The Lodge at Old Trail — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

The Lodge at Old Trail was inspected 14 times between February 9, 2021 and April 14, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 34 violations under 29 distinct standards. 2 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 12 of these 14 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

11/17/2026

Administrator

Elizabeth Barber

Licensing inspector

Kimberly Davis

Inspector phone

(804) 356-3572

Approved for

Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

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

April 14, 2026Complaint survey4 violations

Inspection dates

04/14/2026

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (16) PROTECTION OF ADULTS AND REPORTING

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-14-26 from 10:33 a.m.- 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3-4-26 and 3-16-26 regarding allegations in the area(s) of: the safe, secure unit. Number of residents present at the facility at the beginning of the inspection: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care and related services, admission retention, and discharge of residents, additional requirement for facilities that care for adults with serious cognitive impairments, protection of adults and reporting. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on a review of the resident’s record as well as staff interviews, it was determined that the facility did not ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall.

Evidence

The record for Resident # 1 contained charting notes with the entry date of 1-11-26 that documented that the resident was observed on the floor in her apartment and complained of right hand and right hip pain. Documentation also noted that the resident was assisted from the floor by two staff and was then able to ambulate without assistance.
The record for Resident # 1 contained a fall risk assessment last dated 9-14-25.
Staff #1 and Staff # 2 confirmed that a fall risk assessment was not completed for Resident #1 after she fell on 1-11-26.

Plan of correction

The executive director has instructed the health and wellness director to perform fall risk assessments after a fall as well as, per usual, the condition of the resident changes and at least annually.

22VAC40-73-130-A

Based on a complaint received by the licensing office, staff interviews and a review of documentation, it was determined that the facility did not ensure that all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.

Evidence

The record for Resident # 1 did not contain documentation that the facility reported the elopement of Resident # 1 from the secure unit and the property on 1-3-26 to Adult Protective Services.
The licensing office did not receive a referral from Adult Protective Services regarding the elopement of Resident # 1 from the facility on 1-3-26.

Plan of correction

An in-service for all staff on Mandated Reporting will be conducted 06/04/2026.

22VAC40-73-70-A

Based on a complaint received by the licensing office as well as an interview with facility staff, and a review on documentation, it was determined that the facility did not 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

The facility did not report to the regional licensing office that Resident # 1 had eloped from the secure unit and from the property on 1-3-26 at approximately 4:40 p.m.
Licensing became aware of the incident upon receipt of the complaint on 3-4-26. 3.Staff #1 and Staff #2 confirmed that no report was submitted to the Licensing Office for the elopement of Resident #1.

Plan of correction

The health and wellness staff have been educated to inform the executive director as well as the health and wellness director of incidents that negatively affect or threaten the life, health, safety, or welfare of any resident. The executive director will report these incidents to the regional licensing office within 24 hours.

22VAC40-73-460-D

Based on a complaint received by the licensing office as well as staff interviews and a review of facility documentation, it was determined that the facility did not ensure that it shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

Resident # 1 eloped from the secure unit and the property on 1-3-26 at approximately 4:40 p.m.
Resident # 1 exited the building using a side door outside of the secure unit and walked across the street to a restaurant across from the facility parking lot before staff saw the resident on the way back to the facility after an undetermined amount of time.
According to Weather Underground (wunderground.com) the weather on 1-3-26 in the area of the facility around 4:40pm was approximately 40 degrees.
Staff # 1, Staff # 2, and Staff # 3 all confirmed that the resident eloped from the secure unit and the property on 1-3-26.
The record for Resident # 1 contained charting notes with the entry date of 1-11-26 that documented that the resident was observed on the floor in her apartment and complained of right hand and right hip pain. Documentation also noted that the resident was assisted from the floor by two staff and was then able to ambulate without assistance.

Plan of correction

Immediately following the elopement on 01/03/2026 the passcode was changed. A new process for entering Seasons was implemented. The new process included limiting those with access or knowledge of the code. Alerting Seasons’ staff that a guest /staff was coming to the door to enter. Requiring Seasons’ to be the ones who opened the door to the guest/staff.

