Virginia DSS · Assisted Living Facility

Vitality Living Arlington

📍 3821 Wilson Boulevard, Arlington, VA, 22203

ID 40473One Year licenseActive
18
Inspections
On record
13
With violations
Visits that cited something
5
Clean visits
Nothing cited
45
Violations cited
Individual findings
36
Standards cited
Distinct rules
7
Complaint visits
Prompted by a complaint

Vitality Living Arlington was inspected 18 times between February 12, 2021 and April 27, 2026 by the Virginia Department of Social Services. 13 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 45 violations under 36 distinct standards. 7 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. 16 of these 18 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/23/2026
Administrator
Joni Mauritz
Licensing inspector
Alexandra Roberts
Inspector phone
(804) 845-6956
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

18

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

April 27, 2026Inspection2 violations
Inspection dates
04/27/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND
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: 04/27/2026 8:30am – 10am 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 04/09/2026 regarding allegations in the area(s) of: Buildings and Grounds 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: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents eating breakfast. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at (804) 845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on interview and record review, the facility failed to ensure that buildings shall be kept free of infestations of insects and vermin. The grounds shall be kept free of their breeding places.
Evidence
  1. On 04/09/2026, regional licensing office received an incident report that bed bugs were observed in Resident 1’s room at the facility.
  2. During inspection on 04/27/2026, Staff 1 confirmed that Resident 1 had a bed bug on their person on 04/09/2026.
  3. Record review confirmed that EcoLab came on-site on 04/09/2026, 04/10/2026, 04/11/2026 and 04/22/2026 with notation that EcoLab found and confirmed that bed bugs were in Resident 1 and located addition bed bugs in Resident 2’s bedroom.
  4. This is a repeat violation as the facility was cited for a bed bug infestation on 01/06/2026.
Plan of correction
Not published by VDSS.
22VAC40-73-290-B
Based on interview and observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. Upon arrival at the facility for an onsite inspection on 04/27/2026 at 8:30am, LI did not observe a person in charge posting.
  2. Staff 1 confirmed that there is no posting currently of who is in charge.
Plan of correction
Not published by VDSS.
January 6, 2026Complaint survey2 violations
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 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: 01/06/2026 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 12/31/2025 regarding allegations in the area(s) of: Building and grounds Number of residents present at the facility at the beginning of the inspection: 115 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: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov . Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-495-5956 or by email at Alexandra.n.roberts@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and interview, 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. On 12/30/2025, the regional licensing office received a complaint that bed bugs were observed in Resident 1’s room at the facility.
  2. During an onsite inspection on 01/06/2025, Staff 1 confirmed that bed bugs were found in Resident 1’s room on 12/30/2025 and that an incident report was not sent to licensing staff or office within 24 hours of the incident.
Plan of correction
Not published by VDSS.
22VAC40-73-870-D
Based on record review and interview, the facility failed to ensure that buildings shall be kept free of infestations of insects and vermin. The grounds shall be kept free of their breeding places.
Evidence
  1. On 12/30/2025, the regional licensing office received a complaint that bed bugs were observed in Resident 1’s room at the facility.
  2. During inspection on 01/06/2025, Staff 1 confirmed that Resident 1 had a bed bug on their person on 12/30/2025.
  3. Staff 1 confirmed that EcoLab came on-site on 12/30/2025 and 12/31/2025 in which EcoLab found and confirmed that bed bugs were in Resident 1’s mattress and bed area and treatment was initiated.
Plan of correction
Not published by VDSS.
November 18, 2025Inspection11 violations
Inspection dates
11/18/2025
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 PREPAREDNESS63.2 GENERAL PROVISIONS63.2 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: 11/18/2025 9am - 4:30pm 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: 115 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: 6 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed the residents participating in social hour and eating in the dining hall. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov.
Violations
22VAC40-73-870-B
Based on observation and interview, the facility failed to ensure that the building was well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During facility tour on 11/18/2025, two licensing staff observed black and brown spotting on the ceiling, dried urine around the toilet, and trash in cabinet under the sink in the 4th floor bathroom.
  2. During facility tour on 11/18/2025, two licensing staff smelled strong odors of urine and feces on floors 7 and 8.
  3. Staff 1 was notified of this matter.
  4. Photo evidence was obtained.
Plan of correction
• The 4th floor bathroom was cleaned at the time of inspection • A physical plant audit was completed on 11/20/2025 to verify that common bathrooms were clean and free of odors • Environmental Services Director was in-serviced on regulation 22VAC40-73-870B • Executive Director or designee will perform a physical plant inspection monthly x 3 months to verify that common bathrooms are properly maintained
22VAC40-73-860-I
Based on observation and interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During facility tour on 11/18/2025, two licensing staff observed Room 719 was vacant, unlocked and under construction. Licensing staff observed this room to have exposed installation, cement, paint and other hazardous construction material.
  2. During facility tour on 11/18/2025, two licensing staff observed an unlocked electrical room with exposed wires and a bottle of drain-o in the room.
  3. During facility tour on 11/18/2025, two licensing staff observed the communication closets on floor 7,8, and 9 to be unlocked with exposed wires that control the facility power source labeled “life support system”.
  4. Staff 1 acknowledged the unlocked rooms with cleaning supplies and hazardous materials.
  5. Photo evidence was obtained.
Plan of correction
• Hazardous Materials were secured at time of inspection, and the doors were verified as locked. • A physical plant inspection was completed the week of 11/21 to confirm that hazardous materials were secured in a locked storage area. • An Inservice will be completed by Maintenance Directo regarding securing hazardous materials. • Executive Director or designee will perform a physical plant inspection monthly x 3 months to verify that hazardous materials are secured in a locked storage area.
22VAC40-73-430-H-1
Based on record review and interview, the facility failed to provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains the following information: The date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; The reason or reasons for the discharge; The actions taken by the facility to assist the resident in the discharge and relocation process; and The date of the actual discharge from the facility and the resident's destination.
Evidence
  1. Resident 5 admitted on 04/17/25 and discharged from the facility on 9/19/25.
  2. During renewal inspection on 11/18/2025, Staff 1 confirmed that the facility did not complete a dated statement signed by the licensee or administrator that contains the date on which Resident 5, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; The reason or reasons for the discharge; The actions taken by the facility to assist the resident in the discharge and relocation process; and The date of the actual discharge from the facility and Resident 5’s destination.
