Virginia DSS · Assisted Living Facility

Bickford of Spotsylvania

📍 5000 Spotsylvania Parkway, Fredericksburg, VA, 22407

ID 42295One Year licenseActive
19
Inspections
On record
14
With violations
Visits that cited something
5
Clean visits
Nothing cited
44
Violations cited
Individual findings
31
Standards cited
Distinct rules
11
Complaint visits
Prompted by a complaint

Bickford of Spotsylvania was inspected 19 times between March 19, 2021 and December 11, 2025 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 44 violations under 31 distinct standards. 11 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 17 of these 19 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
04/16/2026
Administrator
Whitney Keeton
Licensing inspector
Sarah Pearson
Inspector phone
(540) 680-9469
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

19

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

December 11, 2025Inspection5 violations
Inspection dates
12/11/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/11/2025 Time In: 12:49 PM Time out: 4:14 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 11/14/2025 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 54 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents engaging in scheduled activities. Additional Comments/Discussion: N/A 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-670-1
Based on record review and staff interview, the facility failed to ensure that when staff administered medications to residents, the following standards applied: each staff person who administered medications should be authorized by 54.1-3408 of the Virginia Drug Control Act. All staff responsible for medication administration should: be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide, except as specified in subdivision 2 of this section.
Evidence
  1. The facility submitted a self-report on 11/14/2025, stating that “an unlicensed employee administered medications to residents."
  2. The facility’s Med Pass Details indicated that staff 1 administered over two hundred medications to approximately thirty residents over the course of the following days: 05/31/2025, 09/21/2025, 10/19/2025, and 11/13/2025.
  3. Upon request the facility, 12/11/2025 was unable to provide a license by the Commonwealth of Virginia to administer medications or a registration with the Virginia Board of Nursing as a medication aide for staff 1.
  4. During the onsite inspection, 12/11/2025, staff 4 confirmed that staff 1 was suspended and was formerly under investigation for administering medications to residents without a license by the Commonwealth of Virginia to administer medications or a registration with the Virginia Board of Nursing as a medication aide.
Plan of correction
Divisional Director of Operations to conduct re-training with Executive Director on state regulations for medication administration in assisted living. Divisional Director of Health and Wellness to conduct re-training with Executive Director and Health and Wellness Director on company medication management plan and medication pass requirements. This includes qualifications for those able to administer medications. The Executive Director and Health and Wellness Director are responsible for ensuring staff responsible for administering medications meet qualification requirements, Divisional Director of Health and Wellness to conduct monthly medication audits in eMar system to assure compliance.
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to have, keep current, and implement a written plan for medication management. The facility’s medication plan should address procedures for administering medication and should include methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670.
Evidence
  1. The licensing department received a self-report on 11/14/2025 stating, “an unlicensed employee administered medications to residents in an assisted living facility” on 05/31/2025, 09/21/2025, 10/19/2025, and 11/13/2025.
  2. The Medication Management Plan stated, “medication is only to be administered, supervised, or reminders given by qualified Bickford Family Members (BFMs). Qualified BFMs: BFMs who are licensed/certified/credentialed to administer medications and whose medications tasks have been successfully delegated by the nurse.
  3. During the onsite inspection, 12/11/2025, staff 4 confirmed that due to insufficient staffing of registered medication technicians an employee who did not meet the qualification requirements for administering medications documented that they administered over two hundred medications to approximately thirty residents over the course of the following days: 05/31/2025, 09/21/2025, 10/19/2025, and 11/13/2025.
Plan of correction
Divisional Director of Health and Wellness to conduct re-training with Executive Director and Health and Wellness Director on company medication management plan and medication pass requirements. This includes qualifications for those able to administer medications. The Executive Director and Health and Wellness Director are responsible for ensuring staff responsible for administering medications meet qualification requirements Divisional Director of Health and Wellness to conduct monthly medication audits in eMar system to assure compliance.
22VAC40-73-280-B
Based on record review and staff interview, the facility failed to maintain a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan should be directly related to actual resident acuity levels and individualize care needs.
Evidence
  1. Upon request the facility did not provide a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for residents in care.
  2. During the onsite inspection, 12/11/2025, staff 4 provided the disclosure statement in lieu of the written plan. Staff 5 confirmed that the written plan was not provided upon request.
Plan of correction
Divisional Director of Operations provided branch disclosure statement that detailed adequate number of staff per shift. Divisional Director of Operations will connect with Vice President of Operations on an updated written staffing plan that details on how many direct care staff are required to meet the needs of the branch residents based on their individualized care needs.
22VAC40-73-280-A
Based on record review and staff interview, the facility failed to ensure to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.
Evidence
  1. During the onsite inspection, 12/11/2025, staff 4 provided a disclosure statement that detailed adequate staff and confirmed the staffing schedule to include both assisted living facility and the safe, secure environment: first shift (7 am – 3 pm) 2 registered medication aides (RMAs) and 3 certified nursing assistants (CNAs) were to be scheduled; second shift (3 pm – 11 pm) 2 RMAs and 3 CNAs; and third shift (11 pm – 7 am) 1 RMA and 2 CNAs.
  2. The May and October 2025 staffing schedules indicated that RMAs were not scheduled on the first shift: 05/31/2025, 10/12/2025, and 10/18/2025.
  3. The November 2025 staffing schedule indicated that one RMA was scheduled on the first shift: 11/09/2025, 11/10/2025, 11/14/2025, and 11/15/2025.
  4. The October and November 2025 staffing schedules indicated that RMAs were not scheduled on the second shift: 10/12/2/2025, and 11/13/2025.
  5. The May, October, and November 2025 staffing schedules indicated that one RMA was scheduled on the second shift: 05/26/2025, 05/31/2025, 10/13/2025, 10/14/2025, 10/15/2025, 10/16/2025, 10/17/2025, 10/18/2025, and 11/15/2025.
  6. The October 2025 staffing schedule indicated that RMAs were not scheduled on the third shift: 10/12/2025, 10/13/2025, and 10/18/2025.
  7. The October 2025 staffing schedule indicated that CNAs were not scheduled on the first and second shift on 10/12/2025.
