Virginia DSS · Assisted Living Facility

Sunrise at Bon Air

📍 2105 Cranbeck Road, Richmond, VA, 23235

ID 39026Two Year licenseActive
18
Inspections
On record
6
With violations
Visits that cited something
12
Clean visits
Nothing cited
21
Violations cited
Individual findings
19
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

Sunrise at Bon Air was inspected 18 times between May 25, 2021 and June 4, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 21 violations under 19 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.

VDSS publishes inspections on a rolling window. 17 of these 18 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
07/01/2026
Administrator
Linda Bishop
Licensing inspector
Shelby Haskins
Inspector phone
(804) 305-4876
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

18

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

June 4, 2026Inspection0 violations
Inspection dates
06/04/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/4/2026 10:15 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: All required postings, activities were in progress, lunch meal and snacks, medication administration, medication administration records(electronic), physician's orders, emergency supplies, water temperature, Additional Comments/Discussion: Staff embers were given the opportunity to ask questions. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov for Shelby Haskins. Shelby,Haskins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 30, 2026Complaint survey0 violations
Inspection dates
03/30/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 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: 03/30/2026 arrival time: 4:00pm departure time: 5:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/12/2026 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS, 22VAC40-73-(8) BUILDINGS AND GROUND and 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Inspector interviewed Sr. Executive Director, Sr. General Manager and newly hired Administrator. Resident record and diagnoses were reviewed. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 6, 2026Complaint survey0 violations
Inspection dates
03/06/2026
Areas reviewed
22VAC40-73 PERSONNEL, 22VAC40-73 STAFFING AND SUPERVISION and 22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/06/2026 arrival time: 3:00pm departure time: 4:15pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/04/2026 regarding allegations in the area(s) of: 22VAC40-73-(3) PERSONNEL, 22VAC40-73-(4) STAFFING AND SUPERVISION and 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Interviewed Executive Director, reviewed staff record (who has been terminated) to include credentials Job Offer/Description, Hiring dates, termination letter. 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 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov Violation Notice Issued: No By signature, the facility representative acknowledges receipt of the inspection findings, including the Inspection Summary, Violation Notice (if applicable), and Supplemental Information, and affirms that the inspector reviewed all information contained therein. Inspector Signature: Shelby Haskins Date Issued: 3/6/2026
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 3, 2025Inspection2 violations
Inspection dates
11/03/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/03/2025 arrival time: 1:40pm departure time 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/29/2025 regarding allegations in the area(s) of: 22VAC40-73-(4) STAFFING AND SUPERVISION, 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS and 63.2-(16) PROTECTION OF ADULTS AND REPORTING. Number of residents present at the facility at the beginning of the inspection: 83 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Inspector interviewed Resident Care Director and acting Administrator. Resident record was reviewed along with staff records reviewed of those staff that were involved in the incident in addition to reviewing the facility’s internal investigation summary. Additional Comments/Discussion: N/A The evidence gathered during the investigation supported the (allegation(s)/self-report) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: Yes
Violations
22VAC40-73-460-A
Based on interviews a review of the facility’s internal investigation, it was determined that the facility failed to ensure that the facility/staff shall assume general responsibility for health, safety, and wellbeing of the residents.
Evidence
  1. Reviewed facility’s internal investigation on the self-report incident involving resident #1.
  2. Reviewed facility’s staff training policy on mandated reporting and direct care training on dealing with difficult residents.
Plan of correction
On October 3, 2025, staff involved in the incident were terminated. On October 3, 2025, the Interim Executive Director retrained all staff working in reminiscence (the day of incident) on mandated reporting requirements, care standards and appropriate management of residents with behaviors. On November 25, 2025 during staff meeting- Business Office Coordinator and/or Executive Director will retrain all staff on mandated reporting, Resident Rights, care standards and how to appropriately manage residents with behaviors. -Any staff not in attendance will receive the required training prior to December 20, 2025. The Business Office Coordinator or designee will train all new staff on mandated reporting and dealing with residents exhibiting behaviors during each new hire orientation. The Business Office Coordinator or designee will ensure all employees receive annual re-training on mandated reporting, resident rights, care standards and managing residents with behavioral concerns.
22VAC40-73-110-1
Based on a review of facility documentation and interviews, it was determined that the facility did not ensure all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. Reviewed staff records and staff training for staff #6 in which training was received in reference to mandated reporting and the facility’s staff in reference to direct care with residents and the facility’s policy.
  2. Interviewed staff #1, staff #2 and staff #4 who confirmed that staff #6 received training in reference to mandated reporting and facility’s staff policy.
