benazepril HCL 10mg every morning for hypertension, hold if systolic blood pressure is less than 100. The March 2021 MAR for resident 3 has staff initials that are circles as not administering either medication at 9am on 3/3/21 with documentation that that the medication was held because of outside of parameters but the MAR does not have documentation of the resident blood pressure to determine that the systolic blood pressure was less than 100. The April 2021 MAR for resident 3 has staff initials circled as not administering either medication on 4/6/21, 4/12/21, 4/14/21, 4/17/21 and 4/18/21. Staff documentation indicate that the medication was held on these days because of outside of parameters. Resident 3's blood pressure that was documented for these held doses show that their systolic blood pressure was above 100 and the medications should have been administered.
Plan of correction
1. Nurses or Director of Nursing will notify residents? Primary Care Physicians of any changes in orders immediately. PCP outside of facility will be notified immediately on physician order sheet by fax and phone. House physician will be called immediately for notification and will review/sign physician order sheets during next clinical visit. 2. Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
22VAC40-73-680-I
Based on a review of medications administration records (MARs), the facility failed to ensure that all required information was documented on resident MARs.
Evidence
  1. The March and April 2021 MARs for resident 1 do not have start dates for the residents prescribed medications. Also the March and April 2021 MARs for resident 1 do not have documentation of staff initials for the administration of the following medications: Duloxetine 30mg at 8am on 3/6/21 and 3/7/21; Refresh Plus Eye drops at 8pm on 4/16/21, 4/17/21 and 4/18/21 and Tamsulosin HCL 0.4mg at 8pm on 4/2/21, 4/17/21 and 4/18/21.
  2. The March and April 2021 MARs for resident 2 do not have documentation of staff initials for the administration of the following prescribed supplement: Ensure Liquid at 9am on 4/14/21 and at 9pm on 3/6/21, 3/7/21 and 3/15/21.
  3. The March 2021 MARs for resident 3 do not have documentation of staff initials for the administration of the following medications: Calmoseptine Onitment in the AM on 3/19/21 and the PM on 3/3/21, 3/4/21, 3/6/21 and 3/7/21.
  4. The April 2021 MARs for resident 5 do not have staff initials for the administration of the prescribed medication Calcium Citrate 250mg at 8am on 4/5/21.
Plan of correction
Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
April 1, 2021Inspection4 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 04/01/2021 and concluded on 05/05/2021. A self- reported incident was received by the department regarding allegations in the areas of Resident care and related services and mixed population. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-1040-A
Based on a review of resident records and staff interviews, the facility failed to ensure that a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms were available on all doors leading to the outside.
Evidence
  1. The facility serves a mixed population as indicated by the record for Resident 1, who was admitted to the facility on 10/26/20. The history and physical dated 10/20/2020 in the record for resident 1 had documentation that resident 1 has a diagnosis of Dementia, has confusion and poor short term memory.
  2. The uniform assessment instruments (UAI's) completed on 10/26/2020 and again on 03/26/2021 for resident 1 had documentation that the resident is disoriented to some spheres some of the time with time, date and place being the spheres affected and that the resident requires supervision with mobility.
  3. The individualized service plans (ISP's) dated 10/26/2020 and 03/26/2021 in the record for resident 1 had documentation under mobility that the resident requires supervision with mobility and will receive supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community. The ISP also had documentation of the residents disorientation to time, date and place and has services listed that resident 1 will be reoriented to time, date and place by the use of a clock/watch, calendar, facility literature and verbal cueing.
  4. The record for resident 1 has documentation in resident notes of the resident being found off of the facility grounds on 03/09/2021. Progress notes dated 03/30/2021 had documentation that resident 1 again left the building and was found off of the facility grounds.
  5. In a phone interview with staff person 1 on 3/30/2021 it was noted that the facility did not have a system of security monitoring of residents with cognitive impairments on facility doors leading to the outside.
Plan of correction
Cameras currently already installed inside and outside of premises of facility. Alarms were immediately installed on all exit doors on first floor to alert staff that residents are or attempting to exit the Alarms were immediately installed on all exit doors on first floor to alert staff that residents are or attempting to exit the building. Proper door signage decals will be placed on all stairwell doors within facility as well as all exit doors leading outside of facility. The signs wills also be placed on every door inside facility in which resident could be potentially harmed if entering. (6/5/21) Administrator is contracting with fencing company to install fencing in back yard area of building to place an enclosure so that all residents can enjoy the outdoors and their freedom of movement is not affected. Administrator will contact fire marshal to ensure that proper locking mechanisms are installed on fencing as well. Administrator will notify Licensing Inspector when proper enclosure installation is completed. Administrator and Director of Nursing will continue to monitor behaviors and need for any additional interventions and implement as needed.
