Virginia DSS · Assisted Living Facility

Living Waters Senior Care

📍 379 North Main Street, Timberville, VA, 22853

ID 41863One Year licenseActive
11
Inspections
On record
11
With violations
Visits that cited something
0
Clean visits
Nothing cited
55
Violations cited
Individual findings
43
Standards cited
Distinct rules
5
Complaint visits
Prompted by a complaint

Living Waters Senior Care was inspected 11 times between July 13, 2021 and September 12, 2025 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 0 with none. Across that history VDSS cited 55 violations under 43 distinct standards. 5 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. 10 of these 11 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
07/31/2026
Administrator
Melissa Green
Licensing inspector
Margaret Woods-Kane
Inspector phone
(804) 724-9618
Approved for
Residential Only · Ambulatory Only

Inspection History

11

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

September 12, 2025Inspection1 violation
Inspection dates
09/12/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 8/19/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/12/2025 9:30 a.m. – 10:30 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: 33 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: 3 Observations by licensing inspector: The licensing inspector reviewed medication administration records, nurses notes, Physicians orders, and the staffing schedule. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-650-C
Based on record review and staff interview, the facility failed to ensure physician's or other prescriber's oral orders were reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. A self-reported incident was received by the regional licensing office on 8/19/2025 stating that the scheduled agency Licensed Practical Nurse (LPN) failed to report for duty on 8/18/2025 and did not provide notice of their absence leaving the morning medications unable to be administered. A replacement was sent, and the practitioner was contacted to ensure all medications were administered in accordance with their recommendations.
  2. Review of the resident records for residents 1, 2, and 3, contained a prescribers oral order to hold the missed medication until next dose for the following residents medications; -Resident 1 (admitted 11/01/2024), Chlorpromazine 25 mg tablet. -Resident 2 (admitted 12/20/2024), Modafinil 200 mg tablet, Fluoxetine 40 mg capsule, and Artificial Tears. -Resident 3 (admitted 5/31/2024), Levothyroxine 150 mg tablet, one tablet at 6:00 a.m.
  3. During an interview with staff 1 when asked if the prescriber signed the verbal orders to hold the five medications for residents 1, 2, or 3, staff 1 answered “[they] didn’t”.
Plan of correction
On 9/12, during the survey the physician was called and verified he was aware of the med pass issue. Upon his next visit to the facility the physician signed a form that verified his instructions on the day of the late/omitted medication issue. A copy of this was sent to the licensing inspector on 10/6/25. It was discussed with the physician the requirements of 22VAC40-73-650-C and signing any instructions or orders within 14 days. The medication aide was also educated on the requirements.
June 26, 2025Inspection13 violations
Inspection dates
06/26/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/26/2025 9:20 a.m. – 3:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 30 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: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, pharmacy review, healthcare oversight, menus, activity calendars and dietician report. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on record review and staff interview the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. Record review completed for residents 1, 2, 3, and 4 contained documentation that the facility ascertained after admission whether the resident was a registered sex offender.
  2. Resident 1 admitted 1/16/2025 had a sex offender search dated 1/21/2025, resident 2 admitted 11/19/2024 had a sex offender search dated 6/3/2025, resident 3 admitted 1/1/2025 had two sex offender searches dated 10/6/2021 and 6/3/2025 and resident 4 admitted 12/20/2024 had a sex offender search dated 12/26/2025.
  3. During an interview with staff 2, when asked if the sex offender searches were completed as required staff 2 stated “no they weren’t”.
Plan of correction
An audit completed of all Residents charts to ensure each resident has a sex offender search. Administrator re- educated on obtaining s:ex offender search on a resident prior to admission. An audit will be completed weekly x 1 month by the RVPO or deslgnee to ensure all new admissions have a timely sex offender search 8/30/25
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation was completed in accordance with the current edition of the Virginia Statewide Fire Prevention Code.
Evidence
  1. Record review of fire drills completed at the facility showed the following drills completed since the last inspection (7/25/2024), 8/16/2024 on first shift 6:00 a.m. – 6:00 p.m., 9/27/2024 on second shift 6:00 p.m. – 6:00 a.m., 10/30/2024 on first shift 6:00 a.m. – 6:00 p.m.., 3/31/2025 on second shift 3:30 p.m., 4/30/2025 on third shift 11:50 p.m., 5/31/2025 on second shift 4:00 p.m.
  2. Upon request the facility did not provide documentation of fire drills completed for November 2024, December 2024, January 2025, or February 2025.
  3. During an interview with staff 2, when asked if there were fire drills completed for November 2024, December 2024, January 2025, or February 2025, staff 2 stated “they were done, but I can’t find the sheet.”
Plan of correction
The administrator was re-educated Regarding fire drill schedule and Fire drill documentation to be located in a central binder with The documentation to be completed located in the same binder. An audit wiil be completed monthly x 3 months by VP or designee to ensure fire drill Process is in place 8/30/25
22VAC40-73-320-A
Based on record review and staff interview, the facility failed to ensure that the admission physical examination and report contained all required information.
Evidence
  1. Record review for resident 1, admitted 1/16/2025, had a physical examination and report that did not include the residents address, telephone, height, weight, or blood pressure.
  2. Record review for resident 3, admitted 1/1/2025, had a physical examination and report that did not include the residents’ address, telephone, height, weight, or blood pressure.
  3. Record review for resident 3 did not contain an admission tuberculosis risk assessment, the only tuberculosis risk assessment in the resident record was dated 4/11/2025.
  4. During an interview with staff 2 when asked if the physical examination and report contained all of the required information for residents 1 and 3, staff 2 stated “no they don’t”.
  5. During an interview with staff 2 when asked if there was an admission tuberculosis risk assessment completed for resident 3, staff 2 stated “I can’t find one”.
Plan of correction
An audit was completed to Ensure history and physical forms were completed in their entirety. Admlnistrator was re- educated on the requirement that the history and physical form Is to be completed prior to admission, to include the TB assessment. An audit will be completed weekly x 30 days on all new admissions by the VP or designee to ensure the history and physical is completed prior to admission 8/30/25
63.2-1720-E
Based on record review and staff interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Record review for nine new hires since the last inspection on 07/25/2024 showed three employees with a criminal history record report that was not completed prior to the 30th day of employment.
