Virginia DSS · Assisted Living Facility

Harmony at Independence

📍 2077 South Independence Boulevard, Virginia Beach, VA, 23453

ID 41961Three Year licenseActive
25
Inspections
On record
15
With violations
Visits that cited something
10
Clean visits
Nothing cited
74
Violations cited
Individual findings
45
Standards cited
Distinct rules
15
Complaint visits
Prompted by a complaint

Harmony at Independence was inspected 25 times between June 7, 2021 and June 2, 2026 by the Virginia Department of Social Services. 15 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 74 violations under 45 distinct standards. 15 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. 23 of these 25 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Three Year
License expires
07/20/2028
Administrator
Kristen Buman
Licensing inspector
Tiffany Jefferson
Inspector phone
(804) 317-0413
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

25

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

June 2, 2026Complaint survey0 violations
Inspection dates
06/02/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: A complaint inspection was completed on 06/02/2026 from 10:45 am to 11:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/08/2026 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: For the complaint inspection, residents were interviewed and observed. Resident rooms were observed. A meal was observed. The staff schedule for the month of May was reviewed. The activity calendars for independent living, assisted living, and memory care were reviewed. An activity was observed in assisted living and memory care. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tiffany Jefferson, Licensing Inspector at 804-317-0413 or by email at t.jefferson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 28, 2026Inspection6 violations
Inspection dates
05/28/2026, 06/02/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Reviewed Standard 22VAC40-73-290B
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: An unannounced monitoring inspection took place on 05/28/26 from 8:11 a.m. to 5:04 p.m. and 06/02/26 p.m. from 8:55 a.m. to 10:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 (2 on Leave of Absence) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 8 Observations by licensing inspector: Breakfast, an assisted living activity and memory care activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, fire drills, first aid kit, medication cat, fire inspection report, health inspection report, health care supervision, nutrition supervision, a staffing schedule, and CPR/First Aid staff listing. Emergency food and water were observed. Water temperature was measured, and the call bell system was monitored. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tiffany Jefferson, Licensing Inspector at (804) 317-0413 or by email at T.Jefferson@dss.virginia.gov.
Violations
22VAC40-90-40-C
Based on the staff record review and staff interview, the facility failed to ensure any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes.
Evidence
  1. The record for staff #9, hire date 02/04/2024, contains a criminal history report dated 06/18/2024 that includes the following two barrier crime convictions: 18.2-57 on 04/26/1995 18.2-51.2 on 04/26/1995
  2. During an interview on 05/28/2026, staff #10 acknowledged that staff #9 was found guilty of two barrier crime convictions and is currently employed by the facility.
Plan of correction
Corrective Action: Upon identification of the deficiency, the employee referenced in the citation was removed from the work schedule pending further review and resolution of employment eligibility requirements. Harmony at independence will separate employment with the employee on or before June 26, 2026. Systemic Review: The Executive Director and Business Office Manager conducted a review of all active employee personnel files to verify criminal background screening compliance and confirm no additional employees were employed with disqualifying barrier crime convictions. Preventive Measures: 1) All criminal history reports will be reviewed by the Executive Director prior to hire. 2) Any applicant with criminal history findings will be reviewed with Human Resources and Regional Leadership before employment decisions are finalized. 3) Education was provided to hiring managers regarding Virginia barrier crime regulations and employment eligibility requirements. Responsible Party: Executive Director/Designee
22VAC40-73-260-A
Based on the staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for staff #3, hire date 01/16/2026 does not contain evidence of current first aid certification.
  2. During an interview on 06/02/2026, staff #8 confirmed that staff #3 does not have current first aid certification.
Plan of correction
Corrective Action: The employee identified in the citation was immediately enrolled in an approved First Aid certification course. Documentation of certification was placed in the employee's personnel file upon completion. Systemic Review: All direct care employee files were audited to verify current First Aid certification requirements and expiration dates. Classes scheduled for June 25th and July 9th for any remaining direct care team members that need a First Aid certification. Preventive Measures: 1) A certification tracking log was implemented to monitor First Aid, CPR, and AED requirements. 2) The Executive Director or designee will review certifications monthly. 3) New employee orientation checklists were updated to include verification of First Aid certification deadlines. Responsible Party: Executive Director/Designee
22VAC40-73-450-C
Based on the resident record and staff interview, 2 of 6 comprehensive individualized service plans (ISP) did not include a written description of all services that will be provided to address identified needs and, if applicable, other services.
Evidence
  1. The record for resident #2 contains a Do Not Resuscitate (DNR) order dated 02/06/2025. The record for resident #2 contains a comprehensive ISP dated 11/09/2025 and updated 01/04/2026. The comprehensive ISP for resident #2 does not include the DNR order.
  2. The record for resident #3 contains a Do Not Resuscitate (DNR) order dated 04/08/2021. The record for resident #3 contains a comprehensive ISP dated 11/09/2025 and updated 01/04/2026. The comprehensive ISP for resident #3 does not include the DNR order.
  3. During an interview on 05/28/2026, staff #6 acknowledged that resident #2 and resident #3’s files contain a DNR that is not listed on the comprehensive ISP.
Plan of correction
Corrective Action: The comprehensive ISPs for the residents identified in the citation were reviewed and updated if needed to include all services being provided, including documentation of existing DNR orders. Systemic Review: A review of all resident ISPs was conducted to ensure physician orders, DNR status, and all required services were accurately reflected. Preventive Measures: 1) ISP review procedures were revised to include a checklist verifying all physician orders, advanced directives, and resident service needs are incorporated. 2) The Health Care Director will review all new and updated ISPs for completeness prior to filing. 3) Staff responsible for assessments and care planning received re-education regarding ISP requirements. Responsible Party: Health Care Director/Designee
22VAC40-73-550-G
Based on the resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents shall be reviewed annually with each resident or his legal representative and
Evidence
  1. thereof by the resident, legal representative, and staff’s written acknowledgement and the date of the review. Evidence:
  2. The record for resident #1, admission date 08/08/2024, contains an Annual Resident Rights/Grievance Procedure Review form that was last signed on 12/20/2024.
  3. During an interview on 05/28/2026 with staff #6, staff #6 confirmed that resident #1 last signed the Annual Resident Rights/Grievance Procedure Review form on 12/20/2024.
Plan of correction
Corrective Action: The resident identified in the citation received an updated review of Resident Rights and Responsibilities. Documentation was completed and signed by all required parties. Systemic Review: All resident files were reviewed to verify annual Resident Rights reviews were completed within required timeframes. Preventive Measures: 1) A tracking system was implemented to monitor annual due dates. 2) Resident Rights reviews will be incorporated into annual reassessment procedures. 3) Monthly audits will be conducted to identify upcoming due dates. Responsible Party: Health Care Director/Designee
22VAC40-73-680-D
Based on the resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains the following orders dated 04/01/2026: Alprazolam 0.25 mg tablet, take 1 tablet by mouth every day; anti-embolism stockings med, apply to legs in the morning and remove at bedtime for edema; Buspirone HCL 5 mg tablet, take one by mouth once every morning; Clopidogrel 75 mg tablet, take 1 tablet by mouth every day; Ensure clear 237 Oral Milliliter, drink 1 bottle by mouth 3 times a day; Famotidine 20 mg tablet, take 1 tablet by mouth at bedtime; NP Thyroid 30 mg tablet, take 1 tablet by mouth every day; Quetiapine Fumarate 25 mg tablet, take 1 and ½ tablet =37.5 mg by mouth at bedtime; Senna Plus 8.6-50mg tablet, take 1 tablet by mouth 2 times a day; Sertraline HCL 50 mg tablet, take 1 tablet by mouth at bedtime.
  2. Resident #1’s MAR dated from 05/01/2026-05/27/2026 documents that the resident did not receive the following medications on the following dates: Alprazolam – 5/15/26 at 9 am; Anti-Embolism Stockings – 5/9/6, 5/10/26; Buspirone – 5/16/26 at 9 am; Clopidogrel – 5/15/26 at 9 am; Ensure – 5/9/26, 5/10/26 and 5/13/26 at 9 pm, 5/15/26 at 9 am and 12 pm; Famotidine – 5/9/26, 5/10/26, and 5/13/26 at 9 pm; NP Thyroid – 5/15/26 at 6 am; Quetiapine – 5/9/26, 5/10/26 and 5/13/26 at 9 pm; Senna Plus – 5/3/26, 5/8/26 and 5/9/26 at 5 pm, 5/15/26 at 9 am; Sertraline – 5/9/26, 5/10/26 and 5/13/26 at 9 pm
  3. During an interview on 5/28/26 with staff #6, staff #6 was unable to produce documentation verifying that these medications were received by resident #1 and could not provide an explanation for the missed dosages.
