Virginia DSS · Assisted Living Facility

Brightview Woodburn(FAIRFAX CO)

📍 3450 Gallows Road, Annandale, VA, 22003

ID 41767Two Year licenseActive
16
Inspections
On record
9
With violations
Visits that cited something
7
Clean visits
Nothing cited
18
Violations cited
Individual findings
15
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Brightview Woodburn(FAIRFAX CO) was inspected 16 times between November 5, 2020 and May 29, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 18 violations under 15 distinct standards. 2 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 14 of these 16 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
Two Year
License expires
11/08/2026
Administrator
Raymond Dennison
Licensing inspector
Jacquelyn Kabiri
Inspector phone
(703) 397-3017
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

16

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

May 29, 2026Inspection2 violations
Inspection dates
05/29/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED 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: 05/29/2026, 9:45 a.m. to 1:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/14/2026 regarding allegations in the area(s) of: Resident Care and Related Service, Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 77 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 (Resident was observed) Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-100-C-2
Based on the facility self-report, record review, and photos, the facility failed to ensure that the sanitation of rooms, including medical equipment, and cleaning and disinfecting procedures, agents, and schedules.
Evidence
  1. According to facility progress notes, on 05/10/2026 at 5:07 p.m., Resident 1 experienced an episode of diarrhea during dinner. The progress note documented that Resident 1 refused assistance from both the private care aide and community staff for cleaning, refused to shower, and refused the use of incontinence products.
  2. On 05/11/2026 at 2:07 p.m., Resident 1 was transported by ambulance to the emergency department.
  3. According to staff statements and photographs provided to the Licensing Inspector (LI), Resident 1's recliner chair, which served as the resident's primary sleeping chair, contained visible fecal matter on the seat cushion and back following the diarrhea episode on 05/10/2026.
  4. Resident 1 returned from the hospital at approximately 4:00 a.m. on 05/12/2026. Staff statements and photographic evidence showed that the recliner remained in the resident's room in the same soiled condition and had not been cleaned, disinfected, or removed while the resident was absent from the facility.
  5. The facility's Infection Control Plan states, "All equipment, instruments, utensils, or any other materials which may harbor infectious substances or lead to transmission of disease shall be disposed of or decontaminated in accordance with all applicable federal, state, and local rules for safe handling."
  6. Staff 1 and Staff 2 acknowledged that the soiled recliner had not been cleaned or removed and stated that the chair was scheduled to be disposed of and the room cleaned on 05/12/2026.
  7. Photo evidence documenting the condition of the recliner and room was obtained from an anonymous collateral contact.
Plan of correction
Correction: The soiled recliner was removed from service, disposed of, and the resident's room was thoroughly cleaned and disinfected in accordance with the facility's Infection Control Plan. Infection control practices were reviewed to ensure appropriate handling of contaminated equipment. System Change: A process has been implemented requiring contaminated furniture, equipment, or other items to be immediately removed from service, cleaned and disinfected, or disposed of when decontamination is not possible. The Maintenance Director/Designee and Health Service Director/Designee will verify completion and document corrective actions. Training: Environmental Services, nursing, and direct care staff will be re-educated on infection control procedures, including the timely cleaning, disinfection, and disposal of contaminated equipment and furnishings in accordance with the facility's Infection Control Plan and 22VAC40-73-100.2.E. Monitoring: The Maintenance Director/Designee will conduct weekly audits for 4 weeks, then monthly for 2 months to verify contaminated equipment and furnishings are promptly cleaned, disinfected, removed, or disposed of as appropriate. Findings will be reviewed through the QAPI process, and corrective action will be taken as needed. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI meetings and initiating any necessary actions.
22VAC40-73-220-A
Based on the record review and interview, the facility failed to when private duty personnel from licensed home care organizations provide direct care or companion services to residents that the direct care or companion services provided by private duty personnel to meet identified needs shall be reflected on the resident's individualized service plan. 1. During the onsite inspection on 5/29/2026, Resident 1’s record (admitted 9/16/2020) began receiving private caregiver services on or about 04/15/2026. 2. Resident 1's Individualized Service Plan (ISP), most recently dated 05/23/2026, did not include the specific services provided by the private caregiver, a description of those services, or the frequency and duration of the services. 3. Staff 1 confirmed the licensing inspector's findings.
