Virginia DSS · Assisted Living Facility

The Legacy at North Augusta, Inc.

📍 1410 A N. Augusta Street, Staunton, VA, 24401

ID 38966One Year licenseActive
20
Inspections
On record
16
With violations
Visits that cited something
4
Clean visits
Nothing cited
35
Violations cited
Individual findings
25
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

The Legacy at North Augusta, Inc. was inspected 20 times between August 31, 2021 and May 4, 2026 by the Virginia Department of Social Services. 16 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 35 violations under 25 distinct standards. 8 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/22/2026
Administrator
Tara Glick
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

20

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

May 4, 2026Complaint survey0 violations
Inspection dates
05/04/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 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: May 4, 2026 from 12:15 p.m. until 12:55 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 05/04/2026 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 100 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector toured the community, including memory care laundry room, inspected resident room and closet, and spoke with resident and staff. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 3, 2025Inspection1 violation
Inspection dates
12/03/2025
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 SERVICESARTICLE 1 – SUBJECTIVITY63.2- (1) General Provisions
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/25/2025 regarding allegations in the area(s) of: Resident care and related services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/3/2025 from 1:09 p.m. until 2:10 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: 100 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector reviewed resident Medication Administration Record, physician orders, and Registered Medication Aid employee file. Additional Comments/Discussion: None 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-reported incident 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The regional licensing office received a self-reported incident on 11/25/2025 indicating that on 11/25/2025 staff 3 had administered medications for resident 2 to resident 1, which included donepezil 10 mg, Allegra 60 mg, venlafaxine 37.5 mg, vitamin D3 50 mg, Azo 95 mg, and fluticasone 50 mg nasal spray.
  2. Review of the medication administration record (MAR) for resident 2 indicated donepezil 10 mg, Allegra 60 mg, venlafaxine 37.5 mg, vitamin D3 50 mg, Azo 95 mg, and fluticasone 50 mg nasal spray was scheduled to be administered at 9 a.m. on 11/25/2025.
  3. Progress note for resident 1 written on 11/25/2025 at 8:52 a.m. by staff 3 stated “resident was given the wrong medication will watch closely on the resident throughout the day”.
  4. Fax sent to resident 1’s primary care provider (PCP) on 11/25/2025 at 8:50 a.m. indicated resident 1 received other residents medications including donepezil 10 mg, Allegra 60 mg, venlafaxine 37.5 mg, vitamin D3 50 mcg, Azo 95 mg, and fluticasone 50 mg nasal spray.
  5. During an interview with LI on 12/3/2025, staff 2 explained that staff 3 was scheduled to work as a registered medication aid (RMA) on memory care only, which is normally where this RMA worked. On 11/25/2025, the day of the medication error, there was a call out and staff 3 was working as an RMA in memory care and on 3 AL (assisted living). Staff 2 stated that staff 3 “got overwhelmed”, which led to the medication error.
Plan of correction
Immediate Corrective Action Taken for Resident #1 Employee #3 immediately reported the incident to the LPN on call and to Resident #l's Primary Care Provider (PCP). Resident #1 was monitored throughout the day of the incident for any adverse effects; no complications were noted. Identification of Other Residents at Risk -A review of current residents receiving medication administration services was completed to determine if any other residents were affected by similar errors. -No additional residents were found to be impacted. -All medications administered during the 24-hour period surrounding the incident were audited with no further discrepancies identified. Corrective Measures to Prevent Recurrence Staff Training & Competency: All medication-certified staff will complete a refresher in Medication Administration Procedures, including documentation, reporting requirements, and the "Six Rights" of medication administration. Staff Member #3 was observed completing a Quarterly Medication Administration Competency on December 3, 2025. Quality Assurance & Oversight: The LPN or Associate Administrator will conduct weekly medication pass observations for 30 days, then monthly thereafter.
September 23, 2025Inspection5 violations
Inspection dates
09/23/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 9/23/2025 9:00 a.m. – 2:30 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: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, pharmacy review, healthcare oversight, menus, activity calendars and dietician report Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-720-A
Based on record review and staff interview, the facility failed to ensure that the Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation (CPR) from a resident in the event of cardiac or respiratory arrest were included on the individualized service plan (ISP).
Evidence
  1. Resident 5 (admitted 3/27/2025) had a DNR order dated 3/27/2025.
  2. The ISP for resident 5 dated 3/26/2025 stated resident 5 was a CPR/Full Code indicating that resident 5 would have CPR provided.
  3. The ISP for resident 5 did not include resident 5’s DNR order.
  4. During an interview with staff 2, when asked if they were aware that the resident had a DNR order, but the ISP showed full code, staff 2 stated “I saw that”.
Plan of correction
Immediate Action Taken: Resident #S's ISP has been updated to reflect the current Do Not Resuscitate (DNR) order. Measures to Prevent Recurrence: An audit will be conducted by the Associate Administrator and LPN Clinical Specialist to verify that all current DNR orders are accurately reflected in residents' ISPs. This will be completed by November 15, 2025. Monitoring: The Associate Administrator, LPN Clinical Specialist, or designee will update ISPs immediately upon receipt of a DNR order. This will be monitored weekly for two weeks, bi-weekly for the following two weeks, and through random audits thereafter.
22VAC40-73-560-E
Based on direct observation and staff interview, the facility failed to ensure all resident records are kept in a locked area.
Evidence
  1. During the facility tour on 9/23/2025 with staff 2, the third-floor case base door was left open with no staff present. Inside of the door were 2 separate rooms with both doors unlocked and open with resident records in an unlocked cabinet.
  2. During an interview with staff 2 when asked if the door was usually left open staff 2 stated “no, I’m not sure why it is open”.
  3. Photo evidence taken.
Plan of correction
Immediate Action Taken: On the day of the inspection, the door to Care Base 3 (Assisted Living) was immediately closed and locked to prevent unauthorized access to resident records. Measures to Prevent Recurrence: All nursing staff will receive re-training on the regulatory requirement and the importance of maintaining the confidentiality and security of resident records by ensuring they are stored in locked areas. This training will be completed no later than November 15, 2025, and documentation will be maintained in each staff member's training file. Monitoring: LPNs and CMAs will conduct daily checks of care base doors on all three Assisted Living floors and in Memory Care to ensure that doors remain closed and locked when unattended.
22VAC40-73-680-H
Based on record review, the facility failed to ensure that at the time medication was administered it was documented on the medication administration record (MAR).
Evidence
  1. Record review for resident 1 admitted 8/27/2025 contained a physicians order for diclofenac sodium external gel dated 8/26/2025, with instructions to apply to both knees topically every six hours for pain.