  4. The record for resident #2 contains the following medication orders: Acetaminophen 500 mg tablet, take 2 tablets by every 8 hours; Ensure liquid, drink one bottle by mouth 2 times a day; Famotidine, take 1 tablet by mouth 2 time a day; Mirtazapine 30 mg oral tablet disintegrating, take one tablet by mouth at bedtime; Quetiapine Fumarate 25 mg oral tablet, take one tablet by mouth at bedtime; Tramadol HCL 50 mg tablet, take 1 tablet by mouth 2 times a day; Trazadone 50 mg tablet, take ½ tablet by mouth at bedtime; Triamcinolone 0.1% cream, apply topically to affected area 2 times a day; Xarelto 15 mg tablet, take one tablet by mouth with evening meal; Mirtazapine 30 mg oral tablet, take one tablet by mouth at bedtime.
  5. Resident #2’s MAR dated from 05/01/26-05/27/26 documents that the resident did not receive the following medications on the following dates: Acetaminophen 500 mg tablet – 5/10/26 and 5/13/26 at 10 pm, 5/26/26 at 2 pm; Ensure – 5/3/26 at 5 pm; Famotidine – 5/3/26 at 5 pm; Mirtazapine 30 mg ODT – 5/10/26 and 5/13/26 at 9 pm; Quetiapine Fumarate – 5/10/26 and 5/13/26 at 9 pm; Tramadol – 5/3/26 at 5 pm; Trazodone – 5/10/26 and 5/13/26 at 9 pm; Triamcinolone – 5/3/26 at 5 pm; Xarelto – 5/3/26 at 5 pm; Mirtazapine 30 mg tab – 5/10/26 and 5/13/26 at 9 pm.
  6. During an interview on 5/28/26 with staff #6, staff #6 was unable to produce documentation verifying that these medications were received by resident #2 and could not provide an explanation for the missed dosages.
Plan of correction
Corrective Action: The residents identified in the citation were observed for adverse outcomes related to missed medication administration. Physician notification was completed. Medication administration records were reviewed and corrected where applicable. Systemic Review: A comprehensive audit of medication administration records was conducted to identify any additional missed medications, documentation discrepancies, or administration concerns. Preventive Measures: 1) All licensed nurses and medication aides received re-education on medication administration requirements, documentation standards, and follow-up procedures for omitted doses. 2) A daily MAR audit process was implemented by nursing leadership. 3) The Health Care Director or designee will conduct weekly medication audits for 90 days and monthly thereafter. 4) Medication omissions will be reviewed during clinical meetings and corrective action taken when trends are identified. Responsible Party: Health Care Director/Designee
22VAC40-73-450-E
Based on the resident record review and staff interview, 3 of 6 comprehensive individualized service plans were not signed by the licensee, administrator, or his designee and by the resident or his legal representative.
Evidence
  1. The record for resident #1 contains a comprehensive ISP dated 11/10/2025 and updated 02/01/2026. The comprehensive ISP for resident #1 does not contain a staff or resident signature.
  2. The record for resident #2 contains a comprehensive ISP dated 11/09/2025 and updated 01/04/2026. The comprehensive ISP for resident #2 does not contain a staff or resident signature.
  3. The record for resident #3 contains a comprehensive ISP dated 11/09/2025 and updated 01/04/2026. The comprehensive ISP for resident #3 does not contain a staff or resident signature.
  4. During an interview on 05/28/2025 with staff #6, staff #6 confirmed that the comprehensive ISPs for residents #1, #2 and #3 did not contain a staff or resident signature.
Plan of correction
Corrective Action: The ISPs identified during the inspection were reviewed and signed by the appropriate staff member and resident or legal representative if needed. Systemic Review: A review of all resident records was completed to ensure required ISP signatures were present. Preventive Measures: 1) A signature audit process was implemented for all new and updated ISPs. 2) ISPs will not be considered complete until all required signatures are obtained. 3) Monthly audits will be conducted to ensure ongoing compliance. Responsible Party: Health Care Director/Designee
October 2, 2025Complaint survey0 violations
Inspection dates
10/02/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/02/2025 (arrival 11:25 a.m. / 3:55 p.m. departure) 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 06/24/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at 757-807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 2, 2025Inspection0 violations
Inspection dates
10/02/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/02/2025 ( arrival 10:00 a.m. / departure 11:24 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: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757)807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 2, 2025Complaint survey1 violation
Inspection dates
10/02/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/02/2025 (arrival 11:25 a.m. / departure 3:55 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/27/2025 regarding allegations in the area(s) of: Admission, Retention, and Discharge of Residents; Resident Care and Related Services; Building and Grounds Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Building and Grounds 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 Darunda Flint, Licensing Inspector at (757)807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. During a tour of the building with staff #1 the hot water temperature was checked in resident #2’s room (temperature reading was 121.6 degrees F), and resident #4’s room (temperature reading was 123.3 degrees F).
  2. Staff #1 acknowledged the water temperatures were not within the required temperature range.
Plan of correction
Not published by VDSS.
May 12, 2025Complaint survey4 violations
Inspection dates
05/12/2025, 05/13/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/12/2025 from 8:50 am to 5:15 pm and 05/13/2025 from 9:45 pm to 1:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/07/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-325-B
Based on record review and interview, the facility failed to ensure a fall risk rating is completed when the condition of the resident changes and after a fall.
Evidence
  1. Resident #1 fell per nursing notes on 03/19/2025, 04/21/2025, and 04/27/2025 and was admitted to hospice on 02/10/2025; however, Resident #1’s record did not include a completed fall risk rating.
  2. Staff #1 confirmed Resident #1 did not have a completed fall risk rating in their resident record.
Plan of correction
1. Fall risk rating was obtained for Resident #1. 2. Resident records to be reviewed to determine that each contains an annual fall risk rating as part their individualized service plan (ISP), and a calendar of reviews to be established based on resident anniversary of admittance to community. 3. Regional Director of Resident Care (RDRC)/Designee to educate Health Care Director (HCD) regarding purpose of and process for obtaining annual fall risk ratings for each resident. 4. Weekly times eight weeks the HCD/Designee to conduct review of resident records based upon established admittance anniversary to ensure that annual fall risk ratings have been completed.
22VAC40-73-450-F
Based on record review and interview, the facility failed to review and update individualized service plans as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #1 was admitted to hospice on 02/10/2025; however, the ISP for Resident #1 (dated 09/28/2024) was not updated to reflect this significant change.
  2. Staff #1 confirmed the most current ISP for Resident #1 was completed on 09/28/2024.
Plan of correction
1. ISP updated for Resident #1. 2. Resident records to be reviewed to confirm that each contains an ISP updated annually or upon change in condition. 3. RDRC/Designee to educate HCD regarding the purpose of and the process for each resident record containing an ISP updated annually or upon change in condition. 4. HCD/Designee to conduct review weekly times eight weeks of resident records to ensure each contains an ISP updated annually or upon change in condition.
22VAC40-73-440-A
Based on record review and interview, the facility failed to complete a resident’s UAI whenever there is a significant change in the resident's condition.
Evidence
  1. Resident #1 was admitted to hospice on 02/10/2025; however, an UAI was not completed to reflect this significant change.
  2. Staff #1 confirmed the most current UAI for Resident #1 was completed on 09/28/2024.
Plan of correction
1. UAI completed for Resident #1. 2. Resident records to be reviewed to confirm that each contains a UAI that has been updated annually or upon change in condition. 3. RDRC/Designee to educate HCD regarding purpose of and process for ensuring each resident's UAI is updated annually or upon change in condition. 4. HCD/Designee to conduct weekly times eight weeks review of resident records to ensure updated annually or upon change in condition.
22VAC40-73-930-D
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. During the onsite visit on 05/13/2025 in the safe, secure environment, the logs for two-hour rounding are not consistently completed to document rounds no less often than every two hours for each resident with an inability to use the signaling device each evening and early morning hours.
  2. For May 2025, the following logs for the following residents do not document rounding during the following timeframes: Resident #1 and Resident #3 from 7p-7a on 05/01/2025-05/12/2025, Resident #2 from 7p-7a on 05/01/2025-05/03/2025 and 05/05/2025-05/12/2025 and 11p-7a on 05/04/2025, and Resident #4 from 7p-7a on 05/01/2025, 05/03/2025, 05/04/2025, 05/06/2025, 05/11/2025, and 05/12/2025 and 11p-7a on 05/02/2025, 05/05/2025, and 05/07/2025-05/10/2025.