  3. Staff #1, staff #2 and staff #4 confirmed that staff #6 was terminated on 10/03/2025.
Plan of correction
On October 3, 2025, the Interim Executive Director retrained all staff working in reminiscence (the day of incident) on care standards, mandated reporting requirements and appropriate management of residents with behaviors. On November 25, 2025 during staff meeting- Business Office Coordinator and/or Executive Director will retrain all staff on care standards, Residents Rights, mandated reporting, and how to appropriately manage residents with behaviors-Any staff not in attendance will receive the required training prior to December 20, 2025 The Business Office Coordinator or designee will ensure all employees receive annual re-training on care standards, mandated reporting, resident rights and managing residentswith behaviors.
May 5, 2025Inspection0 violations
Inspection dates
05/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/05/2025 arrival time: 11:00am departure time: 4:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Inspector completed a Monitoring Inspection. Observed a medication pass, water temperature tested, reviewed fire inspection, reviewed health inspection and had a tour of the building and grounds. Residents were observed having a Cinco De Mayo party at the time of the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 21, 2025Complaint survey0 violations
Inspection dates
04/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/21/2025 arrival time: 11:55am departure time: 1:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/10/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector reviewed resident records to include daily nurse’s notes, physical therapy notes, notes from previous hospitalizations along with meeting and communication logs with the POA. Interviewed with Executive Director, Resident Care Director as well as the resident. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 5/8/2025
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 27, 2025Complaint survey0 violations
Inspection dates
01/27/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 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: 01/27/2025 Arrival time: 11:15am Departure time: 12:15pm 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 01/20/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS, 22VAC40-80-(G7) COMPLAINT INVESTIGATION 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector reviewed facility’s policy in reference to Safe Resident Transfer/Movement training (Safe Resident Movement Program-SRMP) for Direct Care Staff. Inspector also reviewed the resident’s Individualized Service Plan (ISP) Plan of Care. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 31, 2024Complaint survey0 violations
Inspection dates
07/31/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/31/2024 Arrival time: 11:35am Departure time: 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/23/2024 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector observed care manager of the facility and Hospice provider, providing ADL’s and resident care to the resident during the inspection in the resident’s room. Additional Comments/Discussion: Upon an interview with Executive Director, a review of the facility's communication logs for resident, G. Wiggins' Care Plan, UAI, Hospice notes, ISP and other pertinent documentation. The facility's Call Bell service history for July 20-July 22, 2024 was reviewed. The inspector also observed the resident being provided care by a care manager of the facility and Hospice worker from James River Hospice during the inspection. It has been determined that the facility has completed it's due diligence. An exit meeting will be conducted to review the inspection findings. 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. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 4, 2024Inspection0 violations
Inspection dates
06/04/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/04/2024 10:00am to 12:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on May 16, 2024 regarding allegations in the area(s) of: Resident care and related services, Protection of adults and reporting, 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector observed resident #1 records to include Uniform Assessment Instrument (UAI), Individualized Service Plan (ISP) and Medication Administration Record (MAR’s) in addition to the resident’s discharge paperwork from ER visit and skin graph that was completed. Additional Comments/Discussion: Inspector also observed resident in Memory Care unit engaged with other residents watching TV. She sat guarded but in a relatively pleasant demeanor while engaged with staff and others. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 8, 2024Inspection0 violations
Inspection dates
05/08/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/08/2024 arrival 10:30am departure 1:45pm 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: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Inspector observed some of the residents leaving the building for a scheduled field trip. Additional Comments/Discussion: The facility has an award displayed in the building naming them as Best Senior Living Winner for 2024 by A Place for Mom and Best Memory Care 2023-2024 by US News. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 9, 2024Complaint survey0 violations
Inspection dates
01/09/2024
Technical assistance
Staff education on ventilation system by maintenance
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: 1-09-2024, 8:50 – 9:40 a.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 11-02-2023 regarding allegations in the area of: Buildings and Grounds; Safe, Secure Environment. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 8, 2023Inspection0 violations
Inspection dates
09/08/2023
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09-08-2023 – 9:00 a.m. – 9:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on July 7, 2023 regarding allegations in the area of Resident Care and Related Services. 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 20, 2023Complaint survey2 violations
Inspection dates
06/20/2023
Areas reviewed
22VAC40-73 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: 6-20-2023, 1:01 – 1:40 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 3-15-2023 regarding allegations in the areas of Resident Care and Related Services and 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: 76 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: Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-1110-A
Based on record review and interview with staff, the licensee, administrator, or designee failed to determine whether placement in the special care unit is appropriate prior to admission a resident with a serious cognitive impairment in the safe, secure environment (SSE). The determination and justification for the decision shall be in writing and shall be retained in the resident's file.