  2. The Medication administration record (MAR) for resident 1 did not have documentation of the administration of diclofenac sodium external gel on 9/9/2025 at 6:00 a.m., 9/10/2025 at 6:00 a.m., 9/14/2025 at 12:00 a.m., or 9/14/2025 at 6:00 a.m.
Plan of correction
Immediate Action Taken: It was not possible to retroactively correct the missing documentation on the electronic Medication Administration Record ( eMAR). Measures to Prevent Recurrence: All medication aides and nurses will be retrained on proper documentation procedures required after medication administration. Training will be completed by November 15, 2025. Monitoring: The LPN Clinical Specialist or designee will run a report five days per week to review for missing documentation. Appropriate staff members will be notified to complete any outstanding documentation.
22VAC40-73-1110-A
Based on record review and staff interview, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment to a safe, secure environment, the licensee, administrator, or designee determination and justification for the decision was in writing and retained in the resident's file.
Evidence
  1. Resident 1 (admitted 8/27/2025), resident 4 (admitted 7/10/2025), and resident 6 (admitted 3/28/2025) resided in the safe, secure, environment.
  2. Record reviews for residents 1, 4, and 6, did not contain a written determination or justification for placement in the secure environment by the administrator.
  3. Upon request, the facility did not provide a written determination or justification for placement in the secure environment by the administrator for residents 1, 4, or 6.
  4. During an interview with staff 1, when asked if there was a written determination or justification for placement in the secure environment by the administrator for residents 1, 4, or 6, staff 1 stated “I have never done that.”
Plan of correction
Immediate Action Taken: Files for Residents #1, #4, and #6 were corrected on the day of the inspection. Measures to Prevent Recurrence: The Associate Administrator or designee will document the determination and justification in writing for each initial assessment of residents moving into a safe, secure environment. Monitoring: The Associate Administrator or designee will review admission paperwork on the day of move­in to verify all required documentation is complete.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to store cleaning supplies in a locked area.
Evidence
  1. During the facility tour on 9/23/2025 with staff 2, the third-floor case base door was left open with no staff present. Inside of the door was a shelf containing a container of Sani-Cloths and a spray bottle of rapid multi surface disinfectant cleaner.
  2. During an interview with staff 2 when asked if the door to the care base was usually left open staff 2 stated “no, I’m not sure why it is open”.
  3. Photo evidence taken.
Plan of correction
Immediate Action Taken: On the day of the inspection, the door to Care Base 3 in Assisted Living was immediately closed and securely locked. Measures to Prevent Recurrence: All nursing staff will be re-trained on the importance of storing all cleaning supplies and hazardous materials in locked areas. This training will be completed by November 15, 2025. Monitoring: LPNs and CMAs will conduct regular checks of care base doors on all three Assisted Living floors, as well as in Memory Care, to ensure doors remain closed and locked when unattended.
September 23, 2025Inspection1 violation
Inspection dates
09/23/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 9/15/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/23/2025 2:30 p.m. – 3:00 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: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector reviewed medication administration records, staff communication, nurse’s notes, the staff schedule and incident reports. Additional Comments/Discussion: None 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-reported incident 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on 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. A self reported incident was received by the regional licensing office on 9/15/2025 stating that resident 1 (admitted 7/10/2025) received an incorrect dose of their medication.
  2. Record review for resident 1 on 9/23/2025 indicated that resident 1 had a physicians order dated 8/20/2025 for Hydrocodone - acetaminophen tablet, to take one tablet by mouth three times a day at 9:00 a.m., 1:00 p.m., and 8:00 p.m. for pain.
  3. On 8/26/2025 staff 3 did not administer the 9:00 a.m. dose of Hydrocodone – acetaminophen within the scheduled time frame, and administered both the 9:00 a.m. dose and 1:00 p.m. together at 11:00 a.m.
  4. During an interview with staff 1, when asked if the medication was administered in accordance with physicians order staff 1 stated “no”.
Plan of correction
On 8/26/2025, Staff #3 was re-educated on the Six Rights of Medication Administration to address the identified concern. Staff #3 was also directed to immediately notify the resident's Responsible Party, Primary Care Provider (PCP), and Hospice Provider regarding the incident. All Licensed Practical Nurses (LPNs) and Registered Medication Aides (RMAs) will receive re-education on proper medication administration procedures and related regulatory provisions The Associate Administrator or their designee will review Resident #1's-controlled substance record and Electronic Medication Administration Record (eMAR) to verify medications are being administered as prescribed by the PCP. Monitoring will occur weekly for four (4) weeks, followed by random audits thereafter to ensure continued compliance.
September 23, 2025Complaint survey1 violation
Inspection dates
09/23/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 9/19/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/23/2025 3:00 p.m. – 4:15 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: 96 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: 3 Observations by licensing inspector: The licensing inspector reviewed incident reports, staff communication, the staff schedule, and medication administration records. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: 680-D A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-680-E
Based on record review and staff interview, the facility failed to provide treatments as ordered by a physician or other prescriber instructions.
Evidence
  1. A complaint was received by the regional licensing office alleging that resident 1 did not receive their blood glucose monitoring for nine days. 2.Resident 1 (admitted 2/14/2024) had a physician’s order dated 9/24/2025 for True Metrix Blood Glucose Test In vitro strip, with instructions stating one strip in vitro one time a day every two days for DM and one strip in vitro at bedtime every two days. 3.On 11/21/2024 the test strips were switched from pharmacy order to an outside supplier, and the order was discontinued. 4.On 11/30/2025 the facility realized that when the order for the test strips were discontinued there was no other order in the medication administration record to test the blood glucose level. On 11/30/2025 a new physicians order was written for blood sugar check one time a day every two days for diabetes. 5.There were a total of nine days where the blood glucose level was not checked by the facility.
  2. During an interview with staff 2, when asked if the blood sugar was monitored during from 11/21/2025 when the physicians order was discontinued and 11/30/2025 when the physicians order was rewritten, staff 2 stated “no it wasn’t”.
Plan of correction
Not published by VDSS.
June 17, 2025Inspection2 violations
Inspection dates
06/17/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2- (16) PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 6/3/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/17/2025 8:30 a.m. – 10:19 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: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed incident notes, staff communication, and staff training. Additional Comments/Discussion: None 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-reported incident 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on record review and staff interview, 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. On 6/3/2025, the regional licensing office received a self-reported incident from the facility stating resident 1 (admitted 5/5/2025), a resident residing in the special care unit with a diagnosis of a serious cognitive impairment wandered from the facility to a neighboring street.
  2. During an interview with staff 1, when asked how resident 1 was able to exit the locked special care unit staff 1 stated that staff 2 assisted the resident out of the special care unit to the front porch and then proceeded to clock out of work for the day an not notify any of the staff resident 1 was on the front porch unattended.