  8. During the onsite inspection, 12/11/2025, staff 4 confirmed that the facility did not have staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans.
Plan of correction
Divisional Director of Operations to rebuild branch master schedule to reflect the adequate staffing model per disclosure statement as well as conduct training with Executive Director on staffing model and scheduling. This includes how to adjust schedules live due to call outs, time off etc. Divisional Director of Operations to audit schedule weekly for 2 months and annually thereafter to ensure staffing model is being followed, updated for necessary changes, and saved in branch documented records. The Executive Director will be responsible for ensuring there is staff adequate in knowledge, skills and abilities and sufficient in number to provide services to attain and maintain the physical, mental, and psychosocial well-being of residents as determined by assessments and individualized service plans.
22VAC40-73-290-A
Based on record review, the facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time. The facility should maintain a copy of the schedule for two years.
Evidence
  1. Upon request the facility did not provide the staff schedule for 09/21/2025 and 10/19/2025.
  2. During the onsite inspection 12/11/2025, staff 2 confirmed that the staff schedules for 09/21/2025 and 10/19/2025 were “not found” or provided to licensing inspector (LI).
Plan of correction
Divisional Director of Operations to update branch master schedule to reflect adequate staffing model per disclosure statement. This includes the list of all staff members’ names and their perspective job classifications. Divisional Director of Operations to conduct training with Executive Director and Health and Wellness Director on scheduling and staffing model as well as saving all past schedules in branch documented records. Divisional Director of Operations to audit schedules weekly. The Executive Director will be responsible for completing and maintaining for two years written work schedules that include the names and job clarifications of all staff working each shift with an indication of whomever is in charge at any given time. The Divisional Director of Operations will review staffing schedules during routine branch visits for 2 months and annually thereafter to ensure compliance.
December 11, 2025Complaint survey0 violations
Inspection dates
12/11/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 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: 12/11/2025 Time in: 4:15 PM Time out: 5:30 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 11/25/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, Resident Care and Related Services, and Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 54 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents engaging in scheduled activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2025Complaint survey4 violations
Inspection dates
Sept. 24, 2025 and Sept. 25, 2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/24/2024 from 2:50 p.m. until 5:00 p.n. and 9/25/2024 from 9:00 a.m. until 11:50 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/11/2024 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 58 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: 5 Observations by licensing inspector: Therapy services being provided to residents, breakfast and lunch being served, access in and out of the front doors. Additional Comments/Discussion: The staff licensing inspector spoke with appeared knowledgeable about residents and operations. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions please contact (Jeff Marnien) Licensing Inspector at (540) 571 0189 or by email at Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and staff interview the facility failed to notify the Regional Licensing Office (RLO) within 24 hrs. of a major incident that threatened the life, health, safety, or welfare of a resident.
Evidence
  1. During an unannounced complaint inspection, 9/24/2024, the Licensing Inspector (LI) discovered resident 1 (date of admission 8/28/2024) eloped from the facility on 9/5/2024.
  2. Staff 1 confirmed the incident had not been reported to the RLO.
Plan of correction
The Executive Director or Acting Administrator is responsible for completing and communicating all state reportable information to the State Inspector (Regional Licensing Office) within the 24-hour period allowed for reporting all incidents and occurrences.
22VAC40-73-440-A
Based on record review and staff interview the facility failed to ensure a UAI was completed prior to admission.
Evidence
  1. Resident 1 was admitted 8/28/2024. A UAI was completed on 9/9/2024, 13 days after admission.
  2. Staff 3 confirmed the UAI was not completed prior to admission.
Plan of correction
UAI’s to be completed prior to admission for all residents admitting into the facility. This is to be completed by the Health and Wellness Director and or Health and Wellness Coordinator. Executive Director to audit monthly.
22VAC40-73-460-D
Based on record review and staff interview the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident 1 preadmission health and physical (dated 8/26/2024) classified Resident 1 with dementia.
  2. Initial ISP (dated 8/29/2024) in wandering and elopement section describes behaviors of wandering and exit seeking behavior and intervention to provide redirection and exit seeking behavior. In Cognitive section of ISP listed needs included frequent help due to disorientation, memory loss, and difficulty completing tasks.
  3. A UAI dated 9/9/2024 lists behavior patterns as wandering. An admitting UAI was not available.
  4. The facility communication log documented exit seeking behavior, 8/29/2024, 9/1/2024. Resident 1 eloped on 9/5/2024.
  5. Staff 4 statement: On September 15, 2024, resident 1 tried to exit the doors in the dining room. Staff redirected him to the inside courtyard because resident 1 wanted to be outside. Staff 4 returned to check on resident 1 five minutes later and resident 1 was missing. The alarms to the exterior doors did not alarm.
  6. Staff 5 statement: Upon admission resident 1 was confused with location but was able to be independent with self- care, dressing, toileting and eating. On September 15, 2024, staff 5 was able to redirect resident 1 but they were trying to exit the building. Staff 5 checked on resident 1 in the courtyard to give them breakfast in the dining area but resident 1 was not there. The exterior door alarms did not go off and their family was not in the building that day. Family to other residents were in the building and some of them have FOBs to exit the building without staff assistance and without the alarms going off. When resident 1 was located in a neighborhood behind the facility. When resident 1 was found there were no signs of distress or injuries.
Plan of correction
Per resident assessments and care plan needs, interventions are to be put in place and communicated to staff members on proper ways to implement when needed. Training and education also to be conducted with staff members on the specifics of each resident’s service plan and needs as well as updates or changes as they occur. This is to be conducted and managed by the Health and Wellness Director and or Health and Wellness Coordinator. Missing resident elopement drill to be conducted on or before 4/20/2025 to educate and ensure all staff know and understand proper procedure for elopements. In addition, a full audit and inspection will occur to ensure that all doors are secure and are alarming properly. This is to be conducted by the Maintenance Coordinator.
22VAC40-73-930-D
Based on record review and staff interview the facility failed to document rounds which included name of resident, date of rounds, time of rounds, and staff member who made the rounds for residents with an inability to use the signaling device.