  2. During an interview with staff 2 when asked why the criminal history record reports were not completed as required, staff 2 stated "they were found during an audit and we redid them."
Plan of correction
An audit was completed on employee records to ensure employees had a background check completed as there were delays from the State Police mailing results back. Enrolled in the new automated system allowing for criminal background checks to be obtained electronically ensuring timeliness of results.
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted 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:
  2. Record review for staff 4 (hired 5/11/2025) did not contain the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
  3. Upon request, the facility did not provide the results of a tuberculosis risk assessment for staff 4.
  4. During an interview with staff 1, when asked if there was a tuberculosis risk assessment for staff 4, staff 1 stated “no.”
Plan of correction
Staff records were audited to ensure Staff had a TB assessment, PPD or A chest x-ray prior to first day of work. Administrator was re-educated regarding obtaining a TB risk assessment prior to first day of work for any staff member. An audit will be completed weekly x one month by the VP or designee to ensure new employees have TB risk assessment 8/30/25
22VAC40-73-670-1
Based on record review and staff interview, the facility failed to ensure each staff person who administered medication was licensed by the Commonwealth of Virginia to administer medications; or was registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. Record review for staff 3 indicated staff 3 was hired 6/3/2025 as a medication aide.
  2. Record review for staff 3 did not contain documentation of staff 3’s registration with the Virginia Board of Nursing or licensure with the Commonwealth of Virginia.
  3. During an interview with staff 1 when asked if staff 3 was licensed or registered to administer medications, staff 1 stated staff 3 used to administer medications at another facility but was unsure if staff 3 had a current license.
  4. Following record review and the Virginia Board of Nursing license lookup staff 3 did not have a license or registration to administer medications.
  5. Staff 3 administered medications at the facility on the following dates, 6/4, 6/7, 6/8, 6/13, 6/16, 6/21, and 6/22 to 27 residents with a total of 1,815 medications administered.
Plan of correction
An Investigation was initiated For staff 3 immediately. Staff 3 had worked as a medicaiton aide for years prior to Virginia requiring a IIcensure for a RMA. Staff 3 was grandfathered In at that time and did not sit for the exam for the state of VA by the date required by VA Staff 3 was terminated immediately and reported to the Board of Nursing All residents had a clinical review for the dates that Staff 3 worked and no adverse incidents were noted, including any significant change of condition or trips to the ER or hospital. Notification to physician and RP / POA was completed 8/30/25
22VAC40-73-390-A
Based on record review and staff interview, the facility failed to ensure at or prior to the time of admission, there was a written agreement or acknowledgment of notification, dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator.
Evidence
  1. Resident 1 admitted 1/1/2025 did not have a resident agreement in the resident record.
  2. Upon request, the facility did not provide a resident agreement for resident 1.
  3. During an interview with staff 2, when asked if there was a resident agreement for resident 1, staff 2 stated “I don’t see one”.
Plan of correction
resident 1 now has a signed Resident agreement in their record. An audit was completed to ensure all residents have a signed agreement in their record. Administrator re-educated on the admissslon process and to ensure residents sign an agreement prior to or at the time of admission 8/30/25
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the comprehensive Individualized Service Plans (ISP) contained all assessed needs.
Evidence
  1. Resident 1 admitted 1/16/2025 had a Uniform Assessment Instrument (UAI) dated 12/12/2024 that indicated resident 1 was disoriented some spheres some of the time, had wandering behaviors less than weekly and used a cane for ambulation and mobility. The ISP for resident 1 dated 1/17/2025 does not include resident 1’s orientation, behavior, or assistance needed with ambulation and mobility.
  2. Resident 2 admitted 11/19/2024 had a UAI dated 11/3/2024 that indicated supervision needed with bathing and dressing, and incontinence less than weekly. The ISP for resident 2 dated 11/15/2024 does not include the supervision needed with bathing and dressing or incontinence.
  3. During an interview with staff 2 when asked if the needs assessed in the UAI were present on the ISP for resident 1 or resident 2, staff 2 stated “no”.
Plan of correction
Administrator was re-educated on ISP being individualized to reflect current status of resident. The administrator will review 25% of ISPs weekly x 4 weeks to ensure that the ISP reflects current status of the resident. Members of the direct care staff will review and collaborate status of the resident with the administrator. Members of the direct care staff will meet with the administrator when a change of condition or status is noted for a resident and the ISP will be updated at that time. 8/30/25
22VAC40-73-310-D
Based on record review and staff interview, the facility failed to provide written assurance to the resident that the facility had the appropriate license to meet his care needs at the time of admission.
Evidence
  1. Record review for resident 1 admitted 1/16/2025, did not contain a written assurance.
  2. Upon request the facility did not provide a written assurance for resident 1.
  3. During an interview with staff 2, when asked if there was a written assurance for resident 1, staff 2 stated “I can’t find one”.
Plan of correction
Resident 1 has a signed assurance Form in the chart. Audit completed on all residents to ensure that they have assurance Form in chart. Admin was re-educated that all admissions must have a written assurance in the record. Weekly audit x 30 days by the VP or designee to ensure that a written assurance is in the record 8/30/25
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff.
Evidence
  1. Upon request the facility did not provide documentation of a semi-annual review of the emergency preparedness plan completed with all staff.
  2. During an interview with staff 1 when asked if the semi-annual review of the emergency preparedness plan was completed with all staff, staff 1 stated “I just did it on the sixth (6/6/25) but I can’t find the paper”.
Plan of correction
Administrator re-educated on The Emergency prepardness and Response plan exercise and response plan for all staff. Documentation for the 6/6/25 Review was located and sent to the inspector (included prior staff that no longer work at facility) Education given to administrator on organization of lnservices and placing paporwork and documents in EP binder once review is completed. Schedule for semi annual review added to facility calendar to ensure schedule is maintained. 8/30/25
22VAC40-73-990-C
Based on record review and staff interview, the facility failed to ensure that at least once every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced.
Evidence
  1. Record review contained a mental health emergency exercise completed 6/6/2025.
  2. Upon request, the facility did not provide documentation of the six-month resident emergency exercises completed prior to 6/6/2025.