  3. Resident 1 was unsupervised on the front porch from 4:11 p.m. until 4:43 p.m. when the facility was alerted by a family member that the resident 1 was on the street and the resident was returned to the facility without incident at 4:54 p.m.
  4. The resident walked approximately 0.2 miles according to Google Maps, from the facility to the intersection of the main road of North Augusta Street and Edgewood Road.
  5. Weather conditions on 6/3/2025 for Staunton, VA at 4:30 p.m. listed the condition as fair with the temperature at 80 degrees.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) included all identified needs.
Evidence
  1. Resident 1 (admitted 5/5/2025) had an Assessment of Serious Cognitive Impairment dated 4/30/2025 that stated, “some wandering”, and the Uniform Assessment Instrument (UAI) dated 4/18/2025 indicated “Abusive/Aggressive/Disruptive behaviors”.
  2. Review of resident progress notes indicated on more than 15 occasions the resident had experienced aggressive, disruptive, or wandering behaviors.
  3. The ISP for resident 1 did not include the resident 1’s aggressive, disruptive, or wandering behaviors.
  4. During an interview with staff 1, when asked if resident 1’s behaviors were listed on resident 1’s ISP staff 1 stated “no, it doesn’t”.
Plan of correction
Not published by VDSS.
April 22, 2025Inspection1 violation
Inspection dates
04/22/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 4/8/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/22/2025 9:00 am – 9:50 am. 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: 87 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector (LI), reviewed Medication Administration Records and communication. Additional Comments/Discussion: None 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-reported incident 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.
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to administer medications in accordance with physicians or other prescriber’s instructions.
Evidence
  1. A self-report was received by the Regional Licensing Office on 4/8/2025 alleging that resident 1 had received incorrect medications.
  2. Record review for resident 1 indicated that on 3/8/2025 at 9:40am resident 1 was ordered to receive the following medications and did not; Furosemide 40mg, Metoprolol ER 100mg, Potassium ER 10MEq two capsules, and Spironolactone 25mg ½ tablet.
  3. Record review for resident 1 indicated that resident 1 did receive resident 2’s medications including ASA 81mg, Eliquis 5mg, Iron 325mg, HCTZ 12.5mg, Metformin 500mg, Glimepiride 1mg, Metoprolol ER 50mg, Mirabegron ER 25 mg, Senna 8.6mg two tablets, and Venlafaxine ER 150mg.
  4. During an interview with staff 1, when asked if resident 1 received their scheduled medications as ordered on 4/8/2025, staff 1 stated “no, only the Tylenol”, when asked what medications resident 1 received, staff 1 stated resident 1 received resident 2’s medications.
Plan of correction
1.Immediate Corrective Action Taken • The medication aide involved was immediately placed on administrative leave upon discovery of the error. • A thorough internal investigation was conducted, including interviews and review of the Medication Administration Record (MAR). • The medication aide was terminated for failure to follow the facility's medication administration policy and procedures. • The affected resident's POA and PCP were informed and the resident was monitored with no adverse effects identified. 2. Measures to Prevent Recurrence • Re-education and retraining on medication administration policies and 22VAC40- 73-680 standards will be conducted for all medication aides within the next 30days • Mandatory competency checks will be performed quarterly for all medication aides, including: • Resident identification protocols • "Five Rights" of medication administration • Documentation accuracy 3.Monitoring •AL program manager and Administrator will review all medication errors and near misses quarterly. 4. Responsible Party • The AL Program manager is responsible for implementing and monitoring this Plan of Correction. • The Administrator will oversee compliance and ensure timely reporting to the Virginia Department of Social Services.
January 22, 2025Complaint survey0 violations
Inspection dates
01/22/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/22/2025 12:00pm-1:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/14/2025 regarding allegations in the area(s) of: Resident care and related services and building and grounds. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector toured the kitchen and dining room as well as resident areas. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2024Inspection6 violations
Inspection dates
11/06/2024, 11/07/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES22VAC40-90 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: 11/06/2024 9:05am-3:33pm, 11/07/2024 10:00am-12:45pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-720-A
Based on record review and staff interview, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest are included on the individualized service plan (ISP).
Evidence
  1. Resident 3, admitted 2/23/2024, had DNR orders dated 4/23/2024. The ISP for resident 3, dated 2/23/2024, stated that the resident was a “full code” indicating “CPR will be initiated in the event of cardiopulmonary failure”.
  2. Resident 6, admitted 8/13/2024, had DNR orders dated 8/9/2024. The ISP for resident 6, dated 8/6/2024, stated that the resident was a “full code” indicating “CPR will be initiated in the event of cardiopulmonary failure”.
  3. Resident 7, admitted 12/14/2021, had DNR orders dated 9/8/2024. The ISP for resident 7, dated 9/20/2024 stated that the resident was a “full code” indicating “CPR will be initiated in the event of cardiopulmonary failure”.
  4. During an interview on 11/6/2024 with staff 2, when asked if the DNR orders were included on the ISP for residents’ 3, 6, and 7, staff 2 answered “no, it’s not”.
Plan of correction
On 11/7/24 The clinical support specialist, under the direction of the administrator, updated ISPs on resident 3,6 and 7. On 11/11/24 the clinical support specialist reviewed all residents' ISPs to ensure the DNR orders were correctly outlined on each ISP. The Clinical team reviewed the process for approving new DNR orders to ensure once approved the ISP is adjusted. The clinical support specialist, under the direction of the administrator will audit ISPs monthly for code status accuracy.
22VAC40-73-860-I
Based on direct observation the facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area.
Evidence
  1. During the facility tour on 11/6/2024, the second-floor resident laundry room had an unlocked cabinet containing a container of laundry detergent, a bottle of resolve, a bottle of hydrogen peroxide, and two bottles of Lysol and a bottle of oxy clean on the counter. The third-floor resident laundry room had an unlocked cabinet containing one jug of bleach, a bottle of disinfectant cleaner, and a bottle of hydrogen peroxide.
  2. The third-floor common area bathroom contained a container of Sani-cloths and a bottle of Lysol.
  3. The laundry room in the memory care unit had an unlocked closet containing an unlocked housekeeping cart with a can of bathroom cleaner, a bottle of glass cleaner, and a can of furniture polish and a bucket of various cleaners.
  4. Photo evidence taken.
Plan of correction
On 11/7/24, All cleaning supplies and hazardous materials were immediately removed by the administrator. On 11/11/24 The Lead maintenance generalist replaced the locks in housekeeping closets with locks that automatically lock upon closing. The administrator completed education with the community team on 12/4/24 reviewing the importance of keeping all cleaning supplies and hazardous materials locked. The Facilities Manager, under the direction of the administrator, will conduct twice a weekly rounding of the community to ensure all hazardous materials and cleaning supplies are locked.