Evidence
  1. Resident 1 (date of admission 8/28/2024) has an initial Individualized Service Plan (ISP) completed 8/29/2024. In section, Special Care Needs, the provider indicated safety checks are to be performed two times a shift.
  2. LI interviewed Staff 3 on 9/25/2024 who stated safety checks are listed on a task sheet for each resident. The task sheet does not include elements required in the standards.
  3. Staff 3 did not provide documentation safety checks were completed.
Plan of correction
Rounding Log Sheet will be created and kept in a binder in the memory care unit for rounding and safety check purposes. The rounding log will include the following to be added to the documentation: name of residents, date of rounds, time of rounds, and staff member who conducted the rounds. In addition, safety checks will be documented on the staff members? task sheets to indicate safety checks were conducted if in the resident’s care plan. Rounding Log and Task Sheets to be monitored and managed by the Health and Wellness Director and or Health and Wellness Coordinator.
July 8, 2025Complaint survey1 violation
Inspection dates
07/08/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/8/2025 11:15 A.M. – 1:40 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 7/1/2025 regarding allegations in the area(s) of: Building and grounds, and staffing. Number of residents present at the facility at the beginning of the inspection: 57 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, resident rooms, resident bathrooms, and laundry room. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-870-E
Based on observations and a staff interview, the facility failed to ensure that all furnishings, including furniture, were clean and in good repair.
Evidence
  1. The Licensing Inspector (LI) toured the building with Staff 1 on 7/8/2025. During the tour, LI and staff 1 observed that in the memory care area, a fan above the dining room tables had a buildup of dust on its blades, and a chair in the dining area was soiled.
  2. Staff 1 confirmed the fan and chair needed cleaned.
  3. Photo evidence
Plan of correction
Immediate action taken: Will be working in coordination with maintenance director to complete requested items. Specified requests have been completed and acknowledged such as listed in the following statement Living room Chair has been steamed and washed The table in the living room was discarded, and could not be repaired minimally Doors have been retouched, painted and washed throughout the branch Ceiling tiles will be ordered and replaced in the locations listed. Specifically related to tiles near sprinklers access points, we will speak directly to Richmond Sprinkler company to see how to better address this matter related to presentation and the completion of each sprinkler inspection. Exhaust vents have been cleaned and dusted. Responsible Party Executive Director Maintenance Director Housekeeper Completion Date 7/31/2025
April 7, 2025Inspection7 violations
Inspection dates
04/07/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/7/2025 9:20 a.m. – 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 4/3/2025 regarding allegations in the area(s) of: resident care and staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 46 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, secure unit activities and exit door functionality, dining services, and resident room. Additional Comments/Discussion: N/A 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record review and staff interviews, the facility failed to develop a comprehensive ISP that included the identified needs on the UAI and admission physical examination.
Evidence
  1. Resident 1’s UAI, dated 4/3/2025, noted resident 1’s behavior pattern as appropriate. The admitting physical examination, dated 3/28/2025, identified resident 1 as needing memory care supervision as resident noted to wanders/leaves facility that is not secure, with proper supervision. The ISP dated 4/3/2025, identified the resident’s need for frequent redirection due to elopement risk.
  2. Resident 1’s UAI left blank the level of care needed for the resident as either residential living or assisted living. The admitting physical examination identified resident 1 needing memory care.
  3. Staff 4 and staff 5 confirmed the provided UAI was the UAI of record. Staff 7 confirmed the ISP was the comprehensive ISP.
Plan of correction
•The Family Advocate to confirm the date of the move in for potential admission. •Ensure that all UAI’s are thoroughly completed and reviewed upon completion by ED. •Alert staff for via August Health electronic health record of any resident that include identified needs. -Responsible party- HWD/HWC, Family Advocate and Executive Director.
22VAC40-73-930-D
Based on record review and staff interviews, the facility failed to document rounds that were made for residents with a documented service need.
Evidence
  1. During review of the ISP, dated 4/3/2025, for resident 1, the LI noted that safety checks were to be completed four times per shift.
  2. LI requested documentation of the safety checks for resident 1 as noted on the ISP.
  3. Staff 4 and staff 5 confirmed that a round log was not completed documenting the safety checks for resident 1.
Plan of correction
•HWC/HWD to audit rounding charts daily for accuracy and completeness. •Noncompliance addressed through progressive disciplinary policy. •Staff were counseled and provided additional training on documentation requirements -Responsible Party- HWD, HWC and ED for overall compliance.
22VAC40-73-440-A
Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed prior to admission.
Evidence
  1. During record review on 4/7/2025, the LI noted resident 1 was admitted 3/27/2025 to the electronic system, and staff 7 confirmed a physical move in date of 3/31/2025. The UAI had an initial assessment date of 4/3/2025.
  2. During interview on 4/7/2025 staff 4 confirmed resident 1 was admitted 3/27/2025 to their system with a physical move in date of 3/31/2025.
Plan of correction
•All new move ins to be thoroughly discussed with Executive Director, Health and Wellness director and Family advocate. •Scheduled Assessments (UAI) to be placed on HWD calendar 7 days prior to new admission. •UAI alerts to be set for 30-day reminders in electronic health records alongside with assessment. -Responsible party- Health and Wellness Director and Coordinator, Executive Director
22VAC40-73-990-C
Based on record review and staff interview, the facility failed to conduct exercises for resident emergencies, at least every six months, which included procedures for a missing resident.
Evidence
  1. LI requested to see the last two resident emergency exercises. Staff 4 provided a resident emergency exercise conducted on 4/3/2025.
  2. LI requested a resident emergency exercise conducted six months prior to 4/3/2025. Staff 4 confirmed a resident emergency exercise had not been completed prior to 4/3/2025.
Plan of correction
•ED to Review and audit all emergency plans/drills. •Maintenance Director to ensure that routine emergency plans have been appropriately conducted based on scheduled intervals. •All drills have been documented and that present staff have confirmed their attendance. •Conduct monthly in-services for all staff for specified resident emergencies in the months of April and October. •Documentation of staff participation collected for records, to be managed by ED and HWD.