November 12, 2025Inspection1 violation

Inspection dates

11/12/2025

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: 11-12-25 from 11:00 a.m.- 11:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10-21-25 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 60 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on a self-report received from the facility as well as staff interviews and a review of resident records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

-Progress notes for Resident # 1 as well as staff interviews indicated that on 10-13-25 Resident # 1 was given the medication (Carvedilol 12.5 mg for hypertension) of Resident # 2, for which Resident # 1 did not have an order. -The record for Resident # 1 documented that staff notified the resident’s physician, responsible party, and monitored the resident’s blood pressure, for which there were no ill effects from the medication error. -Per the interview with Staff # 2 as well as the Medication Administration record for Resident # 2, Resident # 2 was administered Carvedilol 12.5 mg as ordered on 10-13-25.

Plan of correction

RMA 1 was counseled and required to take the Registered Medication Aid refresher course and be retrained by a licensed nurse. She will not be scheduled to pass medication until her performance improvement plan is complete, and she demonstrates competency as a Registered Medication Aid. Retrain RMA who possibly put card back incorrectly.

November 10, 2025Inspection6 violations

Inspection dates

11/10/2025,11/12/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11-10-25 from 10:02 a.m.- 2:55 p.m. and 11-12-25 from 9:50 a.m.- 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, medication pass, physician’s orders, medication administration records, first aid kit. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-990-C

Based on a review of facility documentation the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.

Evidence

The facility’s last documented practice exercise for a resident emergency was dated 4-30-25. This was confirmed by staff.

Plan of correction

Resident emergency training will be conducted every six months and as needed. The next training is 11/19/2025.

22VAC40-73-720-A

Based on a review of resident records the facility failed to ensure that the written Do Not Resuscitate (DNR) order is included in the individualized service plan (ISP).

Evidence

The record for Resident # 6 contained a DNR order that was not included in the resident’s ISP. This was confirmed by staff.

Plan of correction

The ISP for Resident #6 was amended to include the DNR. In addition, audit will be conducted to ensure that all residents with a DNR have that included in their ISP.

22VAC40-73-430-H-2

Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record.

Evidence

-The record for Resident # 2 (discharge date:10-1-25) did not contain a written discharge statement. -The record for Resident # 5 (discharge date: 6-4-25) did not contain a written discharge statement. This was confirmed by staff.

Plan of correction

Resident #2 and Resident #5 will have discharge statements in their record. An Audit of all discharged residents since the last review will be conducted and missing discharge statements will be created and added to the record.

22VAC40-73-620-A

Based on a review of facility documentation the facility failed to ensure that there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.

Evidence

The facility’s last dietician oversight report was dated 3-20-25. This was confirmed by staff.

Plan of correction

The registered dietician will be reminded of the regulation. Health and Wellness Director will remind registered dietician 6 weeks prior to review deadline.

22VAC40-73-1090-A

Based on a review of resident records the facility failed to ensure that prior to his/her admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

The record for Resident # 6 (admit date: 2-12-24) who resides in the safe, secure unit contained an assessment for serious cognitive impairment dated 11-10-25. This was confirmed by staff.

Plan of correction

As the admission team is aware of the requirement, the use of a checklist will be implemented to ensure all required documentation is collected prior to move in.

22VAC40-73-1030-B

Based on a review of staff records the facility failed to ensure that within four months of the starting date of employment, direct care staff shall attend six hours of training in working with individuals who have a cognitive impairment.

Evidence

The record for Staff # 1 (date of hire: 5-19-25) did not contain documentation of cognitive impairment training. This was confirmed by staff.

Plan of correction

Staff member #1 will receive the cognitive impairment training.

April 29, 2025Inspection5 violations

Inspection dates

04/29/2025,05/02/2025

Areas reviewed

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: 4-29-25 from 10:58 a.m.-3:30 p.m. and 5-2-25 from 10:58 a.m.- 1:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, medication pass, physician’s orders, medication administration records. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-970-A

Based on a review of the facility’s fire and evacuation drills documentation the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).

Evidence

The facility’s last documented date for a fire and emergency evacuation drill was dated 2-27-25.

Plan of correction

The fire drills that were missing for March and April will be completed by 5/9/25. The Environmental Services Director has updated his calendar to ensure that they do not get overlooked again.

22VAC40-73-980-C

Based on a review of the first aid kit the facility failed to ensure that first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.