Plan of correction
• Resident # 5 discharge statement was completed by signed by the Executive Director or designee • An audit will be completed of planned discharged resident from Jan 2025 to the current date to verify that the statement of discharge is completed • The Executive Director and designee were in-serviced on the regulation requiring the statement of discharge • The Executive Director or designee will conduct a random monthly audit of 5% of resident administrative files to verify compliance with the regulation.
22VAC40-73-350-C
Based on record review and staff interview, the facility failed to ensure that each resident or his legal representative is fully informed, prior to or at the time of admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 (? 9.1-900 et. seq.) of Title 9.1 of the Code of Virginia, including how to obtain such information. Written acknowledgment of having been so informed shall be provided by the resident or his legal representative and shall be maintained in the resident's record
Evidence
  1. Resident 1,2,3,4,5 and 6 records did not contain written acknowledgment of having been informed regarding sex offender registry.
  2. Staff 1 confirmed that they do not complete this notification to residents or representative.
  3. Facility was previously cited during the 05/08/2025 inspection.
Plan of correction
• Residents #1, 3, 4, 5, and 6 and their families ( POA/RP) were provided with the annual information regarding the sex offender registry and signatures were obtained acknowledging receipt. • Business office Director conducted an audit of current resident administrative files to verify that annual signatures have been obtained indicating that residents and Responsible Parties have received the annual information. • Business Office Director was in-serviced on regulation 22VAC40-73-350 12/4/2025 • The Executive Director or designee will conduct a random monthly audit of 5% of resident administrative files x _3___ months to verify compliance with the regulation.
22VAC40-73-150-B
Based on interview, the facility failed to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs.
Evidence
  1. On 10/13/2025, licensing staff received an email that Staff 7 resigned (last day of employment 10/10/2025), and Staff 1 would be the point of contact for the facility.
  2. Staff 1 is not a qualified administrator.
  3. During onsite inspection on 11/18/2025, the facility did not have an appointed administrator.
  4. Staff 1 confirmed that facility has not yet employed a new administrator or appoint a qualified acting administrator resulting in a lapse in administrator coverage since 10/10/2025 to date of inspection on 11/18/2025.
Plan of correction
• An administrator was hired an in place on 12/1/2025 • Staff person #1, while not a licensed administrator managed and oversaw the day to day operations of the community
22VAC40-73-150-A
Based on observation and interview, the facility failed to ensure to have an administrator of record.
Evidence
  1. On 10/13/2025, licensing staff received an email that Staff 7 resigned (last day of employment 10/10/2025), and Staff 1 would be the point of contact for the facility.
  2. Staff 1 is not a qualified administrator.
  3. During onsite inspection on 11/18/2025, the facility did not have an appointed administrator.
  4. Staff 1 confirmed that facility has not yet employed a new administrator or appoint a qualified acting administrator resulting in a lapse in administrator coverage since 10/10/2025 to date of inspection on 11/18/2025.
Plan of correction
• An administrator was hired an in place on 12/1/2025 • Staff person #1, while not a licensed administrator managed and oversaw the day to day operations of the community
22VAC40-73-320-A
Based on record review and staff interview, the facility failed to ensure that a resident’s physical examination contained all required information.
Evidence
  1. Resident 1 (admitted 02/24/2025) physical examination, completed on 02/20/2025, was missing the resident’s address and significant medical history.
  2. Staff 1 acknowledged missing information on the physical examination.
Plan of correction
• The Physical Exam for residents # 1 was unable to be updated as he passed away on 11/18/25 • An audit of Physical Exams will be completed to verify that current resident physical exams contain the required information. Exams identified as not in compliance with the regulation will be marked. • The Director of Wellness was in-serviced on the physical examination content requirements on 12/2/2025. • The Executive Director or designee will conduct a random monthly audit of 5% of current resident files for 3 months to verify that the physical exams contain the required information.
22VAC40-73-870-A
Based on observation and interview, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During facility tour on 11/18/2025, two licensing staff observed water fountains on floors 1, 4, 7, 8, and 9 with erosion markings with exposed cups on top of the fountain.
  2. Staff 1 was notified of this matter and confirmed that he could not recall the last time they have been taken apart and cleaned.
  3. Photo evidence was obtained.
Plan of correction
• The water dispensers on floors 1, 4 ,7, 8 and 9 have been serviced • An audit of the water dispensers within the community was completed by Maintenance Director to verify that the machines have been cleaned/serviced and the routine maintenance of these machines was added to the TELS application to ensure that they are maintained on a routine basis. • Environmental Services Director was in-serviced on regulation 22VAC40-73-870A • Executive Director or designee will perform a physical plant inspection monthly x 3 months to verify that water dispensers are properly maintained and clean.
22VAC40-73-925-B
Based on observation and interview, the facility failed to ensure that common face/hand washing sinks have paper towels or an air dryer.
Evidence
  1. During facility tour on 11/18/2025, two licensing staff observed the 4th floor common area bathroom across from physical therapy room to have no paper towels.
  2. Staff 1 acknowledged bathroom not having paper towels.
  3. Photo evidence was obtained.
Plan of correction
• A physical plant audit was conducted on 11/20/25 to verify that common bathrooms paper towel holders are stocked • Environmental Services Director was in-serviced on regulation 22VAC40-73-870B Executive Director or designee will perform a physical plant inspection monthly x 3 months to verify that common space bathrooms paper towel dispensers contain an adequate supply of paper towels • Executive Director or designee will perform a physical plant inspection monthly x 3 months to verify that common bathrooms are properly maintained.
22VAC40-73-450-E
Based on record review and interview, the facility failed to ensure individualized service plans are signed and dated by the resident or his legal representative.
Evidence
  1. During the renewal inspection on 11/18/2025, the following resident’s individualized service plans did not contain written signature from resident or the legal representative: a. Resident 1; ISP dated 07/22/2025 b. Resident 2; ISP dated 03/03/2025 c. Resident 3; ISP dated 01/20/2025 d. Resident 4; ISP dated 03/17/2025 e. Resident 6; ISP dated 10/22/2025
  2. Staff 1 confirmed that Resident 1, 2, 3, 4, and 6’s individualized service plans were not signed and dated by the resident or his legal representative.