22VAC40-73-450-A
Based on record review and staff interview, the facility failed to ensure a preliminary individualized service plan (ISP) was developed on or within seven days prior to the admission, or a comprehensive ISP was developed on the day of admission, to address the basic needs of the resident that adequately protected his health, safety, and welfare.
Evidence
  1. Resident 1 was admitted on 3/27/2025 with a physical move in date on 3/31/2025.
  2. Staff 7 confirmed, 5/21/2025, the ISP, dated 4/3/2025, provided to the LI during the on-site inspection conducted on 4/7/2025, was the Comprehensive ISP and not the Preliminary ISP.
Plan of correction
•Ensure all ISPs are completed by HWD/HWC prior to admission •The family advocate to confirm the date of the move in for potential admission. •Ensure that all ISPs are thoroughly completed and reviewed upon completion by ED. •Alert staff for via August Health electronic health record of any resident that include identified needs.
22VAC40-73-460-D
Based on resident record review and staff interviews the facility failed to provide supervision of resident care, including attention to specialized needs, such as prevention of wandering from the premises.
Evidence
  1. On 4/7/2025, the Licensing Inspector (LI) reviewed resident 1’s admitting history and physical dated 3/28/2025 which identified resident 1 as having wandering and exit seeking behaviors and required placement in a secure unit to reduce risk of elopement.
  2. Resident 1’s Individual Service Plan (ISP), dated 4/3/2025, under the wandering and elopement section, stated the facility will provide redirection for exit seeking behaviors.
  3. During an interview on 4/7/2025, staff 3 stated she was called by law enforcement asking if she knew [resident 1]. The officer informed staff 3 he had found resident 1 outside. Staff 3 assisted resident 1 back to the secure care unit.
  4. During an interview on 4/7/2025, staff 2 stated they were unaware resident 1 was missing until the police called and brought resident 1 back to the facility. Staff 2 also stated that resident 1 was “always actively trying to get out and goes to the same door often.”
  5. On 4/7/2025, LI requested door monitoring/audit records for resident 1. Facility provided Quantum Safety and Security Daily Event reports showing dates/times resident 1 would approach secured doors and whether doors alarmed. a. On 4/2/2025 at 5:47 p.m. (42 seconds) resident 1 was at the rear entrance of the secure unit. b. On 4/2/2025 at 5:47 p.m. (59 seconds) resident 1 activated the alarm at the rear entrance of the secure unit. c. On 4/2/2025 at 5:48 p.m. (15 seconds) resident 1 left the rear entrance of the secure unit. d. On 4/2/2025 at 6:53 p.m. (33 seconds) resident 1 activated the front door alarm of the facility upon return with law enforcement.
  6. Resident 1 was out of the facility for 1 hour and 5 minutes.
Plan of correction
•Elopement Drills to be completed quarterly by Maintenance Director •Facility will place residents on 72 hours observance schedule and highlighted in August Health electronic record system •A new rounding checklist was implemented and must be signed off by care staff and verified by the supervisor at the beginning of day. •ED to review Quantum safety and security Daily event reports weekly, in review with Maintenance director and Health & Wellness Director •Residents identified as affected were assessed for safety and well-being. •Weekly door trigger test at random to be conducted by the Health & Wellness Director and Coordinator to ensure response time of care staff is reciprocated in an appropriate and timely manner. -Responsible Party- HWD, HWC and ED for overall compliance.
22VAC40-73-1150-A
Based on resident record review and staff interviews, the facility failed to ensure doors that lead to unprotected areas were monitored or secured through devices that conform to applicable building and fire codes, including constant staff oversight, security bracelets that are part of an alarm system or delayed egress mechanisms.
Evidence
  1. Resident 1 was admitted to the secure care unit on 3/31/2025.
  2. The Licensing Inspector (LI) received an incident report from the facility advising that resident 1 had eloped from the secure care unit on 4/2/2025 and was returned to the facility by law enforcement. No injuries noted. Facility also noted on the incident report that resident 1’s wander guard would be set to a higher signal and there was a glitch in the system. New wander guards would be ordered.
  3. Staff 2 provided a written statement to the facility on 4/4/2025 which indicated resident 1 “was able to get through the door without the alarm going off due to improperly {sic} working alarm system again this year”
  4. On 4/7/2025, staff 1 demonstrated for the LI how the exit doors would alarm for 15 seconds when pushed prior to opening.
  5. During lunch preparation, the LI stood in the middle of the dining room amongst staff and residents to listen for the door alarm following activation by staff 1. The LI was able to faintly hear the door alarm.
  6. At 12:00 p.m. on 4/7/2025, the LI approached the main door of the secure unit which opened into the dining room of the unit. The LI activated the door alarm and entered the secure unit and observed staff 1 and staff 2 assisting residents with lunch preparations. Neither staff member responded to the door alarm.
  7. Staff 1 confirmed to the LI that staff did not respond to the door alarm when activated.
Plan of correction
•Immediate Action Taken: The resident was returned safely. Family and Physician were notified. The door alarm system was tested and found to be malfunctioning. The system was updated and tested within the next few hours. •Preventative Measures: All exit doors in the memory care unit were inspected and repaired as needed. Doors were remotely reset via JNL company •Door alarms are now included in a daily alarm function checklist to be completed by maintenance staff and signed off. •Staff were re-educated on elopement prevention protocols, including supervision, door security, and emergency response. •Quarterly elopement drills scheduled with staff participation and documentation. -Responsible Party- Health and Wellness Director, Health and Wellness Coordinator, Maintenance Director and Executive Director
April 7, 2025Inspection1 violation
Inspection dates
04/07/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 STAFFING AND SUPERVISION
Comments
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/7/2025 1:45 p.m. – 4:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/23/2025 regarding allegations in the area(s) of: resident care and staffing. Number of residents present at the facility at the beginning of the inspection: 46 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, resident room, dining services Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-150-B-9
Based on email communication and interviews, the facility failed to ensure the assisted living facility operated under the supervision of an acting administrator no more than two times during any two-year period unless authorized to do so by the department.
Evidence
  1. During a previous inspection on 9/20/2024, the Licensing Inspector (LI) determined that staff 5 was the acting administrator for the facility.