22VAC40-73-70-A
Based on a review of resident records 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 record for resident 1 contained documentation in resident notes that on 03/09/2021, the resident was transported to the local hospital by EMS after being found on the ground, off site with injuries to the right side of her face and shoulder complaints. As of the date of this inspection, the facility had not reported this incident to the regional licensing office.
Plan of correction
Administrator will report within 24 hours any incident that results in resident being transported to hospital and/or could effect the health, safety, or wellness of resident or incidents that result in significant injury.
22VAC40-73-450-H
Based on a review of resident records, the facility failed to ensure that care and services specified in the individualized service plan (ISP) were provided.
Evidence
  1. The ISP's dated 10/26/2020 and 03/26/2021 in the record for resident 1 had documentation under mobility that the resident requires supervision with mobility and will receive supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community.
  2. In a phone call with staff person 1 on 03/30/2021 it was expressed that the facility was aware that resident 1 sometimes walked outside by herself to enjoy the weather.
  3. The record for resident 1 had documentation in resident notes of the resident being found on the ground outside of an adjacent facility by that facility's staff on 03/09/2021, and that facility's staff called local EMS. Dispatch contacted this facility and made them aware of resident 1's location and of the incident that had occurred. Documentation in resident notes indicated that Resident 1 had expressed that she had walked outside to enjoy the weather. The resident notes also indicated that resident 1 was transported by EMS to the local hospital for evaluation of injuries to the right side of her face and shoulder complaints.
  4. The record also had documentation in progress notes that on 03/30/2021 resident 1 wandered from the facility grounds and was found on the main road by a local citizen. The progress notes also indicated that resident 1 was not able to express to the citizen where she lived so the citizen contacted the local police for assistance to determine where resident 1 resided.
  5. It was noted that the specified services listed on resident 1's ISP for mobility to include supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community were not provided when resident 1 left the facility on 03/09/2021 or 03/30/2021.
Plan of correction
Administrator conducted immediate action for resident safety to include reassessment that included discharge of resident due to not being appropriate for assisted living. Around the clock caregivers were initiated as well to remain with resident until discharge. Alarms were immediately installed on all exit doors on first floor to alert staff that residents are or attempting to exit the building. Administrator and Director of Nursing initiating an elopement log book to be available at front desk. Elopement book will include all residents with a cognitive impairment diagnosis and is at risk for elopement or wandering. The elopement book will FACE sheet with a verbal description of resident. It will also include two pictures of resident to include one profile and one full body picture.(6/5/21) Administrator and Director of Nursing initiated a rounding log book for staff to routinely monitor all residents with a diagnosis of a cognitive impairment and at risk for elopement or wandering.(6/5/21) Administrator to initiate elopement drill within facility to aide staff with education of steps to take if any resident elopes or wanders. These elopement drills will be begin within 30 days of inspection and will continue to be conducted and results documented quarterly.(6/5/21) Staff will be provided with additional training in the case of a resident eloping or wandering. This training will be provided as an in-service during the elopement drills conducted quarterly. (ongoing)
22VAC40-73-460-D
Based on a review of resident records and staff interviews, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. itt d t ilit 10/26/2020 h d l d t d 10/20/2020 i
  2. Resident 1, who was admitted to the facility on 10/26/2020, had a history and physical dated 10/20/2020 in the record. The history and physical had documentation that resident 1 has a diagnosis of Dementia, has confusion and poor short term memory.
  3. The uniform assessment instruments (UAI's) completed on 10/26/2020 and again on 03/26/2021 for resident 1 had documentation that the resident is disoriented to some spheres some of the time with time, date and place being the spheres affected and that the resident requires supervision with mobility.
  4. The individualized service plan (ISP) dated 10/26/2020 and again on 03/26/2021 had documentation of the residents disorientation to time, date and place and has services listed that resident 1 will be reoriented to time, date and place by the use of a clock/watch, calendar, facility literature and verbal cueing. The ISP dated 10/26/20 also had documentation under mobility that the resident requires supervision with mobility and will receive supervision from POA/RP/Family and all staff to include redirecting, cueing and prompting when outside of the community.
  5. The record for resident 1 had documentation in resident notes of the resident being found on the ground outside of an adjacent facility by that facility's staff on 03/09/2021, and that that facility's staff called local EMS. Dispatch contacted this facility and informed them of resident 1's location and of the incident that had occurred. The resident notes indicated that resident 1 had expressed that she had walked outside to enjoy the weather. Resident 1 was transported to the local hospital by EMS for evaluation.