  3. Picture evidence obtained.
Plan of correction
2VAC40-73-450-E Based on record review and interview, the facility failed to ensure individualized service plans are signed and dated by the resident or his legal representative. Evidence: 1. During the renewal inspection on 11/18/2025, the following resident’s individualized service plans did not contain written signature from resident or the legal representative: a. Resident 1; ISP dated 07/22/2025 b. Resident 2; ISP dated 03/03/2025 c. Resident 3; ISP dated 01/20/2025 d. Resident 4; ISP dated 03/17/2025 e. Resident 6; ISP dated 10/22/2025 2. Staff 1 confirmed that Resident 1, 2, 3, 4, and 6’s individualized service plans were not signed and dated by the resident or his legal representative. 3. Picture evidence obtained. • Emails confirming that the Responsible Parties have reviewed the IPS have been printed and attached to the Service Plans. The Service Plans have also been sent via Adobe Sign for signatures • An audit of current resident ISPs will be completed to verify that they are signed, or an email is attached indicating review. Service plan will also be sent via Adobe Sign as required • DOW or designee will be in-serviced regarding ISP reviews and signatures on 12/2/2025 • Executive Director or designee will conduct a random monthly audit of 5% of resident files x 3 months to verify compliance with the regulation.
22VAC40-73-100-A
Based on record review and staff interview, the facility failed to ensure at least an annual review of infection prevention policies and procedures for any necessary updates. A licensed health care professional, practicing within the scope of his profession and with training in infection prevention, shall be included in the review to ensure compliance with applicable guidelines and regulations. Documentation of the review shall be maintained at the facility.
Evidence
  1. During the onsite inspection on 11/18/2025, licensing staff requested the annual review of infection prevention policies and procedures for any necessary updates.
  2. Staff 1 confirmed that the plan has not been reviewed annually.
Plan of correction
• The Infection control policy was reviewed and signed by Vitality Senior Vice President of Wellness, Syndell Lawhon RN • The Director of Wellness was in-serviced on regulation 22VAC40-73-100 on 12/2/2025 • The infection control policy will be reviewed by Vitalitys’ VP of Wellness and signed annually • Executive Director or designee will verify that a review of the Infection Control policy occurs annual as indicated by the signature on the policy.
October 20, 2025Inspection2 violations
Inspection dates
10/20/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS63.2 GENERAL PROVISIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/20/20205 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: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed residents in the dining room eating lunch and listening to a guest playing the piano. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on interview and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. On 10/15/2025, licensing staff received via email an incident report from Staff 3 detailing that Resident 1 wandered off the premises approximately 0.3 miles at 6:30 a.m. Local temperature was noted to be 55 degrees during the time of the reported incident.
  2. During inspection on 10/20/2025, Staff 1 informed licensing staff as well as noted within the incident report that a local business staff came on-site to the facility on 10/15/2025 around 8:00 a.m. to report that Resident 1 was currently at their place of business. The individual indicated that Resident 1 appeared in a T-Shirt and underwear with their walker. Staff 1 stated they then picked Resident 1 up in the facility bus and brought them back to the facility.
  3. Resident 1’s UAI completed 5/24/2025 Psycho-social status indicates “Wandering/passive – Less than weekly”.
  4. Resident 1’s ISP completed 5/25/2025 indicates “severe impairment”, “disoriented: All spheres, All times, “Visual: Mild impairment”, “minimal wandering issues” with a history of wandering and “Needs protection and supervision because participant makes unsafe and inappropriate decisions”.
  5. Resident 1’s record included ISP (Dated:5/25/2025) and physical examination report (Dated: 9/18/2023) indicating that they have serious cognitive impairment.
  6. Following the reported incident on 10/15/2025, Resident 1 was moved to the facility’s safe, secured unit. The approval of placement form completed on 10/15/2025 also indicates serious cognitive impairment.
  7. Staff 1 confirmed that Resident 1 was able to wander from the premises on 10/15/2025. Staff 1 was unable to verify that appropriate supervision was in place at the time to prevent Resident 1’s departure from the facility on 10/15/2025.
Plan of correction
1. Upon Resident #1’s return to Vitality Living Arlington, the resident was relocated to the community’s secured unit. Applicable documentation, including the Secure Placement Form in place 2. A community-wide inspection of exterior doors was completed to verify proper functionality and ensure that alarm panels and notification systems are fully operational and audible to staff. 3. The Executive Director or designee will review the Door Alarm Testing monthly for three (3) months to verify compliance.
22VAC40-73-1040-A
Based on interview and record review, the facility failed to ensure doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms.
Evidence
  1. On 10/15/2025, Staff 3 reported via email to licensing staff that Resident 1 wandered off the premises approximately 0.3 miles at 6:30 a.m.
  2. Upon review of the Resident 1’s record on 10/20/2025, Resident 1’s ISP (Dated:5/25/2025) and physical examination report (Dated: 9/18/2023) indicated the resident has serious cognitive impairment.
  3. Resident 1’s UAI (dated: 5/24/2025) and ISP also documents the resident wanders.
  4. Per Staff 3 and Resident 1’s ISP, at the time of the incident on 10/15/2025, Resident 1 had a wander guard placed.
  5. During an interview with Staff 3, on 10/20/2025, the facility was unable to verify if the wander guard for Resident 1 to monitor exiting the facility was operational as there was no signal or alert upon the Resident exiting the building. Staff 3 confirmed that there were no cameras or door monitoring devices.
Plan of correction
1. Upon Resident #1’s return to Vitality Living Arlington, the resident was relocated to the community’s secured unit. Applicable documentation, including the Secure Placement Form in place. 2. Resident Service Plans are being reviewed by the Director of Wellness and designee to identify residents at risk for wandering, elopement, and falls. 3. The Executive Director or designee will review a random selection of residents identified as at risk to substantiate accuracy of their service plans. This review will occur monthly for 3 (three) months to verify ongoing compliance.