  2. LI received an email from staff 7 on 10/17/2024 which stated staff 6 would assume the role as acting administrator for the facility beginning 10/17/2024. Staff 6 was acting through 11/20/2024.
  3. LI received an email from staff 7 on 2/10/2025 which stated staff 3 would now be the acting administrator effective 2/10/2025.
  4. LI emailed staff 7 on 2/10/2025, seeking confirmation of compliance with Standard 150-B, Part Six: allowable duration of an acting administrator, and Part Nine: a limit of no more than two acting administrators within a two-year period. No response was received.
  5. Staff 7 did not request to assign a third acting administrator within a two-year period of time.
Plan of correction
The branch has now hired a licensed administrator and is no longer needing to use an acting administrator. Amanda Hemminger is now the Executive Director for Bickford of Spotsylvania effective 5/22/25.
January 16, 2025Inspection11 violations
Inspection dates
01/16/2025, 01/17/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/16/2025 9:00 a.m. – 4:35 p.m., 1/17/2025 9:00 a.m. – 7:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Building and grounds, activities, meal pass, medication pass. Additional Comments/Discussion: This is a renewal inspection. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-950-E
Based on staff interviews, the facility failed to develop and implement an orientation and semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual’s respective responsibilities. The review must be documented by signing and dating.
Evidence
  1. During an interview with staff 1 and staff 2 on 1/16/2025, LI requested the orientation and semi- annual review of the emergency preparedness and response plan. A Disaster Preparedness and Tornado Training course was provided.
  2. Staff 1 and staff 2 confirmed the semiannual review were not completed; documentation was not available and could not be provided.
Plan of correction
Semi-Annual review of the emergency preparedness plans will be conducted and documented with all staff. This to occur at the monthly staff meeting, led by the Maintenance Coordinator and managed by the Executive Director.
22VAC40-73-40-A
Based on record review and staff interview the facility failed to follow their own policies and procedures.
Evidence
  1. During document review on 1/16/2025, LI observed the medication reviews were completed on 2/29/2024, 5/31/2024, and 11/30/2024.
  2. During interview with staff 1 on 1/16/2025, LI asked if the medication reviews were Completed quarterly or every six months? Staff 1 stated they were completed quarterly. LI requested the facility policy stating medication reviews would be completed quarterly.
  3. Staff 1 provided Pharmacy Coordination Policy which stated, “A quarterly medication audit is completed at the Branch by an independent pharmacist.”
  4. LI requested documentation of an August 2024 medication review to complete the quarterly medication review sequence. Staff 1 confirmed the August 2024 medication review could not be located and documentation was not available from the independent pharmacist.
Plan of correction
All medication reviews will be completed by the independent pharmacist quarterly during the months of January, April, July and October, reviewed and completed by the physician, sent to pharmacy, and uploaded to the resident’s chart. This to be managed by the Health and Wellness Director.
22VAC40-73-990-C
Based on staff interviews the facility failed to ensure every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced and documented.
Evidence
  1. LI requested to review documentation of resident emergency exercises every six months.
  2. Staff 1 and staff 2 confirmed the resident emergency exercises were not completed; documentation was not available and could not be provided.
Plan of correction
In addition to the resident emergency training with the staff, resident emergency exercises will be completed during the in-services to help support the training and review. The exercises will be documented and signed by all staff members and management. The exercises and training will be managed and conducted by the Executive Director and Health and Wellness Director.
22VAC40-73-260-C
Based on observation and staff interview the facility failed to post a list of staff who were first aid and CPR certified in the facility so that the information was readily available to all staff at all times and kept up to date.
Evidence
  1. During tour of the facility on 1/16/2025, LI requested to view the posted list of staff who were first aid and CPR certified.
  2. Staff 1 confirmed the list had not been kept current and posted in the facility and the information was not readily available to all staff at all times.
Plan of correction
All Staff CPR/First Aid certifications will be kept on file and posted in front office area and med rooms. The Admin Assistant is responsible for keeping the list updated with information and updates received from the Executive Director and Health and Wellness Director. The Executive Director is responsible for obtaining the staff certifications during the onboarding process.
22VAC40-73-390-A
During document review and staff interview the facility failed to ensure the resident written agreement included a provision that the resident had been informed of the facility policy on weapons on the premises and that the resident has been informed residents could establish and maintain a resident council.
Evidence
  1. During interview with staff 3 on 1/17/2025, LI requested if the resident agreement included information that residents would be informed of the facility policy on weapons along with formation of a resident council.
  2. Staff 3 reviewed resident agreement and confirmed the facility policy on weapons and formation of resident council was not included in the resident agreement.
Plan of correction
Resident Admission Agreement to be sent to Home Office for review and requested updates to include information on branch policy on weapons as well as formation of a resident council. This is to be requested and managed by the Executive Director.
22VAC40-73-960-B
Based on observation and staff interview the facility failed to ensure the emergency evacuation drawing included the location of a telephone to use in an emergency.
Evidence
  1. Licensing Inspector (LI), during a tour of the facility on 1/16/2025, observed the fire and emergency evacuation drawing did not include the identification and location of telephone.
  2. During an interview with LI on January 16, 2025, staff 1 confirmed that the fire and emergency drawing did not include the location of telephones.
  3. Photo evidence taken and labelled P1.
Plan of correction
All emergency evacuation maps in the branch will indicate where the telephones are located for each section of the branch. This will be managed by the Maintenance Coordinator and reviewed quarterly by the Executive Director or as needed if there are updates or changes to be made.
22VAC40-73-120-A
Based on staff record reviews and staff interview the facility failed to ensure the staff orientation and required training occurred within the first seven working days of employment for 4 out of 4 staff records reviewed.
Evidence
  1. LI reviewed staff 2, (date of hire (DOH) 9/12/2024), staff 4 (DOH 8/5/2024), staff 5 (DOH 3/25/2024), and staff 6 (DOH 9/19/2024) employee records on 1/17/2025.
  2. Each orientation record contained a company document stating it must be completed within 10 days of hire. The company orientation document did not include orientation criteria in this subsection.