Plan of correction
1. Resident #1 and Resident #3 were assessed to ensure no adverse outcomes resulted from facility staff's failure to round on these residents at minimum of every two hours after the residents had gone to bed each evening until they rose the next morning. 2. Rounding logs to be reviewed to address and manage facility staff who fail to round on residents with an inability to use the signaling device at a minimum of every two hours after resident has gone to bed each evening until they rise the next morning. 3. HCD to educate direct care staff regarding the purpose of and the process for rounding on residents with an inability to use the signaling device at a minimum of every two hours when residents have gone to bed each evening until they rise the next morning. 4. HCD/Designee to review rounding logs five times per week times eight weeks to ensure that residents who have an inability to use the signaling device are rounded upon at a minimum of every two hours from the time the resident goes to bed each evening until they rise the next morning.
May 12, 2025Complaint survey3 violations
Inspection dates
05/12/2025, 05/13/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-700
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: 05/12/2025 from 8:50 am to 5:15 pm and 05/13/2025 from 9:45 pm to 1:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/08/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-450-F
Based on record review and interview, the facility failed to review and update 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 was admitted to hospice on 03/05/2025.
  2. Staff #1 confirmed the most current ISP for Resident #1 was completed on 04/30/2024.
Plan of correction
1. Resident #1 ISP updated. 2. Resident records to be reviewed to confirm that each contains an ISP updated annually or upon change in condition. 3. RDRC/Designee to educate HCD regarding the purpose of and the process for each resident record containing an ISP updated annually or upon change in condition. 4. HCD/Designee to conduct review weekly times eight weeks of resident records to ensure each contains an ISP updated annually or upon change in condition.
22VAC40-73-325-B
Based on record review and interview, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall.
Evidence
  1. Resident #1 fell per nursing notes on 05/05/2025 and was admitted to hospice on 03/05/2025.
  2. Staff #1 confirmed the most current fall risk rating for Resident #1 was completed on 10/24/2024.
Plan of correction
1. Fall risk rating was obtained for Resident #1 ISPs. 2. Resident records to be reviewed to determine that each contains an annual fall risk rating as part of their ISP, and a calendar of reviews to be established based on resident anniversary of admittance to community. 3. Regional Director of Resident Care (RDRC)/Designee to educate Health Care Director (HCD) regarding purpose of and process for obtaining annual fall risk ratings for each resident. 4. Weekly times eight weeks HCD/Designee to conduct review of resident records based upon established admittance anniversary calendar to ensure that annual fall risk ratings have been completed.
22VAC40-73-440-A
Based on record review and interview, the facility failed to complete a resident’s UAI at least annually and whenever there is a significant change in the resident's condition.
Evidence
  1. Resident #1 was admitted to hospice on 03/05/2025.
  2. Staff #1 confirmed the most current UAI for Resident #1 was completed on 04/30/2024.
Plan of correction
1. Resident #1 UAI complete. 2. Resident records to be reviewed to confirm that each contains a UAI that has been updated annually or upon change in condition. 3. RDRC/Designee to educate HCD regarding purpose of and process for ensuring each resident's UAI being updated annually or upon change in condition. 4. HCD/Designee to conduct weekly times eight weeks review of resident records to ensure updated annually or upon change in condition.
May 12, 2025Inspection28 violations
Inspection dates
05/12/2025, 05/13/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-50 22VAC40-73-490
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/12/2025 from 8:50 am to 5:30 pm and 05/13/2025 from 9:45 am to 1:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-325-B
Based on record review and interview, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall.
Evidence
  1. Staff #4 confirmed the last fall risk rating for Resident #5 was completed on 05/23/2023.
  2. Staff #4 confirmed Resident #6 admitted to hospice on 02/26/2025 and fell per nursing notes on 04/12/2025 and 05/11/2025; however, the last fall risk rating in the record of Resident #6 was completed on 04/26/2024.
Plan of correction
1. A fall risk rating was obtained for Resident #6. 2. A resident record review to be conducted to confirm that a fall risk rating has been conducted on each resident annually and upon change in condition. 3. RDRC/Designee to educate HCD regarding purpose of and process for conducting a fall risk rating for each resident annually and upon change in condition. 4. Weekly times eight HCD/Designee to conduct review of residents completing a new year of residency and residents with changes in condition to confirm that each has an updated fall risk rating.
22VAC40-73-50-B
Based on record review, the facility failed to retain written acknowledgment of the receipt of the disclosure by the resident or his legal representative.
Evidence
  1. There was no written acknowledgment of the receipt of the full disclosure by the residents or their legal representatives for Resident #4 (admitted 04/03/2025) prior to 05/13/2025.
Plan of correction
1. Written acknowledgement of full disclosure obtained for Resident #4. 2. Resident records to be reviewed to ensure written acknowledgment of full disclosure obtained for each. 3. Regional Director of Sales and Marketing (RSDM)/Designee to educate Business Office Manager (BOM) and community sales and marketing team regarding purpose of and process for obtaining written acknowledgement of full disclosure for each new move in. 4. Weekly times eight weeks, BOM/Designee to conduct review of new move in records to confirm written acknowledgement of full disclosure obtained.
22VAC40-73-1100-A
Based on record review and interview, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.
Evidence
  1. Staff #4 confirmed Resident #6 admitted to the safe, secure environment on 04/13/2025 and did not have documentation of approval for placement in a special care unit in their record.
Plan of correction
1. Written approval to be placed in a special care unit was obtained and placed in resident record for Resident #6. 2. A records review of each resident in facility's special care unit conducted to ensure that each record contains written approval for resident placement on a special care unit. 3. RDRC/Designee to educate Harmony Square Director (HSD) related to purpose of and process for ensuring that each resident in a special care unit has written approval for placement. 4. HSD/Designee to conduct weekly times eight weeks audit of newly admitted special care unit resident records to ensure that each contains a written approval for placement.
22VAC40-73-720-A
Based on record review and interview, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan.
Evidence
  1. Staff #4 confirmed Resident #1, Resident #2, and Resident #6 have a DNR order; however, the written order is not documented in their ISPs.
Plan of correction
1. Written order for DNR documented in ISP for Residents #1, #2, and #6. 2. Review of resident records to be conducted to ensure that each ISP contains a written order for residents with a DNR. 3. RDRC/Designee to educate HCD regarding the purpose of and process for documenting DNR in resident ISP. 4. HCD/Designee to conduct weekly times eight weeks audit of resident records to confirm each ISP contains a written order for residents with a DNR.
22VAC40-73-120-A
Based on record review and interview, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment.
Evidence
  1. Staff #5 confirmed the record of Staff #1 (hired 04/28/2025) did not complete their staff orientation and initial training within the first seven working days of employment.
Plan of correction
1. Staff #5 competed required orientation and initial training. 2. Staff records to be reviewed to ensure that each has completed required orientation and initial training. 3. Regional Business Office Specialist (RDBOS) to educate BOM regarding purpose of and process for each new employee receiving required orientation and initial training within first seven days of employment. 4. Weekly times eight weeks, BOM/Designee to conduct review of new employees to confirm each have completed required orientation and initial training within first seven days of employment.
22VAC40-73-450-E
Based on record review and interview, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or their legal representative when reviews and updates of the plan have been made.
Evidence
  1. Staff #4 confirmed the ISPs of Resident #1 (dated 03/31/2025), Resident #2 (dated 04/20/2025), Resident #3 (dated 03/30/2025), Resident #4 (dated 04/23/2025) and Resident #6 (dated 04/27/2025) were not signed and dated by the resident or their legal representative.
Plan of correction
1. Resident #1, #2, #3, #4, and #6 ISPs signed and dated by administrator and by resident or resident legal representative. 2. Resident records to be reviewed to confirm that each contains an ISP signed and dated by administrator and by resident or resident's legal representative. 3. RDRC/Designee to educate HCD regarding purpose of and process for obtaining an ISP for each resident signed and dated by the administrator and by the resident's legal representative. 4. Weekly times eight weeks HCD/ Designee to conduct of new resident records to confirm each contains ISP signed and dated by administrator and by resident's legal representative.
22VAC40-73-980-H
Based on observation, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water with at least 48 hours of the supply on site.
Evidence
  1. Upon review of the facility’s emergency food and water supply, there was no emergency drinking water supply available onsite at the time of inspection.