Evidence
  1. Resident #1’s Approval for Placement in the Special Care Unit was completed by the legal representative for the resident dated 3-10-2023 and the physician dated 3-08-2023. 2.There is no documentation of approval for placement in the SCU by the administrator or administrator’s designee.
Plan of correction
Not published by VDSS.
22VAC40-73-1070-A
Based on record review and interview with staff, the facility failed to ensure when there are indications that ordinary objects may be harmful to a resident with a serious cognitive impairment, these objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. Resident #1’s Progress Notes dated 4-14-2023 documented under Nurse Practitioner [NP] Note, “Skin: skin around lips w/ some erythema, small healing nick area from shaving… Contact Dermatitis: to skin around lips from shaving…”
  2. Additionally, Progress Notes dated 3-14-2023 documented, “…notified wellness resident [#1] observed with redness swelling to face where resident shaves, RP [responsible party] observed resident shaving his bare skin on face and attempted to shave [resident #1’s own] eyebrow, RP removed razor from residents room and brought it to wellness…”
  3. Resident #1’s ISP dated 3-11-2023 documented under Grooming, “Observe for and report any changes in my ability to perform grooming tasks” identified on 9-08-2021. Additionally under Housekeeping services, “Hazardous materials will be kept secured to keep me safe…”
  4. Staff #1 confirmed during interview that Resident #1 hadaccess to an electric razor that caused an injury above his lip and was “under staff supervision” while using it.
Plan of correction
Not published by VDSS.
June 20, 2023Inspection5 violations
Inspection dates
06/20/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Resident Council resolutions Length of activity time code Menu specifications
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-20-2023, 9:00 a.m. – 1:00 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed:3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-750-C
Based on observation and interview with staff, the facility failed to ensure that a written specification that a resident does not wish to have an item listed in subsection B (a separate bed with comfortable mattress, springs, and pillow) was obtained.
Evidence
  1. Resident #1 was observed on 6-20-2023 as having a recliner in his room and no bed. Resident #1’s record did not contain documentation of a preference for not having a bed in the resident’s room.
Plan of correction
A. With respect to the resident/situation cited: ED/RCD reviewed ISP for Resident #1 and include his personal preference of having a recliner in place of bed. B. With respect to how the facility will identify residents/situation with the potential for identified concerns: The Assisted Living Coordinator and Reminiscence Coordinator will audit ISPs of residents with different sleeping accommodation preferences to ensure residents sleeping accommodation preferences are noted. C. With respect to what the systemic measures have been put into place to address stated concern: Upon a residents move in or change in required living accommodations; the community will update ISP with preferred accommodations. D. With respect to how the plan of correction will be monitored. During the monthly wellness visit the RCD or designee will audit residents’ room for preferred sleeping accommodations.
22VAC40-73-1110-B
Based on record review, the facility failed to ensure that six months after placement of the resident in the safe, secure environment (SSE) and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.
Evidence
  1. Resident #5 admitted to the SSE on 3-03-2021 according to the “Review of Appropriateness of Continued Residence in Special Care Unit”. The last review in Resident #5’s record was documented as having been completed on 1-26-2022 and was due in January 2023.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #5 continued special care placement form completed and placed resident file. B. With respect to how the facility will identify residents/situations with the potential for identified concerns: The ED or designee will audit all special care unit resident files to ensure proper documentation of continued placement for Special Care Unit is in place. C. With respect to what systemic measures have been put into place to address the stated concern: Current/New Reminiscence residents’ approval for Placement in Special Care Unit forms will be reviewed by Resident Care Director or designee, prior to move in, 6 months and then annually. D. With respect to how the plan of correction will be monitored: ED will audit all new move ins and renewals for the next 3 months. Executive Director will review the POC and the results of the audit with the department heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-320-A
Based on record review, the facility failed to ensure that a person’s physical examination contained a statement that specifies whether the individual is or is not capable of self- administering medication.
Evidence
  1. Resident #7 admitted 8-25-2022 to the facility. Resident #7’s Physicians Move in Orders dated 8-23-2022 documented six questions under “Patient’s Ability to Self Medicate” including the question as to whether the resident is capable of self-administering medication, which was left unanswered by the physician who completed the form.
Plan of correction
A. With respect to the specific resident/situation: ED or designee has received an updated H & P from current physician for Resident #7 with all areas listed amened “Patient’s Ability to Self-Medicate” including the question as to whether the resident is capable of self-administering medication, which was left unanswered by the physician who completed the form. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The ED will audit all new move in H & P’s for completion prior to move in. C. With respect to what systemic measures have been put in place to address the stated concerns: Upon a Resident moving in the DOS will review MI paperwork to ensure accurate and complete, ED or designee with review H & P as well to ensure accurate and complete. D. With respect to how the POC will be monitored: Over the next 3 months ED will audit all H & P’s for completion and accuracy and review result with Department heads in real time. Additional improvement plans will be implemented as necessary, including training to correct any deficient practices.