  3. Staff 1 reviewed the orientation document and the standards with the LI. Staff 1 confirmed the company orientation form did not meet criteria within this subsection.
Plan of correction
The company orientation document currently lists all sections covered in initial orientation during staff onboarding. The Executive Director to send the document to the home office for a review to ensure the company document is within compliance.
22VAC40-73-690-F
Based on record review and staff interview the facility failed to ensure the medication review included a certification by the licensed health care professional that the requirements of subdivision E1 through E11 of this standard were met.
Evidence
  1. During document review on 1/16/2025, LI observed a medication review, dated 2/29/2024, which did not include certification by the consulting pharmacist that requirements of subdivision E1 through E11 of this standard were met.
  2. Staff 1 reviewed the medication review and confirmed the certification was not included on the form.
Plan of correction
All medication reviews will be completed by the consulting pharmacist quarterly, reviewed and completed by the physician, sent to pharmacy, and uploaded to the resident’s chart. This to be managed by the Health and Wellness Director.
22VAC40-73-990-B
Based on staff interviews the facility failed to ensure resident emergencies were reviewed by the facility, at least every six months, with all staff and documented with the date and staff signature.
Evidence
  1. LI requested the review of resident emergencies with all staff every six months including staff signatures and date.
  2. Staff 1 and staff 2 confirmed the reviews were not completed every six months; documentation was not completed and could not be provided.
Plan of correction
Resident emergencies will be reviewed every six months with all employed staff members at monthly all staff in – services. The in-service and training will be documented and signed by all present staff members during the training for a Spring and Fall review. The training will be managed and conducted by the Executive Director and Health and Wellness Director.
22VAC40-73-960-A
Based on record review and staff interviews the facility failed to ensure the written plan for fire and emergency evacuation which is to be followed in the event of a fire or other emergency was approved by the appropriate fire official.
Evidence
  1. During interview with staff 1 and staff 2 on 1/17/2025, LI asked if the emergency evacuation plan had been approved by the appropriate fire official.
  2. Staff 1 and staff 2 confirmed the plan had not been approved by the appropriate fire official.
Plan of correction
Emergency Evacuation plan to be sent to Fire Marshal for approval. If it is not, will obtain in writing as to why it is not accepted. This to be completed by the Executive Director.
22VAC40-73-970-A
Based on record review and staff interviews the facility failed to ensure fire drills were completed for each shift in a quarter and were not conducted in the same month.
Evidence
  1. During document review, LI observed fire drills were not completed for May 2024, June 2024, July 2024, and August 2024.
  2. Drills were also completed on the first shift 9/23/2024 at 10:40 a.m. and 10/18/2024 at 10:50 a.m.
Plan of correction
All Fire Drills will be conducted monthly rotating shifts each month between 1st, 2nd and 3rd shifts for proper training and review with staff. Drills are to be documented and signed off by all staff present. All fire drills are managed and conducted by the Maintenance Coordinator.
December 5, 2024Complaint survey1 violation
Inspection dates
12/05/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/5/2024 9:30am – 1:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/8/2024 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication room, medication cart, lunch meal being served. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interviews, the facility failed to implement their written plan for medication management.
Evidence
  1. Licensing Inspector (LI) requested the most recent physician order sheet (POS) and Medication Administration Record (MAR) for resident 1 from staff 2 to complete a medication cart review on 12/5/2024. Staff 2 provided POS dated 12/5/2024 and the December MAR. During the cart review the LI and staff 3 observed Tramadol 50mg in the med cart that was not on the POS or the MAR.
  2. During an interview with staff 2 on 12/5/2024, the LI asked if there was an order to discontinue or add the Tramadol 50mg to resident 1’s medication list. Staff 2 stated the Tramadol 50mg was discontinued and staff 2 provided a physician order dated 11/20/2024 to discontinue the Tramadol 50mg.
  3. LI requested the facility medication management plan. The facility medication management plan, PP-61050-Medication management, section #6 Disposal states, following a resident change in medication all unused medications will be returned to the pharmacy or destroyed. The plan further states controlled substances shall be destroyed in a timely manner. Staff 3 stated during an interview on 12/5/2024, the controlled medications are to be destroyed immediately.
  4. LI, during an interview with Staff 2 on 12/5/2024, asked when are medications to be destroyed? Staff 2 responded they are destroyed the same day with two nurses, medication technicians are not allowed to destroy medications. The Tramadol 50mg count log was compared to the Tramadol 50mg in the cart with no discrepancies noted.
  5. Staff 2 and staff 3 observed the Tramadol 50mg in the medication cart, on 12/5/2024, 15 days after the order to discontinue the medication had been given by the physician on 11/20/2024.
  6. Photo evidence taken.
Plan of correction
Per the medication management plan for Bickford, all unused and discontinued medications are to be returned to the pharmacy or destroyed by two nurses immediately after being discontinued, med techs do not destroy the medications. In addition, cart audits are to be conducted monthly by the Health and Wellness Director.
December 5, 2024Complaint survey0 violations
Inspection dates
12/05/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/5/2024 from 1:30 p.m. to 2:00 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 11/19/2024 regarding allegations in the area(s) of: resident records Number of residents present at the facility at the beginning of the inspection: 53 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 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2024Complaint survey4 violations
Inspection dates
09/24/2024, 09/25/2024
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/24/2024 from 2:50 p.m. until 5:00 p.m. and 9/25/2024 from 9:00 a.m. until 11:50 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/11/2024 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 58 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: 5 Observations by licensing inspector: Therapy services being provided to residents, breakfast and lunch being served, access in and out of the front doors. Additional Comments/Discussion: The staff licensing inspector spoke with appeared knowledgeable about residents and operations. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at jeffrey.marnien@dss.virginia.gov.
Violations
22VAC40-73-930-D
Based on record review and staff interview the facility failed to document rounds which included name of resident, date of rounds, time of rounds, and staff member who made the rounds for residents with an inability to use the signaling device.
Evidence
  1. Resident 1 (date of admission 8/28/2024) has an initial Individualized Service Plan (ISP) completed 8/29/2024. In section, Special Care Needs, the provider indicated safety checks are to be performed two times a shift.