  3. During an interview with staff 1 when asked if there is documentation of the six-month resident emergency exercises, staff 1 stated “not at this time”.
Plan of correction
The facility Administrator was re-educated on the requirement for every 6 Month emergency exercises. Prior exercises were in EP binder and dates reviewed. A calendar has been developed to ensure th exercises are timely. A review of the binders in the office and the contents was provided to the new administrator.
22VAC40-73-120-A
Based on record review and staff interview, the facility failed to ensure that the required orientation and training occurred within the first seven working days of employment.
Evidence
  1. Staff 3 (hire date 6/3/2025, start date 6/2/2025) had an orientation form dated 6/2/2025 that was not signed as completed by the employee, staff 4 (hire date 5/11/2025, start date 5/6/2025) had an orientation form completed 5/31/2025, staff 6 (hire date 6/13/2025, start date 6/12/2025) had a blank orientation form, staff 7 (hired 6/4/2025, start date 6/5/2025) had a blank orientation form, and staff 8 (hire date 6/13/2025, start date 5/25/2025) had a blank orientation form.
  2. During an interview with staff 1, when asked if the orientation and training were completed within the first seven working days of employment, staff 1 stated “no”.
Plan of correction
Staff 3, 4, 7,8 no longer work at the facility Staff 6 has completed the Orientation form. Administrator re-educated regarding the orientation for new staff to be completed within 7 days of employment. Audit completed on all employee records to validate orientation 8/30/25
22VAC40-73-980-A
Based on record review and staff interview, the facility failed to ensure a complete first aid kit was on hand in each building at the facility containing all required items.
Evidence
  1. During review of the first aid kit, the following required items were not present in the kit, blankets, either disposable or other, disposable single use breathing barriers or shields for use with rescue breathing or CPR (e.g., CPR mask or other type); plastic bags; small flashlight and extra batteries; thermometer; or triangular bandages.
  2. During an interview with staff 2 when asked if the facility first aid kit had the missing items listed, staff 2 stated “no they aren’t in there.”
Plan of correction
The disaster prepardness Box contained all the components required, however the disaster box was located in the administrators office and was not available To the staff at all times. A separate first aide kit is located in the treatment cart at the nursing station and contains all the required items the administrator was educated on monitoring of The first aid kit for appropriate Items on a regular basis.
May 23, 2025Complaint survey1 violation
Inspection dates
05/23/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on (4/30/2025) regarding allegations in the area(s) of: Resident Care and Related Services and Admission Retention and Discharge of Residents, staffing, supervision, and buildings and grounds. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/23/2025 9:15 a.m. – 12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: The licensing inspector observed residents in the common area and in their rooms, sign in/out logs, and staff communication logs. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on record review and staff interview the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender.
Evidence
  1. Resident 1 admitted 11/1/2024 had a sex offender search dated 11/13/2024.
  2. Upon request the facility did not provide documentation, other than the sex offender search dated 11/13/2024, that the facility ascertained prior to admission whether the resident was a registered sex offender.
Plan of correction
Administrator has been educated on obtaining sex offender search prior to a resident being admitted. An audit was completed to ensure all residents have a sex offender search in their record. New admissions will be audited for the next 30 days to ensure sex offender search was obtained prior to admission
April 3, 2025Complaint survey2 violations
Inspection dates
04/03/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 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: 4/3/2025 11:24am-11:54am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/3/2025 regarding allegations in the area(s) of: Resident to Resident altercation and reporting. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: Observations by licensing inspector: The Licensing Inspector observed the residents during activities and in their rooms. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record review and staff interview the facility failed to update and review the individualized service plans at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 1 admitted 2/8/2022 had an individualized service plan dated 2/27/2024. When asked if there was an updated care plan, staff 1 answered “I don’t know”.
  2. Upon request the facility did not provide an updated care plan.
  3. Resident 1 had a care plan dated 2/27/2024 that did not indicate that the resident experienced aggressive behaviors.
  4. The care notes for resident 1 indicated that resident 1 experienced behaviors on the following dates: • 5/1/2022, cursed at other residents • 1/16/2023, yelled at other residents • 2/19/2023, cursing and throwing belongings • 4/27/2023, cursed at other residents and staff, threw belongs • 6/11/2023, cursed at staff • 2/5/2024, cursed at staff • 10/29/2024, name called other residents • 11/20/2024, cursed at other residents and staff • 2/12/2025, taking other residents belongings, report of “being extremely rude to residents, yelling, pushing, and calling nasty names to them” • 3/1/2025, threw a plate at a staff person. • 3/20/2025, pushed another resident • 3/25/2025, called another resident inappropriate name • 3/30/2025, pushed another resident
  5. During an interview with staff 3, when asked if resident 1 had aggressive behaviors staff 3 stated “yes, all the time”.
Plan of correction
Resident #1 was given a 30 day notice and is no longer in the facility. An audit is being completed to ensure that residents ISPs have been updated to reflect residents current condition The new administrator will be signed up to take the Virginia ISP training and will complete that training by 6/30/25
22VAC40-73-70-A
Based on record review and staff interview the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. A complaint received by the regional licensing office on 4/3/2025 alleged that resident 1 had pushed resident 2 on 3/20/2025 and again on 3/30/2025.
  2. During an interview with staff 2, when asked if the incident that occurred on 3/20/2025 or the incident that occurred on 3/30/2025 was reported to the regional licensing office staff 2 answered “no”.
Plan of correction
Staff were in-serviced on 4/11/25 regarding abuse, neglect and reporting. Staff were also educated on communication to administrator promptly at the time of any incident The administrator will report any major incident to the office within 24 hours per regulatory guidance. New administrator will be educated on reporting and the regulatory requirements Resident #1 is no longer at the facility
April 3, 2025Complaint survey3 violations
Inspection dates
04/03/2025
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: 4/3/2025 10:00am-11:23am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/24/2025 regarding allegations in the area(s) of: Building and grounds. Number of residents present at the facility at the beginning of the inspection: 36 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: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The Licensing Inspector observed residents in their apartments and during activities. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: 22VAC40-73-860-D and 22VAC40-73-870-A. 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 the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on direct observation, the facility failed to ensure the interior of all buildings were maintained in good repair and kept clean.