22VAC40-73-490-D
Based on record review and interview with staff, the facility failed to ensure the healthcare oversight included the specific residents for whom the oversight was provided must be identified.
Evidence
  1. Healthcare oversight documents dated 12-28-2022 and 6-12-2023 did not identify the residents reviewed for either oversight period. Staff #1 confirmed during interview that the residents reviewed were not identified with the healthcare oversights from either period.
Plan of correction
A. With respect to the specific resident/situation cited: Residents reviewed during the healthcare oversight period have been attached to oversight form. B. With respect to how the facility will identify resident/situations with the potential for the identified concerns: ED and RCD will include names of resident records reviewed during oversight period. C. With respect to what the systemic measures have been put into place to address stated concern: The Resident Care Director and ED will review healthcare oversight to ensure all standards are met. D. With respect to how the Plan of correction will be monitored: 6 months following the implementation of the POC ED will audit the HealthCare oversight.
22VAC40-73-450-D
Based on record review and interview with staff, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.
Evidence
  1. Resident #7 admitted 8-25-2022. Resident #7’s ISP dated 2-28-2023 did not document hospice services; however, hospice notes in Resident #7’s record ranged from 2-22-2023 to 6-19-2023 and were ongoing at the time of inspection.
Plan of correction
A. With respect to the specific resident situation: Resident #7 ISP updated to include hospice provider & contact information with agreed upon plan of care. B. With respect to how the facility will identify residents/situations with the potential for identified concerns: The Assisted living and Reminiscence Coordinator will audit all residents receiving hospice services to confirm services are included on the ISP. C. With respect to what systemic measures have been put in place to address the stated concern: Upon a resident beginning Hospice service, the Resident Care Director or designee will update the ISP with information of the Hospice agency and services provided. Upon completion of updating the ISP the respective Care coordinator will review the ISP to verify it has been updated with the information of the Hospice Agency and services being provided. D. With respect to how the plan of correction will be monitored: During the Interdisciplinary team meeting and up to 3months following the implementation of the POC, the executive director will review the POC and the results of the audit with the department heads.
October 13, 2022Complaint survey5 violations
Inspection dates
10/13/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTSXX 22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Other non-prescription, OTC items kept in resident rooms
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-13-2022, 8:20 – 11:00 a.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 9-06-2022 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 80 Number of resident records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 Alexandra Poulter, Licensing Inspector at 804-662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observation and interview with staff, the facility failed to ensure a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents.
Evidence
  1. During a tour of the facility on 10-13-2022, the following was observed: a. Resident #3’s bathroom contained a barrier cream that is prescribed to the resident. Resident #3’s UAI dated 5-24-2022 documented that the resident’s medications are to be administered by professional nursing staff.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #3’s barrier cream was removed from bathroom during the inspection and placed in the secured medication cart. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Assisted Living Neighborhood Coordinators conducted rooms sweeps at the time of the inspection to verify that all prescription medications identified as being administered by professional nursing staff were secured on the medication cart. C. With respect to what systemic measures have been put into place to address the stated concern: All medication aides upon hire will be trained on securing medications from being available to residents. On a quarterly basis all medication aides are trained on the process of securing prescribed medications from being available to residents. The Assisted Living and Reminiscence neighborhood Coordinators conduct rooms sweeps weekly to verify that there are no unsecured prescription medications. The Wellness nurses also do room sweeps during their monthly wellness visits and verify that there are no unsecured prescription medications. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-440-A
Based on record review and interview with staff, the facility failed to ensure the UAI was completed at least annually.
Evidence
  1. Resident #4 admitted 6-2-2021. Resident #4’s current UAI was not in the record. Staff did not produce a UAI when requested onsite or after inspection.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #4; Neighborhood Coordinator acquired verification with resident responsible party (RP) for the UAI dated 8-13-2022. This UAI was placed in resident’s record. B. With respect to how the facility will identify situations with the potential for the identified concerns: An audit of current resident UAIs will be performed to verify compliance of responsible party (RP) review and sign-off. An audit of current resident UAI’s was performed to verify each resident has a current UAI and that UAI’s are being completed at least annually C. With respect to what systemic measures have been put into place to address the stated concern: Wellness Nurses and Neighborhood Coordinators have been trained to verify that current UAIs are in resident records and that UAI’s are being completed at least annually. Quarterly audits, for three quarters, will be conducted by the Resident Care Director and/or the Executive Director to verify each resident has a current UAI and UAIs will be completed annually. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-640-A
Based on record review and interview with staff, the facility failed to implement a written plan for medication management including methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. The facility’s policy “Medication Not Available” dated 03-2021 documents, “Every effort should be made to proactively order/reorder medications to avoid medications not being available when needed.”