  2. LI interviewed Staff 3 on 9/25/2024 who stated safety checks are listed on a task sheet for each resident. The task sheet does not include elements required in the standards.
  3. Staff 3 did not provide documentation safety checks were completed.
Plan of correction
Rounding Log Sheet will be created and kept in a binder in the memory care unit for rounding and safety check purposes. The rounding log will include the following to be added to the documentation: name of residents, date of rounds, time of rounds, and staff member who conducted the rounds, in addition, safety checks will be documented on the staff members' task sheets to indicate safety checks were conducted if in the resident's care plan. Rounding Log and Task Sheets to be monitored and managed by the Health and Wellness Director and or Health and Wellness Coordinator.
22VAC40-73-70-A
Based on record review and staff interview the facility failed to notify the Regional Licensing Office (RLO) within 24 hrs. of a major incident that threatened the life, health, safety, or welfare of a resident.
Evidence
  1. During an unannounced complaint inspection, 9/24/2024, the Licensing Inspector (LI) discovered resident 1 (date of admission 8/28/2024) eloped from the facility on 9/5/2024.
  2. Staff 1 confirmed the incident had not been reported to the RLO.
Plan of correction
The Executive Director or Acting Administrator is responsible for completing and communicating all state reportable information to the State Inspector (Regional Licensing Office) within the 24-hour period allowed for reporting all incidents and occurrences.
22VAC40-73-440-A
Based on record review and staff interview the facility failed to ensure a UAI was completed prior to admission.
Evidence
  1. Resident 1 was admitted 8/28/2024. A UAI was completed on 9/9/2024, 13 days after admission.
  2. Staff 3 confirmed the UAI was not completed prior to admission.
Plan of correction
UAI's to be completed prior to admission for all residents admitting into the facility. This is to be completed by the Health and Wellness Director and or Health and Wellness Coordinator. Executive Director to audit monthly.
22VAC40-73-460-D
Based on record review and staff interview the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident 1 preadmission health and physical (dated 8/26/2024) classified resident 1 with dementia.
  2. Initial ISP (dated 8/29/2024) in wandering and elopement section describes behaviors of wandering and exit seeking behavior and intervention to provide redirection and exit seeking behavior. In Cognitive section of ISP listed needs included frequent help due to disorientation, memory loss, and difficulty completing tasks.
  3. A UAI dated 9/9/2024 lists behavior patterns as wandering. An admitting UAI was not available.
  4. The facility communication log documented exit seeking behavior, 8/29/2024, 9/1/2024. resident 1 eloped on 9/5/2024.
  5. Staff 4 statement: On September 15, 2024, resident 1 tried to exit the doors in the dining room. Staff redirected him to the inside courtyard because resident 1 wanted to be outside. Staff 4 returned to check on resident 1 five minutes later and resident 1 was missing. The alarms to the exterior doors did not alarm.
  6. Staff 5 statement: Upon admission resident 1 was confused with location but was able to be independent with self-care, dressing, toileting and eating. On September 15, 2024, staff 5 was able to redirect resident 1 but they were trying to exit the building. Staff 5 checked on resident 1 in the courtyard to give them breakfast in the dining area but resident 1 was not there. The exterior door alarms did not go off and their family was not in the building that day. Family to other residents were in the building and some of them have FOBs to exit the building without staff assistance and without the alarms going off. When resident 1 was located in a neighborhood behind the facility. When resident 1 was found there were no signs of distress or injuries.
Plan of correction
Per resident assessments and care plan needs, interventions are to be put in place and communicated to staff members on proper ways to implement when needed. Training and education also to be conducted with staff members on the specifics of each resident's service plan and needs as well as updates or changes as they occur. This is to be conducted and managed by the Health and Wellness Director and or Health and Wellness Coordinator. Missing resident elopement drill to be conducted on or before 4/20/20205 to educate and ensure all staff know and understand proper procedure for elopements. In addition, a full audit and inspection will occur to ensure that all doors are secure and are alarming properly. This is to be conducted by the Maintenance Coordinator.
September 24, 2024Complaint survey4 violations
Inspection dates
09/24/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/24/2024 11:00am – 2:40pm 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 May 22, 2024 regarding allegations in the area(s) of: Resident Care. Number of residents present at the facility at the beginning of the inspection: 58 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: 4 Observations by licensing inspector: Observed lunch being served, employee accessing resident information on the computer system that would accompany the resident being sent out during an emergency. Additional Comments/Discussion: All staff interviewed during the inspection were knowledgeable in how to access resident information quickly. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to notify the Regional Licensing Office (RLO) within 24 hours of a major incident that threatened the life, health, safety, or welfare of a resident.
Evidence
  1. During an interview with staff 1 on 9/24/2024 the Licensing Inspector (LI) requested resident 1's communication log. Resident 1's date of admission was 3/12/2024.
  2. Resident 1 had documented falls noted in the communication log on 5/9/2024 and 5/11/2024 which occurred in resident 1’s room.
  3. The LI interviewed staff 1on 9/24/2024 and requested emails to the RLO communicating resident 1’s falls.
  4. Staff 1 confirmed the incident’s had not been reported to the RLO.
Plan of correction
All documented falls and events of residents being sent out for falls and or emergent situations are to be reported to the RLO within a 24 hour period of time. In addition, updates will be sent on the situation pertaining to the residents and events as they occur. This is to be reported and managed by the Executive Director.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) was updated as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 1 experienced falls on 5/9/20254, 5/11/2024. Resident 1 also wandered out of the memory care unit into the assisted living area on 5/10/2024.
  2. Resident 1’s ISP (dated 4/28/2024) under Special Care Needs stated that safety checks would be completed two times a shift for resident 1.
  3. During an interview with staff 2 on 9/24/2024 with the LI, staff 2 confirmed the ISP for resident 1 was not updated with interventions to reduce falls or additional interventions for exit seeking behaviors.
Plan of correction
All ISP’s will be updated when there is a change in the resident’s condition and or if there is a new need identified. This includes updates, interventions, and details on how to implement the changes for the staff. This is to be managed by the Health and Wellness Director and or Health and Wellness Coordinator.