Evidence
  1. During the facility tour on 4/3/2025, the following was observed: • Two resident room windows’ (room 6 and room 8 south hall) and the north hallway windows’ top glass would not stay in place and fell down abruptly when the window was unlocked. • The common area restroom by the dining room contained one wall that had been stripped of the paint with chipped and missing drywall, and gaps in the laminate flooring where flooring is missing. • The flooring by the dining room common bathroom ended greater than one inch from the wall leaving an uncovered gap in the floor. • The hallway entrance by the dining room leading into the south side hallway had a broken transition strip leaving pieces of broken wood on the floor. • Resident room #2 south contained two holes in the middle of the floor, a hole in the wall behind the door, missing drywall on the wall beside the sliding door, and large water stains on the ceiling around the sprinkler head and overhead light.
  2. Photo and video evidence taken.
Plan of correction
Maintenance repaired the window pully system on windows. Common area Restroom was scheduled for remodel prior to survey. Contractor completed remodel by 4/15/25. Walls, subfloor, flooring, toilet, sink fixtures, plumbing and walls panted were all included in remodel. Photos included of remodel Contractor realigned the floating flooring and added additional trim and stabilization 4/8/25 see photos included Contractor replaced transition strip 4/8/25 see photos Room #2 is closed for complete remodel including flooring, walls, ceiling and subfloor. Licensed Contractor estimates it to be completed by June 30th. Pending no underlying issues that would extend repair time.
22VAC40-73-860-I
Based on direct observation the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During the facility tour on 4/3/2025, a housekeeping cart was left in the south resident hallway unattended and covered with a bed sheet containing one bottle of all- purpose cleaner, one bottle of window cleaner, two cans of disinfectant spray, one bottle of foaming bathroom cleaner, one container of Comet Bleach powder, and one bottle of bathroom cleaner with bleach.
  2. Photo evidence taken.
Plan of correction
Housekeeper was educated that cart must be placed in locked area when not in use, or items must be locked in cart cubby when cart is not in use. Oral counseling form was placed in employee file with acknowledgement of regulatory guidance.
22VAC40-73-860-D
Based on direct observation the facility failed to ensure that all doors closed effectively, and any operable window was effectively screened.
Evidence
  1. During the facility tour on 4/3/2025, there were 15 total operational windows that did not have a screen in place.
  2. The courtyard sliding door on the southside hall resident room number two did not completely close and was unable to be locked.
  3. Photo evidence taken.
Plan of correction
Contractor replaced missing screens May 7th, 2025 See attached video of tour of outside of facility. Courtyard door was installed less than a year ago and is under warranty. Claim filed. Room #2 is closed for complete remodel including flooring, walls, ceiling and subfloor. Contractor estimates it to be completed by June 30th. Pending no underlying issues.
March 21, 2025Complaint survey6 violations
Inspection dates
03/21/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 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: 3/21/2025 9:30am-3:05pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/5/2025 regarding allegations in the area(s) of: resident care and related services, building and grounds, and protection of adults and reporting. Number of residents present at the facility at the beginning of the inspection: 38 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: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) 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 Jessica Gale Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-290-A
Based on record review and staff interview the facility failed to maintain a written work schedule that included an indication of whomever is in charge at any given time.
Evidence
  1. The staff schedule provided at the time of inspection dated 3/16-3/29 did not include an indication of whomever is in charge at any given time.
  2. During an interview with staff 1, when asked if the schedule included an indication of the person in charge, staff 1 stated “no, but I can add it”.
Plan of correction
The designated staff in charge on the written work schedule NOW has a indicator beside the employee that is deemed to be the designated staff in charge. This indicator was added at the time of the survey.
22VAC40-73-530-B
Based on direct observation, staff and resident interviews, the facility failed to ensure doors leading to the outside were not locked from the inside or secured from the inside in any manner that amounts to a lock.
Evidence
  1. This facility is licensed as a residential only, ambulatory only facility.
  2. The doors leading to the outside of the facility are secured by a code locking system, in which a 4-digit numerical pin must be entered in order to exit the building, If the pin is unknown, there is no way to exit the facility.
  3. During an interview with resident 1, when asked if they are able to exit the building independently resident 1 stated “yes, when I remember the code”. Resident 1 was asked if they could demonstrate how to enter the code. Resident 1 was observed by the Licensing inspector and staff 1 attempting to enter the code, a code was attempted twice before resident 1 stated “I can’t remember it” and was unable to leave the facility.
  4. During an interview with staff 1 and staff 2, when asked if there were other residents who would need assistance to exit the facility with the door lock in place, staff 2 answered “yes” and provided a list of 8 residents who are unable to exit the facility without assistance entering the code to exit.
Plan of correction
All residents were assessed by a RN on April 4, 5, 6th to determine if any risk existed from a cognitive and safety perspective. As a result of the clinical assessment 7 residents referred to the CSB to complete a new UAI to determine if these residents still qualify for residential living. CSB did come to do those assessments but as of 5/6/25 the facility has not received the reassessments of these residents. These are needed for the continuum of care at new facility. The door handle was modified to a regular handle with a bolt lock on 4/4/25. Staff were assigned to monitor the door initially but as of this time none of the identified 7 residents have even attempted to exit. Follow up with the CSB to inquire about the assessments has been communicated several times since the assessments were completed. Door alarm system was detached and door is now a regular entry door. The responsible parties were notified of the unlocked door. Responsible parties of the 7 residents were notified that CSB would be completing assessments and that they residents may have to be move from the facility if the assessment indicates they are not appropriate for a "Ambulatory Only" facility.
22VAC40-73-680-C
Based on record review, resident and staff interviews, the facility failed to ensure medications were not administered earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. During an interview with resident 1, they advised that on 3/20/2025, their bedtime medications were administered at 6:00pm as opposed to the scheduled 8:00pm by staff 2.