Plan of correction
1. Emergency drinking water was ordered and shipped and currently onsite. 2. A schedule of replacement of drinking water created based upon expiration date of current stock. 3. Regional Director of Dining Services (RDSD) educated the community Dining Services Director (DSD) regarding the purpose of and process for maintaining a 96-hour supply of emergency drinking water onsite. 4. DSD/ Designee to conduct monthly times four months audit of emergency drinking water to ensure that a 96-hour supply is in stock onsite.
22VAC40-73-1090-A
Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents are assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Staff #4 confirmed Resident #1 did not have a complete serious cognitive assessment as page 2 of the assessment was unable to be located at the time of the inspection.
Plan of correction
1. A serious cognitive assessment was completed for Resident #1. 2. Resident records reviewed to confirm that a serious cognitive assessment has been conducted for each resident diagnosed with dementia with an inability to recognize danger or protect his own safety and welfare. 3. RDRC/Designee to educate HCD regarding purpose for and process of conducting serious cognitive assessments for each resident diagnosed with dementia with an inability to recognize danger or protect his own safety and welfare. 4. HCD/Designee to conduct weekly times eight week weeks reviews of resident records of residents with a diagnosis of dementia to ensure each contains a complete serious cognitive assessment.
22VAC40-73-325-A
Based on record review and interview, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed.
Evidence
  1. Staff #4 confirmed Resident #3 (admitted 02/27/2025) and Resident #4 (admitted 04/03/2025) have their comprehensive ISP completed; however, there was not a completed fall risk rating in the record of Resident #3 and Resident #4 who meet the criteria for assisted living care.
Plan of correction
1. Fall risk rating was obtained for Resident #3 and Resident #4 ISPs. 2. Resident records to be reviewed to determine that each contains a fall risk rating as a part of their ISP. 3. RDRC/Designee to educate Health Care Director (HCD) regarding purpose of and process for obtaining fall risk rating for each newly admitted resident. 4. Weekly times eight weeks HCD/ Designee to conduct review of newly admitted resident records to confirm a fall risk rating completed for each.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident #2 has an order for Midodrine 2.5 mg tablet to be administered 3 times a day with a parameter to hold for SBP>120.
  2. Resident #2’s May 2025 MAR indicates the resident did not receive their Midodrine 2.5 mg tablet at 9am on 05/02/2025-05/04/2025; however, it does not indicate Resident #2’s BP.
Plan of correction
1. Resident #2 BP assessed and medication administered as ordered. 2. Audit of MAR to be conducted to confirm that care staff responsible for administering resident medications are assessing BP parameters prior to administering BP medications. 3. HCD/Designee to educate care staff responsible for administering resident medications related to assessing BP prior to administering BP medications. 4. HCD/Designee to conduct twice weekly times eight weeks audit of MAR to confirm that residents BPs are being assessed prior to administration of BP medication.
22VAC40-73-680-C
Based on observation and record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. During a medication observation with Staff #1 around 9:15 am, Resident #1 was not administered their Metoprolol 50 mg tablet as it was scheduled for 8 am administration.
  2. During a medication observation with Staff #2 around 9:35 am, Resident #2 was administered 3 of their scheduled 8 am medications (Allegro eye drops, Calcium 600-D3 20 mcg tablet, and Metoprolol 25 mg tablet).
Plan of correction
1. Resident #1 and Resident #2 was administered respective medications as ordered. Staff #1 and Staff #2 were educated related to purpose of and process for administering resident medications according to the facility's standard dosing schedule. 2. Audit of Medication Administration Record (MAR) being conducted to confirm that residents are receiving their medications according the facility's standard dosing schedule. 3.HCD/Designee to educate staff responsible for administering resident medications to be educated regarding the purpose of and process for administering resident medications according to the facility's standard dosing schedule. 4. HCD/Designee to conduct twice weekly times eight weeks review of MAR to confirm that resident medications are being administered according to the facility's standard dosing schedule.
22VAC40-73-980-C
Based on record review and interview, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. Staff #4 was unable to provide documentation of monthly checks of the first aid kit for 10/2024 to 4/2025.
Plan of correction
1. First aid kits were checked and related documentation completed of monthly check. 2. Each first aid kit to be audited to ensure each contains required and in-date items with supporting documentation. 3. RDRC/Designee to educate HCD regarding purpose of and process for completing documentation related to monthly first aid kit audits. 4. HCD/Designee to conduct weekly times eight weeks audits of documentation related to weekly times eight weeks first aid kit audits.
22VAC40-73-980-A
Based on observation, the facility failed to ensure a first aid kit for the building contain items as identified in the standard. Items with expiration dates must not have dates that have already passed.
Evidence
  1. The building first aid kit included antiseptic ointment expired 12/2024 and hand cleaner expired 1/2025. The building first aid kit also did not have a disposable single-use breathing barrier or shield for use with rescue breathing or CPR.
Plan of correction
1. Expired items removed from the first aid kit, and missing items added to the first aid kit to ensure first aid kit contains all required items. 2. Community first aid kits were audited to ensure that each contains required items and that expired items are removed and replaced. 3. RDRC/Designee to educate HCD regarding purpose of and process for ensuring first aid kits contain required items and that each are in-date. 4. HCD/Designee to conduct weekly times eight weeks audits of first aid kits to ensure each contains required and in-date items.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Anti-Diarrheal 2mg caplet expired 03/23/2025 for Resident #7, PRN Acetaminophen 325mg tablet expired 03/08/2025 for Resident #8, PRN Acetaminophen 325mg tablet expired 03/13/2025 and PRN Senna 8.6mg tablet expired 03/13/2025 for Resident #9, PRN Ibuprofen 600mg tablet expired 04/30/2025 for Resident #10, PRN Loperamide 2mg capsule expired 04/26/2025, PRN Cyclobenzaprine 5mg tablet expired 04/26/2025, and PRN Quetiapine Fumarate 25mg tab expired 04/26/2025 for Resident #11.
Plan of correction
1. Expired medications for Residents #7, #8, #9, #10, and #11 were removed from respective med carts. 2. Med carts audit to be conducted to ensure that all expired resident medications are removed. 3. RDRC/Designee to educate HCD regarding written plan for medication management to include methods to prevent the use of outdated medications. 4. Weekly times eight weeks med cart audit to be conducted to confirm the removal of expired medications.
22VAC40-73-970-A
Based on record review, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in 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.
Evidence
  1. The facility did not conduct a fire and emergency evacuation drill in March 2025 or April 2025.
Plan of correction
1. Fire and emergency evacuation drills conducted on all shifts. 2. Fire and emergency evacuation drills scheduled monthly throughout the remainder of the calendar year 2025, and through June 2026. 3. RDO to educate MD regarding purpose of and process for conducting monthly fire and emergency evacuation drills per Virginia Statewide Fire Prevention Code. 4. MD/Designee to conduct weekly times eight weeks review of scheduled fire and evacuation drills, and related plans to conduct at least monthly.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.
Evidence
  1. Resident #1 (admitted 04/25/2025) and Resident #4 (admitted 04/03/2025) did not have a completed sex offender screening in their record prior to 05/12/2025.
Plan of correction
1. A sex offender screening was obtained for Resident #1 and Resident #4. 2. Resident records to be reviewed to ensure that each contains a sex offender registry. 3. RDSM to educate sales team regarding purpose of and process for obtaining a sex offender screening on each new resident. 4. Weekly times eight weeks review to be conducted of new resident records to confirm that each has a sex offender screening.
22VAC40-73-940-A
Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. The last inspection by the appropriate fire official was completed on 09/06/2023.
Plan of correction
1. Annual Fire Prevention Inspection conducted on May 15, 2025. 2.Fire Prevention Inspections reviewed to determine timeliness of inspections in order to work with Fire Marshall's Office accordingly. 3. Regional Director of Operations (RDO) to educate Maintenance Director (MD) related to Virginia Statewide Fire Prevention Code requiring at least an annual inspection. 4. Recently conducted Annual Inspection to be reviewed weekly times eight weeks for citations and related plans of correction.
22VAC40-73-260-A
Based on record review and interview, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #5 confirmed Staff #3 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of correction
1. Staff #3 obtained documentation of a current certification in first aid. 2. Direct care staff records to be reviewed to confirm that each has documentation of a current certification in first aid. 3. BOM to be educated by RDBOS regarding purpose of and process for obtaining documentation of a current certification in first aid. 4. Weekly times eight weeks BOM/Designee to conduct review of direct care staff records to confirm documentation of a current certification in first aid.