  2. The key code for MD on the facility’s Medication Administration record (MAR) documented it stands for “medication pending delivery”. The following resident’s medications were marked MD on the following dates: a. Resident #1 - Ensure Liquid on 8-3-2022 and 8-4-2022 twice a day, and Acetaminophen 5 ml 8-2-2022 twice out of three times. b. Resident #2 - Vitamin D Capsule 50 mcg on 7-14-2022 and 7-15-2022, and 8-5-2022, 8-7-2022, 8-8-2022, 8-10-2022, and 8-11-2022. c. Resident #3 - Lubricating Jelly Gel nostrils 8-1-2022 – 8-3-2022 AM, 8-3-2022 PM, 8-4-2022 AM, 8-6-2022 through 8-8-2022 AM/PM, 8-9-2022 AM, 8-10-2022 AM/PM, 8-11-2022 AM, 8-12-2022 AM, 8-15-2022 AM/PM, 8-16-2022 through 8-22-2022 AM, 8-17-2022 PM and 8-19-2022 through 8-22-2022 PM 8-24-2022 AM/PM, 8-25-2022 AM, 8-26-2022 AM/PM, 8-27-2022 through 8-31-2022 AM, 8-27-2022 PM, 8-29-2022 PM, and 8-31-2022 PM; Colace 2-n-1 8-6-2022 PM, 8-17-2022 AM, 8-18-2022 AM, 8-20-2022 AM. d. Resident #5 - Trazodone 7-1-2022 and 8-17-2022 through 8-23-2022.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1 did not experience any adverse effects. Resident #1’s Ensure Liquid and Acetaminophen 5ml was ordered and obtained immediately. The medication was received and is available for administration. Resident #2 did not experience any adverse effects. Resident #2’s Vitamin D Capsule 50 mcg was ordered and obtained immediately. The medication was received and is available for administration. Resident #3 did not experience any adverse effects. Resident #3’s Lubricating Jelly Gel nostrils was ordered and obtained immediately. The medication was received and is available for administration. Resident #5 did not experience any adverse effects. Resident #5’s Trazodone was ordered and obtained immediately. The medication was received and is available for administration. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Wellness Nurses conduct daily audits of the medications pending delivery and follow up with the Medication Care Managers (MCM) and the Pharmacy to verify medications are delivered timely. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director (RCD) or Designee will re-educate Medication Care Managers, by utilizing the medication management plan and program, on the processes and procedure to confirm that resident medication is available as prescribed by the physician(s). The MCMs were re-educated to continue to report disparities to the RCD or Wellness Nurses so that any discrepancy can be addressed timely by the pharmacy and physicians. The RCD or Designee will conduct the refresher training on monthly bases for (2) quarters. The RCD or the Wellness Nurse (WN) conduct random audits of the e-MARs and Medication Carts weekly for three months to confirm that medications are available as prescribed by the physician(s). D. With respect to how the plan of correction will be monitored: The RCD or designee present the results of the audits to the Quality Assurance and Performance Improvement (QAPI) Committee for three months. During and at the end of the three-month period, the QAPI committee will evaluate the results of the audit and determine if additional focus or action is warranted. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure the individualized service plans (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #5 admitted 2-17-2020. Resident #5’s most recent update of the ISP was dated 8-24-2021. 2.Staff #1 confirmed during the inspection that the resident’s ISP was outdated during interview.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #5’s ISP was updated on 7/22/22. The current ISP was reviewed by staff, resident and responsible party to verify content. All signatures obtained and documentation filed. B. With respect to how the facility will identify situations with the potential for the identified concerns: An audit of current resident ISPs will be performed to verify compliance of accuracy of resident conditions, all signatures obtained, and documentation filed. C. With respect to what systemic measures have been put into place to address the stated concern: Wellness Nurses and Neighborhood coordinators have received education on ensuring that all parties have reviewed compliance components for ISP’s. A quarterly audit, for three quarters, will be conducted for by the Resident Care Director and/or the Executive Director to ensure resident and/or responsible party signed/executed acknowledgement and agreement on resident ISP. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-450-E
Based on record review and interview with staff, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan.
Evidence
  1. Resident #1 admitted 8-21-2020. Resident #1’s ISP dated 8-6-2022 was last signed by the facility staff; however, the last signature from Resident #1’s responsible party was 8-5-2021.