  6. A phone call was received from staff person 1 on 03/30/2021 to make the LI aware of an incident pertaining to resident 1 eloping from the facility.
  7. Documentation dated 03/30/2021 in progress notes explained that Resident 1 eloped from the facility and was found by a citizen of the community down on the main road (Graves Mill Road) some distance away from the facility walking towards the interstate (US Route 29). The progress notes also indicated that the citizen explained that the resident could only identify herself but not where she lived so the citizen contacted the local police who assisted in identifying where the resident resided. Documentation in the progress notes showed that resident 1 was returned to the facility by the citizen at 1:24pm. Documentation from staff person 1 signed and dated on 04/01/2021 shows that the facility reviewed video footage and determined that resident 1 left the facility through a dining room door at 11:29am
  8. In reviewing the record for resident 1 and interviews with staff person 1 on 03/30/2021 it was noted that no additional measures were put in place between 3/9/2021 and 3/30/2021 to provide supervision to prevent resident 1 from wandering from the facility.
Plan of correction
Administrator initiated including a cognitive impairment assessment and elopement/wander risk assessment to accommodate the history and physical that is provided to the physician of any potential resident that has been diagnosed with any cognitive impairment. This documentation will be completed by physician prior to move-in to aid in decision of admission to facility. Administrator and Director of Nursing will be reassessing all residents with a diagnosis of cognitive impairment and dementia. Administrator and Director of Nursing will be auditing all UAIs and ISPs of current residents with dementia or any cognitive impairment diagnosis to include proper interventions to include alarms, staff monitoring/rounding, signage on doors, re-orientation, etc. Administrator and Director of Nursing will ensure that all ISPs reflect behavioral observations for current and future residents upon admission and as needed. Administrator requests that # 4 and # 7 of Evidence be removed due to resident not being confused during incident on 03/09/21. Resident was not confused, was able to identify information on all spheres, and did not exhibit aimless wandering and was able to identify her purpose during this incident.
March 4, 2021Complaint survey0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 03/04/2021 and concluded on 03/29/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation 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.
January 25, 2021Complaint survey2 violations
Inspection dates
Jan. 25, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE 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 1/25/2021 and concluded on 3/30/2021. A complaint was received by the department regarding allegations in the areas of infection control. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued.
Violations
22VAC40-73-100-F
Complaint related: Yes
Evidence
  1. In discussion with collateral witness 1 on 1/28/2021, it was expressed that recommendations to fit test employees for N95 masks and to use those regularly instead of KN95 were given to the facility on 10/11/2020 by the local Virginia Department of Health. As of 1/26/2021, the day of the virtual inspection, it was expressed by staff person 6 that only 4 employees have been fit tested for N95 mask use. Staff person 7 expressed during the virtual inspection that a train the trainer class was scheduled with 2 employees so N95 mask fit testing can be completed for all required employees.
Plan of correction
As of March 11, 2021 all staff eligible to be fit tested had been properly fit tested and provided with N95 masks. Going forward, as recommended by local epidemiologist, all new employees will be fit tested within 14 days of start date if there is no active COVID cases within facility. If there are active COVID cases within facility new employees will be fit tested and provided N95 masks before start date. Any employee deemed ineligible for fit tested due to any reason will not work with any residents that have tested positive for COVID. Employee will also be required to wear both surgical mask and face shield, gloves, gowns and any other PPE required and provided. Any employee that has been or will be deemed ineligible for fit testing will be reported to LI and to local epidemiologist for further instructions.
22VAC40-73-40-A
Based on a review of staff records and facility documentation, the licensee failed to ensure compliance with relevant state law, with other relevant regulations and the facility's own policies and procedures.
Evidence
  1. The records for staff persons 1 through 5 were reviewed on 2/4/2021 and did not contain documentation of written certifications required under code section 16VAC25-220- Emergency Temporary Standard Infectious Prevention: SARS- certifications required under code section 16VAC25 220 Emergency Temporary Standard Infectious Prevention: SARS CoV-2 Virus that Causes COVID-19. An interview conducted with staff person 6 expressed that they were unable to verify that this training had been conducted with facility staff.
Plan of correction
Administrator has received all training materials required. All staff will receive necessary as required training no later than May 8, 2021. Going forward, all new employees will receive required training within 14 days of start date. All staff will be documented as receiving training and certification of completion will be provided to employee and will also be stored with employee file.