Plan of correction
Correction: The resident's Individualized Service Plan (ISP) was immediately updated to include the private duty caregiver services, including a description of the services provided, frequency, and duration. All residents receiving private duty services were reviewed to ensure their ISPs accurately reflect those services. System Change: A process has been implemented requiring the Health Service Director/Designee to review and update the ISP whenever private duty services are initiated, changed, or discontinued to ensure the resident's identified needs and services are accurately documented. Training: The Health Service Director/Designee and applicable nursing staff will be re-educated on the requirements of 22VAC40-73-220.A, including documentation requirements for private duty caregiver services within the ISP. Monitoring: The Health Service Director/Designee will audit all residents receiving private duty services weekly for 4 weeks, then monthly for 2 months to verify ISPs accurately reflect the services provided. Findings will be reviewed through the QAPI process, and corrective action will be taken as needed. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI meetings and initiating any necessary actions.
January 14, 2026Inspection0 violations
Inspection dates
01/14/2026
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: 01/14/2026, 1:00 p.m. to 2:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/07/2026, regarding allegations in the area(s) of: Direct Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Daily Activities Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 14, 2026Inspection0 violations
Inspection dates
01/14/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
TA: If ISP is obtained electronically, the file needs a written paper signature, or signatures captured in an electronic method.
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: 01/14/2026, 12:00 p.m. to 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/07/2026, regarding allegations in the area(s) of: Direct Care and Related Services, Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 79 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, and 3 written statements from staff. Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Daily Activities Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 3, 2025Inspection2 violations
Inspection dates
10/03/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
The current paper and electronic filing system is cumbersome and not easy to access during the inspection. The LI didn't have independent access to the electronic files; they were manually opened by staff or printed.
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: 10/03/2025 10:00 a.m. to 4:30 p.m. and 10/09/2025 9:30 a.m. to 10:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities and lunch Additional Comments/Discussion: n/a 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-210-C
Based on record review and staff interview, the facility failed to ensure that medication staff receive continuing education as required by the Virginia Board of Nursing.
Evidence
  1. The record for staff 2 did not contain evidence that staff 2 completed an annual refresher course in medication administration, per section 18VAC90-60-100-B of the Virginia Board of Nursing website, continued competency.
  2. In an interview with staff 1, it could not be verified that staff 2 had received the annual medication administration training, and the training record was not located onsite during the inspection.
Plan of correction
The associate was enrolled in a refresher course in medication administration. Upon completion, a copy will be placed in the associate file and tracked by the Business Office Director alongside the annually renewed license.
22VAC40-73-610-B
Based on observation and documentation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents.
Evidence
  1. During the tour of the facility with staff 1, the Wellspring Village secure community did not have weekly menus posted in a conspicuous place for residents to view.
  2. Photo evidence taken.
Plan of correction
The noted violation was corrected the same day. A seven-day menu was posted inside the enclosed bulletin board in the Wellspring Village common space which is accessible to residents. The Dining Services Director or designee will post the menu weekly.
October 21, 2024Inspection2 violations
Inspection dates
10/21/2024 10/22/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report63.2- (18) Facilities and Programs
Comments
Type of inspection: ¿Renewal¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/21/24, 10:00am-2:42pm and 10/22/2024, 9:45am-4:15pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: (89) 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities, dancing instruction and lunch. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-620-B
Based on record review and staff interview, the facility failed to ensure that dietary oversight was certified and that the requirements were met, including the date of the oversight, identification of the residents for whom the oversight was provided and any recommendation.
Evidence
  1. The dietary oversight records dated 03/28/2024, for Residents #7, #8, and #9 did not have a certification statement that requirements were met as required in Standard 22VAC40-73-620 for special diets.''
  2. The dietary oversight records dated 03/28/2024, do not have a certification statement required in Standard 22VAC40-73-620 for special diets.
  3. On 10/22/2024, LI interviewed Staff 2, regarding the missing certification statement on the dietary oversight records. Staff 2 confirmed the absence of a certification statement from the facility's dietician report.