Evidence

The last documented date of the review of the first aid kit was 3-13-25 and the expiration date of the antiseptic ointment was September 2022.

Plan of correction

An immediate audit will be performed on each first aid kit and once per month following the audit. Out of date materials will be discarded and replaced.

22VAC40-73-310-D

Based on a review of resident records the facility failed to ensure that based upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record.

Evidence

The record for Resident # 5 (admit date: 11-11-24) did not contain written assurance.

Plan of correction

The letter of assurance was given to the resident on 5/7/2025. The checklist used to keep track of admission documents will be kept active until all of the documents are returned by resident or family and accounted for.

22VAC40-90-40-B

Based on a review of criminal history record reports the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.

Evidence

There was no criminal history record report for Staff # 24 (date of hire: 8-28-24).

Plan of correction

The criminal history back ground check for Staff # 24 was obtained on 4/29/25. There will be quarterly audits of the personnel files. Also, all sworn statements and background checks will be scanned into a digital folder to avoid the loss of paper documents.

22VAC40-73-950-E

Based on a review of facility documentation as well as an interview with staff, the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services.

Evidence

The facility provided documentation of a review of its emergency preparedness and response plan last dated 4-17-24 for staff only but it did not include residents and volunteers. This was confirmed by facility staff.

Plan of correction

Residents, volunteers and staff will be oriented to the Emergency Preparedness and Response Plan. There will be an all staff & volunteer meeting on 5/14/25 and 11/12/25 and every six months thereafter, where the Plan will be discussed. Residents will receive written information on 5/12/25.

July 23, 2024Inspection1 violation

Inspection dates

07/23/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-23-24 from 9:49 a.m.-10:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on a self-report received from the facility as well as staff interviews, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

-The record for Resident # 1 contained physician’s orders for the month of November 2023 that noted “ Lispro Insulin 100u/ML Inject subcutaneously per sliding scale before meals.” -The record for Resident # 2 contained physician’s orders for “Lispro Insulin per sliding scale” (via pen). -Per the self-report from the facility as well as interviews with Staff # 1 and Staff # 2, on 11-18-23 the Medication Aide administered the insulin of Resident # 2 which was in an insulin pen, to Resident # 1, instead of Resident # 1’s insulin vial.

Plan of correction

Not published by VDSS.

October 30, 2023Inspection3 violations

Inspection dates

10/30/2023,11/09/2023

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-30-23 from 10:36 a.m.- 3:45 p.m. and 11-9-23 from 10:05 a.m.- 12:05 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, lunch meal/menu, resident activities, first aid kit, medication pass, physician’s orders, Medication Administration Records (MARs). An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-100-C-1

Based on observation, the facility failed to ensure the use of standard precautions for infection control.

Evidence

During the medication pass observation, the med tech failed to sanitize or wash hands with soap and water between each med pass.

Plan of correction

Place hand sanitizer on each med cart. Retrain all med techs on the proper technique for hand sanitization between residents during medication pass.

22VAC40-73-210-B

Based on a review of staff records the facility failed to ensure that all direct care staff shall attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.

Evidence

The record for Staff # 2 (date of hire: 6-28-22) did not contain documentation of 18 hours of annual training.

Plan of correction

Audit all direct care staff training records. All direct care staff will be up to date and compliant with their training requirements.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.

Evidence

The record for Staff # 1 (date of hire: 4-20-23) did not contain documentation of first aid certification.

Plan of correction

Audit all direct care staff certification for first aid. Host first aid training for staff who are not in compliance.

July 12, 2023Inspection0 violations

Inspection dates

07/12/2023

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: 7-12-23 from 12:20 p.m.- 1:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7-19-22 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 63 Number of resident records reviewed: 1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 12, 2023Inspection0 violations

Inspection dates

07/12/2023

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: 7-12-23 from 11:00 a.m.-12:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6-16-22 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 63 Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 8, 2023Inspection9 violations

Inspection dates

05/08/2023,05/16/2023

Areas reviewed

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-8-23 from 11:00 a.m.- 5:00 p.m. and 5-16-23 from 10:20 a.m.- 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit, emergency food and water, lunch meal/menu, medication pass, physician’s orders, Medication Administration Records (MARs). An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-120-A

Based on a review of staff records the facility failed to ensure that the orientation and training required shall occur within the first seven working days of employment.