  2. The medication administration record (MAR) for resident 1 showed the following medication orders and time of administration, - Trazadone 100mg, 1 tablet at 7:00pm, administered at 5:55pm by staff 2. -Famotidine 20mg tablet, 1 tablet at 8:00pm, administered at 5:54pm by staff 2. -Mirtazapine 15mg tablet, one tablet at bedtime , 8:00pm, administered at 5:54pm by staff 2.
  3. Review of the MAR’s indicated that on 3/20/2025 staff 2 administered medications to 28 residents, a total of 120 medications administered greater than one hour prior to the scheduled administration time.
  4. During an interview with staff 2, when asked if the medications were administered greater than one hour prior to the ordered administration time, staff 2 stated “yes they were, I started the bedtime med pass around 5:30pm because I needed to leave at 6:00pm, I had to be at work again at 6:00am and there is no RMA (registered medication aide) scheduled after 6pm.”
Plan of correction
Registered Medication Aides that were involved attended an in-service held by held by [contracted pharmacy], Medication Aide instructor. The inservice included appropriate times and intervals to give medications. Counseling for the involved medication aides was completed and placed into their employee files. Random periodic checks of medication administration times are to be completed through the month of April to verify education and retraining effectiveness.
22VAC40-73-870-E
Based on direct observation, the facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition.
Evidence
  1. During the facility tour on 3/21/2025, one of two ovens in the kitchen was missing the front glass cover and there were two cabinet doors that had been broken and removed, one cabinet door that was broken, and one drawer that had been broken off.
  2. Photo evidence taken.
Plan of correction
A new stove had been ordered at the time of the survey. Lowes delivered the new stove and took the old one away. Cabinet opening was measured and a new door had to be ordered. Door was delivered and contractor called to schedule a time to install door and repair drawers. Staff instructed to inform administrator of any needed minor repairs immediately and place them in a maintenance notebook (ongoing).
22VAC40-73-150-B-1
Based on record review and staff interview, the facility failed to notify the department's regional licensing office in writing within 14 days of a change in a facility's administrator, including the resignation of an administrator and appointment of an acting administrator.
Evidence
  1. In an email from staff 3 on 3/25/2025, staff 3 confirmed the last date of employment for staff 4 and appointment of staff 2 as acting administrator as 12/21/2024.
  2. The regional licensing office was not notified of the change in facility administrator until the date of inspection, 3/21/2025.
  3. In an email dated 3/25/2025 from staff 3, staff 3 stated “We did not notify the DSS office regarding the change of administrator from staff 4 to staff 2”.
Plan of correction
The department has been notified since the survey of any changes to the administrator. The facility has added administrator communication to their agenda for the weekly corporate calls.
22VAC40-73-280-B
Based on record review and staff interview, facility failed to maintain a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care and directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. Upon request, the facility did not provide a written staffing plan.
  2. During an interview with staff 1, when asked if there was a written staffing plan staff 1 stated “I know there was one”.
Plan of correction
Staffing plan was verified and placed into the policy manual for ease of locating the document. The staffing plan will be reviewed if the census drops and or if the acuity and needs of the residents change.
July 25, 2024Inspection5 violations
Inspection dates
07/25/2024; 07/26/2024
Areas reviewed
22VAC40-73 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 AFFIRMATION
Technical assistance
Reviewed standard 590 Number of meals and availability of snacks 610 Menus for meals and snacks Recommend consult with registered dietician for meal and snack planning.
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: 7/25/2024 9:15 a.m. – 5:15 p.m. and 7/26/2024 10:00 a.m. – 3:00 p.m. Number of residents present at the facility at the beginning of the inspection: 30 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 client files, 3 focused. Number of staff records reviewed: 4 employee files. Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector (LI) observed the residents during activities, meals and medication administration. The following were reviewed at the time of inspection: menu, food intake, activity calendar, fire drills, emergency drills, resident council minutes, dietician report, healthcare and medication oversight, Fire Marshall inspection, VDH inspection. LI reviewed corrective actions completed since the last inspection. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-590-B
Based on observation, resident and staff interview, facility failed to have snacks available at all times for all resident.
Evidence
  1. Resident 1’s ISP dated 03/11/2024 and Resident 2’s ISP’s dated 02/27/2024 both state that resident will have meals and snacks prepared and served throughout the day 2.Resident 5 stated “sometimes we have pudding at night…most people buy their own snacks”. 3.Staff 1 showed inspector the kitchen pantry and confirmed there were not snacks on hand.
Plan of correction
22VAC40-73-590 1.The dietician list appropriate snacks to be served on the menu daily for the kitchen staff to have on hand. 2.Snacks will not be scheduled moving forward and will be be available upon request from a resident. 3.Residents with restrictions will have orders written from their physician with any snack restrictions (ie: bariatric, diabetic, etc.). 4.The administrator will check posting of snacks daily during environmental rounds. And ensure the availability of snacks daily.
22VAC40-73-450-C
Based on record review, facility failed to address on Individual Service Plans (ISP), how identified mental health needs would be provided.
Evidence
  1. Resident 1’s (admission 3/02/21) ISP dated 03/11/2024 did not describe how mental health services will be provided and by whom. Resident 1 receives mental health services as demonstrated by Psychiatric Periodic Evaluation notes dated 07/11/2024.
  2. Resident 2’s (admission 2/25/22) ISP dated 02/27/2024 did not describe how mental health services will be provided and by whom. Resident 2 receives mental health services as demonstrated by Psychiatric Periodic Evaluation notes dated 06/13/2024.
Plan of correction
22VAC40-73-450-C.2 1.Residents 1 & 2 ISP has been corrected to reflect the provider and who is providing the behavioral services. 2.All residents receiving Behavior services have the provider and who is providing listed on their ISP 3. The administrator will be responsible for the ISP reflecting services and will be the only person to update ISPs.
22VAC40-73-870-A
Based on direct observation, 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 the facility tour two licensing inspectors observed in the enclosed outdoor area, two picnic tables with broken plastic tops.
  2. Wooden gazebo in the enclosed outdoor area has a rise/change in level to enter the decking. There is no step, ramp or handrail.
  3. Photo evidence taken.
Plan of correction
22VAC40-73-870-A 1.The picnic tables were replaced during survey. A handicap ramp per code was built for the gazebo the day after survey. The ramp width and grade of the ramp did not require handrail (see photos and Life safety code). 2.The administrator will complete environmental rounds daily upon entering the facility. 3.Any repairs or maintenance will be communicated with business office and owner and will be scheduled for professional repair.