Plan of correction
The community hired a new Dietitian on 12/1/24. The new vendor’s paperwork includes the certifica-tion statement that requirements were met as required in Standard 22VAC40-73-620.
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to ensure the current on-site person in charge was posted, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. The facility did not have a posting of the staff member on duty or manager on duty.
  2. No posting or listing was observable of the listing of succession of the person(s) in charge.
  3. Staff 2 confirmed that a posting was not posted for viewing.
Plan of correction
The noted violation was resolved the same day. The onsite person in charge signage had the role/title of each person versus the full name which caused this violation. The signage now includes the name and title of each person in charge. The signage remains posted at the front entrance of the community.
June 12, 2023Inspection0 violations
Inspection dates
06/12/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:31 am on 6/12/2023 and exited at 12:05 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 (4/24/2023, 5/11/2023, and 5/21/2023) regarding allegations in the area(s) of resident care and related services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 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 inspected training records to ensure that previous B2 violation, cited on 3/22/2023, were corrected. 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. 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.
March 22, 2023Inspection3 violations
Inspection dates
03/22/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:13 am on 3/22/2023 and exited at 12:50 pm on 3/22/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/30/2023 and 3/1/2023 regarding allegations in the area(s) of personnel, and resident care and related services. Number of resident records reviewed: 2 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed video footage of an alleged abusive incident that took place on 3/1/2023. 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. 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
22VAC40-73-130-A
Based upon a review of records, the facility failed to ensure that all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of resident’s in accordance with that section.
Evidence
  1. A written statement provided by Staff #2 on 3/2/2023, documented that on 3/1/2023, Staff #2 witnessed Staff #1 telling Resident #1 to “shut up” and then witnessed Staff #1,“hit his (Resident #1’s) butt because of what he was saying.”
  2. According to the written statement provided by Staff #2 on 3/2/2023, regarding the incident witnessed on 3/1/2023 in which Staff #1 struck Resident #1 on the butt, “ I know I should have reported this and I have to report this.” Staff #2 stated in her written statement of 3/2/2023, “I should have reported but I didn’t report.”
Plan of correction
On March 8, 2023, all associates in Wellspring Village were required to watch the training video titled “Recognizing, Reporting and Preventing Abuse.” The Executive Director, Health Services Director, and Wellspring Village Director, spoke to all associates prior to the video to explain why they were watching it and explained again that they are mandatory reporters of abuse, neglect, and exploitation. The facility terminated the two associates who observed the incident and explained (to the two associates) that it was because they did not report the abuse.
22VAC40-73-640-A
Based upon a review of records, the facility failed to implement methods in the medication management plan to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. According to the written report provided by the facility, Staff #5, and Staff #6, on 1/30/2023, failed to follow the “med tech protocol which says that incoming med tech/nurse and outgoing med tech/nurse must count the pills (controlled substances).”
  2. A written statement provided by Staff #6, the incoming med tech on 1/30/2023, documents that Staff #6 arrived on the floor and stood in the door as the floor nurse (Staff #5) counted the pills with the outgoing med tech from the night shift.
Plan of correction
The wellness nurse and the med tech who failed to follow the plan were given performance counseling on 2/3/2023 for not counting medications before they turned over the keys to the medication cart which is a violation of our Medication Management Plan. The health services director (HSD) did a review of our Medication Management Plan (particularly page 6, item 15, Maintenance of Schedule II-V Medications) with the med techs and wellness nurse involved and also reviewed our entire Medication Management Plan with all med techs on 2/8/2023.
22VAC40-73-250-C
Based upon a review of records, the facility failed to ensure that personal and social data to be maintained on staff and included I the staff record are as follows: verification of current professional license.
Evidence
  1. According to the record for Staff #2, the license for nurse aide for Staff #2 expired on 3/31/2022.
  2. A search on the Virginia Department of Health Professions website conducted on 3/22/2023, confirmed that the nurse aide license for Staff #2 was currently expired.
Plan of correction
On 3/25/2023, the Executive Director reviewed the status of all licenses of health and wellness staff. Those who did not have updated licenses were taken off the schedule until their license was up to date.