22VAC40-73-320-A
Based on record review, the facility failed to ensure, within the 30 days preceding admission, the physical examination including 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. Staff #4 was unable to provide Resident #3’s TB risk assessment as part of their admitting physical examination (dated 02/10/2025).
  3. Staff #4 was unable to provide the completed TB risk assessment and page 3 of Resident #4’s physical examination (dated 03/28/2025).
Plan of correction
1. A TB risk assessment was obtained for Resident #3 and Resident #4. 2. Resident records to be reviewed to confirm that each resident has a TB risk assessment within 30 days preceding admission. 3. RDSM to educate marketing department regarding purpose of and process for obtaining TB risk assessment within 30 days preceding admission for each new resident. 4. Weekly times eight weeks BOM to conduct review of new resident records to confirm that each has a TB risk assessment within 30 days preceding admission.
22VAC40-73-550-G
Based on record review and interview, the facility failed to annually review the rights and responsibilities of residents with each resident or their legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. Staff #5 confirmed the last review of resident rights and responsibilities for Staff #3 was completed on 02/15/2024.
  2. Staff #4 confirmed there has not been a review of resident rights and responsibilities for Resident #4 within the past 12 months.
Plan of correction
1. Staff #3 and #4 received review of the resident rights and responsibilities. 2. Staff records reviewed to confirm each staff has received annual review of resident rights and responsibilities. 3. RDBOS to educate BOM regarding purpose of and process for each staff receiving annual resident rights and responsibilities review. 4. Weekly times eight weeks review of staff records to be conducted to confirm each contains documentation of annual resident rights and responsibilities review.
22VAC40-73-440-B
Based on record review and interview, the facility failed to ensure the administrator or the administrator's designated representative approves and then signs the completed UAI for private pay individuals.
Evidence
  1. Staff #4 acknowledged the UAIs for Resident #1 (dated 03/31/2025), Resident #2 (dated 04/20/2025), Resident #3 (dated 12/23/2024), Resident #4 (dated 04/03/2025), and Resident #6 (dated 04/21/2025) were not approved and signed by the administrator or the administrator’s designated representative.
Plan of correction
1. UAIs approved and signed by the administrator have been obtained for Residents #1, #2, #3, #4, and #6. 2. Resident records to be reviewed to confirm that each contains administrator approved and signed UAIs. 3. RDRC/Designee to educate HCD regarding purpose of and process for obtaining administrator approved and signed UAIs. 4. Weekly times eight weeks review of new resident records to be conducted to confirm each contains administrator approved and signed UAIs.
22VAC40-90-40-B
Based on record review and interview, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #6 was hired on 10/10/2024; however, the criminal history record report for Staff #6 was completed 05/12/2025.
  2. Staff #7 was hired on 07/31/2024; however, the criminal history record report for Staff #7 was completed 10/13/2024.
  3. Staff #5 confirmed the hire dates and dates of their completed criminal history record report for Staff #6 and Staff #7.
Plan of correction
1. A criminal record report was obtained for Staff #6 and Staff #7. 2. A review of staff records conducted to ensure that each contains a criminal record report on or prior to the 30th day of employment. 3.RDBOS to educate BOM regarding purpose of and process for obtaining criminal record report for each employee on or prior to the 30th day of employment. 4. BOM/Designee to conduct weekly times eight weeks audit of newly hired employee's employee records to ensure each contains a criminal record report on or prior to the 30th day of employment.
22VAC40-73-410-A
Based on record review, the facility failed to ensure upon admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. 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 (admitted 04/25/2025) did not have evidence of receiving orientation in their resident records.
Plan of correction
1. Signed and dated documentation related to new resident orientation obtained for Resident #1 record. 2. Resident records to be reviewed to confirm that each contains signed and dated confirmation that each resident received new resident orientation. 3. RDBOS to educate BOM regarding purpose of and process for each new resident receiving new resident orientation and each resident record containing signed and dated documentation of the same. 4. Weekly times eight weeks review of new resident records to be conducted to confirm each contains signed and dated documentation of new resident orientation.
22VAC40-73-1110-B
Based on record review and interview, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee perform a review of the appropriateness of each resident's continued residence in the special care unit.
Evidence
  1. Staff #4 confirmed the last annual review of appropriateness for continued residence in the special care unit for Resident #5 was completed on 06/30/2023.
Plan of correction
1. A review of appropriateness for continued residence in special care unit was conducted and placed in resident record for Resident #5. 2. A review of each resident of the special care unit resident records was conducted to ensure each contained an annual review of appropriateness for continued residence in special care unit. 3. RDRC/Designee to educate HSD regarding purpose of and process for conducting annual review of appropriateness for continued residence in a special care unit. 4. HSD/Designee to conduct weekly times eight weeks review of newly admitted residents to the special care units resident records to confirm each contains an annual review of appropriateness for continued residence in a special care unit.
22VAC40-73-450-A
Based on record review and interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. Resident #3 was admitted to the facility on 02/27/2025; however, the ISP for Resident #3 was completed on 03/30/2025.
  2. Resident #4 was admitted to the facility on 04/03/2025; however, the ISP for Resident #4 was completed on 04/23/2025.
  3. Staff #4 confirmed there was no preliminary plan of care or ISP on or within seven days prior to the day of admission nor any ISP completed prior to 03/30/2025 for Resident #3 and 04/23/2025 for Resident #4.
Plan of correction
1. Resident #3, #4 ISP completed. 2. Resident records to be reviewed to confirm that each contains an up to date ISP. 3 RDRC/Designee to educate HCD regarding the purpose of and process for creating a preliminary ISP for each new resident on or within seven days prior to day of admission. 4. Weekly times eight HCD/ Designee to conduct review of new resident records to confirm that each contains preliminary ISP on or within seven days of move in.
22VAC40-73-320-B
Based on record review and interview, the facility failed to annually complete a risk assessment for tuberculosis on each resident 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. Staff #4 confirmed the last TB risk assessment for Resident #5 was completed on 02/21/2024.
  3. Staff #4 confirmed the last TB risk assessment for Resident #6 was completed on 02/25/2024.
Plan of correction
1. A TB risk assessment was obtained for Resident #5 and Resident #6. 2. Resident records to be reviewed to confirm that each resident has a TB risk assessment as evidenced by the completion of a current screening form published by or consistent with the Virginia Dept of Health (VDH). 3. RDSM to educate marketing department regarding purpose of and process for obtaining TB risk assessment for each new resident on a form published by or consistent with the VDH. 4.Weekly times eight weeks BOM to conduct review of new resident records to confirm that each has a TB risk assessment on a form published by or consistent with the VDH.
22VAC40-73-250-D
Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Additionally, each staff person or household member required to be evaluated are to annually submit the results of a risk assessment, documenting that the individual is free 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. Evidence:
  2. Staff #5 confirmed Staff #1 was hired on 04/28/2025; however, the TB risk assessment for Staff #1 was completed on 05/12/2025.
  3. Staff #5 was unable to provide a TB risk assessment for Staff #3 in 2024.
Plan of correction
1. A TB risk assessment was obtained for Staff #1 and Staff #3. 2. Staff records to be reviewed to confirm that each staff person or household member required to be evaluated has an annual TB risk assessment. 3. BOM to be educated by RDBOS regarding purpose of and process for obtaining annual TB risk assessments for each staff person or household member as required. 4. Weekly times eight weeks BOM/Designee to conduct review of staff and resident records to confirm required persons records contain an up to date TB risk assessment.
22VAC40-73-1110-A
Based on record review and interview, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment.
Evidence
  1. Staff #4 confirmed Resident #4 (admitted 04/03/2025) and Resident #6 (admitted 04/13/2025) did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of correction
1. Appropriately signed documentation of the determination and justification of placement in special care unit was obtained and placed in respective resident records for Residents #4 and #6. 2. Resident records of special care unit residents conducted to ensure that each contains appropriately signed documentation of the determination and justification of placement in a special care unit. 3. RDRC/Designee to educate HSD regarding purpose of and process for each resident of special care unit resident record containing appropriately signed documentation of the determination and justification of placement in a special care unit. 4.HSD/Designee to conduct weekly times eight weeks review of newly admitted residents to special care unit resident records to confirm each contains appropriately signed documentation of the determination and justification of placement in a special care unit.
May 12, 2025Complaint survey0 violations
Inspection dates
05/12/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/12/2025 from 8:50 am to 5:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/08/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 10, 2025Complaint survey4 violations
Inspection dates
04/10/2025, 04/17/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Technical assistance
22VAC40-73-470
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/10/2025 from 1:15 pm to 2:50 pm and 04/17/2025 from 12:00 pm to 12:34 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/09/2025 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services, and Buildings and Ground. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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: Resident Care and Related Services and Buildings and Ground. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-460-H
Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met.