Evidence

The record for Staff # 4 (date of hire: 4-6-22) did not contain documentation of staff orientation and initial training.

Plan of correction

Staff #4 signed and acknowledged being trained and receiving an orientation when she was rehired. The Administrative Services Director has created a system for all rehires to be treated as new hires with all new documentation.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.

Evidence

-The record for Staff # 3 (date of hire: 2-27-23) did not contain first aid certification. -The record for Staff # 4 (date of hire: 4-6-22) contained first aid certification that expired in January 2023.

Plan of correction

Staff #3 provided a copy of her certification which expires August 11, 2023. Staff #4 obtained her first aid certificate on May 16, 2023. The H&W director and the Administrative Services Director have created a system to track the obtainment of required documents.

22VAC40-73-450-E

Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

-The record for Resident # 8 (admit date 11-11-22) contained an ISP created on 11-28-22 that was not signed or dated by the licensee, administrator, or his designee. -The record for Resident # 10 (admit date: 10-16-2020) contained an ISP created on 10-12-22 that was not signed or dated at all. -The record for Resident # 5 (admit date: 8-18-14) contained an ISP created on 8-11-22 that was not signed or dated at all.

Plan of correction

Resident #8’s ISP was signed by the Health and Wellness Director. Resident #10’s ISP was signed by the resident and Health and Wellness Director. Resident #5’s ISP was signed by the resident’s responsible party and Health and Wellness Director. The Health and Wellness Director has created a system that ensures the documents are reviewed and signed after being finalized.

22VAC40-73-450-C

Based on a review of resident records the facility failed to ensure that the ISP contained a written description all identified needs based on the UAI.

Evidence

The record for Resident # 9 (admit date: 5-5-14) contained an ISP created on 7-11-22 that did not address the following needs identified on the resident’s UAI dated 6-30-22: bladder incontinence (weekly or more), dressing (physical assistance), and orientation (disoriented-some spheres, some of the time.)

Plan of correction

Resident #9’s ISP was updated to include catheter rather than incontinence, assistance with dressing, and address his disorientation.

22VAC40-73-550-G

Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person.

Evidence

of this review shall be the staff person’s written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. Evidence: The record for Staff # 4 (date of hire: 4-6-22) did not contain written acknowledgment of an annual review of resident rights.

Plan of correction

Staff #4 reviewed and signed the resident’s rights document. The Administrative Services Director has created a system for all rehires to be treated as new hires with all new documentation.

22VAC40-73-450-F

Based on a review of resident records the facility failed to ensure that ISP shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

-The record for Resident # 3 (admit date: 3-11-21) contained an ISP last dated 3-29-23. -The record for Resident # 4 (admit date: 1-15-22) contained an ISP last dated 1-31-23.

Plan of correction

Both residents have a current ISP as of May 16, 2023.

22VAC40-73-580-A

Based on a review of facility documentation the facility failed to ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as

Evidence

d by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: The facility’s last health inspection was dated 3-22-22.

Plan of correction

The Dining Services Director had an appointment for a health inspection scheduled. The health inspector came on June 2, 2023. The Dining Services Director has been given instructions from the Health Department on how to request the inspection.

22VAC40-73-990-C

Based on an interview with the administrator the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced.

Evidence

The facility did not have documentation of a practice exercise for a resident emergency.

Plan of correction

A safety emergency drill occurred on May 26, 2023 for first shift. An elopement drill is scheduled for June 8, 2023 2nd shift. A resident emergency transport to the hospital drill is scheduled for June 9, 2023 for 3rd shift.

22VAC40-73-440-A

Based on a review of resident records the facility failed to ensure that the UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

-The record for Resident # 3 (admit date: 3-11-21) contained a UAI last dated 3-29-23. -The record for Resident # 4 (admit date: 1-15-22) contained a UAI last dated 2-7-23.

Plan of correction

Both residents have a current UAI as of June 6, 2023.