22VAC40-73-450-F
Based on direct observation, record review, and staff interview the facility failed to ensure that the ISP was reviewed or updated following a significant change of a residents’ condition.
Evidence
  1. During a medication pass observation conducted on 11/7/2024, resident 7, admitted 12/14/2021, was observed with oxygen therapy being provided and a foley catheter in place.
  2. During an interview with staff 2 on 11/7/2024, when asked when the resident received orders for oxygen and the catheter, staff 2 stated that the resident returned from the hospital on 9/20/2024 with the oxygen and catheter in place.
  3. During a record review for resident 7 on 11/7/2024, the ISP dated 9/20/2024 did not include oxygen therapy or the use of a catheter.
Plan of correction
On 11/7/24 The clinical support specialist, under the direction of the administrator, updated the individualized service plan for resident seven. On 11/12/24 the clinical support specialists reviewed ISPs on any resident who had a change in condition/hospitalization in the past 3 months. Those ISPs were updated to include pertinent changes. Administrator held education with clinical support specialists to review process for completing UAI and ISP following any resident's change in condition. For the next 3 months, the administrator or designee will audit each resident's UAI and ISP following hospitalization for accuracy.
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure each staff person required to be evaluated annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. During record review for staff 4 (Hired 9/18/2023) completed 11/6/2024, the staff record contained only a tuberculosis risk assessment dated 9/18/2023.
  3. During an interview with staff 5 on 11/6/2024, staff 5 confirmed that the annual risk assessment had not yet been completed.
Plan of correction
On 11 /11 /24 The Talent and Culture Director, under the direction of the administrator, audited all personal files for annual TB risk assessments. All missing documents were completed and uploaded. The Talent and Culture Business Partner, in partnership with the administrator, will ensure completion and uploading of the TB risk assessment into the personal file annually. The Talent and Culture Business Partner, under the direction of the administrator, will audit Personal files every 6 months for compliance with 22VAC40-73-250-D.
22VAC40-73-1110-A
Based on record review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee provided in writing that placement in the special care unit is appropriate and retained in the resident file.
Evidence
  1. Resident 1, admitted 6/27/2024, resides in the secure environment within the facility. Following record review for resident 1 on 11/6/2024, the written appropriateness for placement was not contained in the resident record.
  2. Resident 3, admitted 2/23/2024, resides in the secure environment within the facility. Following record review for resident 3 on 11/6/2024, the written appropriateness for placement was not contained in the resident record.
  3. During an interview with staff 1 on 11/6/2024, staff 1 confirmed that the written appropriateness for placement was not completed prior to placement in the secure environment. Staff 1 stated that there was confusion on the initial written appropriateness for placement and the review of appropriateness for placement that is completed after 6 months of placement in a secure environment.
Plan of correction
On 11/11 /24 the administrator added a document to charts of all residents residing in the Memory Care neighborhood outlining that their placement in the special care unit was appropriate. This document was added to the admission process for all future residents. The community sales team was educated by the administrator on this new process. LPN clinical support specialist, under the direction of the administrator, will audit clinical files of all residents residing in memory care each quarter for completion of the required documentation.
22VAC40-73-700-1
Based on direct observation, record review, and staff interview, the facility failed to obtain a valid physicians order for oxygen therapy.
Evidence
  1. During a medication pass observation conducted on 11/7/2024, resident 7, admitted 12/14/2021, was observed with oxygen therapy being provided at 1L via nasal canula by concentrator.
  2. During a record review for resident 7 on 11/7/2024, there were no physician orders for oxygen therapy.
  3. During an interview with staff 2 on 11/7/2024, when asked to provide the physicians order for oxygen therapy, staff 2 stated that there were no physician orders in the resident record for the oxygen therapy, and that the resident returned from the hospital on 9/20/2024 with the oxygen in place.
Plan of correction
On 11/7/24 the clinical support specialist contacted the PCP for Resident 7 and obtained a verbal order for the Oxygen. The order was properly processed and added to the resident's file. On 11/11/24 The administrator contacted the Hospice team to review the importance of communicating with the assisted living team when new orders are obtained so those orders can be entered in the resident's chart at the community. The administrator also held an education with the clinical support team outlining the importance of assessing residents returning from the hospital to ensure they have appropriate orders. Monthly, the clinical Support specialists, under the direction of the administrator, will complete record reviews to ensure all residents receiving Oxygen have a valid order.
May 28, 2024Inspection4 violations
Inspection dates
05/28/2024, 05/29/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/28/2024 8:30am – 4:49pm, 05/29/2024 08:30am – 12:45pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection Number of residents present at the facility at the beginning of the inspection: 74 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments and the staff during daily duties and medication administration. The Licensing Inspector reviewed the following at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight, and pharmacy review. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure fire drills are completed on each shift in a quarter in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. Staff 1 confirmed the facility shifts include shift 1 as 7am – 7pm and shift 2 as 7pm – 7am.
  2. Fire drill documentation shows the fire drills for quarter 1 of 2024 as 1/31/24 at 3:30pm (Shift 1), 2/21/2024 at 10:00am (Shift 1), and 3/20/2024 at 3:00pm (Shift 1).
Plan of correction
Staff has been re-educated on the standards for fire drills. A fire drill for the 7pm-7am shift was completed on 05/31/2024. Lead Maintenance will continue to ensure drills are completed on each shift, 7am – 7pm and 7pm – 7am.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure cleaning supplies and hazardous chemicals are stored in a locked area.
Evidence
  1. Two licensing staff observed the laundry room door in the secured unit, unlocked and containing 2 bottles of cleaner on a shelf and a bottle of laundry detergent on the counter.
  2. Inside of the laundry room was an additional closet unlocked and containing an unlocked and open cleaning cart with multiple bottles of cleaning supplies as well as a shelf, and bucket containing multiple bottles of cleaning supplies.
  3. Staff 4 stated “it was left unlocked”.
  4. Photo evidence taken
Plan of correction
Staff has been re-educated on the standards for cleaning supplies and hazardous chemicals. Laundry room and other storage areas will be checked for compliance daily by the Administrator.
22VAC40-73-700-1
Based on record review and staff interview, the facility failed to ensure oxygen orders contain all required information.
Evidence
  1. Resident 4 has an oxygen order dated 5/8/2024 that states “oxygen 2-4L/min for SOB”. There order does not contain the source or the delivery device.
  2. Staff 1 stated “the order is missing the information”
Plan of correction
Staff has been re-educated on the information required for a valid oxygen order. New orders are being reviewed by Clinical Support Specialist to ensure compliance. This order has been corrected.
22VAC40-73-320-A
Based on record review and staff interview, the facility failed to ensure a physical exam is completed within 30 days prior to admission.