Evidence
  1. On 04/10/2025, the laundry hamper in Resident #1’s apartment was noted to be overflowing. There were also dirty rags noted in Resident #1’s shower.
Plan of correction
Resident #1s laundry need was addressed to include gathering and laundering of dirty rags found in the shower. Other residents units were visited for laundry needs that have not bee addressed timely. Laundry schedules reviewed for twice weekly audit to ensure resident laundry is being attended to timely. Twice weekly finings to be submitted monthly to the community Quality Assurance Committee to revise process as needed.
22VAC40-73-660-A
Based on observation, the facility failed to ensure medications and dietary supplements prescribed for residents to be administered by the facility are stored in a medicine cabinet, container, or compartment.
Evidence
  1. Resident #1 has an order for staff to administer Nystatin 2 times daily to feet.
  2. A tube of Nystatin cream was noted at Resident #1’s bedside on 04/10/2025.
Plan of correction
Resident #1s Nystatin cream was removed from the bedside. Other residents units searched to ensure medications to be administered by the facility care staff is properly stored in a medicine cabinet, container, or compartment. Care staff educated related to proper storage of medications and dietary supplements prescribed for residents to be administered by the facility. Unit searches twice weekly by care staff twice weekly to ensure medications and dietary supplements are stored properly. Findings from above to be submitted monthly to the community Quality Assurance committee to revise process as needed.
22VAC40-73-450-E
Based on record review and interview, the facility failed to ensure the individualized service plan be signed and dated by the resident or their legal representative when reviews and updates of the plan have been made.
Evidence
  1. Resident #1’s ISP (dated 11/01/2024) is not signed and dated by the resident or their legal representative.
  2. Staff #1 confirmed Resident #1’s ISP has not been signed by the resident or their legal representative.
Plan of correction
HCD/Designee to meet with Resident #1s legal representative to sign and date Resident #1s ISP. Resident ISPs to be reviewed for resident and/or legal representative signature and documented date of signature. Executive Director (ED) to educate Health Care Director (HCD)/Designee of regulation 22VAC40-73-45-E related to signing and dating resident ISPs. Resident ISPs to be reviewed weekly times four weeks and monthly times three weeks with findings to be reported to community Quality Assurance (QA) Committee monthly for process review and revision as needed.
22VAC40-73-460-B
Based on record review, the facility failed to ensure care provision and service delivery be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The facility’s call bell system policy indicates “failure to answer alerts in a customary period of time (approximately 4 minutes) could result in disciplinary action.”
  2. From 03/01/2025-04/10/2025, there were 48 instances the response time for Resident #1’s pendant exceeded over 15 minutes.
  3. From 03/01/2025-04/10/2025, there were 8 instances the response time for Resident #2’s pendant exceeded over 15 minutes.
Plan of correction
Resident #1 was visited to address any concerns resulting from the call bell not having been answered timely. Past seven days call bells reports were reviewed to determine those that were not answered timely to visit those residents to address concerns related to their call bells not having been answered timely. Staff to be educated on policy related to timely answering of call bells. Call bell response times to be reviewed daily by Management Team at Daily Morning Meeting for follow up with both affected resident and responsible staff. Review of the above to be submitted monthly to community Quality Assurance Committee for review and revision as needed.
April 2, 2025Complaint survey0 violations
Inspection dates
04/02/2025, 04/10/2025, 04/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/02/2025 from 12:12 pm to 1:15 pm, attempted at 1:15 pm on 04/10/2025, and 04/17/2025 from 12:00 pm to 12:34 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/31/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 18, 2025Inspection3 violations
Inspection dates
03/18/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/18/2025 from 10:25 am to 11:20 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/17/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 03/15/2025, Staff #2 administered Resident #1 the 4 pm medications (Duloxetine 60 mg capsule and Eliquis 5 mg tablet) for Resident #2.
Plan of correction
1. Resident #1 was sent to hospital to ensure no adverse reactions resulted from receiving meds not prescribed. 2. MAR reviewed to ensure other residents received medications as and only as prescribed. 3. Community med techs and nurses to be educated related to the five rights of medication administration. 4. MAR review to ensure residents received medications as and only as prescribed. Review of the above to be submitted to QA Committee weekly times four weeks and monthly times two months.
22VAC40-73-210-B
Based on record review and interview, the facility failed to ensure all direct care staff attend at least 18 hours of training annually. Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence
  1. The facility was unable to provide documentation of 2024 annual training for Staff #2.
Plan of correction
1.Staff #2 completed required Annual Training. 2. ED/Designee to conduct audit of direct care staff ensure that each have completed the required hours of training. 3. Direct care staff to be educated related to completing the required hours of training on an annual basis. 4. ED/Designee to conduct audit of direct care staff training to ensure care staff have completed the required hours of training. Review of the above to be submitted to QA Committee weekly xs four weeks and monthly xs two months.
22VAC40-73-560-I
Based on record review, the facility failed to ensure a current picture of each resident be readily available for identification purposes or, if the resident refuses to consent to a picture, there be a narrative physical description, which is annually updated, maintained in his file.
Evidence
  1. Resident #1’s record did not include a current picture or a narrative physical description in their resident record prior to the onsite inspection.
Plan of correction
1. Resident #1's medical record was updated to include a current picture. 2. Current resident's medical records audited to ensure that each is updated with a current picture or narrative physical description. 3. ED/Designee to educate health care director related to regulation requiring each resident's medical record to include a current picture or a narrative physical description. 4. HCD/Designee to conduct audits to ensure each resident's medical record includes a current picture or a narrative physical description. Review of the above to be submitted to QA Committee weekly xs fours weeks and monthly xs two months.
February 27, 2025Complaint survey6 violations
Inspection dates
02/27/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/27/2025 from 11:15 am to 1:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/24/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Resident Accommodations and Related Provisions. Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on record review, the facility failed to implement their medication management plan to include methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. Resident #1 received an order to change their PRN Tylenol order to be administered scheduled every 8 hours on 02/04/2025.
  2. Resident #1’s record included the physical order as well as a nurse note documenting this change.
  3. The February 2025 MAR for Resident #1 indicates the scheduled Tylenol 500 mg (2 tablets by mouth every 8 hours) was not transcribed to the MAR until 02/13/2025.
Plan of correction
1. LPN reviewed Resident #1 Tylenol order in the medication administration record (MAR) to ensure that it was entered and being administered in accordance with prescriber's instructions. 2. LPN reviewed medical record to ensure that pending medication orders were complete to include medication delivered, MAR revised, and medication being administered in accordance with prescriber's instructions. 3.Health Care Director educated on policy and procedure related to LPN review of pending orders to ensure medications delivered and administered in accordance with prescriber's instructions. 4. Health Care Director or LPN designee to review pending orders in medical record daily to ensure medications have been delivered, in the MAR, and being administered according to prescriber's instructions. Review of the above to be submitted to QA Committee weekly times four weeks and monthly times two weeks.
22VAC40-73-460-B
Based on record review, the facility failed to ensure care provision and service delivery be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The facility’s call bell system policy indicates “failure to answer alerts in a customary period of time (approximately 4 minutes) could result in disciplinary action.”
  2. In February 2025, there were 21 instances the response time for Resident #1’s pendant exceeded over 15 minutes.
  3. In February 2025, there were 4 instances the response time for Resident #2’s pendant exceeded over 15 minutes.
Plan of correction
1. Resident #1 and #2 were immediately visited to address any concerns resulting from the call bell not having been answered timely. 2. Past seven days call bells reports were reviewed to determine those that were not answered timely to visit those residents to address concerns related to their call bells not having been answered timely. 3. Staff to be educated on policy related to timely answering of call bells. 4. Call bell response times to be reviewed daily for review by Management Team at daily Morning Meeting for follow up with both affected resident and responsible staff. Review of the above to be submitted to QA Committee weekly times four and monthly times two months.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident #1 received an order to change their PRN Tylenol order to be administered scheduled on 02/04/2025.
  2. The February 2025 MAR for Resident #1 did not start administering the scheduled Tylenol 500 mg (2 tablets by mouth every 8 hours) until 02/14/2025.