May 8, 2025Inspection1 violation
Inspection dates
05/08/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS63.2 GENERAL PROVISIONS22VAC40-90 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: 5/08/2025 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: 101 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed residents in the common area engaging with one another. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-350-C
Based on record review and staff interview, the facility failed to ensure that each resident or his legal representative is fully informed, prior to or at the time of admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered pursuant to Chapter 9 (§ 9.1-900 et. seq.) of Title 9.1 of the Code of Virginia, including how to obtain such information. Written acknowledgment of having been so informed shall be provided by the resident or his legal representative and shall be maintained in the resident's record.
Evidence
  1. Resident 1, Resident 2 & Resident 3’s resident records did not contain written acknowledgment of having been informed regarding sex offender registry.
  2. Staff 3 confirmed that they have not been completing this notifications to residents or family.
Plan of correction
The Administrator and Designee were made aware that prospective residents must be informed and acknowledge that a sex offender inquiry will be conducted. An audit was completed by the Business Office Director to verify the presence of a sex offender inquiry for current residents. The Business Office is in the process of communicating this information to the POAs/Responsible Parties. This communication is expected to be completed by 6/15/2025. The Business Office Director will verify that prospective residents are informed of the regulation and that the policy of Vitality Arlington is followed. The Executive Director or Designee will review new resident move-in files monthly for three months to ensure compliance with the sex offender inquiry requirements.
February 25, 2025Complaint survey1 violation
Inspection dates
02/25/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-80 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: 02/25/2025 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 01/30/2025 regarding allegations in the area(s) of: Physical Abuse Number of residents present at the facility at the beginning of the inspection: 112 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Observed the residents eating in the dining hall and walking around fellowshipping. 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. However, violation(s) not related to the complaint 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 Alexandra Roberts, Licensing Inspector at 804-495-5956 or by email at Alexandra.n.roberts@dss.virginia.gov
Violations
22VAC40-73-340-B
Based on record review and staff interview, facility failed to ensure that the administrator or his designee documents that the individual's psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the admission.
Evidence
  1. Resident 1’s (Admitted: 2/13/24) hospital history and physical indicates Resident 1 is diagnosed with paranoia, hallucinations, mood disorder, and a psychological disorder. Resident 1 is prescribed an antipsychotic (Seroquel 25mg), antidepressant (Lexapro) and a hypnotic (Ativan).
  2. Staff 1 confirmed that they do not have documentation that Resident 1’s history was reviewed to help determine appropriateness of admission.
Plan of correction
Administrator and Wellness Director reviewed the process of obtaining the psychosocial and behavioral history, including medications with support from the Vitality Operations and Clinical team. An audit of current residents with a history of psychosocial or behavioral needs will be completed by 6/30/2025 and referrals will be made to third party providers as appropriate with consent from the resident and/or POA Executive Director or Designee will conduct an audit of three (3) random resident files per month X 3 months to confirm compliance to the regulation is met.
October 17, 2024Inspection13 violations
Inspection dates
10/17/2024, 10/18/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
The facility should ensure that Durable Do Not Resuscitate (DNR) orders are readily available to authorized persons when necessary. The code status should be accurate on all resident documents.
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: 10/17/2024 Time In: 1:30 PM Time Out: 3:44 PM 10/18/2024 Time In: 8:38 AM Time Out: 4:27 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: 119 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI observed a medication pass. LI observed residents eating lunch and dinner, entering and exiting the facility for community outings, residents engaging with visitors, residents interacting with staff, residents watching television in the main lobby, and residents participating in physical therapy. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. Resident 2 (ISP date, 08/15/2024), Resident 3 (ISP date, 08/13/2024), Resident 5 (ISP date, 10/10/2024), Resident 6 (ISP date, 08/06/2024), Resident 7 (ISP date, 05/23/2024), and Resident 8’s (ISP date, 10/10/2024) individualized service plans were not signed and dated by the residents or their legal representatives.
  2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who confirmed that the individualized service plans were not signed or dated. Staff 6 stated they would work on getting signatures on all plans.
Plan of correction
• ISP on resident 2,3,5,6,7,8 has been completed and signed • Ensure responsible parties are signing off on the ISP. • ISP will be signed in person or via docu sign going forward. • If unable to obtain signature state in the ISP. • DOW and Wellness coordinator to audit monthly for signatures. • Results and Findings reviewed at all QA Meetings with Leadership
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that the individualized service plans were reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 9’s (admit date, 06/28/2024) special diet was not included in the individualized service plan (08/04/2024).
Plan of correction
• Review ISP for diet orders to ensure diet orders are mentioned in the ISP complete by 1/30/25
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensure that Do Not Resuscitate (DNR) Orders were only carried out in a licensed assisted living facility when the written order was included in the individualized service plan.
Evidence
  1. Resident 6’s (admit date, 04/27/2023) record contains a Durable Do Not Resuscitate (DNR) order dated 02/07/2024.
  2. Resident 6’s individualized service plan dated 08/06/2024 has “FULL CODE” stamped in red at the top of the first page and is not written as an identified need within the document.
  3. On 10/18/2024, LI interviewed Staff 5 who confirmed that the plan stated, “full code.”
Plan of correction
• Resident #6 ISP updated at time of inspection and DNR was updated as well at time of inspection • DOW or designee to Review charts for DNR documents, update EHR and ISP’s with proper code status complete by 1/30/25 • Inservice with • DOW and ED to coordinate verify charts quarterly moving forward and will be reviewed at QA meeting with Leadership.
22VAC40-73-260-A
Based on staff record review, the facility failed to ensure that each direct staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff 4’s (hire date, 05/13/2022) first aid certification was not provided upon request.
  2. On 10/18/2024, licensing inspector (LI) interviewed Staff 6 who confirmed that Staff 4’s first aid certification was not present in the record.
  3. Staff 5’s (hire date, 07/16/2024) first aid certification expired on 09/11/2024.
  4. On 10/18/2024, LI interviewed Staff 6 who stated that Staff 5 was a first aid instructor and was positive that Staff 5 had an updated certification. Staff 6 stated an intention to contact Staff 5 for an updated certification. LI was not provided an updated first aid certification for Staff 5.