Evidence
  1. Resident 4 (Admitted 6/28/2023) has a physical exam dated 04/19/2023.
  2. Staff 1 stated “That’s the only one we have”
Plan of correction
Staff has been re-educated on the required documents for admission. The physical exam was located and filed in resident’s chart. Future admissions will be checked by the Administrator to ensure all required documents are obtained.
May 8, 2023Inspection1 violation
Inspection dates
05/08/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended a meeting be held with all residents on the assisted living unit to remind them of the requirements for staff to observe them take their medications. Also recommended an in-service be held with all staff and agency staff who administer medications and that a checklist of key requirements be reviewed, signed and dated by each staff
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: 5/8/2023 from approximately 2:00 pm to 4:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Self-reported incidents were received by VDSS Division of Licensing on 3/6/2023, 3/25/2023, 3/31/2023 and 4/24/2023 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 (only reviewed selected sections) Number of staff records reviewed: 3 (only reviewed selected sections) Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration records, physicians’ orders and staff qualifications. Additional Comments/Discussion: A follow-up inspection will occur based upon the medication administration violation. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-reports of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reports 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-680-D
Based upon documentation and interviews, the facility failed to ensure medications were administered in accordance to the physicians’ orders and the standards of practice in the Virginia Board of Nursing curriculum for four of the four resident records reviewed.
Evidence
  1. The medication aide curriculum states on page 6, 3.E.3, “Medication Aides may not pre-pour medications for anyone (including self).”
  2. The medication aide curriculum states on page 25, 6.a. 1 – 6, “Identify the rights of medication administration: 1.Right client 2.Right medication 3.Right dose 4.Right route 5.Right time 6.Right documentation”
  3. On 3/6/2023 at 3:00 pm, two medication cups filled with medications were found in resident 4’s room. Staff 4 stated the medications in cup one appeared to be the 9:00 pm medications Gabapentin one 100mg tablet and Trazadone one 50 mg tablet. The second cup appeared to be the 9:00 am medications which included Vitamin D 2000 units, Allegra Allergy one 60mg tablet, Donepezil one 10mg tablet and Venlafazine HCL one 37.5mg tablet. Staff 4 stated agency staff 1 reported to her that on 3/6/2023, she left one cup with resident 4’s medicine on the counter, as directed by the resident, and she did not observe the resident take the medicine. Resident 4 could not remember when or who placed the first cup in the room. Staff 4 reported staff 5 stated she observed resident 4 take her medications the evening of 3/5/2023.
  4. Resident 1 had a signed physician’s order for Brimonidine Tartrate 0.2% solution, one drop in right eye.
  5. On 3/25/2023, a progress note stated staff 2 removed a bottle from a bag labeled as Brimonidine Tartrate and administered one drop into the right eye. The resident immediately stated the drop burned more than usual. Staff 2 checked the bottle and it was labeled as ear wax cleaning drops.
  6. On 3/31/2023, agency staff 1 prepared medications for resident 2 then immediately prepared medications for resident 3, prior to administering the prepared medications for resident 2. Staff 1 then administered one cup of the medications to resident 2. As soon as resident 2 swallowed the medications, staff 1 realized resident 2 was given resident 3’s medications (Calcium D3 one 600mg tablet, Famotidine one 20mg tablet, Metformin one 500mg tablet, Pradaxa one 150mg tablet and one Preservision capsule.
  7. On 4/24/2023 at 7:15 am, staff 3 found a medication cup and water on resident 4’s bedside table. The medications were Anastrozole one 1mg tablet, Levothyroxine Sodium one 25mcg tablet, Vitamin D3 two 25mcg tablets and Preservision + multivitamin one tablet.
  8. Resident 4 had signed physician’s orders for Anastrozole one 1mg tablet, Levothyroxine Sodium one 25mcg tablet, Vitamin D3 two 25mcg tablets and Preservision + multivitamin one tablet.
  9. The April medication administration record for resident 4 was blank on 4/24/2023 for the 6:00 am medications Anastrozole one 1mg tablet, Levothyroxine Sodium one 25mcg tablet, Vitamin D3 two 25mcg tablets and Preservision + multivitamin one tablet.
Plan of correction
Education will be provided to all nurses and registered medication aides by registered nurse (RN) for proper process of administration medications according to physician orders and registration medication aide approved curriculum. Routine and random medication pass observations will be completed on at least one team member weekly by RN Clinical Educator to ensure compliance
May 8, 2023Complaint survey1 violation
Inspection dates
05/08/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Ensure at least two staff remain on the secured unit at all times and recommended all staff attend and in-service regarding the staffing requirements for a secured unit.
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: 5/8/2023 from approximately 11:50 am to 2:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/28/2023 regarding allegations in the areas of: Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Staffing and staff schedule Additional Comments/Discussion: Ensure all staff are knowledgeable of the staffing requirements for the secured unit and that all staff are clearly trained in what to do and who to contact if there are staffing concerns/problems. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-1130-C
Based upon interviews, the facility failed to ensure two staff remained on the secured unit at all times.
Evidence
  1. The staff schedule for 4/27/2023 listed staff 2 and 3 working the secured unit from 7:00 pm to 7:00 am, staff 4 working first floor and also assigned as charge nurse from 6:45 pm to 7:15 am, and staff 7 (nurse) working third floor for assisted living (AL) from 6:45 pm to 7:15 am...
  2. On 5/8/2023, the licensing inspector (LI) interviewed staff 2 who stated she worked the night shift (7:00 pm to 7:00 am) on the secured unit on 4/27/2023. She stated she was informed by the previous shift staff that staff 3 would be pulled to work the third floor of AL and staff 7 would be working the secured unit. Staff 2 stated she asked the staff to remain on the secured unit while she went to question staff 4 about the change. Staff 2 stated she told staff 4 that staff 7 was the nurse who was assigned to administer medications to all residents on the third floor – assisted living and the secured unit and that she was supposed to be the one who floated between the units – not the direct care aide. Staff 2 stated staff 4 told her they had a meeting and that was what they were supposed to do.
  3. Staff 2 stated when staff 7 had to administer medications to the AL residents, especially during the morning hours, she was the only staff working on the secured unit. Staff 2 stated the charge nurse was not contacted to have a staff replace staff 7 when staff 7 left the secured unit. Staff 2 stated there was only one staff during those times.
  4. On 5/8/2023, the LI interviewed staff 3 who stated he was assigned to work the third floor AL on 4/27/2023 from 7:00 pm to 7:00 am.
  5. On 5/8/2023, the LI interviewed staff 4 who stated staff 2 and 7 were assigned to the secured unit and staff 4 was assigned to third floor A. Staff 4 stated if staff needed help they should have called and no staff communicated that they needed help. Staff 4 also stated the staffing for the secured unit was two aides and one nurse who administers medications for third floor AL and secured unit.