Plan of correction
1. LPN reviewed Resident #1 Tylenol order in the MAR to ensure that it was entered and being administered in accordance with the prescriber's instructions. 2. LPN reviewed medical record to ensure pending medications were complete to include medication delivered, MAR revised, and medications are being administered in accordance with prescriber's instructions. 3. Health Care director educated by Regional Director of Resident Care on policy and procedure related to LPN review of pending orders to ensure medications delivered and administered in accordance with prescriber's instructions. 4. Health Care Director of LPN designee to review pending orders in medical record daily to ensure medications received, in the MAR, and being administered in accordance with prescriber's instructions. Review of the above to be submitted to QA Committee weekly times four weeks and monthly times two months.
22VAC40-73-150-B-2
Based on interview, the facility failed to notify the Virginia Board of Long-Term Care Administrators and the department’s regional licensing office of a change in the facility’s administrator.
Evidence
  1. On 12/16/2024, Staff #2 notified via email the facility’s licensing inspector that Staff #2 will serve as the administrator on record.
  2. Staff #2 was not onsite during the inspection held on 02/27/2025 and was asked to provide clarification on their availability at the facility.
  3. On 03/03/2025, Staff #2 indicated Staff #3 has served as the administrator on record as of 12/16/2024.
  4. Staff #2 indicated via email the facility failed to notify the licensing office regarding this change in administrator.
  5. On 03/04/2025, the Department of Health Professions also confirmed their office has not received an application or information regarding Staff #3.
Plan of correction
1. On Friday, February 28, 2025 the Regional Director of Operations contacted DSS to provide proper notification that Staff #2 is the current acting administrator for Harmony at Independence. 2. Previous changes in administration notifications reviewed to determine that proper notifications was indeed provided in a timely manner. 3. Senior Vice President of Operations to educate Regional Director of Operations regarding oversight to ensure changes in administration notifications are submitted to DSS in a timely manner. 4. Regional Director of Operations to monitor all changes in administration for Harmony at Independence to ensure proper notification is provided to DSS in a timely manner. Review of the above to be submitted to QA Committee weekly times four and monthly times two months.
22VAC40-73-750-E
Based on observation, the facility failed to ensure sufficient bed linens.
Evidence
  1. Photo #1 was taken on 02/22/2025 around 1:00pm and shows Resident #1 laying directly on their mattress with no bed linens.
Plan of correction
1.Bed linens were changed immediately upon notification that resident was lying directly on mattress with no linens. 2. Audit of bed linens to be conducted of residents out of the community and/or recently returned to identify other beds with no or insufficient bedding for immediate correction. 3.Staff to be educated on making beds immediately after resident is out of the community for any reason (i.e. leave of absence or hospitalization. 4.HCD or designee to conduct check at the beginning of each shift units of residents out of the community as stated above. Review of the above to be submitted to QA Committee weekly times four weeks and monthly times two weeks.
22VAC40-73-280-B
Based on record review and interview, the facility failed to maintain a written plan that specifies 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.
Evidence
  1. The facility provided a Healthcare Daily Staffing Sheet as their staffing written plan. The sheet indicates it is subject to change based on the current census, needs of the residents and staffing; however, it does not describe how the facility evaluates and determines the number and type of direct care staff required the day-to-day, routine direct care needs for the residents in care.
Plan of correction
1. Educated Health Care Director re 280-B regulation. 2. Conduct daily review of staffing in accordance with company staffing ratios as published via company's allowable hours. 3. Audit schedules to ensure appropriate staffing levels and submit to QA Committee weekly times four weeks and monthly times two months.
January 14, 2025Complaint survey0 violations
Inspection dates
01/14/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/14/2025 from 11:30 am to 12:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 11, 2024Inspection0 violations
Inspection dates
12/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/10/2024 from 11:35 am to 12:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/20/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 26, 2024Complaint survey1 violation
Inspection dates
07/26/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/26/2024 from 11:35 am to 1:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/23/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 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: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-460-B
Based on record review, the facility failed to ensure care provision and service delivery be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #1’s care plan indicates the resident will use a pendant to call for assistance in addition to rounds every 2 hours for safety concerns and unanticipated needs.
  2. From March 28, 2024 to June 26, 2024, there were 87 instances where the response time from Resident #1’s pendant exceeded over 30 minutes.
Plan of correction
Training with the nursing staff on our call bell responsiveness policy and procedures will be conducted by the HCD & HSD on 8/23/24 Moving forward call bell response logs from the previous day will be reviewed daily at stand up and follow-up conversations will be held with team members and residents as needed to understand the root causes of any persistent or lengthy delays. Interventions will be put into place to address any identified causes of delays.
June 4, 2024Inspection4 violations
Inspection dates
06/04/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 06/04/2024 from 8:35 am to 2:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophen 500 mg tablets expired 06/03/2024 and PRN Promethazine 25 mg tablets expired 05/22/2024 for Resident #10 and PRN Tramadol 50 mg tablets expired 01/26/2018 for Resident #11.
Plan of correction
Expired medications removed from Medication cart for Resident #10 & 11 by the RMA & HCD on 6/04/24. Ongoing: RMAs will be re-educated to monitor medication expiration dates as they are completing the med pass to check for expiration dates, and to remove expired medications. With oversight from the HCD, HSD and/or designee RMAs will do weekly checks of the medication carts to check for expired medications and other proper medication storage practices. The HCD, HSD and/or designee will conduct a monthly audit of all medication carts.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #2 (hire date 01/22/2024) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of correction
The BOM/designee assigned Staff # 2 to an approved first aid training course to be completed on 6/06/24. Moving forward the BOM and/or designee will ensure that all new employees who do not have certification obtain it within the first 60 days of employment. During the monthly audit of employee files, the First Aid and CPR training on each employee will be validated as current and taught through an approved training provider per the standards.
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive ISP include a description of current identified needs and written description of what services will be provided to address identified needs.
Evidence
  1. Resident #6 had a change to regular liquids and discontinuance of thickened liquids on 03/06/2024; however, the ISP for Resident #6 (dated 02/23/2024) indicates the resident has a mechanical soft with nectar thickened liquids and does not reflect this change.
Plan of correction
Resident # 6 ISP updated to reflect diet change from thickened liquids to regular liquids by the HSD on 6/4/2024. Ongoing: The HCD, HSD and/or designee will assure that when physician’s orders are transcribed they are cross-referenced with the resident’s ISP to assure that all information on residents newly identified needs and associated services are reflected on the service plan.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.
Evidence
  1. Resident #5 (admitted 04/16/2024) did not have a completed sex offender screening in their record.
Plan of correction
Resident # 5 Sex Offender screening completed and filed in their business record by the ED on 6/4/2024. Moving forward the DSM, ED and/or designee will create a pre-admit checklist for admissions files to include verifying that all sex offender screens are completed prior to admission and filed in the resident’s business record.
March 8, 2024Inspection0 violations
Inspection dates
03/08/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/07/2024 from 9:30 am to 10:55 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/04/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 8, 2024Complaint survey0 violations
Inspection dates
02/08/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/08/2024 from 11:55 pm to 12:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/04/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 19, 2023Complaint survey0 violations
Inspection dates
10/19/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/19/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/10/2023 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 21, 2023Inspection8 violations
Inspection dates
06/21/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/21/2023 from 8:35am to 3:37pm 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophen 325 mg tablets expired 05/21/2023 for Resident #11 and PRN Benzonatate 100 mg capsules expired 06/15/2023 for Resident #12.
Plan of correction
Expired medications removed from Medication cart for Resident #11 & 12 by the HCD on 6/21/23. Moving forward, a weekly med cart audit for expired medications will be conducted by the HCD/HSD and/or designee.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #1 (hire date 1/5/23) and Staff #3 (hire date 7/19/22) works as direct care staff and do not have documentation of a current certification in first aid in their staff record.
Plan of correction
The BOM/designee assigned Staff # 1 & 3 to a first aid training to be completed by 7/30/23. Moving forward the BOM/designee will create a tickler monthly auditing all employees’ files to ensure each employee is within standard.
22VAC40-73-1140-B
Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section.
Evidence
  1. Staff #1 (hire date 1/5/23) works as direct care staff; however, Staff #1 participated in 1.25 hours of training in cognitive impairment within four months of their hire date.
  2. Staff #3 (hire date 7/19/22) works as direct care staff; however, Staff #3 participated in 6.5 hours of training in cognitive impairment within four months of their hire date.
Plan of correction
Staff #1 & 3 educated on the importance of attending all mandatory training. Cognitive Impairment Training Courses assigned by the BOM/designee to staff #1 & 3 to meet hours required. This will be completed by 7/30/23. Moving forward the BOM/designee will create a tickler monthly auditing all employee training hours to include Cognitive Impairment Training Courses to ensure each employee is within standard.