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to update the fall risk rating after a resident fall.
Evidence
  1. Resident 1 had documented falls on 5/9/2024 and 5/11/2024 per the facility communication logbook.
  2. During an interview with staff 2 on 9/24/2024, the LI requested the fall risk rating for resident 1 following the 5/9/2024 fall and the 5/11/2024 fall.
  3. Staff 2 stated the fall risk rating was not completed as required after each fall.
Plan of correction
Fall Risks Ratings will be updated and completed after every fall for each resident and uploaded into the resident chart. This to be conducted by and managed by the Health and Wellness Director and or Health and Wellness Coordinator.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to review the written plan for resident emergencies at least every six months and document the review with all staff.
Evidence
  1. The LI interviewed staff 1 on 9/24/2024 and requested the six-month review of the resident emergency plan with all staff.
  2. Staff 1 confirmed the resident emergency plan was not reviewed with staff every six months and had not been reviewed with staff previously.
Plan of correction
The branch emergency plan will be reviewed and documented during in-service times every six months with staff. All staff will sign off during full review and training. This to be conducted by the Executive Director and Maintenance Coordinator.
September 20, 2024Complaint survey0 violations
Inspection dates
9/20/2024
Areas reviewed
22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/20/2024 10:45am – 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/7/2024 regarding allegations in the area of: Admission, retention and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Toured the building and observed activities in memory care, lunch being served. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 27, 2024Inspection2 violations
Inspection dates
06/27/2024
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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/27/2024 10:30 a.m.-2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: All required postings, activities, lunch meal, medication administration pass, physician’s orders, medications, emergency supplies Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions. Accompanied by Licensing Inspector Shelby Haskins. 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, Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on a review of staff records one out of four records did not have a current TB test or screening.
Evidence
  1. Staff member #2 record did not have any evidence a TB test or screening.
Plan of correction
Nurse Practitioner instructed to complete TB screening for staff #2. Completed and placed in file 6/28/2024.
22VAC40-73-490-A-2
The facility did not ensure a quarterly Health Care Oversight was completed.
Evidence
  1. There was no document available to review during the inspection.
Plan of correction
Director contacted Regional Nurse and scheduled quarterly health Care oversight and ensure is completed quarterly.
March 30, 2023Inspection1 violation
Inspection dates
03/30/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: March 30, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 55 Number of records reviewed and interviews conducted- 8 records (both staff and residents), 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meal times. The Licensing Inspector reviewed the following during the inspection: Menus, activity calendars, pharmacy reviews, fire drills, emergency drills and health care oversight. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-450-D
Based on resident record review and staff interview, it was determined that the facility failed to have a coordinated plan of care on the Individualized Service Plan (ISP) for a resident receiving hospice services.
Evidence
  1. Resident A had no coordinated plan of care for Hospice services on the ISP dated November 22, 2022.
Plan of correction
All ISPs will reflect a coordinated plan of care between the facility and hospice. The branch nursing staff will audit resident records to ensure compliance.
March 21, 2023Complaint survey1 violation
Inspection dates
03/21/2023
Areas reviewed
Staffing and SupervisionResident Care and Related ServicesBuildings and Grounds
Comments
Date of Inspection: March 21, 2023 Type of Inspection: Complaint Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 56 Number of records reviewed and interviews conducted- 1 record, 4 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. There was an allegation of faulty equipment and inadequate staffing to meet the needs of a resident in care. Part of the allegation was determined to be valid. A violation was issued for this inspection.
Violations
22VAC40-73-870-E
Based on resident record review and staff interview, it was determined that the facility did not have equipment in good repair at the time of the inspection.
Evidence
  1. Resident A had a pendant that was not in good working order at the time of admission on March 2, 2023.
Plan of correction
The pendant for Resident A was changed as soon as it was discovered. Staff monitored this resident all through the late day and night upon admission. All pendants throughout the Branch will be checked to see if in working order.
January 18, 2023Complaint survey1 violation
Inspection dates
01/18/2023,01/19/2023
Areas reviewed
Staffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related Services
Comments
Date of Inspection: January 18 and 19, 2023 Type of Inspection: Complaint Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 56 Number of records reviewed and interviews conducted- 3 records, 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. There was an allegation of neglect for resident in care. The was no evidence to support this allegation and it was determined to be not valid. There was a violation cited at the time of inspection.
Violations
22VAC40-73-520-I
Based on direct observation by the licensing inspector and facility staff, it was determined that the facility failed to have a schedule of activities posted as required.
Evidence
  1. The activity calendar for the month was not posted in the facility as required.
Plan of correction
The Branch staff will ensure that all activity calendars are posted as required.
January 5, 2023Complaint survey0 violations
Inspection dates
01/05/2023
Areas reviewed
PersonnelResident Care and Related Services
Comments
Date of Inspection: January 5, 2023 Type of Inspection: Complaint Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 56 Number of records reviewed and interviews conducted- 1 record, 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. There was an allegation of neglect for a resident in care. The report was determined to be not valid and there were no violations found during the inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 7, 2022Inspection1 violation
Inspection dates
06/07/2022,06/10/2022
Areas reviewed
PersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: June 7 and 10, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 59 Number of records reviewed and interviews conducted- 3 resident records and 3 staff records, 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and snack time as well as physical therapy. The Licensing Inspector reviewed the following reports during the inspection: fire drills, healthcare oversight, pharmacy review and dietician report. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-450-D
Based on resident record review and staff interview, it was determined that the facility failed to have a coordinated plan of care on the Individualized Service Plan (ISP) between the Hospice agency and the facility.
Evidence
  1. Resident A's ISP dated April 11, 2022 had no documentation of a coordinated plan of care between the facility and the Hospice agency.
Plan of correction
Resident A's ISP has been corrected. All ISPs will have documentation to reflect a coordinated plan of care between the facility and the Hospice agency for residents in care.
March 19, 2021Inspection0 violations
Inspection dates
March 19, 2021 and March 23, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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 renewal inspection was initiated on March 19, 2021 and concluded on March 23, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 49. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, fire drills, training, and healthcare oversight submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.