  6. On 5/8/2023, the LI interviewed staff 1 and 6 and both stated staff were told that two aides remain on the secured unit at all times and the nurse floats between AL and the secured unit.
Plan of correction
Two direct care staff were on the schedule for 4/27/2023. At all times the secured unit maintains a minimum of two direct care staff. Education was provided to staff confirming staff cannot remove staff from the secured unit that will result in less than two on the unit. The administrator confirms the schedule daily for compliance.
May 8, 2023Complaint survey1 violation
Inspection dates
05/08/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Technical assistance
Recommended replacing the carpet in the rooms that have a urine smell.
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: 5/8/2023 from approximately 10:00 am to 11:50 am 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 4/28/2023 regarding allegations in the areas of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 8 Observations by licensing inspector: Resident rooms and common areas on the secured unit and common areas on the assisted living unit. Additional Comments/Discussion: Family members were also interviewed as well as outside agency staff. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virgiia.gov@dss.virginia.gov
Violations
22VAC40-73-870-B
Based upon observations and interviews, the facility failed to ensure all areas remained free of foul odors.
Evidence
  1. On 5/8/2023, the licensing inspector (LI) and staff 1 conducted room checks on the secured unit and the rooms for resident 2 and 3 both smelled of urine. Resident 3’s room also had feces on the carpet next to his bed.
  2. On 5/8/2023, the LI interviewed staff 1 and 2 and both stated the rooms for residents 2 and 3 smelled of urine and that feces was observed on resident 3’s carpet. Staff 2 stated there was feces on the carpet at 7:00 pm the previous day (5/7/2023) and staff tried to clean it up with wipes, Sani-cloths, and soapy paper towels. Staff 2 stated resident 2’s room smelled of urine sometimes but resident 3’s room smelled of urine all the time.
  3. On 5/8/2023, the LI interviewed staff 3 and 4 and both stated resident 3 had a bowel movement and they cleaned him up and reported to housekeeping that there was feces on the carpet. Both staff stated it was reported to housekeeping over the weekend that there was feces on resident 3’s carpet.
  4. On 5/8/2023, the LI interviewed collateral 1 who stated resident 2’s room often smelled of urine when entering and that it was reported to staff.
  5. On 5/8/2023 at the LI interviewed collateral 2 who stated feces was on the carpet when she arrived to resident 3’s room and that “the room smells like urine pretty much every time I come.”
Plan of correction
Housekeeping cleaned all units cited. Housekeeping is scheduled specifically to these rooms that require additional cleaning and will be documented. Maintenance is shampooing the units and hallways at a minimum weekly and additionally if needed. The Maintenance Manager is monitoring daily to ensure compliance and monitoring all units during daily rounds.
March 31, 2023Complaint survey2 violations
Inspection dates
03/31/2023
Areas reviewed
22VAC40-73 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 GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/31/2023 from approximately 9:37 am to 5:20 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/28/2023 regarding allegations in the areas of: Administrative and Administrative Services, Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 86 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: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 8 Observations by licensing inspector: On the secured unit: Resident rooms and common areas, medication administration and documentation and staff and resident record reviews. Additional Comments/Discussion: Staff schedules and progress notes were also reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-680-K
Based upon documentation, the facility failed to ensure all as-needed (PRN) orders included the specific symptoms for administering medications and what to do if symptoms persist for three of three resident records reviewed.
Evidence
  1. Resident 1’s signed physician’s orders for Bisacodyl (2/21/2023) and Lorazepam (3/18/2022 and 7/19/2022) did not include what to do if symptoms persist and the order for Lorazepam also did not include symptoms that indicate the use of the medications.
  2. Resident 2’s signed physician’s orders for Colace (2/24/2023) and Tylenol (2/14/2023) did not include what to do if symptoms persist and the symptoms that indicate the use of the medications.
  3. Resident 3’s signed physician’s orders for Furosemide (2/18/2023) and Quetiapine Fumarate (1/10/2023) did not include what to do if symptoms persist and the symptoms that indicate the use of the medications.
Plan of correction
A full audit was performed by RN on all facility residents PRN orders for completion. New orders were obtained to include the specific symptoms for administering medications and what to do if symptoms persist. Education will be provided to all nurses and medication aides by RN on the Virginia assisted living facility requirements for PRN orders to ensure staff obtaining verbal or written orders ensure those orders meet the requirements. Weekly audits of new PRN orders with be completed by RN/Care coach for one month to ensure all new orders for PRN medications are complete. If 95% compliance not achieved, audits will continue weekly until 95% compliance is achieved for one consecutive month and then will move to monthly.
22VAC40-73-680-I
Based upon documentation, the facility failed to ensure all required information was included on three of three medication administration records (MARs) reviewed.
Evidence
  1. The March MAR for resident 1 did not include the reason Lorazepam was given on 3/18/2023 at 1:20 pm.
  2. The March MAR for resident 2 did not include the reason Tylenol was given on 3/11/2023 at 2:57 pm.
  3. The progress notes for resident 3 indicated Quetiapine Fumarate was administered on 1/12/2023 at 1:36 pm, 4:45 pm, 7:51pm and 11:44 pm; on 1/17/2023 at 11:56 pm and 3/26/2023 at 8:45 pm; however, the January and March MARs were blank on all of these dates.
Plan of correction
Education will be provided to all nurses and registered medication aides (RMAs) by registered nurse (RN) on proper process for documenting medication administration, including the requirements for as-needed (PRN) medication administration which includes reason for administration and effectiveness. Weekly audits of MARs will be completed by RN/ care coach for one month to ensure reason for PRN medication administration was documented appropriately. If 95% compliance not achieved, audits will continue weekly until 95% compliance is achieved for one consecutive month and then will move to monthly.
January 10, 2023Inspection1 violation
Inspection dates
01/10/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Recommended an in-service be provided for all direct care and nursing staff regarding the requirement to document all rounds conducted by registered medication aides.
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: 1/10/2023 from approximately 1:45 pm to 3:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/10/2023 regarding allegations in the area of: Resident Care. Number of residents present at the facility at the beginning of the inspection: N/A 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Resident and resident room. Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-930-D
Based upon documentation and interviews, the facility failed to ensure rounds were documented.
Evidence
  1. The rounds documentation for resident 1 indicated the last round conducted on 1/9/2023 was at 6:36 pm. The 7:00 pm to 7:00 am shift staff had no documentation of rounds.
  2. On 1/10/2023, the licensing inspector interviewed staff 1 and 2 who were the two staff on duty on the secured unit. Both staff, who are registered medication aides (RMAs) stated RMAs may conduct rounds but it is the direct care aides that are to conduct and document the rounds. Staff 1 was the assigned RMA and staff 2 was the assigned direct care aide from 7:00 pm to 7:00 am on 1/10/2023. Both staff 1 and 2 stated they did not document the rounds they conducted every two hours as they were RMAs.