22VAC40-73-970-A
Based on record review and interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in 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.
Evidence
  1. Staff #6 could provide evidence of the fire and emergency evacuation drill conducted on 5/23/23; however, there was no documentation of previous drills conducted over the past 3 months.
Plan of correction
The MD and/or designee will ensure a record of monthly fire and emergency evacuation drills are kept in a binder located in their office.
22VAC40-73-325-B
Based on record review, the facility failed to ensure a fall risk rating is completed at least annually.
Evidence
  1. Upon review of the resident’s record, the last annual fall risk rating for the Resident #2 was completed on 9/17/2021.
  2. Upon review of the resident’s record, the last annual fall risk rating for the Resident #3 was completed on 2/25/2020.
Plan of correction
Resident #2 & 3 Annual Fall Risk completed and updated by the HCD/HSD on 6/28/23. Moving forward a chart audit tool including Fall Risk Assessments to be completed on all current and new residents and placed in each resident’s medical chart with due dates. This tool will be audited quarterly by the HCD/HSD and/or designee.
22VAC40-73-550-G
Based on record review, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. The following resident records did not include a current written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year: Resident #2, Resident #3, and Resident #4.
Plan of correction
Residents # 2, 3, & 4 review of resident’s rights with written acknowledgement to be reviewed and updated with resident and legal representative by the ED by 7/10/23. Moving forward the BOM and/or designee will create a tickler audit with due dates for renewal of resident rights evidenced by a written acknowledgement on all residents.
22VAC40-73-700-2
Based on observation, the facility failed to post "No Smoking-Oxygen in Use" signs and enforce the smoking prohibition in any room of a building where oxygen is in use.
Evidence
  1. During a tour of the facility, Resident #2 and Resident #10 were noted to have an oxygen concentrator in their apartment; however, there is not a “No Smoking-Oxygen in Use” sign posted outside their apartment.
Plan of correction
“No Smoking-Oxygen in Use” sign placed outside of resident #2 & 10 apartment doors by the HSD on 6/21/23. Moving forward the HCD/HSD and/or designee will conduct a weekly audit on all residents on oxygen to ensure signs are posted outside of their apartment doors.
22VAC40-73-210-B
Based on record review, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments.
Evidence
  1. Staff #5 (hire date 10/3/2019) works as an RMA/CNA; however, from 10/2021-10/2022, Staff #5 completed 2.25 hours of annual training.
Plan of correction
Staff #5 educated on the importance of attending all mandatory training. Training Courses assigned by the BOM/designee to staff #5 to meet hours required. This will be completed by 7/30/23. Moving forward the BOM/designee will create a tickler monthly auditing all employee training hours to ensure each employee is within standard.
May 1, 2023Complaint survey1 violation
Inspection dates
05/01/2023, 05/02/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2023 from 11:30 am to 12:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/17/2023 regarding allegations in the area(s) of: Part VI Resident Care and Related Services. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-560-G
Based on record review, the facility failed to ensure residents be allowed access to their own records. A legal representative of a resident shall be provided access to the resident's record or part of the record as allowed by the scope of his legal authority.
Evidence
  1. The legal representative of Resident #1 requested access to the resident’s record via email on 01/25/2023 and completed the Authorization for Release of Protected Health Information form as required by the facility’s procedure on 01/26/2023 to Staff #1. Despite the written request to release the resident’s records and completion of the Authorization for Release of Protected Health Information form, as of 05/02/2023, the facility has not provided access to the resident’s record to the legal representative of the resident.
Plan of correction
Not published by VDSS.
July 5, 2022Inspection2 violations
Inspection dates
07/05/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 07/05/2022 from 8:35am to 3:16pm 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #2 (hire date 1/13/22) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of correction
Employee has been educated and mandated to receive education that meets the regulation cited. Recurring First Aid training will be offered with staff attendance being monitored and scheduled.
22VAC40-73-720-A
Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan.
Evidence
  1. Upon review of Resident #3’s record, there are inconsistencies in regards to the resident’s code status. The Durable DNR order in the resident’s record is dated 4/29/22. The ISP (dated 5/16/22) indicates on the front page the code status as a Full Code; however, within the ISP, it indicates the code status as a DNR effective 4/1/22.
  2. Upon review of Resident #7’s record, there are inconsistencies in regards to the resident’s code status. The personal data and resident’s record indicate the resident as a full code; however, the ISP (dated 7/13/22) indicates Resident #7 is a DNR.
Plan of correction
Code Status reviewed with residents and POA and corrected in ISP. ISP will be updated upon receipt of DNR.
July 6, 2021Inspection2 violations
Inspection dates
July 6, 2021 and July 8, 2021
Areas reviewed
A renewal inspection was initiated on 7/1/21 and concluded on 7/8/21. The Administrator was contacted by telephone to initiate theinspection. The Administrator reported that the current census was 86. The inspector emailed the Administrator a list of items required tocomplete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, menu,activities calendar, and staff schedules submitted by the facility to ensure documentation was complete. The inspector conducted the on-siteportion of the inspection on 7/2/21. An exit interview with the Administrator on the date of the inspection, where findings were reviewed andan opportunity was given for questions, as well as for providing any information or documentation which was not available during theinspectionInformation gathered during the inspection determined non-compliances with applicable standards or law, and violations were documentedon the violation notice issued to the facility
Violations
22VAC40-73-440-B
Based on record review and discussion the facility failed to ensure the administrator approves and signs the completed Uniform Assessment Instrument.
Evidence
  1. Resident #3’s Uniform Assessment Instrument (UAI) dated 12/15/20 was completed by a staff member at the facility.
  2. Resident #3’s UAI dated 12/15/20 did not have the assessor’s signature nor was it signed and dated by the Administrator.
  3. Staff #5 acknowledged that Resident #3’s UAI dated 12/15/20 did not contain the assessor’s signature nor was it signed and dated by the Administrator.
Plan of correction
Resident #3's UAI has been reviewed and signed by the Healthcare Director and the Administrator. The Executive Director will audit 5% of all UAI's to ensure they have been reviewed and signed. Person responsible: Brenda Stevenson and Shawn Buckon
22VAC40-73-450-E
Based on record review and discussion the facility failed to ensure the individualized service plan was signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. Resident #3’s Individualized Service Plan (ISP) dated 2/1/21 was provided by the facility.
  2. Resident #3’s ISP was not signed and dated by the licensee, administrator, or his designee, nor the resident or his legal representative.
  3. Staff #5 acknowledged that Resident #3’s ISP dated 2/1/21 was not signed and dated by the licensee, administrator, or his designee, nor the resident or his legal representative.
Plan of correction
Resident #3's ISP has been corrected and signed by the Healthcare Director and the Administrator. The Executive Director will audit 5% of all ISP's to ensure the resident, responsible party, Administrator and all participants of the ISP have reviewed and signed. Person Responsible: Brenda Stevenson and Shawn Buckon
June 7, 2021Complaint survey1 violation
Inspection dates
June 7, 2021 , June 11, 2021 , June 14, 2021 and June 15, 2021
Areas reviewed
22VAC40-73 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 GROUNDS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 6/7/21 and concluded on 6/15/21. A complaint was received by the department regarding allegations in the areas of staffing, resident care, and maintenance of buildings and grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-320-A
Based on record review and discussion, the facility failed to ensure that 3 of the 4 physical examination reports reviewed documented the descriptions of the persons? reactions to known allergies.
Evidence
  1. Resident #1’s physical examination report dated 2/23/21 did not document a description of reactions to known allergy: NSAIDS.
  2. Resident #2’s physical examination report dated 2/24/2020 did not document a description of reactions to known allergies: Sulfa, Macrobid, Bexxar, Codeine, Brompheniramine, Lyrica, and Zocor.
  3. Resident #3’s physical examination report dated 2/11/2020 did not document a description of reactions to known allergies: Anastrozole, Arimidex, Aromasin, Azathioprine, Cephalexin, Codeine, Diovan, Doxepin, Exenatide, Gluten, Imuran, Detemir, Nifedipine, Sitagliptin, Lovastatin, Metformin, Niacin, and Statins.
  4. Staff #5 acknowledged the aforementioned physical examination reports did not include the descriptions of the residents? reactions to the aforementioned allergies.
Plan of correction
The Healthcare Director will audit 3 charts each day until all resident files have been corrected To be corrected by July 20.2021 The 3 Physical examination reports that were reviewed on 6/15/21 have been corrected