November 30, 2021Inspection0 violations

Inspection dates

11/30/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

An unannounced focus monitoring inspection was conducted remotely by the licensing inspector on November 30, 2021 to follow up on a previously cited high risk violation regarding resident call bell response times. A sample of 8 resident records were reviewed. No violations were cited. Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 25, 2021Inspection3 violations

Inspection dates

10/25/2021,10/27/2021,10/29/2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

A renewal inspection was initiated on October 25, 2021 and concluded on October 29, 2021. The executive director was contacted by telephone to initiate the inspection. The executive director reported that the current census was 61. The inspector emailed the executive director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, physician's orders, Medication Administration Records (MARs) and other facility documentation submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on October 29, 2021 which included a tour of the facility and the observance of resident rooms, facility postings, building and grounds, emergency food/water, and the medication cart. An exit interview was conducted with the executive director and resident care director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations

22VAC40-73-580-A

Based on a review of facility documentation the facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health.

Evidence

The facility provided documentation of a health inspection report from the Virginia Department of Health last dated 1-30-2020.

Plan of correction

1. Specific steps taken to correct non-compliance with the standard: a. Virginia Department of Health conducted an annual inspection on November 1, 2021. 2. Measures implemented to prevent non-compliance from occurring again: a. The Virginia Department of Health suspended on-site inspections from March of 2020 to May of 2021 due to the COVID pandemic. Therefore, the Virginia Department of Health was not able to conduct an inspection during that time. Furthermore, due to the backlog of inspections created during this time the Virginia Department of Health was not able to inspect this community per the normal schedule. b. Moving forward, the Executive Chef or his designee will proactively contact the Virginia Department of Health to request an annual inspection. 3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. Executive Chef, Tony Hughes b. Sous Chef, Justin Martin c. Maureen Davis, Executive Director

22VAC40-73-970-E

Based on a review of facility documentation the facility failed to document the participation of residents in fire and emergency drills.

Evidence

The facility documented the Number of Residents Participating as "0" on the Record of Required Fire and Emergency Evacuation drills for October 2020 through October 2021. The facility only provided documentation of signatures of residents participating in the Fire and Emergency Evacuation Drill dated 5-20-21.

Plan of correction

1. Specific steps taken to correct non-compliance with the standard: a. Community staff, as indicated below, will ensure monthly documentation of resident participation in fire and/or emergency drills. 2. Measures implemented to prevent non-compliance from occurring again: a. The Maintenance Director will document monthly resident participation in fire and/or emergency drills. b. The Maintenance Director will submit this documentation to the Executive Director for review monthly. 3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. James Morris, Maintenance Director b. Maureen Davis, Executive Director

22VAC40-73-70-A

Based on a review of resident records, the facility failed to report to the regional licensing office within 24 hours a major event that negatively affected or that threatened the life, health, safety, or welfare of a resident.

Evidence

Progress Notes dated 10-5-21 for Resident # 3 stated that resident "had a cat scan and it showed he has active inflammation pockets in his lungs that are destroying his lung tissue which is coming from him having COVID". The facility's executive director informed the licensing inspector during the inspection that the resident tested positive for COVID-19 on 9-21-21 and the facility reported it to the Health Department on 9-27-21. However, the facility failed to report the positive COVID case to the licensing inspector.

Plan of correction

1. Specific steps taken to correct non-compliance with the standard: a. Executive Director reported this situation to the licensing inspector during the renewal inspection. 2. Measures implemented to prevent non-compliance from occurring again: a. Community staff, as referenced below, will continue reporting future similar situations to the Health Department and now the licensing inspector as well. 3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. Alicia Doyle, Assistant Care Director b. Rebecca Pierce, Resident Care Director c. Maureen Davis, Executive Director

August 18, 2021Complaint survey1 violation

Inspection dates

08/18/2021,08/24/2021,09/28/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated complaint inspection was initiated on August 18, 2021 and concluded on September 28, 2021. A complaint was received by the department regarding allegations in the areas of resident care. The resident care director was contacted by telephone to conduct the investigation. The licensing inspector emailed the resident care director a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on August 24, 2021. The evidence gathered during the investigation supported some of the allegation(s) of non-compliance with standards or law, and violations were issued. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations

22VAC40-73-460-B

Based on some resident interviews and a review of the facility's call bell response log, the facility failed to provide prompt response by staff to the residents' needs to ensure that care provision and service delivery were resident care centered to the maximum extent.