Plan of correction
Staff attended in-service for required documentation of completed rounds by the designated direct care aide. Assisted living program manager will audit round documentation daily until 1/31/22 to ensure compliance and then monthly for compliance.
January 10, 2023Inspection0 violations
Inspection dates
01/10/2023
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: 1/10/2023 from approximately 3:20 pm to 4:09 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/9/2023 regarding allegations in the area of: Resident Care Number of residents present at the facility at the beginning 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 4, 2022Complaint survey0 violations
Inspection dates
11/04/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 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: 11/4/2022 from approximately 12:55 pm to 3:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/3/2022 regarding allegations in the areas of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Staffing, pictures of staff and staff schedules Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 19, 2022Inspection4 violations
Inspection dates
10/19/2022, 10/20/2022
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 IMPAIRMENTS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Ensure language used is appropriate to services provided – first aid versus wound care. If treatment provided is for wound care, then only nurses may provide the care. If any area is open and beyond the superficial layer, then it is considered wound care. Only superficial skin care, such as a skin tear that requires first aid, may be provided by a registered medication aide. Ensure physicians’ orders include the correct wording to ensure on-going compliance.
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: 10/19/2022 from approximately 7:10 am to 6:45 pm and 10/20/2022 from approximately 7:30 am to 7:15 pm 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: 89 (74 assisted living, 15 secured unit) 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 + selected section of one additional record Number of staff records reviewed: 4 + 2 agency staff + selected sections of 3 additional staff + I volunteer Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 6 Observations by licensing inspector: Completed medication administration observations for three residents and reviewed the October 2022 medication administration records, signed physicians’ orders and medications for those residents. Also observed activities, meals, required postings and staffing. Additional Comments/Discussion: Checked the stat box, first aid kit, reviewed the health care oversights and special diets and three private sitter records. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-560-E
Based upon observations and interviews, the facility failed to ensure resident records were kept in a locked area.
Evidence
  1. During the facility tour on 10/19/2022, the LI observed the care base on the first floor unlocked and unattended. Resident records were stored in an unlocked cabinet in the care base.
  2. On 10/19/2022, the LI interviewed staff 6 who stated she was told as long as the door was shut it did not need to be locked.
Plan of correction
Locked and secured the door immediately. Staff retrained on the necessity of keeping the door closed and locked when unattended. All new staff will be trained upon hire. The Care Coach/ED or designee will perform daily rounds to ensure compliance
22VAC40-73-260-C
Based upon observations, documentation and an interview, the facility failed to ensure the posting with staff who were certified in first aid (FA) and cardiopulmonary resuscitation (CPR) remained current.
Evidence
  1. On 10/19/2022, the licensing inspector (LI) observed the posted list of staff with current FA and CPR in the second floor care base on the bulletin board. The list was dated May 2022.
  2. The list did not include staff that were hired since July 2022.
  3. On 10/20/2022, the executive director (ED) reviewed the list and stated it did not include staff hired since July 2022.
Plan of correction
Notified scheduler to update CPR/First Aid posting. Updated list posted. The scheduler will update list upon new hires and renewal of certification. The Care Coach will audit monthly for compliance
22VAC40-73-1140-B
Based upon documentation and an interview, the facility failed to ensure four of six staff completed at least 10 hours of dementia training within the first four months of hire.
Evidence
  1. Staff 2 (hired 9/20/2021) completed 6 hours of dementia training from 9/20/2021 to 1/20/2022.
  2. Staff 4 (hired 11/1/2022) completed 4 hours of dementia training from 11/1/2022 to 3/1/2022.
  3. Staff 8 (hired 6/1/2022) completed 5 hours of dementia training from 6/1/2022 to 10/1/2022.
  4. Staff 9 completed 1 hour of dementia training from 5/1/2022 to 9/1/2022.
  5. On 10/20/2022, the Li interviewed ED who stated these were the only training hours completed for these staff.
Plan of correction
Steps to correct non-compliance: staff completed required dementia training. The department director/education director will audit dementia training completion monthly for new hires. New hires will be notified immediately to complete training for compliance
22VAC40-73-860-I
Based upon observations and interviews, the facility failed to ensure all cleaning supplies were kept in a locked storage area.
Evidence
  1. During the facility tour on 10/19/2022, the LI observed two large containers of bleach in the first floor hallway outside of the maintenance storage closet. The containers were left in an unlocked area and were unattended. Also, the cleaning supply closet in the kitchen was observed by LI with the door open, key in the lock and unattended.
  2. LI showed staff 7 the open cleaning closet and she stated it should be locked.
  3. The LI also showed the ED the containers of bleach and she stated the staff know better than to leave cleaning supplies unlocked.
Plan of correction
The two containers were immediately moved to a lock area. Secured the cleaning supply closet immediately and removed key from lock. Staff retrained on the necessity of keeping all cleaning supplies locked at all times. All new staff will be trained immediately upon hire. The Facilities Manager or designee will ensure compliance through daily rounds.
May 17, 2022Complaint survey2 violations
Inspection dates
05/17/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Technical assistance
1. Reviewed the requirements for notifying licensing and adult protective services and the importance of documenting behaviors exhibited by residents and contacts with all required parties. 2. Recommended the 24 hour report be printed and placed in the care bases for easy access to all direct care staff. Note: This information was available to all direct care staff to review on the computer. According to staff interviews, this information was reviewed during verbal reports at the beginning of each shift. 3. Recommended an in-service for all staff be conducted to review documentation and reporting requirements.
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: 5/17/2022 from approximately 11:50 am to 5:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/16/2022 regarding an allegation in the area of resident care. Number of residents present at the facility at the beginning of the inspection: 65 on the assisted living unit and 18 on the memory care unit. Number of resident records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 12 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were in the area of administrative services and resident care. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-70-A
Based upon documentation and interviews, the facility failed to ensure major incidents that threatened the life, health and safety of residents were reported to the licensing office within 24 hours.
Evidence
  1. Progress notes on 5/9/2022, 5/10/2022 and 5/11/2022, stated inappropriate touching occurred between residents 1 and 2.
  2. On 6/1/2022, the licensing inspector (LI) interviewed the administrator who stated none of these incidents were reported to the licensing office within 24 hours.
Plan of correction
Review of 22VAC40-73-70 regarding incident reporting requirements to the licensing office within 24 hours will be completed by the care coach or executive director. The care coach will hold an in-service with all direct care staff to ensure they have knowledge and understand reportable incidents and that they must notify a supervisor of any such incident at the time of the incident, or at the time they learn of the incident. Incident reports will be submitted for all records cited. The care coach will monitor all progress notes daily to ensure incident reports are submitted within 24 hours
22VAC40-73-470-F
Based upon documentation and interviews, the facility failed to notify the legal representative for one of two residents within 24 hours of three incidents.