  2. Staff #1 confirmed the ISP was not signed by the resident or responsible party for updates of the ISP.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #1’s ISP was reviewed by the staff, resident, and responsible party. All signatures obtained and documentation filed. B. With respect to how the facility will identify situations with the potential for the identified concerns: An audit of current resident ISPs will be performed to verify that staff, resident and responsible party have reviewed the specifics of the ISP and signatures have been obtained. C. With respect to what systemic measures have been put into place to address the stated concern: Wellness Nurse and Neighborhood coordinators have received education on best practices to ensure all ISP’s are review by staff, residents, and RPs to ensure ISP’s are properly documented and executed. A quarterly audit, for three quarters, will be conducted for by the Resident Care Director and/or the Executive Director to ensure resident and/or responsible party signed/executed acknowledgement and agreement on resident ISP. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
June 17, 2022Inspection6 violations
Inspection dates
06/17/2022
Areas reviewed
¿22VAC40-73 GENERAL PROVISIONS¿22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿22VAC40-73 PERSONNEL¿22VAC40-73 STAFFING AND SUPERVISION¿22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿22VAC40-73 BUILDINGS AND GROUND¿22VAC40-73 EMERGENCY PREPAREDNESS¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿63.2 GENERAL PROVISIONS¿63.2 PROTECTION OF ADULTS AND REPORTING¿63.2 LICENSURE AND REGISTRATION PROCEDURES¿63.2 FACILITIES AND PROGRAMS¿22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿22VAC40-80 THE LICENSE¿22VAC40-80 THE LICENSING PROCESS¿22VAC40-80 COMPLAINT INVESTIGATION¿22VAC40-80 SANCTIONS
Technical assistance
Items in Special Care Unit - labeling
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/17/2022, 9:15 a.m. – 2:52 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 Number of resident records reviewed: 10 Number of staff records reviewed: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility, meal observation, medication pass, review of 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI) and other sources.
Evidence
  1. Resident #1 admitted 4-14-2022. Resident #1’s UAI dated 4-14-2022 documented resident requires no assistance with money management; however, the resident’s comprehensive ISP dated 4-22-2022 documented on 4-14-2022 under Finances, “Family, resident or resident’s representation manages all financial matters independently.”
  2. Resident #2 admitted 3-01-2022. Resident #2’s UAI dated 3-01-2022 document resident requires no assistance with laundry; however, the resident’s comprehensive ISP dated 3-04-2022 documented on 3-01-2022 under Laundry, “My laundry for linen and clothing is performed by my family”.
  3. Resident #4 admitted 8-31-2014. Resident #4’s UAI dated 1-06-2022 documented under Behavior Pattern (where options include “Wandering – Less than Weekly or Weekly or More”), as “Appropriate”; however, the resident’s comprehensive ISP dated 1-16-2022 documented, “I am an elopement risk/wanders”, and “I wander less than weekly”.
  4. Resident #6 admitted 2-11-2019. Resident #6’s UAI dated 1-27-2022 documented “Mechanical help” with stairclimbing; however, the comprehensive ISP dated 4-04-2022 documented under Stairclimbing, “I do not climb the stairs due to no stairs in the Sunrise community.” Additionally, the UAI documented, no assistance with money management; however, the ISP under Finances, “Family, resident or resident’s representative manages all financial matters independently.”
  5. Resident #8 admitted 3-03-2018. Resident #8’s UAI dated 5-24-2022 documented no assistance for bathing; however, the comprehensive ISP dated 5-28-2022 documented under Bathing Assistance, “My bathing care needs will be provided by Sunrise Care Team, my bathing care needs will be provided in my room, I need a shower/tub chair to assist with bathing, I need grab bars to assist with bathing, Observe for and report any changes in bathing assistance, Observe for and report any changes in my bathing ability, I am independent with bathing.” Under Bathing Preferences, the ISP documented, “I prefer to take a shower or sponge bath daily – HOSPICE COMPLETES MY SHOWERS/BATHS IF HOSPICE IS NOT AVAILABLE PLEASE MAKE SURE ITS COMPLETED”.
  6. Resident #7 admitted 6-30-2021. Resident #7’s UAI dated 5-05-2022 documented “human help, physical assistance” under bathing; however, the comprehensive ISP dated 6-17-2022 documented under Bathing Assistance, “My bathing care needs will be provided by Sunrise Care Team. My bathing care needs will be provided in My Apartment on Tuesday Mornings. I need a shower/tub chair to assist with bathing. I need grab bars to assist with bathing. Observe for and report any changes in my bathing ability. I need physical assistance of 1 person with bathing. Encourage me to participate with bathing as much as possible.” The UAI documented under Walking, “mechanical help only”; however, the ISP documented under Walking, “I need a walker to assist with walking. I am independent with Mechanical Help with walking. I do not walk due to (POST LEFT HIP FX).”