Plan of correction
• Staff members 4,5,6 will have completed CPR training 1/30/25 • Continuation of staff records and licensure will be audited by BOD and reviewed at QA meeting with leadership • Ed or Designee will conduct random audit for new or current employee that we are compliant with certification. Education provided to leadership to ensure compliance. • ED to verify and bring to QA
22VAC40-73-610-B
Based on LI observation and staff interview, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents.
Evidence
  1. A daily menu was displayed on a television in the lobby.
  2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who stated that the daily menu was posted as a PowerPoint slide on the television screen in the lobby. Staff 6 confirmed that it was a daily menu posted that the residents are able to swipe through to the next day.
  3. On 10/17/2024, LI observed the daily menu posted on the television screen. LI observed Staff 6 attempt to swipe to the next day. The presentation would not slide. Staff 6 stated, “the screen must be locked.” Staff 6 requested assistance from the dining department. LI observed that the USB was not in the television which was required for residents to view the rest of the menu. Staff 6 placed the USB in the television and was able to show LI how residents are able to move through the presentation.
  4. Photo evidence taken.
Plan of correction
• Menus posted by Dining Room • Menus are displayed on Electronic Board – the weekly and monthly plus everyday options and snacks on Menu available. • Dining leadership will verify posted menus are up to date • Menu Chats conducted with residents to educate and inform of options. • Paper menus also posted for resident review • Results and Findings reviewed at all QA Meetings with Leadership
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure that each resident’s prescription medications and any over-the-counter (OTC) drugs and supplement ordered for the resident were filled and refilled in a timely manner to avoid missed dosages. The facility failed to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. Resident 2 (admit date, 01/01/2020) had an order for Lidocaine Pain Relief 4% Cream, order date, 05/17/2023 (apply topically to affected area of neck/low back three times daily as needed for pain). Lidocaine Pain Relief 4% Cream was not on-site for self-administration.
  2. On 10/18/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that the Lidocaine Pain Relief 4% Cream was not found in the medication cart. Staff 7 stated, “I will check downstairs overflow.” LI completed the medication review and returned to the main level and executive office suites. Staff 7 did not provide the medication from the “downstairs overflow.”
  3. Resident 5 (admit date, 12/31/2015), who self-administers medication, had an order for Acetaminophen 325 MG, order date, 08/02/2022 (take 2 tablets (650 mg) by mouth every 6 hours as needed for moderate pain). Acetaminophen 325 MG was not on-site for self-administration.
  4. On 10/18/2024, LI interviewed Resident 5 who stated, “I don’t have Tylenol. That’s what I use Naproxen for, works better than most anything.”
  5. Resident 5 had an order for Aveeno Daily Moisturizing 1.2% Lotion, order date, 08/02/2022 (assist patient with apply lotion topically to both arms every day as needed for skin deficiency). Aveeno Daily Moisturizing 1.2% was not on site for self-administration.
  6. On 10/18/2024, LI interviewed Resident 5 who stated, “I don’t use that that anymore. I use Excedrin. There’s no doctor’s order. I have very dry skin.
  7. Resident 5 had an order for Combivent Respimat 20-100 MCG, order date, 01/12/2024 (inhale 1 puff twice daily). Combivent Respimat 20-100 MCG was not on site for self-administration.
  8. On 10/18/2024, LI interviewed Resident 5 who stated, “when I was in the hospital they gave it to me. I had the flu and was told to take it for a week. It’s gone now… been gone for a while.”
  9. Resident 5 had an order for Culturelle Digestive Health, order date, 08/02/2022 (take 1 capsule by mouth every day * do not crush). Culturelle Digestive Health was not on site for self-administration.
  10. On 10/18/2024, LI interviewed Resident 5 who stated, “I don’t take it anymore.”
  11. On 10/18/2024, LI interviewed Staff 7 who stated, “that’s what you take with antibiotic. That should have been discontinued. Why it’s there, I don’t know.”
  12. Resident 5 had an order for Sea-Clens Wound Cleanser, order date, 01/30/2023 (cleanse open area on R ishium and R buttock, pat dry, apply calcium alginate, cover with border foam dressing twice weekly). Sea-Clens Wound Cleanser was not on site for self-administration.
  13. On 10/18/2024, LI interviewed Resident 5 who stated “that was for the wound on my leg. It’s all fixed now. I don’t take it anymore.”
  14. Resident 5 had an order for Baclofen 20 MG, order date, 08/02/2022 (take one tablet by mouth three times daily). There were three expired bottles of Baclofen 20 MG on site, expiring 02/08/2023, 04/23/2023, and 07/04/2023.
  15. On 10/18/2024, LI interviewed Resident 5 who stated, “sometimes I combine new drugs into the old bottle.”
  16. Resident 5 was self-administering Naproxen Sodium 220 MG without a physician’s order.
  17. On 10/18/2024, LI interviewed Resident 5 who stated, “I got it from my online pharmacy. I only take it when I have a headache.”
  18. Resident 5 was self-administering Methenamine HIPP 1 GM without a physician’s order. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
• #1-26 have all been corrected . • Inspect med carts and orders to ensure that each resident’s prescription medications and any OTC drugs and supplement ordered for the resident were filled and refilled in a timely manner. Complete by 1/30/25 • Asses self-med residents every 6 months. • Ensure medications have active orders and matches with what is being self-administered. Complete by 1/30/25 • Encourage residents to notify nurses with any changes. • Ongoing encouragement and education with Independent resident on the importance of audits and self medication management. • DOW or designee to perform random audit of one resident each month for 7 months.
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure that no medication or dietary supplement was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter (OTC), and sample medications.
Evidence
  1. Resident 2 (admit date, 01/01/2020) had Acetaminophen 325 MG (take 2 tablets (650 MG) by mouth every 6 hours as needed for mild pain, headaches, or fever for up to 30 doses) stored in the medication cart. Resident 2’s Physician Order Review (10/18/2024), September 2024 medication administration record (MAR), and October 2024 MAR did not include an order for Acetaminophen 325 MG.
  2. On 10/18/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that Resident 2 did not have an order for Acetaminophen 325 MG.
Plan of correction
• Review every chart for diet and medication order changes to ensure that no medication or dietary supplement was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Complete by 1/30/25 • Finding will be reviewed by the team at the next quality assurance meeting
22VAC40-73-320-A
Based on resident record and staff interview, the facility failed to ensure that a residents’ physical examination contained the following: the person’s address, blood pressure, and general physical condition, including a systems review as is medically indicated.