22VAC40-73-610-B
Based on observation, facility failed to ensure the daily menu included snacks based on USDA guidance.
Evidence
  1. Posted menu and kitchen menu for week 7/21-7/27 does not include a snack or list what snacks are available.
  2. Posted notice for mealtimes indicated Snack at 2:30 pm and 7:30 pm. During the days of inspection, two licensing staff did not see an afternoon snack or any snacks throughout the day.
Plan of correction
22VAC40-73-610-B 1.Menus for meals and snacks for the current week will be posted daily for the residents. 2.The dietician will develop and approve the menu and snack list according to the US department of Agricultures food guidance system and the Food and Nutritional Board of the National Academy of Sciences, considering the age, sex and activity of the resident. 3.The menus will be kept for 2 years. The administrator will monitor for posting of menu and snacks daily during environmental rounds.
22VAC40-73-450-F
Based on review of records and staff interview, facility failed to review and update Individualized service plan on an annual basis.
Evidence
  1. Resident 3’s (admission 10/28/21) record contained the most recent update to the Individual Service Plan dated 10/26/2022.
  2. Staff 1 confirmed there was not a more recent review completed.
Plan of correction
22VAC40-73-450.F 1.Resident 3 has now had their ISP updated to reflect current status and care 2. All residents ISP have been reviewed and updated as needed to reflect current status and care. 3.The administrator will be responsible for the ISP reflecting current status and care and will be the only person to update ISPs.
June 17, 2024Inspection20 violations
Inspection dates
06/17/2024, 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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/17/2024 9:05am – 1:20pm, 6/18/2024 9:00am-4:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 31 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, emergency drills, fire drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358. or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on record review and staff interview, the facility failed to ensure the rights and responsibilities of residents are reviewed annually with each staff person.
Evidence
  1. Upon request the facility did not provide an annual review of resident rights for staff 1 hired 6/20/2019, staff 3 hired 02/20/2021, or staff 5 hired 10/13/2022.
  2. Staff 1 stated in an interview “I can’t find it” when asked if there was documentation of an annual review of resident rights.
Plan of correction
Annual review of resident rights were completed with all staff and filed in their individual employee files. Annual review of Resident rights has been placed in the Administrators “To-do” calendar as an annual reminder.
22VAC40-73-560-E
Based on direct observation the facility failed to ensure all resident records are kept current, retained at the facility, and kept in a locked area.
Evidence
  1. Two licensing inspectors observed the resident records stored on unlocked shelves behind the counter at the nursing station.
  2. During an interview with Staff 1, staff 1 confirmed that the nurse’s station is unable to be locked.
  3. Photo evidence taken.
Plan of correction
The Administrator placed all charts in locked area 6.18.24
22VAC40-73-260-C
Based on direct observation and staff interview, the facility failed to ensure the list of all staff who have current certifications in First Aid or Cardiopulmonary Resuscitation (CPR) is kept up to date. 1. The current list of staff with CPR included 5 terminated employees. 2. Staff 1 reviewed the list and confirmed it is not up to date.
Plan of correction
The list was updated on 6/18/24. Administrator will update as needed when employees are terminated from the payroll system.
22VAC40-73-410-A
Based on record review and staff interview, the facility failed to ensure acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. Resident 1 (date of admission 5/31/2024) and Resident 3's (date of admission 3/22/2023) orientation did not contain a signature and date.
  2. During an interview staff 1 reviewed the orientation for resident 1 and 3 and confirmed there was no signature present for the resident or responsible party.
Plan of correction
The administrator will ensure a signature and date will be documented on the orientation sheet upon orientation of the resident. If the resident is unable to sign themselves, a phone call will be placed to the legal representative by the Administrator and witnessed by another staff member to notify them of the orientation and to let them know a copy of the form will be mailed to them and it will be imperative that it is signed and sent back. The Administrator and witness will sign and date the form with time the call was made.
22VAC40-73-610-B
Based on direct observation and staff interview, the facility failed to ensure the menu for the current week is posted in an area conspicuous to the residents. 1. Two licensing inspectors did not observe a menu posted for the week posted in an area conspicuous to the residents. 2. Staff 1 was interviewed and stated “it stays in the kitchen”
Plan of correction
The menu is being posted daily in a conspicuous area. This is the responsibility of the cook. The administrator will ensure it is posted during her environmental rounds and RMA will monitor on the weekends.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 1 admitted 5/31/2024 had a sex offender search dated 6/17/2024.
  2. Resident 3 admitted 3/22/2023 has a sex offender search dated 5/3/2024.
  3. Resident 5 admitted 4/16/2023 has a sex offender search dated 5/8/2023.
Plan of correction
Administrator will run a check to verify if the potential resident is a sex offender prior to admission.
22VAC40-73-970-A
Based on record review and staff interview the facility failed to ensure fire drills were completed accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. 1. Upon request, the facility did not provide record of fire drills completed for the year 2023, months March, April, August, September, or October. 2. Staff 1 stated “I forgot to do March”, “I could not find April”, and “I cannot find those” when asked to provide the documentation of completed drills
Plan of correction
Fire drills will be completed per regulatory guidance and will be filed under the tab “fire drills” in the Administrators Regulatory Binder. Fire drills were scheduled on the Administrators “to do” calendar for a reminder.
22VAC40-73-680-M
Based on record review, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Resident 5 has a physician’s order dated 4/25/2023 that states “Guaifenesin 100mg/5ml 118 (Robitussin 100mg/5ml liq) take 10 ml by mouth every 4 hours as needed for cough.” During a review of medications this medication was not present in the medication cart.
  2. Staff 5 stated “I don’t have that in here; I don’t think it ever came in”
Plan of correction
Medications are currently available for resident #5. The Administrator will complete random audits along with the RMA on duty to verify medications are available
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities is completed.
Evidence
  1. Upon request, the facility did not provide documentation of the semi-annual review of the emergency preparedness plan for staff or residents.