Evidence

-The facility's call bell response log for Resident # 1 indicated the following: In June 2021 there were approximately 15 instances where it took 8-20 minutes for staff to clear the call bell after accepting it. There were approximately 13 instances where it took staff 21-30 minutes. In July 2021 there were approximately 29 instances where it took 8-20 minutes and approximately 13 instances where it took 21-30 minutes. In August 2021 there were approximately 27 instances where it took 8-20 minutes and approximately 4 instances where it took 21-30 minutes. -The facility's call bell response log for Resident #2 indicated the following: In June 2021 there were approximately 33 instances where it took staff 8-20 minutes to clear the call bell after accepting it and approximately 19 instances where it took 21-30 minutes. In July 2021 there were approximately 32 instances where it took 8-20 minutes and approximately 8 instances where it took 21-30 minutes. In August 2021 there were approximately 22 instances where it took 8-20 minutes, approximately 10 instances where it took 21-30 minutes, and 1 instance where it took 31-39 minutes. -The facility's call bell response log for Resident # 3 indicated the following: In June 2021 there were approximately 72 instances where it took staff 8-20 minutes to clear the call bell after accepting it and approximately 13 instances where it took 21-30 minutes. In July 2021 there were approximately 60 instances where it took 8-20 minutes and approximately 9 instances where it took 21-30 minutes. In August 2021 there were approximately 35 instances where it took 8-20 minutes, approximately 6 instances where it took 21-30 minutes, and 1 instance where it took 31-39 minutes. -Two of the residents interviewed confirmed that staff did not respond quickly when they pulled the call bell.

Plan of correction

1. Specific steps taken to correct non-compliance with the standard: a. Executive Director created an automatically generated daily alarm history report which the monitoring system e-mails to the Executive Director, Resident Care Director, and Assistant Care Director each day. b. Executive Director created an audit tool which the Resident Care Director or Assistant Care Director will complete daily to ensure review of the alarm history report. 2. Measures implemented to prevent non-compliance from occurring again: a. Executive Director created an automatically generated daily alarm history report which the monitoring system e-mails to the Executive Director, Resident Care Director, and Assistant Care Director each day. b. Executive Director created an audit tool which the Resident Care Director or Assistant Care Director will complete daily to ensure review of the alarm history report. The Resident Care Director or Assistant Care Director will investigate excessive response times, reconcile discrepancies or address with staff, and document accordingly. c. The Resident Care Director and Assistant Care Director will submit completed audit tools to the Executive Director for review. 3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. Alicia Doyle, Assistant Care Director b. Rebecca Pierce, Resident Care Director c. Maureen Davis, Executive Director

April 2, 2021Inspection1 violation

Inspection dates

April 2, 2021 and May 25, 2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on March 31, 2021 and concluded on May 28, 2021. A self-reported incident was received by the department regarding allegations in the area of medication administration. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations

22VAC40-73-680-I

Based on a review of facility documentation, the facility failed to ensure that the Medication Administration Record (MAR) contained the initials of the direct care staff administering the medication.

Evidence

The MAR for Resident # 1 was initialed five times by Staff # 1 to indicate the administration of Oxycodone 5 mg tablets on the following dates: March 3, 9, 10, 14, and 23. However, the Individual Resident's Controlled Substance Record for Resident # 1 was signed by Staff # 1 to indicate the administration of Oxycodone 5 mg twelve times with the following dates noted: March 2, 3, 9, and twice on March 10, 13, 14, 22, and 23.

Plan of correction

Staff member who committed the violation was terminated. Med techs and nurses were educated to review the narcotic/controlled substance count sheets for PRN medications during shift change. Med techs and nurses were taught to then compare the documentation on the count sheet to the documentation on the Medication Administration Record (MAR). Med techs and nurses were trained to verify that the documentation on the count sheet and the MAR match. Lastly, med techs and nurses were educated to document this verification process on the count sheet. A nurse, the Assistant Care Director, or Resident Care Director will routinely audit the count sheets to ensure this process occurs as instructed.

February 9, 2021Inspection0 violations

Inspection dates

Feb. 9, 2021 and Feb. 12, 2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

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 February 9, 2021 and concluded on February 12, 2021. The executive director was contacted by telephone to initiate the inspection. The executive director reported that the current census was 61. The inspector emailed the executive director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, physician's orders, Medication Administration Records (MARs), and other facility documentation submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.