Evidence
  1. Resident 8’s (admit date, 09/04/2024) physical examination was missing Resident 8’s address, blood pressure, and general physical condition, including a systems review.
  2. On 10/18/2024, licensing inspector (LI) interviewed Staff 8 who confirmed that the address, blood pressure, and general physical condition sections were left blank on the physical examination form.
Plan of correction
• Ensure physical examinations are completed and every section is filled out prior to admission moving forward. • Audit files to ensure that they are filled out the person’s address, blood pressure, and general physical condition, including a systems review as is medically indicated. • Finding will be reviewed by the team at the next quality assurance meeting
22VAC40-73-970-E
Based on facility record review and staff interview, the facility failed to ensure that the record included the number of residents participating, any special conditions, the time it took to complete the drills, and problems encountered, if any.
Evidence
  1. June – September 2024 (06/28/2024, 07/31/2024, 08/24/2024, 09/23/2024) fire drills were missing the number of residents participating, any special conditions simulated, the time it took to complete the drill and problems encountered.
  2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who stated being unaware that the form did not have the necessary information. Staff 6 stated that the form will be updated to include all necessary information.
Plan of correction
• Drills conducted in October and November were completed and signature were obtained , • We have ensured that signature proof of resident participation is documented and part of the Emergency Log • Executive Director or designee will conduct an audit of the fire drill documentation monthly x six months to verify adherence to the regulation • 11/1/2024--Environmental Services Director and team were Inservice by ED on the acceptable documentation as it relates to fire drills conducted at the community • Finding will be reviewed by the team at the next quality assurance meeting.
22VAC40-73-830-E
Based on facility record review and staff interview, the facility failed to ensure to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. June, July, and September 2024 (06/26/2024, 07/24/2024, 09/25/2024) resident councils did not include a written response to the residents.
  2. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who confirmed that there were not any written responses to the resident councils. Staff 6 stated that the “concern/suggestion/feedback” section was not used by staff to respond to the resident concerns.
Plan of correction
• Correction has been Implemented and responses added to the issues brought up by Residents at the monthly meetings on 11/15/2024 • Responses are in the notebook where minutes are kept from the meetings when applicable. • 12/6/2024 Resident council meetings for 2024 were reviewed by Engagement Director and unresolved items were addressed where needed. • 11/18/2024 Management team in-service by ED on the procedure for addressing issues from resident specific meetings when applicable • ED or designee will monitor resident meeting minutes for issues/concerns that need to be addressed and will verify that such items are being resolved moving forward • Finding will be reviewed by the team at the next quality assurance meeting
22VAC40-73-1110-A
Based on resident record review and staff interview, the facility failed to ensure to obtain written approval prior to placing a resident with a serious cognitive impairment, in a safe, secure environment.
Evidence
  1. Resident 3 (admit date, 07/09/2024) approval for placement in special care unit was completed on 07/25/2024.
  2. On 10/18/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that Resident 3’s approval for placement in special care unit was completed after admission.
Plan of correction
• Memory care admission will have to have approval of placement form responsible party prior to admission. • DOW and MCD will audit all admission before completion of admission to ensure proper authorization is in place for admission to MC • ED educated DOW and MC Director that all forms need to be fully completed • ED to be final approval and verify at contract signing with POA to ensure is in place at contract signing.
22VAC40-73-70-A
Based on facility record review and staff interview, the facility failed to ensure to report to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident.
Evidence
  1. On 08/09/2024 four residents and one staff tested positive for COVID. On 08/10/2024 two residents and one staff tested positive for COVID. On 08/11/2024 two residents tested positive for COVID. On 08/12/2024 three residents and one staff tested positive for COVID. On 08/13/2024 one resident tested positive for COVID.
  2. Fifteen residents tested positive for COVID, and it was not reported to the licensing office.
  3. On 10/17/2024, licensing inspector (LI) interviewed Staff 6 who stated Arlington County Public Health Division was contacted on 08/13/2024. Staff 6 stated the reporting policy for COVID was lifted and was unaware that this was something that should still be reported to licensing.
  4. On 10/17/2024, LI received an email from Staff 7 sharing the Vitality Living Respiratory Line List. The Respiratory Line List showed the names of residents and staff that tested positive for COVID, the onset dates, and dates of COVID testing.
  5. On 08/08/2024 Resident 3 was found on the floor, lying on the right side, next to the nightstand. Resident 3 was transported to Virginia Hospital Center diagnosed with a head injury. This incident was not reported to licensing.
  6. On 10/17/2024, LI requested a list of falls since July 2024. Staff 7 provided the name and incident report of Resident 3.
Plan of correction
• Notify all covid cases within 24 hours to the state effective immediately • There have been no cases since date of inspection – • Educated all leadership on 11/25/24 that moving forward that ALL COVID cases need to be reported to VDSS as well. • Results /Findings reviewed at next QA meeting • Notify State of any injury related to fall effective immediately • ED and DOW responsible for this action – will review at every QA meeting. • ED and or DOW to notify VDSS on all falls with injury. • Inservice in place to educate staff when fall occurs – and reporting related to fall. • Dow or designee will review any falls at daily alignment from day before. • Results and Findings reviewed at all QA Meetings with Leadership
22VAC40-73-650-E
Based on resident record review and staff interview, the facility failed to ensure the resident record contained the physician’s or other prescriber’s signed written order.
Evidence
  1. Resident 9’s (admit date, 06/28/2024) record contained a Physician’s Diet Order document with the box marked with an X for a Carbohydrate Controlled Diet that did not contain a signature for the physician or other prescriber.
  2. On 10/17/2024, licensing inspector (LI) interviewed Staff 7 who confirmed that the physician’s diet order form was completed on the day of admission on 6/28/2024 and was not signed.
Plan of correction
• Review charts for diet orders ensuring all current orders are signed by MD or NP and matches with Yardi complete by 1/30/25
June 18, 2024Complaint survey1 violation
Inspection dates
06/18/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of Inspection: Complaint Inspection Date of Inspection: June 18th 2024 4:30pm - 5pm 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: 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: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s) area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.