  2. Staff 1 stated during an interview “we haven’t done it”
Plan of correction
The Emergency preparedness and response plans were reviewed with staff with emphasis placed on each individuals' respective responsibilities. A copy of the list was made and placed in the office for reference.
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, 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
Evidence
  1. Upon request the facility did not provide documentation of the annual review of the sex offender information for resident 1, 2, 3, or 5.
  2. Staff 1 stated in an interview, “we haven’t done that”
Plan of correction
Each Resident has been fully informed of their right to exercise whatever due diligence they deem necessary with respect to information on any sex offenders. A notice will be mailed or emailed to each legal representative to notify them of the same rights. The annual notification has been added to the Administrators “to do” calendar as a annual reminder.
22VAC40-90-40-B
Based on record review, the facility failed to ensure criminal history report is obtained prior to the 30th day of employment for each employee.
Evidence
  1. Upon request the facility did not provide a completed criminal history report for Staff 2 hire date 11/22/2023.
  2. Staff 4 hire date 10/12/2022 has a criminal history report dated 1/13/2023.
  3. Staff 5 hire date 10/13/2022 has a criminal history report dated 1/13/2023.
  4. Staff 6 hired 6/7/2023 has a criminal history report dated 9/6/2023.
  5. Staff 1 stated during an interview “ I couldn’t find them, so I sent them off again”
Plan of correction
The Administrator will send the form upon accepted offer of employment by the employee and will write date it was mailed on a copy of the form and place in the employee file. If administrator has not received in 14 days, A call will be placed to the agency to inquire about the background check. If the background check is not received within the 30 days, the employee will be taken off the schedule until received.
22VAC40-73-450-F
Based on record review the facility failed to ensure Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition
Evidence
  1. Resident 3 has a Uniform Assessment Instrument (UAI) dated 1/3/2024 had supervision needed with bathing, dressing, toileting. Mechanical assistance with transferring. Incontinence of bowel and bladder weekly or more, and mechanical assistance with ambulation and mobility as an identified need. The ISP dated 3/19/2024 did not include bathing, dressing, toileting, transferring, incontinence, ambulation, or mobility.
  2. Resident 5 has a UAI dated 4/22/2024 indicating mechanical help needed for bathing, toileting, transferring, and walking. The ISP dated 4/20/2024 does not include, bathing, dressing, transferring, ambulation or mobility.
  3. During an interview with staff 5, when asked if resident 5 used any assistive devices for the listed activities as of the day of inspection staff 5 stated “yes”.
  4. Staff 7 stated during an interview that they are still working with staff 1 to ensure all assessed needs are included on the ISP.
Plan of correction
Individualized service plans were audited to ensure the current ISP reflected the current status of the resident. Upon admission the ISP will be developed to reflect the current status of the resident and updated accordingly.
22VAC40-73-210-A
Based on record review and staff interview, the facility failed to ensure all direct care staff attend at least 14 hours of training annually.
Evidence
  1. Staff 3 hired 2/20/2021 completed 9 hours 32 minutes of training from 2/20/2023-02/20/2024.
  2. When interviewed, staff 1 confirmed what was listed is the only training hours completed.
Plan of correction
Administrator has been educated on types, length, topics, verification of learning techniques, and record keeping of required iservices. A schedule of in-services has been created and placed on the Administrators “to-do” calendar as a reminder.
22VAC40-73-640-A
Based on record review, the facility failed to implement a written plan for medication Management specifically, methods to ensure that each resident's prescription medications and any over the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident 3 has a physician’s order dated 4/30/2024 stating “Nystatin 100k U/gm Pwd 30 (Mycostatin 100,000u/gm powd) Apply topically to affected area 2 times a day.
  2. The Medication Administration Record for resident 3 indicated from 6/1/2024-6/18/2024 waiting on delivery.
  3. Staff 5 was interviewed and stated “That medication never came in from the pharmacy.”
Plan of correction
An addendum has been added to the Medication Management protocol to address steps staff must take to ensure medications and supplements are filled and received timely. RMA’s were educated on this new process.
22VAC40-73-870-A
Based on direct observation, 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. Two licensing inspectors observed the wooden landing and ramp leading outside through the emergency exit has wooden boards sticking up in multiple places.
  2. The main kitchen was observed with various drawers and cabinet doors falling off of the hinges.
  3. The main light fixture above the medication carts was observed with a missing cover and missing a light bulb.
  4. Photo evidence taken.
Plan of correction
The wooden ramp boards were repaired. The kitchen cabinet doors were repaired. The light fixture was repaired. Administrator to complete environmental rounds per facility preventative maintenance protocol.
22VAC40-73-290-B
Based on direct observation and staff interview, 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. Two licensing inspectors did not observe the current staff person in charge posted in the facility.
  2. Staff 1 stated during the interview “we haven’t done that”
Plan of correction
The posting of the current on-site person in charge is located at the nursing station in a large frame. Staff have been educated on the duties of the person in charge and the process for posting the person in charge name each shift.
22VAC40-73-980-A
Based on direct observation, the facility failed to ensure the facility first aid kit includes all required items.
Evidence
  1. The first aid kit for the facility did not contain 12 of 16 required items. The missing items include a working flashlight, extra batteries, CPR mask, cold pack, gauze pads, hand cleaner, plastic bags, thermometer, triangular bandages, adhesive tape, or band aids.
  2. During an interview, staff 7 stated that staff use things and don’t refill the kit.
Plan of correction
The first aid kit and emergency box has been replenished with the required items and a numbered zip tie placed on the lock. The administrator and RMA monitors the placement of the zip tie during rounds. If the zip tie is broken, an inventory is taken, missing items replaced, and a new numbered zip tie will be put on the box. Staff have been educated on this process.
22VAC40-73-960-B
Based on direct observation and staff interview, the facility failed to ensure the fire and emergency evacuation plan shows primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers, as appropriate.
Evidence
  1. Two licensing inspectors observed the fire and emergency evacuation plan posted in the facility that did not show secondary route, areas of refuge, telephones, fire alarm boxes, or fire extinguishers.
  2. Staff 1 was interviewed in response to the plan and stated “They aren’t on there”
  3. Photo evidence taken.
Plan of correction
The facility has modified their signage to reflect a secondary route, area of refuge, telephones, fire alarm boxes and extinguishers. Education was completed with staff and residents to the new signage and a copy was given to each resident and staff.