February 3, 2023Complaint survey0 violations
Inspection dates
02/03/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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 9:45 am on 2/3/2023 and exited at 1:00pm on 2/3/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/27/2023 regarding allegations in the area(s) of resident care. Number of residents present at the facility at the beginning of the inspection: 84 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 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 allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 22, 2022Inspection2 violations
Inspection dates
09/22/2022
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 8:48 am on 9/22/2022 and exited at 4:50 pm on 9/22/2022. 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: 91 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 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch and engaging in physical activity. 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) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-250-D
Based upon a review of documents, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The staff record for Staff #2 did not contain the proper screening form documenting the absence of tuberculosis in a communicable form.
Plan of correction
We will only accept evidence of the absence of tuberculosis in a communicable form on a screening form published by the Virginia Department of Health or a form consistent with it.
22VAC40-90-40-B
Based upon a review of records, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The criminal history record reports for the following staff members were completed more than 30 days after their hire dates: Staff #2, #3, #4, #10, #11, #12, #13, #15, #16, #!7, #18, #19, #20, #21, #22, #23, #24, and #25.
Plan of correction
We will be sure to run Virginia criminal history record reports on each new employee on or prior to the 30th day of employment for each employee.
May 17, 2022Inspection1 violation
Inspection dates
05/17/2022/05/18/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 was onsite on 5/17/2022 from 11:04 am until 3:10pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/23/2022, 5/11/2022, and 5/15/2022 regarding allegations in the areas of: Staffing and Supervision and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 69 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Observed the room of the resident who exited her room through the back door that led outside to the patio. Observed memory care resident who recently fell after being combative with staff. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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
22VAC40-73-325-B
Based upon a review of records and interviews, the facility failed to ensure that the fall risk rating for residents who meet the criteria for assisted living care shall be reviewed and updated after a fall.
Evidence
  1. According to the progress notes, Resident #1 suffered falls on 4/23/2022 and 5/10/2022. During the interview with the administrator on 5/17/2022, it was reported that the most recent fall risk rating for Resident #1 was completed on 2/17/2022. According to the progress notes, Resident #3 suffered a fall on 5/13/2022. The administrator indicated during the interview on 5/17/2022, that the last fall risk rating for Resident #3 was completed on 5/10/2022.
Plan of correction
Standard #325-B-3 Administrator and Health Services Director will perform a fall assessment after each resident fall.
October 27, 2021Inspection0 violations
Inspection dates
10/27/2021,12/08/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 10/27/2021 and concluded on 12/8/2021. A self-reported incident was received by the department regarding allegations in the area of resident care. 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 self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 13, 2021Inspection0 violations
Inspection dates
10/13/2021,10/25/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated monitoring inspection was initiated on 10/13/2021 and concluded on 10/25/2021. A non-mandated monitoring inspection was conducted to ensure correction of previous B-2 violations cited during the last inspection. 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 any non-compliance with any standards or law. No violations were cited.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 21, 2021Inspection2 violations
Inspection dates
09/21/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
A renewal inspection was initiated on 9/21/2021 and concluded on 9/24/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 85. The inspector emailed the administrator a list of items required for to complete the remote documentation review portion of the inspection. The inspector reviewed four resident records, four staff records, healthcare and dietary oversight reports, staff work schedule, monthly activity schedule, monthly menu, fire drill reports, annual fire and health inspection reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 10/6/2020 were reviewed. The inspector conducted the on-site portion of the inspection on 9/23/2021. An exit interview was conducted with the Administrator on 9/24/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-90-40-B
Based upon a review of records, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. According to the staff roster, the date of hire for Staff #5 was 7/14/2021. The Criminal Record Report in the record for Staff #5 was dated 9/22/2021, more than 30 days after the 30th day of employment.
  2. The facility was unable to provide a criminal history record report for the following staff: Staff #6 hired on 7/28/2021;Staff #7 hired on 8/2/2021; Staff #8 hired on 6/15/2021; Staff #9 hired on 6/15/2021; Staff #10 hired on 6/28/2021; Staff #11 hired on 7/7/2021.