  7. Staff #1 confirmed the above mentioned above during interview.
Plan of correction
A. With respect to the specific resident/situation cited: The Assisted Living Coordinator and Resident Care Director have reviewed the UAI and ISP for Residents #1,2,4,6,8 and 7 and included a description of identified care needs and date. Resident #1 's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The ISP was updated to reflect that the resident requires family assistance with money management. Resident #2's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The UAI was updated to reflect that the resident requires assistance with laundry, provided by family. Resident #4's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The UAI was updated to reflect that the resident wanders less than weekly. Resident #6's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The ISP was updated to reflect that the resident requires mechanical assistance with stairclimbing and the UAI was updated to reflect assistance with money management. Resident #8's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The UAI was updated to reflect that the resident requires mechanical and human assistance with bathing. The ISP was updated to reflect that the resident requires grab bars and a shower chair for bathing with assistance by Hospice or Sunrise. Resident #7's UAI and ISP were reviewed to verify needs identified were captured on the ISP. The ISP was updated to reflect that the resident requires B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Assisted Living and Reminiscence Coordinators have audited resident UAls and ISPs to confirm resident care needs were captured on the ISP. C. With respect to what systemic measures have been put into place to address the stated concern: Upon completion of the UAI and ISP the designated Coordinator will review the contents of both documents to verify they are complete and consistent with the information documented. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-960-B
Based on observation, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes.
Evidence
  1. Photographic evidence obtained on 6-17-2022 showed the facility fire and emergency evacuation drawing documented “exit route”, “telephone”, “fire extinguisher” and “alarm”; however, no primary and secondary routes were identified, nor were the areas of refuge or assembly areas.
Plan of correction
With respect to the specific resident/situation cited: The facility fire and emergency evacuation drawing has been updated to include the primary and secondary evacuation route, as well as areas of refuge, assembly areas, and fire alarm boxes. The new document has been posted. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Maintenance Coordinator has inspected Emergency Evacuation drawings to verify drawings include primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. C. With respect to what systemic measures have been put into place to address the stated concern: Annually the Maintenance Coordinator will review the regulatory requirements for emergency evacuation drawing and verify changes to the drawings are not required. If so, the drawing will be updated to meet regulatory requirements and re-posted. Training will be provided to team members as needed. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months, the Executive Director and Department Heads will review the Plan of Correction (POC) to verify implementation. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-1100-C
Based on record review, the facility failed to document that the order of priority specified in subsection A of this section was followed (Prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority), and the documentation shall be retained in the resident's file.
Evidence
  1. Resident #10 admitted 3-02-2016 to the facility and relocated to the facility Special Care Unit (SCU) in July 2021. On the “Approval for Placement in Special Care Unit” form, it was blank for “Explanation of why written approval was not obtained from each individual higher on the list of priority.”
  2. Staff #1 confirmed during interview.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #10's Approval for Special Placement Form was reviewed by the Executive Director and the form was amended to include a response and explanation of why written approval was not obtained from each individual higher on the list of priority of the form. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director conducted an audit of Reminiscence resident's Approval for Placement in Special Care Unit forms to confirm that the section, "To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority" was completed correctly. Any forms missing this section was updated accordingly and signed and dated with the date of the change. C. With respect to what systemic measures have been put into place to address the stated concern: New Reminiscence resident's Approval for Placement in Special Care Unit forms reviewed by the Resident Care Director or designee, prior to move in to confirm that the section, "To be completed by assisted living facility. Explanation of why written approval was not obtained from each individual higher on the list of priority" was completed correctly. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-980-H
Based on record review and interview with staff, the facility failed to ensure at least 48 hours of the emergency food supply was on site at any given time.
Evidence
  1. Staff #2 escorted the licensing inspector offsite on 6-17-2022 to the storage unit where the emergency food is kept approximately .5 miles down the road.
  2. The facility emergency food supply was not kept onsite at any given time as confirmed by Staff #1 and Staff #2.
Plan of correction
A. With respect to the specific resident/situation cited: The Dining Service Coordinator has relocated the 48 hours of emergency food supply from the offsite storage to onsite secure storage area. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The facility practice of storing emergency food supply offsite is discontinued. C. With respect to what systemic measures have been put into place to address the stated concern: As the emergency food supply is replenished it will be stored onsite at the community. The Dining Service Coordinator will conduct monthly inspections of emergency food supply onsite to confirm at least 48 hours of supply available. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-320-A
Based on record review, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility that contained a description of the person’s reaction to any known allergies.