Evidence
  1. Progress notes indicated inappropriate touching occurred between residents 1 and 2 on 5/9/2022, 5/10/2022 and 5/11/2022.
  2. Progress notes indicated the legal representative for resident 2 was not notified of the incidents until 5/13/2022.
  3. On 5/17/2022, the LI interviewed staff 1, 2, 3 and 4 and all of them stated they did not notify the legal representative of resident 2 within 24 hours regarding the incidents that occurred.
  4. Staff 2 stated she met with the legal representative of resident 2 on 5/13/2022 and informed her of the incidents.
Plan of correction
Review of 22VAC40-73-470.F regarding notifying the legal representative within 24 hours of an incident will be completed by the direct staff person in charge or the care coach. The care coach will hold an in-service with all direct care staff to review the process and timeline of notifying legal representatives of reportable incidents. The care coach will monitor all progress notes daily to ensure legal representatives are notified of incidents within 24 hours.
August 31, 2021Inspection2 violations
Inspection dates
08/31/2021, 09/01/2021, 09/03/2021
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 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
1. Recommended indicating the minimum length of each activity and only indicating the start and end time of the activity when it is different from the minimum length. 2. Fire inspection needs to be submitted to the licensing inspector upon completion. 3. The resident orientation form may be signed by the family member; however, the resident must still sign the form, even when the resident has a serious cognitive impairment. 4. Recommended when resident has signed an agreement to have meals in room that this information be included on the individualized service plan. 5. Update the name and contact information of the new licensing administrator on all Residents' Rights forms and discard any previous forms so they are not used. 6. Recommended the administrator send an email to the fire inspector to get clarification on the requirements for fire drills. 7. Note on schedule which staff are assigned to the secured unit.
Comments
A monitoring inspection was initiated on 8/31/2021 and concluded on 9/3/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 99. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed five resident and five staff records, selected sections of six additional resident and three staff records, one volunteer record, one contract staff record, activities calendar, menu, staff schedules, fire drills, health care oversight, dietary reviews, medication administration records, physicians' orders and other information submitted by the facility to ensure documentation was complete. The inspector conducted a virtual inspection on 9/3/2021. An exit interview was conducted with the administrator on the date of the virtual 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 with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-640-A
Based upon documentation and interviews, the facility failed to implement the medication administration plan for two of the five resident records reviewed.
Evidence
  1. Resident 4 had a physician's order signed 8/10/2021 for "Diclofenac Sodium Gel 1% apply two gram transdermally every 8 hours as needed for Pain in hands. If no relief in 48 hours, contact PCP." The renewed order indicated the start date was 10/27/2020.
  2. The August and September medication administration records (MARs) for resident 4 listed "Diclofenac Sodium Gel 1% apply 2 gram transdermally every 8 hours as needed for Pain in hands. If no relief in 48 hours, contact PCP."
  3. On 9/3/2021, the licensing inspector (LI) along with staff 7 conducted a virtual medication cart audit and the Diclofenac Sodium Gel was not found in the medication cart.
  4. On 9/3/2021, the LI interviewed staff 7 and she stated the gel was not in the medication cart.
  5. Resident 5 had signed physician's orders to self-administer Biotene Dry Mouth, Artificial Tears and Hydrocortisone Cream.
  6. The August and September MARs for resident 5 listed the Biotene Dry Mouth, Artificial Tears and Hydrocortisone Cream as "May keep at bedside for resident to self-administer."
  7. The uniform assessment instrument (UAI) completed 6/24/2021, indicated resident 5 "Self-administers Artificial Tears, Biotene and Hydrocortisone."
  8. The individualized service plan (ISP) for resident 5, completed and signed on 6/24/2021 by staff stated, "Resident will be safe administering approved medications in their apartment per PCP orders." Artificial Tears, Biotene and Hydrocortisone were then listed.
  9. On 9/3/2021, the LI (virtually) along with staff 7 went to resident 5's room and she stated she did not have the Artificial Tears, Biotene and Hydrocortisone Cream as she was out. Staff 7 asked where these medications would be kept and then checked this area and around her room and the medications were not found.
  10. An assessment for resident 5 to self-administer these medications was completed on 8/2/2021 by the director of assisted living (DAL).
  11. A progress note for 7/1/2021 electronically signed by staff 8 stated, "Resident's son brought in Artificial Tears, Biotene, and Hydrocortisone for resident to self-admin-two bottles of each, should be notified to bring in more 9/1/21."
  12. On 9/3/2021, the LI interviewed the administrator who stated there was no documentation indicating the family was notified to reorder these medications.
  13. The facility's medication management plan states under the section Pharmacy Communication, 7.a. "All medications will be monitored by the staff responsible for administering medication. All orders will be double checked by the night shift charge nurse/med tech nightly in PCC/eMAR for accuracy and filled in a timely manner. The pharmacy will be notified within 7 days prior to the last dose being administered. All communication of medication ordering will be documented in PCC as an order or reorder. 9.a. All medication staff are responsible for monitoring the need for refills and the pharmacy will be notified within 7 days prior to the last dose being administered. A LPN/RMA will enter reorder in PCC to ensure refill request sent. LPN/RMA will sign off as supply available when medication arrives. This applies to both scheduled and PRN medication."
Plan of correction
The physician discontinued all orders for the Diclofenac. The Artificial Tears, Biotene and Hydrocortisone were discontinued per the physician. Nursing staff administering medication will complete an in-service by 9/24/21 reviewing the medication management plan to ensure medication orders are entered into the MARs correctly, ordered medications are available in the medication cart, approved self-administering medications are available and ensuring communication to responsible family at least seven days prior to the last dose when reordering is needed. The director of nursing will audit MARs, medication carts and self-administering medications quarterly to ensure compliance.
22VAC40-73-680-G
Based upon observations, documentation and an interview, the facility failed to ensure one of three residents' medications reviewed were properly labeled.
Evidence
  1. Resident 1 had physician's orders signed on 8/11/2021 for therapeutic multivitamin, one tablet by mouth one time a day for heath maintenance, and vitamin D-3 one 125mcg tablet by mouth one time a day for health maintenance.
  2. On 9/3/2021, the LI, along with staff 7, conducted a cart audit and the over-the-counter therapeutic multivitamin and vitamin D-3 did not have pharmacy labels nor were they labeled with the resident's name.
  3. On 9/3/2021, the LI interviewed staff 7 and she stated these two medications were not labeled with the resident's name.
Plan of correction
The over-the-counter (OTC) medications were immediately properly labeled with the resident's name. Nursing staff administering medications will complete an in-service by 9/24/21 to review the medication management plan for labeling resident medications. The director of nursing will audit the medication carts quarterly to ensure compliance.