22VAC40-73-350-A
Based on record review and staff interview, the facility failed to register with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code area in which the facility is located, pursuant to § 9.1-914 of the Code of Virginia.
Evidence
  1. The facility did not provide documentation of sex offender notifications.
  2. Staff 1 stated during the interview that they got a new email in January of 2024, and it hasn’t been registered.
Plan of correction
The administrator has registered their new email with the registry and signed up for email notifications
22VAC40-73-880-B
Based on direct observation during facility tour and resident interview, the facility failed to ensure a temperature of at least 72 degrees is maintained in all areas used by residents.
Evidence
  1. Resident 4 was observed in the hallway by two licensing inspectors rubbing arms stating, “ooh its’s cold”.
  2. Two licensing inspectors observed the thermostat in the resident hallways indicating a temperature set to 70 degrees.
  3. Photo evidence taken.
Plan of correction
The thermostat setting was changed on 6/17/24 during the survey. The thermostat is under a locked cover and only Administrator has the key.
June 17, 2024Complaint survey2 violations
Inspection dates
06/17/2024
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: 6/17/2024 8:35am-9:02am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/22/2024 regarding allegations in the area(s) of building and grounds. Number of residents present at the facility at the beginning of the inspection: 31 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: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The Inspector toured the facility including all common area restrooms Additional Comments/Discussion: 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-925-A
Based on direct observation during the facility tour and resident interviews, the facility failed to ensure there was an adequate supply of toilet tissue accessible to each commode.
Evidence
  1. Two Licensing Inspectors observed on the day of inspection the common area restroom near the dining and living area to be without toilet paper.
  2. Resident 1 stated “I furnish my own toilet paper, you have to ask at the desk if you don’t have your own”
  3. Resident 2 stated “most of the time there is no toilet paper or paper towels in the bathroom” Photo evidence taken.
Plan of correction
Toilet Paper is available in all bathrooms. Housekeeping monitors all bathrooms daily Monday – Friday for toilet paper. Additional toilet paper is available at the nursing station in the event someone runs out of toilet paper. Staff on the weekend monitor of toilet paper availability in the bathrooms. Administrator will also monitor for toilet paper availability on their environmental rounds.
22VAC40-73-925-B
Based on direct observation during the facility tour and resident interviews, the facility failed to ensure that common hand washing sinks have paper towels or an air dryer for handwashing.
Evidence
  1. Two Licensing Inspectors observed on the day of inspection the common area restroom near the dining and living area to be without paper towels.
  2. Resident 2 stated “most of the time there is no toilet paper or paper towels in the bathroom”
  3. Staff 1 stated “they have been ordered but they haven’t come in yet”
  4. Photo evidence taken.
Plan of correction
Hand dryers are available in the two main shower / bathrooms. Paper towels for the dispensers in the public restrooms are available, residents personal bathrooms have rolls of paper towels available or (cloth hand towels if that is what they prefer for their personal bathroom) Housekeeping monitors all bathrooms daily Monday-Friday for paper towels and provides as needed, staff on the weekend are responsible for monitoring for paper towels in bathrooms and will provide as needed. Administrator will also monitor for paper towel availability on their environmental rounds.
July 30, 2022Inspection1 violation
Inspection dates
07/30/2022
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 PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/30/22 8:30am Two Inspectors 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: 33 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Overall, the building was clean. Postings were as required. Emergency drills and outside inspections complete. Fire: 6/20/22 Health: 3/17/22 Additional Comments/Discussion: Recommended adding units given for sliding scale insulin directly on the MAR for monitoring purposes. The facility noted they had participated in the infection control team process including a visit on 6/27/22. Provided information for facility to update residents rights with the contact information for the new ombudsman. An exit meeting will be conducted to review the inspection findings. The facility has requested their licensing status to be changed to Residential Only with the issuance of this license. The evidence gathered during the inspection determined non-compliance with one 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on a review of six resident files, all six of the files had items missing from the service plans (ISP) matching the current identified needs based on the uniform assessment instrument or physical /dietary paperwork. This included special diets, mechanical supports, mental health supports, and the level of assistance noted on the UAI versus the ISP in general.
Plan of correction
All files are being reviewed and corrections made accordingly. Review also indicates some updates needed in the UAI itself as level of independence has increased. The administrator along with trained staff assume responsibility for correcting and maintaining compliance in the future..
July 13, 2021Inspection1 violation
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 1Subjectivity22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
To work with the pharmacy on issues discussed. If licensing can be of assistance please contact this inspector at (540) 292-5930 or via email.
Comments
A renewal inspection was initiated on 07/13/2021 and concluded on 08/13/2021. The new administrator was contacted by telephone and email to initiate the inspection. The administrator reported that the current census was 23. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records plus 9 additional background checks and sworn disclosures for staff hired after last inspection, staff schedules , health and fire inspections and related emergency drills, healthcare and dietary oversight along with pharmacy documentation submitted by the facility to ensure documentation was complete. The inspector conducted the remote on-site portion of the inspection on 08/13/2021 which included building and grounds, postings, emergency food supply, medication cart review, resident rooms and common areas. An exit interview was conducted with Administrator and her preceptor on the 08/13/2021 of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with one applicable standard or law, and a violation was documented on the violation notice issued to the facility. Thank you to the staff and residents for your cooperation during this remote inspection process. Should you have additional questions or concerns please call (540) 332-2330 or email this inspector at sharon.deboever@dss.virginia.gov.
Violations
22VAC40-73-680-I
Based on a desk review of medication administration records for residents 1, 2 and 3 and discussions with the new administrator and her preceptor, multiple medications for the three residents were missing a diagnosis. The corresponding orders did not consistently have a diagnosis but those that did were not transcribed to the e-mar.
Plan of correction
The facility has had ongoing discussions with both physicians and the pharmacy regarding the need for a diagnosis both on the order and the medication administration record. A new service contract is being discussed as apparently that is not a part of the current service provided by our pharmacy. The administrator and preceptor will correct and be responsible for monitoring to maintain compliance.