Evidence
  1. Resident #9 admitted 6-30-2021. The resident’s “Physician’s Move in Orders” consistent with the physical examination form documented allergies of Cephalexin, Codeine Phosphate, Diazepam, Penicillin, and Pentazocine-Naloxone; however, the form didn’t request allergy reactions and allergy reactions were not provided.
Plan of correction
A. With respect to the specific resident situation cited: The physician for resident #9 was notified by the Wellness Nurse of the "Physician's Move in Orders" (physical examination forms) did not include the question regarding allergy reactions. The physicians provided the responses, and the forms were updated. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: An audit was conducted of resident's physical examination forms to verify they are complete and include the question regarding allergy reactions and response if applicable. Any forms missing allergy reaction question and/or responses will be communicated with the respective physician for updating. C. With respect to what systemic measures have been put into place to address the stated concern: The process for reviewing physical examination forms upon receipt for complete responses to required fields and questions was reviewed with the nursing staff. The Director of Sales, Resident Care Director and Wellness Nurses have been in serviced on reviewing physical examination forms upon receipt for complete responses to all required fields and questions. The Resident Care Coordinator or designee reviews new admission physical examination forms to verify the form is complete with responses to required fields and questions D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-450-D
Based on record review, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.
Evidence
  1. Resident #10 admitted 3-02-2016. The resident’s “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” documented the start of care for services for the resident as 2-02-2022, and the latest recertification for hospice care services was through 7-31-2022. Resident #10’s most current ISP was dated 1-16-2022 and did not document hospice services were in place.
  2. Staff #1 acknowledged the aforementioned information
Plan of correction
A. With respect to the specific resident/situation cited: The Assisted Living Coordinator has reviewed and updated resident #10's ISP to include Hospice Services. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Assisted Living and Reminiscence Coordinators will audit ISPs of residents receiving Hospice Services to confirm services are included on the individualized service plan. C. With respect to what systemic measures have been put into place to address the stated concern: Upon a resident beginning hospice service, the Resident care Coordinator or designee will update the ISP with information of the Hospice agency and services being provided. Upon completion of updating the ISP the respective Care Coordinator will review the ISP to verify it has been updated with information of the Hospice agency and services being provided. Changes in resident care will be communicated with the care managers. D. With respect to how the plan of correction will be monitored: During the QAPI meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
December 16, 2021Inspection1 violation
Inspection dates
12/16/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
A remote monitoring was conducted regarding a self-report on December 16, 2021. The Administrator was interviewed via email regarding Administration and Administrative Services.
Violations
22VAC40-73-70-A
Based on interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Staff #1 reported on 12-15-2021 via email that, "...unfortunately [Staff #2] became ill and tested positive for COVID and also out of the community."
  2. The regional licensing office was not notified of the COVID positive reported incident until 12-15-2021 despite Staff #2 testing positive on 12-10-2021. The Central regional office was not notified within 24 hours.
Plan of correction
A. With respect to the specific violation cited: On 12/16/2021 the Executive Director (ED) reported to the Licensing inspector by email two events that occurred at the community. Upon identification of the events protocols were promptly followed by the Department Head Team and no negative outcomes from late reporting occurred. B. With respect to how the facility will identify procedure for timely reporting: The ED provided training and material to the Department Head Team on reporting major events as required to Regional Licensing in the absence of the ED. C. With respect to what systemic measures have been put into place to address the stated concern: Upon an event occurring the ED is notified and determines if the event needs to be reported to the Regional Licensing office and follows the reporting procedures. Daily the ED and the Department Head Team review the events that have occurred within the past 24 hours. The events are reported as required to the Regional Licensing office by the ED. In the absences of the ED, a department head team member or a trained designee completes the reporting process. Upon return the ED verifies the reporting process was properly followed. D. With respect to how the plan of correction will be monitored: The verification of this reporting process will be evaluated and confirmed the ED, RCD or designee at Quality Assurance and Performance Improvement (QAPI) meeting for the next 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted The Executive Director, RCD or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
May 25, 2021Inspection0 violations
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Comments
This inspection was conducted by Licensing staff using an alternate remote protocol necessary due to state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 5/25/2021 and concluded on 5/28/2021. The Associate Executive Director was contacted by telephone to initiate the inspection. The Associate Executive Director reported that the current census was 62. The Inspector emailed the AED a list of items required to complete the inspection. The Inspector reviewed 4 resident records, 4 staff records, staff schedules, Virginia criminal background checks and sworn affidavits, physician's orders, medication administration records, activity calendars, medication/pharmacy review, health care and dietitian oversights, fire inspection and drills submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.