Violations
22VAC40-73-460-B
Based on record review and interview, staff failed to ensure prompt response by to resident needs via call bell alert.
Evidence
  1. LI reviewed call bell response times provided by Staff 2.
  2. Resident 4 pushed call bell for assistance on 6/14/2024 at 17:38 (5:38pm) and it was responded to at 18:13 (6:13pm).
  3. Resident 5 pushed call bell for assistance on 6/9/2024 at 14:10 (2:10pm) and it was responded to at 15:22 (3:10pm). Another time on 6/17/24 at 16:32 (4:32pm) and it was responded to at 19:01 (7:01pm)
  4. LI interviewed Resident 5 who stated it takes a long time to get a response when pressing the call bell all the time.
  5. Staff 2 and Staff 5 viewed the response times and stated facility does not have a required response time or policy but it should not take a long time to respond.
Plan of correction
1. Weekly checks on residents call bell response Week 1: floor 1 and 4 Week 2: Floor 5 and 6 Week 3: Floor 7 Week 4: Floor 8 and 9 2. Educate all care staff on importance of call bell response. 3. Submit proposal for new or updated call bell system.
June 17, 2024Inspection5 violations
Inspection dates
06/17/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of Inspection: Monitoring Inspection Date of Inspection: June 17th 2024 thru June 18th 2024 - 8am - 4:30pm 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: 144 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 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in activities. LI spoke with 1 family member present during the inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.
Violations
22VAC40-73-980-A
22VAC40-73-980-A Based on observation and staff interview, the facility failed to ensure a complete first aid kit is on hand.
Evidence
  1. First aid kit on hand did not include: Plastic bags, disposable blankets, flashlight, batteries, or a thermometer or breathing barriers.
  2. Staff 5 & Staff 2 stated that they did not know that the additional items were needed for first aid kit on hand.
Plan of correction
Items missing have been purchased and replaced and placed in designated area. All staff trained in Town Hall and documented attendance. Director of Wellness and Executive Director will audit randomly.
22VAC40-73-950-F
22VAC40-73-950-F Based on record review and staff interview, the facility failed to review the emergency preparedness plan annually or more often as needed. The review shall be documented by signing and dating.
Evidence
  1. Emergency preparedness plan was updated on 01/01/2024. There was no documentation that updates were communicated to staff or residents for the semi-annual review.
  2. Staff 2 confirmed that facility does not have a documented semi-annual log of training for staff and/or residents on the plan.
Plan of correction
Training put in place for Residents and staff. Training for Residents will take place at Resident Council every third Wednesday of the month. Staff training happens monthly as well at the Town Hall . Last resident council was 6/26/24, next one will be 7/24/24. Town Halls will complete staff trainings needed in Emergency Preparedness – next one is 7/18/24. ED will randomly review attendee sign in sheets for resident and staff compliance.
22VAC40-73-320-A
Based on record review, facility failed to ensure that 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 and shall contain all required components.
Evidence
  1. Resident 4’s physical examination report dated 12/12/23 was missing ambulatory or non-ambulatory status, address, and date of birth.
Plan of correction
Resident mentioned in report physical exam was updated by Nurse Practitioner. DOW will audit current resident H&P for required information. Going forward Director of Wellness or designee will review state required paperwork prior to admission.
22VAC40-73-980-C
Based on record review and staff interview, facility failed to ensure month first aid kits are checked at least monthly to ensure all items are present.
Evidence
  1. LI requested documentation from staff 6 who maintains the first aid kit. Staff 6 informed that she does not complete documentation for first aid kit and would ask Staff 2.
  2. Staff 2 confirmed that facility does not have a monthly check/documentation to provide and has not been completed.
Plan of correction
Log in place effective immediately. Log is monitored by Director of Wellness and Assistant Director of Wellness monthly. Executive Director will monitor quarterly.
22VAC40-73-390-C
Based on record review, facility failed to ensure that resident agreements shall be updated whenever there are changes that are dated and signed by the licensee or administrator as well as the resident or their legal representative.
Evidence
  1. Staff 5 provided LI the updated and revised resident agreement dated as being revised on 02/09/2024. Resident agreement was updated in March of 2023 and then again on 02/09/2024.
  2. Resident 1’s resident agreement was signed and dated 05/21/22.
  3. Resident 2’s resident agreement was signed and dated 09/12/22.
  4. Resident 4’s resident agreement was signed and dated 12/12/23.
  5. Staff 2 and 5 stated that they were unaware that resident agreements needed to be updated and re-signed when revisions are made.
Plan of correction
Director of Business will audit current resident files for the most current version of the community agreement, complete with all required party signatures. For new admissions; agreements will be reviewed prior to admission by the ED.
December 14, 2023Complaint survey0 violations
Inspection dates
12/14/2023
Areas reviewed
Resident Care and Related Services
Comments
Date of Inspection: December 14, 2023 Type of Inspection: Complaint inspection Standards Investigated: As stated above Complaint was determined not valid. If you have any questions, please do not hesitate to contact me at (540) 680-9469 or sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection, you can find the information on the internet: www.dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 9, 2023Inspection1 violation
Inspection dates
08/09/2023
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: LI entered the building at 9:50 am on 8/9/2023 and exited at 3:30 pm. 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 6/12/2023, 7/10/2023, 7/28/2023, 8/5/2023, and 8/6/2023 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: 103 Number of resident records reviewed: 5 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-720-A
Based upon a review of records, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility when written orders are included in the individualized service plan (ISP).
Evidence
  1. During a focused monitoring inspection on 8/9/2023, LI observed that DNR orders were not included on the ISP’s for Residents #2 and #4.
Plan of correction
On August 14, 2023, the Director of Wellness obtained DNR orders and updated ISPs for Resident #2 and #4. An audit of current charts was completed on 8/15/2023, and findings were corrected at time of audit to include DNR orders reflecting on the resident’s ISP. Beginning on 8/18/2023, the ED and/or designee will audit 3 resident records weekly for 4 weeks, bi-weekly for 4 weeks, and monthly for 1 month for the presence of DNR orders on the ISP. Results will be discussed in monthly QA meeting.