Plan of correction
There was no adverse outcome as a result of this deficient practice. An audit of all other employees' records was conducted, and all were found to be in compliance with the standards set forth by the licensing agency. The Business Office Director was counseled and re-educated on 10/5/2021 regarding obtaining criminal history record reports for all candidates for employment prior to the actual start date of employment. The Business Office Director and Executive Director will audit records of all candidates for employment to ensure criminal history record report is obtained prior to the start date of employment, or at least, within 30 days of employment by 10/11/2021.
22VAC40-73-680-D
Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. According to the physician's order dated 5/21/2021, Resident #3 is to receive 2 capsules of Gabapentin at approximately 9:00 pm. The Controlled Drug Receipt/Record/Disposition form indicates that on 9/13/2021, Resident #3 received 1 capsule of Gabapentin at approximately 9:45 pm.
Plan of correction
There was no adverse outcome noted for this resident as a result of this occurrence. An audit of all residents' narcotic records was conducted and there was no other finding of this deficient practice. The Medication Aide who improperly administered the medication was counseled and re-educated on 10/5/2021 on the facility's Medication Management Policy which is consistent with the standards set forth by the licensing agency and the Virginia Board of Nursing. All other Medication Aides were re-educated on the Medication Management policy and process on 10/6/2021. The Medication Aides will audit residents' narcotic records daily, on each shift, as assigned and the Health Services Director will audit all residens' narcotic record on a weekly basis to monitor and ensure compliance by 10/11/2021.
September 3, 2021Inspection0 violations
Inspection dates
09/03/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 9/3/21 and concluded on 10/1/21. A self-reported incident was received by the department regarding allegations in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 29, 2021Complaint survey1 violation
Inspection dates
June 29, 2021 and July 14, 2021
Areas reviewed
22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated complaint inspection was initiated on 6/29/2021 and concluded on 7/14/2021. A complaint was received by the department regarding allegations in the areas of buildings and grounds. The administrator was contacted by email and the director of nursing was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 6/29/2021. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. 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; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-870-D
Based upon a review of records and interview with administration and a collaborative contact, 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. Inspection reports provided by the pest control company to the facility, indicated evidence of mice in and/or around the facility during the following visits: 12/3/2020--Pest control reports provided by the facility reported that the pest control company placed two snap traps in bar and closet next to bar after mice droppings and a hole in the floor were found. Pest control replaced a snap trap in the dry storage room where "staff removed a captured mouse." Pest control replace four snap traps in the maintenance office, two in the locker room, and two in the mechanical closet between the locker room and maintenance office after staff reported a mouse in those areas in the basement. Pest control replaced two snap traps and "two glue traps in Directors office in front to activity room in 1st floor after a mouse was seen there." Pest control inspected the exterior and found "that there are several doors that have gaps underneath of them." Pest control checked and re-baited rodent stations and found evidence of mice activity in "both stations on right side of front door and in last station at back." 12/17/2020--Pest control reports provided by the facility reported that the pest control company added two mouse traps to the laundry room on the 1st floor after staff reported seeing a mouse in the laundry room. Pest control found and removed one captured mouse in the electrical closet next to the bar and removed a second captured mouse that was located in the bar. 1/7/2021--Pest control reports provided by the facility reported that the pest control company found and removed three mice from the bar and electrical room next to the bar and placed traps under the stairs where staff reported "had seen a mouse." Pest control found evidence of mouse activity in "one of the new stations and one by right corner of the building." 1/21/2021--Pest control reports provided by the facility reported that the pest control company found and removed two mice in bar and found evidence of mouse activity in station by trash dumpster. 2/4/2021--Pest control reports provided by the facility reported that the pest control company found mouse droppings on a corner in the kitchen. 3/4/2021--Pest control reports provided by the facility reported that the pest control company found and removed a captured mouse in bar and one in closet next to the bar. 3/18/2021--Pest control reports provided by the facility reported that the pest control company found and removed two captured mice in bar and one under stairs near the bar. 4/1/2021--Pest control reports provided by the facility reported that the pest control company found and removed one captured mouse in a trap under the basement stairs.