November 8, 2022Inspection0 violations
Inspection dates
11/08/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: LI entered the facility at 8:15 am on 11/8/2022 and exited the facility at 12 noon on 11/8/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/6/2022 regarding allegations in the area(s) of resident care and related services and admission, retention, and discharge of resident. A focused monitoring inspection to ensure correction of previous B-2 violations was also conducted at the same time. Number of residents present at the facility at the beginning of the inspection: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. Focused monitoring inspection to ensure correction of previous B-2 violation: 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. Focused monitoring inspection regarding self-reported incident: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 6, 2022Inspection1 violation
Inspection dates
10/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
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: LI entered the facility at 8:50 am on 10/6/2022 and exited the building at 5:00 pm on 10/6/2022. 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: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 (2 of which were discharged residents) Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-680-C
Based upon a review of records, observation of medication administration, and interviews, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times such as before, after, or with meals.
Evidence
  1. The Licensing Inspector (LI) observed Staff #2 administering medications to Resident #5 at approximately 10:20 am on 10/6/2022. LI observed that 6 of the 15 medications scheduled for 9 am were not administered. Staff #2 told LI that Resident #5 often refuses to take all of the 9 am medications at one time and that she would “try again around lunch time to get him to take the remaining medications.” According to the Medication Administration Record (MAR) for Resident #5, the six medications LI did not observe being administered at approximately 10:20 am were administered by Staff #2. An interview with a collateral contact revealed that Staff #2 reported to the collateral contact that the remaining six medications scheduled for approximately 9 am were administered to Resident #5 at approximately 11:42 am on 10/6/2022.
Plan of correction
Resident #5’s medication times have been changed to meet his preference after receiving MD orders. Med Techs will be re-educated on company policy for when a resident refuses to take medications as ordered. DOW or Designee will audit similar residents’ medication administration records and obtain MD orders to change administration times as needed. Audits will be completed by 10/21/2022. DOW or Designee will do monthly random audits of MARs for timeliness of medication administration to monitor for compliance.
August 5, 2022Complaint survey0 violations
Inspection dates
08/05/2022
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:08 am on 8/5/2022 and exited at 10:25 am on 8/5/2022. 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 7/12/2022 regarding allegations in the area(s) of: Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 106 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: 2 Observations by licensing inspector: LI observed the loading dock area of the building where trash is removed and where deliveries are made. 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 Jamie Eddy Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 21, 2022Inspection4 violations
Inspection dates
06/21/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD 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: LI entered the facility at 8:44 am on 6/21/2022 and exited at 4:40pm on 6/21/2022 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: 105 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration, residents eating breakfast and residents engaging in activities. Additional Comments/Discussion: There has been a transition in the administrative team in the last few months. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-720-A
720-A-2 Based upon a review of records, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest are included on the individual service plan (ISP).
Evidence
  1. According to the medical records, Resident #2, Resident #6, Resident #7, and Resident #8 have DNR orders. The Individualized Service Plans (ISPs) for Resident #2, Resident #6, Resident #7, and Resident #8 do not include DNR status.
Plan of correction
All current resident ISPs will be reviewed and the designation of DNR status will be added to those who have proper supporting documentation in place. DOW will do monthly random chart audits to monitor for compliance.
22VAC40-73-260-A
260-A-1 Based upon a review of records, the facility failed to ensure that each direct care staff shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad or fire department.
Evidence
  1. The staff record for Staff #1, #3, and #5 did not contain evidence of current first aid certification.
Plan of correction
All direct care staff employee files will be audited for proof of First Aid, and those associates that are not current will complete the training by 7/31/2022. Staff #1, #3, and #5s proof of completion has been added to their files. BOD will do monthly random employee file audits to monitor for compliance.
22VAC40-90-30-B
40-90-30-B Based upon a review of records, the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. The sworn statement or affirmation documents in the staff files of the following staff members were either not signed or not completed in full: Staff #8, Staff #12, Staff #19, Staff #37 Staff #39, Staff #41, Staff #42, and Staff #43
Plan of correction
All current employee files will be audited for missing sworn statements of attestation. HR will obtain sworn statements of attestation for: Staff #8, Staff #12, Staff #19, Staff #37, Staff #39, Staff #41, Staff #42, and Staff #43 by 7/31/2022. BOD will do monthly random employee file audits to monitor for compliance.
22VAC40-73-250-C
250-C-6 Based upon a review of records, the facility failed to ensure that the following information is maintained on staff and included in the staff records: an original criminal record report.
Evidence
  1. The staff records for Staff #4 and Staff #5 did not contain a criminal record report.
Plan of correction
All potential employees will have background checks obtained prior to start of employment. BOD will do monthly random employee file audits to monitor for compliance.
September 22, 2021Complaint survey1 violation
Inspection dates
09/22/2021, 09/23/2021
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Licensing Inspector (LI) conducted a complaint investigation on 09/22/2021 and 09/23/2021 regarding staff qualifications. LI reviewed Virginia Department of Health Professions license lookup for the Assisted Living Facility Administrator License. The complaint is deemed valid as violation related to Standard 22VAC40-73-140 was cited. Exit interview conducted with the Administrator and the violation notice regarding the standard deemed valid was corrected. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-140-E
Based on documentation, facility failed to ensure that the administrator shall be licensed as an assisted living facility administrator by the Virginia Board of Long-Term Care Administrators.
Evidence
  1. On 09/22/2021, the Virginia Department of Health Professionals license lookup documented that the Assisted Living Facility (ALF) Administrator license and ALF Preceptor license had expired on 03/31/2021.
Plan of correction
On 9/22/21 the administrator was made aware of the expired license as the state had an incorrect email address resulting in the administrator never receiving notification of expired license. Upon notification the license was renewed immediately and email address updated and confirmed with the Department of Health Professionals.
April 20, 2021Inspection0 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 4/20/2021 and concluded on 4/21/2021. A self-reported incident was received by the department regarding allegations in the areas of personnel exploitation of a resident. The administrator was contacted for an entrance interview by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Exit interview with the administrator was conducted on 4/21/2021.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 12, 2021Complaint survey0 violations
Inspection dates
Feb. 12, 2021
Areas reviewed
22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 2/12/2021 and concluded on 2/17/2021. A complaint was received by the department regarding allegations in the areas of buildings and grounds. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.