Plan of correction
Pest control inspections have been conducted by a professional pest control contractor of the affected areas and the entire building. There were no further findings of the deficient practice since 4/1/2021. A professional pest control contractor will provide onsite preventive services two times each month (on a bi-weekly basis) for the interior and exterior areas of the building. The contractor will report all findings to the Maintenance Director to ensure all recommendations and mitigation plans are implemented in a timely manner. This frequency of service is ongoing and will continue through the 2021 calendar year. All maintenance staff, housekeepers, resident assistants, and nurses will be educated to promptly report any observed or suspected signs of pest activity, in any part of the building, to their immediate supervisor. The supervisor will then provide notification to the Maintenance Director and Executive Director for further action by August 2, 2021. The Maintenance Director and Executive Director will make weekly rounds to inspect all previously affected areas of the building to ensure there is no recurrence of pest activity by August 2, 2021.
November 5, 2020Inspection3 violations
Inspection dates
Nov. 5, 2020 and Nov. 10, 2020
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 11/5/2020 and concluded on 11/10/2020. A self-reported incident was received by the department regarding allegations in the area of resident care. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. One resident record was reviewed. The exit interviewed was held with the administrator by telephone. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return 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; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based upon a review of records, the facility failed to implement a written plan for medication management that would ensure that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. The written physician's order received on 7/15/2020 to discontinue the administration of Lexapro does not appear on the Medication Administration Records (MARS), nor does the written physicians' order received on 7/15/2020 to begin the administration of Remeron.
Plan of correction
The resident was assessed by the prescribing physician immediately upon discovery of the medication error. There was no adverse outcome noted as a result of this occurrence. An audit of all resident records was conducted and there was no other finding of this deficient practice. The Wellness Nurse who documented the order in the Progress Notes but did not transcribe the order in the Quick Mar system was counseled and re-educated on 11/5/2020 on the Resident Care Order policy and process for completing order entries in a timely manner. The nurse was also re-educated on confirming orders entered by other nurses, prior to, and after shifts. The other Wellness Nurse who documented the order on the succeeding shift, is on extended leave at this time. Upon return to the facility, the nurse will receive counseling and re- education on 11/30/2020. All nurses will be re-educated on the order approval process as outlined in the Resident Care Order policy and the use of the 24-Hour Report sheet to communicate by 11/30/2020. The Health Services Director has resumed and will continue auditing all resident care orders on a daily basis to monitor and ensure compliance with the Resident Care Order policy. 22VAC40 73 650 A
22VAC40-73-650-A
Based upon a review of records, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. On 7/15/2020 the facility received a written physicians' order to discontinue administration of Lexapro. According to the Medication Administration Records (MARS), Resident #1 continued to receive the discontinued medication from 7/16/2020 through 11/3/2020.
Plan of correction
The resident was assessed immediately by the prescribing physician upon discovery of the medication error. There was no adverse outcome noted as a result of the occurrence. An audit of all resident records was conducted and there was no other finding of this deficient practice. The Wellness Nurse who documented the order in the Progress Notes but did not transcribe the order in the Quick Mar system was counseled and re-educated on 11/5/2020 on the Resident Care Order policy and process for completing order entries in a timely manner. The nurse was also re-educated on confirming orders entered by other nurses, prior to, and after shifts. The other Wellness Nurse who documented the order on the succeeding shift, is on extended leave at this time. Upon return to the facility, the nurse will receive counseling and re-education on 11/30/2020. All nurses will be re-educated on the order approval process as outlined in the Resident Care Order policy and the use of the 24-Hour Report sheet to communicate by 11/30/2020. The Health Services Director has resumed and will continue auditing all resident care orders on a daily basis to monitor and ensure compliance with the Resident Care Order policy.
22VAC40-73-680-D
Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The physician for Resident #1 wrote an order for Remeron 7.5 mg (milligrams) to be taken by mouth every evening. According to the Medication Administration Records (MARS) from 7/15/2020 through 11/4/2020, the Remeron was never administered. The Remeron medication was discontinued per physicians' order on 11/4/2020.
Plan of correction
An audit of all resident records was conducted and there was no other finding of this deficient practice. All nurses will be re-educated on the Resident Care Order policy to ensure that all medications are administered according to the prescriber's order by 11/30/2020. The Health Services Director will continue auditing all resident care orders on a daily basis to monitor and ensure compliance with prescriber's orders for medication administration.